The suspected scaphoid injury: resource implications in the absence of magnetic resonance imaging

Introduction: Undiagnosed and untreated scaphoid fractures have poorer outcomes and many patients are unnecessarily immobilised for prolonged periods of time to avoid missing occult injuries. Magnetic resonance imaging has a high sensitivity and specificity in detecting occult scaphoid fractures, but many units do not routinely use this imaging modality in the diagnostic pathway. We aimed to determine the patterns of suspected scaphoid injuries, report the process of care, and calculate the costs involved in their management. Methods: We prospectively identified all adult patients referred to fracture clinic at the Royal Infirmary of Edinburgh with a scaphoid-related injury, between October 2007 and September 2008. Clinical notes were examined retrospectively. We defined three injury groups: true fractures, occult fractures, and suspected scaphoid injuries. We analysed patient demographics, treatment timelines, and the treatment costs involved. Results: Fracture clinic received 537 scaphoid-related referrals. There were 87 true fractures, 43 occult fractures, and 407 suspected injuries, incurring average treatment costs of 1,173 pound, 773 pound, and 384 pound respectively. Occult fractures accounted for 33% of all confirmed scaphoid fractures. The majority of scaphoid-related referrals (76%) were never proven to have a scaphoid fracture, and many were unnecessarily immobilised. The costs involved in the treatment of suspected scaphoid injuries were found to be higher than the cost of magnetic resonance imaging (97) pound. Conclusion: In this group of suspected scaphoid injury, we believe the introduction of an early magnetic resonance imaging protocol would lead to an earlier definitive diagnosis and potentially a more cost-effective service.