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Original Research |
1 Institute of Nuclear Medicine, University College London, UCH (T5), 235 Euston
Rd., London, United Kingdom NW1 2BU.
2 University Department of Radiology, University of Cambridge, Addenbrooke's
Hospital, Cambridge, CB2 2QQ, United Kingdom.
Received April 21, 2005;
accepted after revision June 13, 2005.
Address correspondence to A. M. Groves
(drashleygroves{at}hotmail.com).
Abstract
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MATERIALS AND METHODS. To assess scaphoid imaging protocols, an international survey of imaging practice was performed. Two hundred hospitals worldwide were sent a survey regarding their scaphoid trauma imaging protocols. Only replies from hospitals that had full CT, MRI, and scintigraphy facilities were accepted.
RESULTS. Data were obtained from 105 hospitals, of which 23 had fixed protocols. The number of scaphoid radiographic views varied from two to six. Before second-line investigations were initiated, repeat radiographs were usually performed in 76 of the 105 hospitals. In 29 hospitals, other imaging techniques were used without further radiography. The usual second-line investigation was MRI in 31/105, CT in 19/105, and scintigraphy in 14/105. Further protocols included CT or MRI in 10/105, CT or scintigraphy in 6/105, scintigraphy or MRI in 6/105, CT then MRI (if CT was negative) in 1/105, both CT and scintigraphy in 1/105, and scintigraphy then CT (if positive) in 1/105. There was equal preference among MRI, CT, and scintigraphy in 10/105 centers, and clinical examination and radiographs were used alone in 6/105.
CONCLUSION. The survey reveals marked inconsistency in the imaging of acute scaphoid injury. Although other factors may have played a role, limited scientific evidence regarding the ideal imaging in acute scaphoid trauma may be the root of this inconsistency.
Keywords: musculoskeletal imaging • trauma • wrist
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To improve detection of occult scaphoid fractures, 99mTc-methylene diphosphonate skeletal scintigraphy has been widely used [5]. To enhance fracture detection and localization further, single-photon emission tomography (SPET) [6] and radiographic-scintigraphic image coregistration have been used successfully [7]. However, scintigraphy remains limited in resolution and specificity [8]. To improve specificity and maximize cortical and trabecular anatomic detail, CT has been used to detect scaphoid fractures and it has been claimed that the technique is useful [9]. However, CT is insensitive compared with scintigraphy [10]. This limitation has been addressed by development of CT/scintigraphic coregistration techniques that combine the anatomic detail of CT with scintigraphic sensitivity [11]. In addition, the use of high-frequency sonography probes has afforded detailed spatial resolution images that may have potential in diagnosing scaphoid fractures [12].
Increasingly, MRI has been shown to be useful in detecting scaphoid fractures [13-15]. In some hospitals, wrist MRI is performed almost as a primary investigation in the emergency department [16]. The American College of Radiology (ACR) deems MRI and radiography as the most appropriate investigations in imaging acute scaphoid trauma [17]. The United Kingdom's Royal College of Radiologists gives equal weight to MRI, CT, and scintigraphy in the imaging of acute scaphoid trauma [18] when radiographs are negative.
To optimize patient care, health care professionals are under increasing pressure to work toward best practice [19] through methods such as the use of standardized management protocols. Considering the potential clinical implications of suboptimal management of patients with suspected scaphoid fracture, we performed an international survey of hospital imaging practice to determine the degree of consistency in diagnostic protocols.
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Whether the respondent answered directly or not was noted. The respondent's field of expertise was also documented. Institutions surveyed were selected from those whose staff members had published musculoskeletal imaging journal articles in the prior 12 months and from those from overseas hospitals listed in the directories of the national college of radiologists in a given country or continent.
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Eighty-eight of the 105 institutions that replied were university hospitals. In total, 89.5% (94/105) of responses were directly from respondents and 10.5% (11/105) were obtained via a respondent's colleague. Of those responding to the survey, 95.2% (100/105) were imaging doctors (nine nuclear physicians and 91 radiologists) and 4.8% (5/105) were physicians managing trauma (two orthopedic surgeons, two emergency department physicians, and one internist).
Among the 105 hospitals, no more than seven (6.7%) shared identical scaphoid imaging strategies. The most common protocol was four radiographic reviews repeated at 10 to 14 days followed by MRI (performed in seven hospitals). Of the 105 hospitals, 23 (21.9%) had a fixed protocol while 82 (78.1%) did not. The number of scaphoid radiographic views acquired varied from two to six. Repeat radiographs were usually performed before second-line investigations in 72.4% (76/105) of hospitals, whereas in 27.6% (29/105) more sophisticated investigations were used without further radiography.
