MRI scans in diagnosing scaphoid fractures with normal X-ray results
Date First Published:
July 3, 2010
Last Updated:
July 16, 2010
Report by:
Zinnirah Zainodin, Medical student (University of Manchester)
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
Search Details:
[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$.mp.]
Limit to English language AND humans AND all adult (19 plus years).
AND
[exp Magnetic Resonance Imaging OR magnetic resonance imaging$.mp. OR MRI$.mp. OR MR scan$.mp.]
Outcome:
267 papers were identified in Medline, only four identified relevant to the three-part question.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Magnetic Resonance Imaging of Occult Scaphoid Fractures. Gaebler C, Kukla C, Breitenseher M, Trattnig S, Mittlboeck M, Vecsei V. 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). | ||||
| Early MRI in the management of clinical scaphoid fracture Brydie A, 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. |
| Use of early magnetic resonance imaging in the diagnosis of occult scaphoid fractures: The CAST Study (Canberra Area Scaphoid Trial). Kumar S, O’Connor A, Despois M, Galloway H 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). | ||||
| Role of MRI in the diagnosis of clinically suspected scaphoid fracture: analysis of 611 consecutive cases and literature review. Khalid M, Jummani ZR, Kanagaraj K, Hussain A, Robinson D, Walker R. 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. |
Author Commentary:
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
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:
- Gaebler C, Kukla C, Breitenseher M, Trattnig S, Mittlboeck M, Vecsei V. . Magnetic Resonance Imaging of Occult Scaphoid Fractures.
- Brydie A, Raby N. Early MRI in the management of clinical scaphoid fracture
- 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).
- 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.