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Three Part Question

In [adult patients with a suspected scaphoid fracture], can [MRI] [diagnose a fracture in an initially negative X-ray result]?

Clinical Scenario

A 25-year-old right-handed carpenter came to the Emergency Department (ED) with a recent history of a fall onto his outstretched hand. He complained of pain in the wrist and some tenderness was reported in the anatomical snuffbox. The subsequent X-ray showed no abnormality. Should the patient undergo another investigation, such as an MRI, there and then?

Search Strategy

Ovid MEDLINE(R) 1950 to June Week 4 2010
[exp Scaphoid Bone OR exp Carpal Bones OR scaphoid$.mp. OR exp Fractures, Bone OR fracture$.mp]
Limit to English language AND humans AND all adult (19 plus years).
AND
[exp Magnetic Resonance Imaging OR magnetic resonance imaging$.mp. OR MRI$.mp. OR MR scan$.mp.]

Search Outcome

267 papers were identified in Medline, only four identified relevant to the three-part question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Gaebler C et al. 1996 Austria.	32 patients (21 male, 11 female), mean age: 29.5 years old present with clinically suspected scaphoid fracture but negative initial x-ray findings	Prospective blind, Diagnostic cohort study	Scaphoid fracture ((MRI after 0-6 days) as compared to x-ray result(after 10-30 days) )	6	Publication bias not mentioned, Small samples size, Statistical analysis of the result was not discussed
			Occult capitatum fracture((MRI after 0-6 days) as compared to x-ray result(after 10-30 days) )	2
			fracture of radius ((MRI after 0-6 days) as compared to x-ray result(after 10-30 days) )	2
			Ligament rupture (MRI (after 0-6 days) as compared to x-ray result(after 10-30 days) )	6
			Specificity	100% (95% confidence interval of 89.12 - 100)
			Sensitivity	100% (95% confidence interval of 60.70 - 100).
Brydie A and Raby N 2003. Scotland.	195 patient (112 male, 83 female), average age: 36 years old: scaphoid fracture was clinically suspected at the ED but not demonstrated on the initial scaphoid series radiographs	Diagnostic cohort studies	MRI result	99-normal, 20-bone brusing, 37-scaphoid fracture, 28-distal radius fracture, 2-capitate fracture, 2-triquetral fracture, 2-trapezoid fracture, 1-hamate fracture, 1-trapezium, 1-metacarpal, 2-non-diagnostic (patient movement)	Publication bias not mentioned. Data obtained from questionnaires form filled by clinicians, may not be completed correctly. 106 patients discharged without follow up. The patient group was not justified.
Kumar S et al 2005 Australia	22 patients (17 male, 5 female), mean age: 27 years old): presented within 24 hours after trauma at the Emergency Department (ED) with clinical findings suggestive of a scaphoid fracture but no evidence of fracture on the initial X-ray	Prospective diagnostic cohort study	MRI result (within 24 hrs)	6-scaphoid fractures, 2-distal radus fracture, 1-hamate fracture, 1-gout, 12-no fractures or bone bruise only(From the n=12, 7-no fracture seen)	Small samples size Publication bias not mentioned Statistical analysis of the result was not discussed
			MRI (within 24 hrs)	100% sensitivity (confidence interval 72.3–100) and 100% specificity (confidence interval 75.8–100).
Khalid M et al. 2010 Wales.	611 patients (398 males, 213 females) mean age: 29.64 years old Presented to ED with suspected scaphoid fracture but negative initial x-ray	Diagnostic cohort studies	MRI findings	269-normal MRI scan, 272-acute bony injuries (including scaphoid fractures and bruises), 23-acute soft tissue injuries, 47-incidental findings	No comparison to controlled group was made. Statistical analysis of the result was not discussed. MRI sensitivity and specificity were not included.

Comment(s)

Studies by Kumar et al and Gaebler et al claimed that 24 hr MRI and MRI within 0-6 days respectively are 100% sensitive and specific, but due to the small study sample, it is arguable that early MRI is the method of choice to detect occult scaphoid fractures. A similar BET had been developed previously with the conclusion that early MRI is the method of choice in EDs for diagnosing occult scaphoid fractures

Clinical Bottom Line

MRI scans may be used in Emergency Departments to detect scaphoid fractures and other soft tissue injuries within 14 days if the initial X-ray scan shows no abnormality.

References

1. Gaebler C, Kukla C, Breitenseher M, Trattnig S, Mittlboeck M, Vecsei V. Magnetic Resonance Imaging of Occult Scaphoid Fractures. The Journal of Trauma: Injury, Infection, and Critical Care. 1996; 41(1): 73-6
2. Brydie A, Raby N Early MRI in the management of clinical scaphoid fracture The British Journal of Radiology. 2003; 76: 296–300
3. Kumar S, O’Connor A, Despois M, Galloway H Use of early magnetic resonance imaging in the diagnosis of occult scaphoid fractures: The CAST Study (Canberra Area Scaphoid Trial). NZMJ 2005, Vol 118 No 1209
4. Khalid M, Jummani ZR, Kanagaraj K, Hussain A, Robinson D, Walker R. Role of MRI in the diagnosis of clinically suspected scaphoid fracture: analysis of 611 consecutive cases and literature review. Emerg Med J. 2010; 27: 266-9.