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British Journal of Radiology (2003) 76, 296-300
© 2003 British Institute of Radiology
doi: 10.1259/bjr/19790905
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Early MRI in the management of clinical scaphoid fracture

A Brydie, BSc, MRCP, FRCR and N Raby, MRCP, FRCR

Department of Radiology, Western Infirmary, Dumbarton Road, Glasgow G11 6NT


   Abstract
Top
 Abstract
Introduction
 Methods and materials
 Results
 Discussion
 Conclusions
 References
 
The incidence of MRI detected scaphoid and other wrist fractures was determined in a clinical setting in patients with suspicion of scaphoid injury and negative initial radiographs. The influence on subsequent patient management was examined. Patients attending Accident and Emergency over a 25 month period with suspected scaphoid fracture and normal scaphoid series plain films were referred for wrist MRI. Scans comprising T1 weighted spin echo and short tau inversion recovery (STIR) coronal sequences were performed in a dedicated extremity low field MRI scanner within 14 days of injury. Subsequent effects on patient management were ascertained by clinician completed questionnaire. 195 patients were scanned. There were 37 scaphoid fractures (19%), 28 distal radius fractures (14%), 9 fractures of other carpal bones (5%) and 119 studies with no fracture. The management of 180 patients (92%) was altered as a result of the MRI scan. Occult fractures are present in almost two fifths of patients with suspected scaphoid fracture and normal initial plain films. Half of these are scaphoid fractures. MRI allows an early definitive diagnosis to be made, changing patient management in over 90% of cases and should be regarded as the gold standard investigation in this population.


   Introduction
Top
 Abstract
 Introduction
Methods and materials
 Results
 Discussion
 Conclusions
 References
 
Fracture of the scaphoid bone is the most common carpal fracture [1] and is complicated by non-union, with associated risk of avascular necrosis, in 5% to 12% of cases [2, 3]. Initial radiographs will detect a fracture when present in 70% to 90% [2, 4]. A meta analysis of several large series has shown that scaphoid fracture is initially radiographically occult in approximately 16% of cases [5]. Fracture can take up to 6 weeks to become evident on plain films [6]. It is therefore common practice to immobilize the wrist when there is clinical suspicion of a scaphoid fracture with normal radiographs. This is the so-called "clinical scaphoid fracture". These patients have further clinical and radiological review at intervals until definitive diagnosis or resolution of symptoms. This safety first approach results in many patients having their wrist unnecessarily immobilized, with attendant implications for work and daily activities and for health service resources. As Barton [7] states "we over-treat a lot of patients to avoid undertreating a few".

Isotope bone scintigraphy has been advocated as a second line investigation in cases of clinical scaphoid fracture. It has high sensitivity for fracture but poor specificity, with a false positive rate of 25% when compared with delayed radiographs [8, 9]. Although more selective than plain radiographs, a significant proportion of patients are still over-treated.

MRI has been shown to be an effective method of demonstrating occult skeletal fractures [10]. The MRI appearance of proven scaphoid fractures was described in the early 1990s [11]. Subsequently several small series of early MRI in cases of clinical scaphoid fracture have shown promising results [6, 12–17].

We report the largest series to date of MRI in suspected scaphoid injury applied in routine clinical practice.


   Methods and materials
Top
 Abstract
 Introduction
 Methods and materials
Results
 Discussion
 Conclusions
 References
 
Patients
The study population comprises consecutive cases of clinically suspected scaphoid fracture with normal scaphoid series plain radiographs (anteroposterior (AP), lateral and a single oblique view) referred from Accident and Emergency (A&E). All patients received a soft wrist splint and underwent wrist MRI that in all cases was performed within 14 days of injury and prior to further clinical review. During the course of the study a subgroup of 62 patients who had only AP and lateral wrist or hand radiographs were erroneously referred for MRI scan. These patients were therefore outside the study protocol. Scans were never the less performed. These patients are referred to in the discussion.

Clinical assessment and initial interpretation of the scaphoid series radiographs for the purposes of MRI referral was performed by a member of the A&E medical staff. Subsequent referral for MRI was at the discretion of the A&E doctor, but it was stated policy within the department that all cases of clinical scaphoid fracture be referred for MRI. The study period was April 1998 to May 2000.

MRI protocol
MRI scans were performed on a 0.2 T dedicated extremity scanner (Artoscan; Esaote, Genoa, Italy). Coronal scans only were obtained using the following parameters:

  1. Spin echo (SE) T1 (repetition time (TR) 450, echo time (TE) 24, 3 acquisitions, 3.0 mm slice thickness, 16 cm field of view, matrix 192 x 192, acquisition time 4.39 min).
  2. Short tau inversion recovery (STIR) (TR 1320, TE 30, TI 70, 3 acquisitions, 3.0 mm slice thickness, 16 cm field of view, matrix 192 x 160, acquisition time 6.43 min).

