Role of MRI in the diagnosis of clinically suspected scaphoid fracture: analysis of 611 consecutive cases and literature review

Khalid, Mohammed; Jummani, Z.; Kanagaraj, K.; Hussain, Amir; Robinson, Denise; Walker, Russell

doi:10.1136/emj.2008.058750

Cited by 26 publications

(30 citation statements)

References 27 publications

(43 reference statements)

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“…71 Studies show that often MRI has a higher sensitivity for occult fracture diagnosis than x-ray or CT alone. 72,73 In the reviewed trials that only used x-rays, it is possible that falsely negative radiographs were used as the reference standard. This imperfect criterion standard bias affects estimates of US operating characteristics by either decreasing the number of false negative US or increasing the number of false positives, which will falsely increase sensitivity or decrease specificity, respectively.…”

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confidence: 99%

Diagnostic Accuracy of History, Physical Examination, and Bedside Ultrasound for Diagnosis of Extremity Fractures in the Emergency Department: A Systematic Review

Joshi

Lira

Mehta

et al. 2013

Academic Emergency Medicine

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Objectives: Understanding history, physical examination, and ultrasonography (US) to diagnose extremity fractures compared with radiography has potential benefits of decreasing radiation exposure, costs, and pain and improving emergency department (ED) resource management and triage time. Methods:The authors performed two electronic searches using PubMed and EMBASE databases for studies published between 1965 to 2012 using a strategy based on the inclusion of any patient presenting with extremity injuries suspicious for fracture who had history and physical examination and a separate search for US performed by an emergency physician (EP) with subsequent radiography. The primary outcome was operating characteristics of ED history, physical examination, and US in diagnosing radiologically proven extremity fractures. The methodologic quality of the studies was assessed using the quality assessment of studies of diagnostic accuracy tool (QUADAS-2).Results: Nine studies met the inclusion criteria for history and physical examination, while eight studies met the inclusion criteria for US. There was significant heterogeneity in the studies that prevented data pooling. Data were organized into subgroups based on anatomic fracture locations, but heterogeneity within the subgroups also prevented data pooling. The prevalence of fracture varied among the studies from 22% to 70%. Upper extremity physical examination tests have positive likelihood ratios (LRs) ranging from 1.2 to infinity and negative LRs ranging from 0 to 0.8. US sensitivities varied between 85% and 100%, specificities varied between 73% and 100%, positive LRs varied between 3.2 and 56.1, and negative LRs varied between 0 and 0.2. Conclusions:Compared with radiography, EP US is an accurate diagnostic test to rule in or rule out extremity fractures. The diagnostic accuracy for history and physical examination are inconclusive. Future research is needed to understand the accuracy of ED US when combined with history and physical examination for upper and lower extremity fractures.ACADEMIC EMERGENCY MEDICINE 2013; 20:1-15 © 2013 by the Society for Academic Emergency Medicine E xtremity injuries are among the most frequent reasons for visiting the emergency department (ED). These injuries are significant, comprising over 42.4 million injury-related visits to the ED in 2006. 1The typical work-up of the injured patient generally involves a medical provider obtaining a history and physical examination, often followed by radiologic imaging. However, many times the radiologic imaging may be negative or inconclusive, which calls to question whether the imaging contributed to the management or outcome of the patient. Studies have shown that often the imaging obtained is unnecessary and results in radiation exposure to patients and increased ED wait times. 2There is a low rate of positive radiography when assessing for fractures as evidenced by a retrospective review by Bentohami et al.,3 in which only 50% of upper extremity x-rays showed fractures, and another ...

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confidence: 99%

Diagnostic Accuracy of History, Physical Examination, and Bedside Ultrasound for Diagnosis of Extremity Fractures in the Emergency Department: A Systematic Review

Joshi

Lira

Mehta

et al. 2013

Academic Emergency Medicine

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“…It is standard practice for patients to be immobilised in a plaster cast for 10–14 days, followed by repeated clinical examination and repeat radiographs 1, 7, 13, 14, 15. Patients may undergo serial radiographs and clinical review at intervals over several weeks until a definitive diagnosis is made 5, 8, 9, 12. It has been argued that the prevalence of true fractures is low, with 3 out of 4 patients needlessly immobilised 10, 12, 16.…”

