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Magnetic resonance imaging or bone scintigraphy in the diagnosis of plain x ray occult scaphoid fractures
  1. Bernard Foex, Consultant,
  2. Peter Speake, House Officer,
  3. Rick Body, Clinical Research Fellow

    Abstract

    A short cut review was carried out to establish whether magnetic resonance scanning or bone scintigraphy is better at identifying scaphoid fractures not apparent on plain x rays. Altogether 11 papers were found using the reported search, of which four presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.

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    Report by Bernard Foex, Consultant, Peter Speake, House OfficerChecked by Rick Body, Clinical Research Fellow

    Clinical scenario

    An adult presents to the Emergency Department review clinic two weeks after falling onto his outstretched hand. A scaphoid fracture was suspected but no fracture was seen on plain scaphoid views. He continues to have scaphoid tenderness. You wonder whether a magnetic resonance scan would be better than a bone scan in confirming or excluding a scaphoid fracture.

    Three part question

    In an adult with a [clinically suspected scaphoid fracture] is [magnetic resonance imaging better than bone scintigraphy] at [reaching a diagnosis]?

    Search strategy

    Medline from 1966 until March Week 1 2005: ((fracture&scaphoid fracture.mp or exp Scaphoid Bone or scaphoid injury.mp AND [$.af. OR fracture#.w..de. OR Hand-fracture#.de. OR hand-injury#.de. OR fracture-nonunion#.de.) OR (scaphoid-fracture#.de.)) AND (Nuclear-Magnetic-Resonance-Imaging#.de. OR (magnet$ ADJ reson$ ADJ imag$).mp. OR (magnet$ ADJ reson$ ADJ spect$).mp. OR mri.af. OR nmr.af.) AND ((bone ADJ scan).mp. OR Bone-scintiscanning#.de. OR Medronate-Technetium-TC-99m#.de. OR Technetium-99m.#.de OR Whole-body-scintiscanning#.de. OR scintigraph$.af.))

    Search outcome

    Altogether 23 papers were found. Only three addressed the question. One further paper was found by searching the references. These four papers are shown in table 2.

    Table 2

    Comment(s)

    Only 145 patients appear to have been entered into any sort of comparison between the two imaging modalities. Magnetic resonance imaging appears slightly superior in diagnosing occult scaphoid fractures. Magnetic resonance imaging also allows accurate diagnosis of clinically significant soft tissue injuries, which may otherwise be missed. It is also quicker to perform than a bone scan. However, some patients with claustrophobia will not tolerate it.

    CLINICAL BOTTOM LINE

    Magnetic resonance imaging is the investigation of choice in the clinically suspected scaphoid fracture after negative initial and 10–14 day follow up x rays. A bone scan is a reasonable alternative in patients with claustrophobia.

    Report by Bernard Foex, Consultant, Peter Speake, House OfficerChecked by Rick Body, Clinical Research Fellow

    References

    View Abstract

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