All MRI examinations were read by one of two Consultant Radiologists experienced in MRI. In accordance with previous studies a diagnosis of fracture was made if there was evidence of a discrete low signal line on T1 images which traversed the scaphoid from cortex to cortex with a corresponding area of high signal on the STIR image. Diffuse reduction in T1 signal with increase in T2 signal but with no linear component were diagnosed as bone bruising. The resolution of the MRI scanner was considered insufficient for reliable diagnosis of ligamentous injury, correspondingly there is no report of these.

Data collection
Referring clinicians were asked to complete a one-page questionnaire detailing the date of injury, clinical signs, radiographic findings, clinical diagnosis and treatment plan. The questionnaire accompanied the MRI request form. The MRI findings were entered by the Radiologist reading the examination, following which the clinician was asked to indicate the subsequent treatment plan. MRI and radiographic examination details were verified via the computerized patient records held on the hospital's radiology system computer and where necessary patient clinical records were examined with regard to clinical diagnosis, management and follow up.


   Results
Top
 Abstract
 Introduction
 Methods and materials
 Results
Discussion
 Conclusions
 References
 
Patients
195 patients in whom scaphoid fracture was clinically suspected but not demonstrated on the initial scaphoid series radiographs underwent MRI within 14 days of injury. A further 62 patients who were erroneously referred for MRI after only hand or wrist radiographs were scanned. They are outside the study protocol but are included in the discussion to emphasise the need to ensure strict protocols are adhered to when instituting a new service to prevent erosion of clinical and economic benefits.

Average patient age was 36.0 years (range 12.1 years to 83.8 years, standard deviation (SD) 17.8 years). There were 83 female patients (42.6%) and 112 male patients (57.4%). All patients had tenderness in the anatomical snuffbox. Mean time from injury to radiograph was 1.2 days (SD 1.9 days). All examinations were performed within 14 days of injury; 74% were performed within 72 h (Figure 1Go).



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  		Figure 1. MRI time post injury.

 
MRI results
99 examinations were normal (51%) and 20 showed carpal or distal radius bone bruising (10%) (Table 1Go). Fracture was diagnosed on 74 examinations (38%). Scaphoid fracture was demonstrated in 37 patients (19%). The distal radius was the next most common fracture site, occurring in 28 patients (14.4%), in 26 of the 28 cases the fracture was not seen on the initial radiographs and only 9 of the cases were noted to have tenderness at the distal radius. In 9 patients (4.6%) fractures of other carpal bones were diagnosed. Two studies were considered to be of non-diagnostic quality owing to patient movement.


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  		Table 1. MRI results

 
Patient management
Following MRI the 74 cases of fracture were immobilized appropriately to the fracture type and reviewed clinically. 106 cases (54%) were discharged without further follow-up. 15 cases (8%) (8 bone bruising, 7 normal) were immobilized and reviewed. All of these 15 cases were subsequently discharged pain free after one clinic visit. Only one case had further MRI prior to discharge, this confirmed bone bruising. Thus, as a consequence of early MRI, 180 patients (92%) had their management altered from immobilization and fortnightly review to either immediate discharge or immobilization and clinic review appropriate to their particular fracture.


   Discussion
Top
 Abstract
 Introduction
 Methods and materials
 Results
 Discussion
Conclusions
 References
 
A gold standard is a benchmark against which others can be compared. In terms of investigations it should be that which is closest to the absolute truth. For investigation of the "clinical scaphoid fracture" plain radiographs have been the gold standard to date. We believe that MRI should now assume this role.

Diagnostic accuracy is a description of how close a given investigation is to the actual truth. There are three important statistical considerations in determining the accuracy of an investigation: sensitivity (the true negative test ratio); specificity (the true positive test ratio); and reliability (the inverse relation of interobserver variation). For an investigation to be accurate it is required to have high sensitivity and specificity and to be highly reliable.

In the investigation of clinical scaphoid fracture, plain radiographs fare badly when subjected to these statistical analyses. Tiel-van Buul [18] assessed reliability of reporting of scaphoid radiographs. Four observers of varying experience reported 134 radiographs taken at 1 day, 2 weeks and 6 weeks post trauma. In all combinations of observers at each time interval, reliability was poor with a kappa value of less than 0.4. The authors concluded that, as a kappa value in excess of 0.6 is required for an investigation to be deemed reliable, plain radiograph should not be used as the gold standard investigation of clinical scaphoid fracture.

