Early MRI diagnostics for suspected scaphoid fractures subsequent to initial plain radiography

In the United Kingdom, diagnostic management of patients presenting to emergency department with a scaphoid injury varies. Follow-up plain radiographs, after an initial inconclusive X-ray, are common practice. We optimised the diagnostic pathway for these patients by focusing on the most appropriate diagnostic modality and on minimising the time to follow-up diagnostics.

A baseline audit in the period 2008-2009 involving a total of 184 patients was conducted, and after the introduction of new local guidelines for scaphoid injury diagnostics, a follow-up audit involving 79 patients was undertaken in 2010-2012.

In the original audit, 130 patients had only scaphoid radiographs, of which 23 underwent initial and follow-up X-rays, and 107 initial-only radiographs. Of those 23, just one single patient (4%) displayed a scaphoid fracture. Others underwent three imaging procedures: initial radiographs, follow-up radiographs and either bone scan (41 patients) or MRI (13 patients). A further 6/41 (15%) and 4/13 (31%) fractures were detected by bone scan and MRI, respectively. In the re-audit, when MRI replaced follow-up X-rays and bone scans, 7 out of 77 (9%) patients were diagnosed with scaphoid fracture. Time from initial plain radiograph to follow-up MRI was reduced from an original mean of 36 to 14 days during the re-audit period.

The introduction of early MRI enhances scaphoid injury diagnostics and accelerates patient management. We therefore endorse the introduction of this approach on a wider scale through an update of the clinical guidelines for scaphoid injuries.