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Cost-Effectiveness of Immediate MR Imaging Versus Traditional Follow-Up for Revealing Radiographically Occult Scaphoid Fractures

¹ All authors: Department of Radiology, Duke University Medical Center, Erwin Rd., Rm. 1504, Durham, NC 27710.

View larger version (160K): [in a new window]   Fig. 1A. —20-year-old man with injury sustained while boxing 2-3 months previously who presented with continued generalized wrist pain and stiffness. Scaphoid fracture of wrist was not visible on initial radiograph and remained radiographically occult during entire course of therapy. Coronal T2-weighted fast spin-echo MR image (TR/TE, 4000/72) with fat saturation shows nondisplaced fracture as distinct linear focus of low signal intensity (arrow) with surrounding bright edema.

View larger version (185K): [in a new window]   Fig. 1B. —20-year-old man with injury sustained while boxing 2-3 months previously who presented with continued generalized wrist pain and stiffness. Scaphoid fracture of wrist was not visible on initial radiograph and remained radiographically occult during entire course of therapy. T1-weighted spin-echo coronal MR image (500/11) obtained at same time as A shows that fracture line (arrows) is slightly less evident in surrounding low-signal-intensity edema.

View larger version (24K): [in a new window]   Fig. 2. —Flowchart shows clinical pathways available to clinician in setting of positive (+) clinical examination (CE) for scaphoid fracture (e.g., fall on outstretched hand and snuffbox tenderness). - indicates negative.

View larger version (158K): [in a new window]   Fig. 3A. —23-year-old woman who fell backward onto outstretched arm and presented with wrist pain. Initial radiograph fails to reveal scaphoid fracture.

View larger version (152K): [in a new window]   Fig. 3B. —23-year-old woman who fell backward onto outstretched arm and presented with wrist pain. T2-weighted fast spin-echo coronal MR image (TR/TE, 4000/72) with fat saturation obtained 24 days after initial radiograph shows diffuse heterogeneous high signal intensity (arrow) throughout scaphoid bone.

View larger version (158K): [in a new window]   Fig. 3C. —23-year-old woman who fell backward onto outstretched arm and presented with wrist pain. T1-weighted coronal MR image (500/14) through scaphoid bone obtained at same time as B shows subtle linear focus of low signal intensity (arrow) across mid waist of scaphoid bone.

View larger version (119K): [in a new window]   Fig. 4A. —16-year-old boy who fell onto outstretched hand and incurred dorsiflexion injury to right wrist. Patient was seen at family medical clinic, where radiographs were obtained that raised possibility of scaphoid fracture. Radiograph obtained at initial visit is inconclusive.

View larger version (136K): [in a new window]   Fig. 4B. —16-year-old boy who fell onto outstretched hand and incurred dorsiflexion injury to right wrist. Patient was seen at family medical clinic, where radiographs were obtained that raised possibility of scaphoid fracture. T2-weighted fast spin-echo coronal MR image (TR/TE, 4233/72) with fat saturation through scaphoid bone, obtained with flex coil through casting material 13 days after initial radiography, shows obviously poor signal-to-noise ratio. Even with this limitation, linear low-signal-intensity focus (straight arrow) surrounded by high-signal-intensity edema is seen. Contusion of distal radial metaphysis is incidentally observed (curved arrow).

View larger version (184K): [in a new window]   Fig. 4C. —16-year-old boy who fell onto outstretched hand and incurred dorsiflexion injury to right wrist. Patient was seen at family medical clinic, where radiographs were obtained that raised possibility of scaphoid fracture. T1-weighted coronal MR image (500/14) through scaphoid bone obtained at same time as B shows that low-signal-intensity fracture line is not well visualized in equally low-signal-intensity region of edema (white arrow). Contusion of distal radial metaphysis (black arrow) is again noted.

View larger version (136K): [in a new window]   Fig. 5A. —14-year-old boy who fell on wrist. Initial radiograph reveals no evidence of scaphoid fracture. Subtle band of sclerosis (arrows) that most likely represents torus fracture was missed on initial interpretation.

View larger version (189K): [in a new window]   Fig. 5B. —14-year-old boy who fell on wrist. T2-weighted fast spin-echo coronal MR image (TR/TE, 4000/74.2) with fat saturation through scaphoid bone, obtained 11 days after initial radiography, reveals linear low-signal-intensity focus (black arrow) surrounded by high-signal-intensity edema. Diffuse bright edema of distal radial metaphysis suggests torus fracture (white arrow).

View larger version (194K): [in a new window]   Fig. 5C. —14-year-old boy who fell on wrist. T1-weighted coronal MR image (500/14) through scaphoid bone obtained at same time as B shows low-signal-intensity fracture line is not well visualized in equally low-signal-intensity region of edema (white arrow). Diffuse low-signal-intensity edema of distal radial metaphysis again suggests torus fracture (black arrow).

View larger version (161K): [in a new window]   Fig. 6A. —20-year-old man with mild snuffbox tenderness after falling on outstretched hands during basketball practice. Initial wrist radiograph shows negative findings.

View larger version (175K): [in a new window]   Fig. 6B. —20-year-old man with mild snuffbox tenderness after falling on outstretched hands during basketball practice. T1-weighted coronal MR image (TR/TE, 500/11) through scaphoid bone, obtained 2 days after initial radiographs, shows no evidence of trauma. T2-weighted images were similarly unremarkable.

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