Isotope bone scanning in clinical scaphoid fracture has been shown to be highly reliable and to have sensitivity approaching 100% however specificity is less good with two large series [8, 9] both finding a false positive rate of 25% when compared with delayed radiographs.

CT of clinical scaphoid fracture suffers from sensitivity problems. Tiel-van Buul et al [19] found that CT missed 21% of occult scaphoid fractures on an single read and 16.7% on a double read.

Statistical assessment of MRI of the wrist in clinical scaphoid fracture has been performed. Those studies that have assessed sensitivity and specificity of MRI against delayed radiographs have revealed excellent results. Gaebler [13] reported sensitivity and specificity for scaphoid fracture of 100%, Hunter [5] reported 100% sensitivity and Breitenseher [14] reported 100% specificity, 100% sensitivity for one reader and 100% specificity, 95% sensitivity for a second reader.

Reliability of MRI has also been addressed. Breitenseher [14] reported a kappa value of 0.953, Bretlau [15] reported a kappa value of 0.8 and Hunter [5] reported kappa values for each imaging sequence used of 0.87 (STIR), 0.96 (proton density weighted) and 0.96 (T1 weighted). These figures are well in excess of the 0.6 kappa value regarded as satisfactory for an investigation to be deemed valid [17].

All but one of the small published studies [15] used a 1.0 T or 1.5 T body scanner with a surface coil and three imaging sequences. We used a dedicated extremity low field MRI scanner with a two sequence imaging protocol (coronal STIR and T1 SE).

Breitenseher [20] compared the diagnostic capabilities of the Esaote 0.2 T low field dedicated extremity MRI scanner and a 1.0 T body MRI scanner (NT10, Philips, The Netherlands) in scaphoid fracture and concluded that there was no difference in fracture detection between the two systems.

Breitenseher has also analysed the sensitivity of three imaging sequences (T1 SE, STIR and T2* gradient echo (GE)) [14]. The T2* GE sequence was the least sensitive for trabecular fracture lines (47%), cortical fracture lines (14%) and bone marrow oedema changes (59%). The STIR sequence had a sensitivity of 88%, 100% and 100%, respectively, for the above abnormalities, the corresponding T1 SE sensitivities were 88%, 21% and 100%. The authors concluded that the combination of T1 SE and STIR sequences, as used in the current study, had the highest sensitivity for demonstration of fracture.

Plain film detects 70–90% of scaphoid fractures [2, 4] and so remains the initial investigation of choice in suspected scaphoid trauma. Owing to its excellent diagnostic accuracy we believe that MRI should be regarded as the gold standard investigation in the cases in which the initial radiographs are normal.

In our population of patients with "clinical scaphoid fracture" MRI of wrist performed within 14 days of injury demonstrated a radiographically occult scaphoid fracture incidence of 19%. There are seven smaller published studies of MRI within 2 weeks of scaphoid injury as the first subsequent investigation following negative initial plain radiographs [5, 12–17]. Ours is the first study to report on findings obtained in a working clinical setting rather than in a research setting. The findings of the other studies are detailed in Table 2Go.


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  		Table 2. Studies of acute MRI in clinical scaphoid fracture

 
The published data shows a wide range of scaphoid fracture incidence from 13.3% [12] to 36.1% [5]. The scaphoid fracture incidence of 19% in the current study, although similar to the 16% detection rate by delayed radiographs [5], is below the cumulative average incidence of the previous studies of 24.4% (Table 2Go). Five of these studies used delayed radiographs as the gold standard with which to compare the MRI findings [5, 12–15]. Cumulatively these five studies detected 50 fractures in 217 patients, a fracture incidence of 23%. Of these 50 fractures detected by MRI, 48 were followed up with delayed radiographs and in only one case was the fracture not radiographically confirmed. Therefore the fracture incidence as detected by plain radiographs in these studies was at worst 22%, with the worst case assumption that the two cases not followed up would have had negative radiographs. Our study is of consecutive referrals in a routine clinical setting and therefore more likely to represent the true fracture incidence.

The importance of appropriate case selection is demonstrated by the 62 referrals for MRI that were made on the basis of "clinical scaphoid tenderness", i.e. tender anatomical snuffbox, yet had only hand or wrist radiographs performed. The failure to perform dedicated scaphoid radiographs is likely to indicate that the clinician did not really suspect a scaphoid fracture when the patient was first examined and the radiographs ordered. These MRI studies yielded only 3 scaphoid fractures out of 62 studies (4.8%). Audit of the service should highlight and prevent such inappropriate studies. This has been instituted in our department.

