Immediate MRI in Emergency Department Improves Diagnosis of Scaphoid Fractures
By Nancy Melville
CHICAGO -- December 2, 2019 -- The use of immediate magnetic resonance imaging (MRI) in the emergency department (ED) improves diagnostic accuracy in identifying scaphoid and other wrist fractures while reducing overall costs, according to a study presented here at the 2019 Annual Meeting of the Radiological Society of North America (RSNA).
“The early use of a more expensive but more sensitive diagnostic tool [MRI] improved the diagnostic accuracy of the acute pathway and streamlined the subsequent elective follow-up, leading to reduced overall NHS costs,” said Davina Mak, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom.
As many as 40% of scaphoid fractures are not evident on x-ray and clinicians commonly err on the side of caution and immobilise patients’ arms even if there is no clear evidence of a fracture. Meanwhile, a missed diagnosis can result in non-union or delayed union or worse outcomes.
Dr. Mak and colleagues evaluated the clinical and cost implications of an approach providing immediate MRI in the acute management of patients with suspected scaphoid fracture and negative x-rays. Of 136 patients with no fractures visible on the initial x-ray who were recruited, 65 were randomised to standard care while 67 received MRI evaluation.
Of the patients, 4 of 65 in the control group and 7 of 67 in the MRI group were found to have scaphoid fractures (P = .37). In addition, 5 (7.7%) patients in the control group and 15 in the MRI group had other bone fractures (P = .01).
The use of MRI improved the diagnostic accuracy in the diagnosis of scaphoid fracture compared with the standard of care (100% vs 93.8%), and diagnosis of any other fracture was also improved (98.5% vs 84.6%).
The use of immediate MRI had a probability of 96% and 100% of being cost-effective at months 3 and 6, respectively, considering traditional willingness-to-pay thresholds.
Mean time spent in the ED was significantly shorter for the control group (2 hrs, 12 min) compared with the MRI group (3 hrs, 20 min; P
“As could be expected, the time spent was longer in the MRI group; however we did avoid the need for 35 patients to have any follow-up at all in secondary care because they were found to have no fracture,” said Dr. Mak.
“Although challenging, the implementation of the new pathway with immediate MRI in the management of suspected scaphoid fractures went live in October and is now part of our standard of care,” he said.
[Presentation title: Clinical and Cost-Effectiveness Implications of Utilizing Immediate Acute Magnetic Resonance Imaging (MRI) in the Management of Patients With Suspected Scaphoid Fracture and Negative Initial Radiographs: Results From a Randomized Clinical Trial. Abstract SPCT10C]