As Table 2 shows, the timing of further imaging (after initial normal radiographs) varied. The usual definitive investigation was MRI in 29.5% (31/105), CT in 18.1% (19/105), and scintigraphy in 13.3% (14/105) of the hospitals. Further protocols included CT or MRI [9.5% (10/105)], scintigraphy or CT [5.7% (6/105)], scintigraphy or MRI [5.7% (6/105)], both CT and scintigraphy [1.0% (1/105)], CT then (if negative) MRI [1.0% (1/105)], and scintigraphy then (if positive) CT [1.0% (1/105)]. There was equal preference among MRI, CT, and scintigraphy in 9.5% (10/105) of hospitals. Clinical examination and plain radiographs alone were used in 5.7% (6/105) of hospitals. Table 3 summarizes these preferences by geographic area.
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In Europe, CT was the most commonly used second-line investigation, whereas in Australasia it was bone scintigraphy. Elsewhere MRI was the most common definitive investigation (Table 4). In nonuniversity hospitals, scintigraphy and MRI were the most used investigations. MRI was the most common singly used investigation in those hospitals surveyed from both journal articles and the directories. However, in those surveyed from journal articles, the use of CT and scintigraphy was relatively less prevalent than in those from the directories.
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Eleven hospitals volunteered that economics or availability or both had influenced their scaphoid protocol.
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The use of CT in our survey was relatively widespread and was favored in 19 hospitals as a single, definitive, second-line investigation and was used in a further 27 scaphoid imaging regimes. However, the sensitivity of CT has long been questioned [10], and even when using modern multidetector machines, this insensitivity is still recognized [21]. Even so, CT is recommended by the ACR to evaluate fracture displacement [17]. Scintigraphy was also used by many hospitals, despite the ACR deeming its use as inappropriate [17]. However, the United Kingdom's College of Radiologists guidelines gives the same weighting to scintigraphy as it does to CT and MRI. Interestingly, these guidelines recognize that there is only limited scientific evidence available regarding the best imaging technique in acute scaphoid trauma [18].
Many physicians have suggested MRI as the investigation technique of choice for detecting occult wrist fractures [13-16]. Presumably this evidence influenced the ACR guidelines. However, the guidelines are several years old and incorporate the consensus of expert opinion and scientific literature at that time [17]. In our survey, MRI was the most prevalent investigational technique (after radiographs) used in the diagnosis of occult scaphoid fracture. However, it was not universally used. Economic factors and MRI availability may have limited its use, despite evidence that early use of MRI in diagnosing scaphoid fractures is considered economically worthwhile [16, 22]. Many hospitals, including major university hospitals in the United States, opted for CT or scintigraphy even when there was ready access to MRI. Consequently, economics and availability must not be the only factors that influence the choice of imaging technique.
There was wide variation in the timing of further scaphoid imaging among the hospitals. The rationale for performing delayed imaging is controversial. It is argued that in some patients symptoms may subside with delay, reducing the need for further investigation. Also it is claimed that fracture widening may allow radiographic identification, which might be initially undetectable [17]. Nonetheless, if further imaging is performed immediately and not delayed, an early diagnosis can be made, which helps avoid the overtreating of many patients. However, there remains a lack of scientific literature on the matter of determining when repeat radiographs should be performed or whether they should be performed at all [16, 22].
The relative absence of fixed scaphoid imaging protocols within the survey is somewhat predictable. In many countries, several private practitioners may work in a single hospital, each with their own imaging preference. Moreover, the choice of imaging investigation technique may be strongly influenced by differences in preference between imaging doctors and the referring trauma physician. This suggests that a multidisciplinary approach may be necessary.
In conclusion, the reasons for the inconsistency in acute scaphoid trauma imaging strategies are likely to be multifactorial. It is difficult for health care providers to perform the investigation of choice if that technique is unavailable. However, in institutions without such limitations this inconsistency of practice might need addressing. This may include a need for additional research to clarify the best scaphoid imaging strategy as well as better consensus between referrers and radiologists.
| APPENDIX 1: Questions Asked in Survey Regarding Departmental Scaphoid
Imaging
Protocola Is the scaphoid protocol fixed? How many radiographic views are performed? Do you repeat views before further imaging and if so when? What further imaging do you use and when?
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