A further advantage of MRI is the ability to detect occult fractures of bones other than the scaphoid. 37 such fractures were detected in the study group, of which 33 had not been seen on the initial radiographs and 27 had not exhibited any signs other than anatomical snuffbox tenderness.

Distal radius fracture was the most common non-scaphoid wrist fracture and was radiographically occult in 26 patients (13.3%). This is of the same order of magnitude as the cumulative figure of 11% derived from the other studies. For these patients MRI allowed the correct immobilization to be applied early after injury.

Occult fractures of bones other than the scaphoid were present almost as frequently as occult scaphoid fractures (17% vs. 19%). Whilst these occult fractures, being undisplaced, were unlikely to cause any adverse long-term sequelae had they gone untreated, they would most likely have been the source of continued pain in the wrist until properly healed. Early MRI diagnosis of such fractures permits early definitive treatment and prevents needless interval reviews searching for a non-existent scaphoid fracture as the explanation for on-going symptoms.

The greatest impact of MRI on patient management is the early exclusion of occult fracture. MRI excluded fracture in 119 cases, of which 106 were discharged immediately and the remaining 15 were discharged after the first clinical review. This represents an enormous reduction in the over-treatment inherent in using delayed plain radiographs as the second line investigation.

Our figures imply that in normal working practice MRI allows approximately three-fifths of patients with clinical scaphoid fracture to be discharged without further review. The remaining two-fifths will have occult fractures demonstrated of which only half will be scaphoid fractures. These patients will therefore receive early appropriate treatment without unnecessary interval review and re-imaging.

At the authors's institution, early wrist MRI in clinical scaphoid fracture was offered on a routine clinical basis only when a dedicated low field extremity scanner was installed. The perception prior to this was that acute scaphoid cases would swamp the capacity of the high field body scanner and do so in an unpredictable manner. In actual fact, even including the 62 cases which had not had scaphoid series radiographs performed, the numbers amounted to 255 cases in 25 months: between two and three cases per week. With a scanning time of just over 10 min, the entire investigation time would amount to less than two half hour slots per week which should not present an insurmountable obstacle to the provision of an early scanning service on a department's MRI scanner.

The economics of providing an acute wrist MRI service for clinical scaphoid fracture have recently been addressed in our department [21]. With an MRI scan cost of £50, it was estimated that a clinic visit would have to cost the hospital more than £30 for the provision of the MRI service to be of economic benefit. Early MRI scanning was shown to be of greater economic benefit than scanning after a 14-day clinical and radiological review.

In another European country with a different health care system [16] it was estimated that the cost of the MRI roughly equalled the saving in clinic attendance. Similarly, a cost analysis in the North American system has estimated that cost of MRI equates almost to the cost of a single outpatient review attendance [22].

Of probably greater economic significance to the country as a whole, but much harder to quantify, is the reduction in days required off work brought about by patients not being unnecessarily put in an immobilizing cast.


   Conclusions
Top
 Abstract
 Introduction
 Methods and materials
 Results
 Discussion
 Conclusions
References
 
MRI can now justifiably be regarded as the gold standard investigation for clinical scaphoid fracture. Using MRI we have determined that the incidence of occult scaphoid fracture is 19%. MRI enables the correct diagnosis to be reached early and by directing appropriate patient management, prevents the unnecessary over-treatment of the majority of patients thus bringing both health and economic benefits. Our experience is that it is feasible to provide this service despite the resource worries over MRI scanning. Patient selection is an important issue as there is a tendency for indication creep. Regular audit is required to prevent this.


   Acknowledgments
 
Thanks to Dr Nigel McMillan who reported a number of the MRI studies, to all the MRI radiographers who performed the studies and to the Casualty staff for their co-operation with the questionnaires.

Received for publication June 25, 2002. Revision received February 20, 2003. Accepted for publication March 14, 2003.


   References
Top
 Abstract
 Introduction
 Methods and materials
 Results
 Discussion
 Conclusions
 References
 

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  9. Brismar J. Skeletal scintigraphy of the wrist in suggested scaphoid fracture. Acta Radiol 1988;29:101–7.[Medline]
  10. Yao L, Lee JK. Occult intraosseous fracture: detection with MR imaging. Radiology 1988;167:749–51.[Abstract/Free Full Text]
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  17. Tiel-van Buul MMC, Roolker W, Verbeeten BWB, Broekhuizen AH. Magnetic resonance versus bone scintigraphy in suspected scaphoid fracture. Eur J Nucl Med 1996;23:971–5.[CrossRef][Medline]
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