Section: Introductionmentioning

confidence: 99%

“…MRI has been proven to be both sensitive and specific for the detection of occult scaphoid fractures, with a suggested sensitivity and specificity of almost 100% 1, 9, 12, 13, 17, 18, 19. Performing an MRI when the patient first presents with a wrist injury has traditionally been considered impractical, due to its lack of availability particularly in rural areas, and large cost 1, 9, 12. However, many studies have suggested that MRI may actually be a more cost‐effective imaging method, allowing an earlier definitive diagnosis and the reduction in patients being overtreated 11, 16, 20, 21.…”

Section: Introductionmentioning

confidence: 99%

Early MRI versus conventional management in the detection of occult scaphoid fractures: what does it really cost? A rural pilot study

Kelson

Davidson

Baker

2016

J of Medical Radiation Sci

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IntroductionTo compare the cost‐effectiveness and patient impact between acute magnetic resonance imaging (MRI) management and conventional management in the diagnosis of occult scaphoid fractures in a rural setting.MethodsConsecutive patients presenting to a rural emergency department (ED) with a suspected scaphoid fracture were randomly assigned to either conventional management (6) or acute MRI management (10) (3 patients were excluded from the study analysis). All healthcare costs were compared between the two management groups and potential impacts on the patients’ pain, mobility and lifestyle were also measured.ResultsThere were no significant differences between the two groups at baseline. There was one (10%) scaphoid fracture in the MRI group and none in the conventional group (P = 0.42). A larger proportion of other fractures were diagnosed in the MRI group (20% (2) vs. 16.7% (1), P = 0.87), as well as less clinic attendances (1 (0–2.25) vs. 4 (2.25–5)) and diagnostic services (1 (1–1.25) vs. 2 (1–3)). Median management costs were $485.05 (AUD) (MRI) and $486.90 (AUD) (conventional). The MRI group had better pain and satisfaction scores as well as less time of immobilisation, treatment and time off work.Conclusion MRI dramatically reduces the amount of unnecessary immobilisation, time of treatment and healthcare usage in a rural setting. The two protocols are suggested to be equivalent financially. When potential societal costs, the amount of unnecessary immobilisation, low prevalence of true fractures and patient satisfaction are considered, acute MRI should be the management technique of choice. Further studies are still required to assess the best method for managing bone bruise within the scaphoid.

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“…This approach has been recently questioned because of the costs involved in over‐treating those with no fracture. In response to this, some authors advocate using magnetic resonance imaging (MRI) early to exclude fracture as this has high sensitivity, specificity and accuracy and has been shown to be cost effective 12 . Other investigations include bone scintigraphy and computed tomography (CT).…”

Section: Diagnosismentioning

confidence: 99%

Review of treatment of acute scaphoid fractures: R1

Hickey

Hak

Logan

2012

ANZ Journal of Surgery

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Scaphoid fractures are common. Clinical suspicion and early diagnosis and treatment are vital in order to avoid complications such as avascular necrosis. The management of these fractures depends on fracture characteristics, specifically the degree of displacement. With consideration of patient factors, such as occupation, the treatment can be non-operative or operative. There has been much debate in the recent literature regarding the best management of these fractures. The purpose of this review was to identify the current evidence for non-operative and operative treatment. Undisplaced and minimally displaced fractures can be managed non-operatively with a scaphoid cast. Surgical treatment is used for fractures with displacement of >1 mm.

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Role of MRI in the diagnosis of clinically suspected scaphoid fracture: analysis of 611 consecutive cases and literature review

Abstract: MRI is a useful and effective tool in the diagnosis of radiologically occult wrist injuries. It is feasible to do MRI scans in a timely manner in a district general hospital.

Cited by 26 publications

References 27 publications

Diagnostic Accuracy of History, Physical Examination, and Bedside Ultrasound for Diagnosis of Extremity Fractures in the Emergency Department: A Systematic Review

Diagnostic Accuracy of History, Physical Examination, and Bedside Ultrasound for Diagnosis of Extremity Fractures in the Emergency Department: A Systematic Review

Early MRI versus conventional management in the detection of occult scaphoid fractures: what does it really cost? A rural pilot study

Review of treatment of acute scaphoid fractures: R1

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