Emerg Med J 30:202-207 doi:10.1136/emermed-2011-200676
  • Original article

Cost and clinical effectiveness of MRI in occult scaphoid fractures: a randomised controlled trial

  1. Martin Watson4
  1. 1Department of Orthopaedics, Barnet General Hospital, Barnet, Hertfordshire, UK
  2. 2Department of Clinical Imaging, Worthing Hospital, Worthing, West Sussex, UK
  3. 3Department of Emergency Medicine, West Middlesex Hospital, Isleworth, Middlesex, UK
  4. 4Department of Clinical Imaging, West Middlesex Hospital, Isleworth, Middlesex, UK
  1. Correspondence to Dr Martin Watson, Department of Clinical Imaging, West Middlesex University Hospital, Twickenham Road, Isleworth TW7 6AF, UK; martin.watson{at}
  1. Contributors The study concept was by MW and the study design was by MW and ND. The literature search was by NKP, ND and MW. Clinical studies were by ZM and MW with data acquisition by ND, ZM and MW. Data and statistical analyses were by NKP and ND. Manuscript preparation was by NKP and ND, with manuscript editing and review by NKP, ND, ZM and MW.

  • Accepted 28 February 2012
  • Published Online First 13 April 2012


Background Clinical and radiographic diagnoses of scaphoid fractures are often challenging at the time of injury. Patients are therefore usually reassessed which has cost implications. Various investigations exist but MRI has been suggested as effective in diagnosing these injuries early.

Aim To determine whether early MRI in suspected occult scaphoid fractures is more clinically and cost effective than conventional management with immobilisation and reassessment.

Methods All patients presenting to the Emergency Department at a district general hospital with a suspected occult scaphoid fracture were randomised into two groups, MRI (early scan of the wrist, discharged if no injury) and control (reassessment in clinic).

Results 84 patients were randomised into MRI (45) and control (39) groups. There were no baseline differences apart from greater dominant hand injuries in the MRI group (62% (26) vs 36% (14), p=0.02). There were three (6.7%) scaphoid fractures in the MRI group and four (10.3%) in the control group (p=0.7). More fractures (15.6% (7) vs 5.1% (2), p=0.9) and other injuries were detected in the MRI group who had fewer mean clinic appointments (1.1±0.5 vs 2.3±0.8, p=0.001) and radiographs (1.2±0.8 vs 1.7±1.1, p=0.03). Mean management costs were £504.13 (MRI) and £532.87 (control) (p=0.9). The MRI group had better pain and satisfaction scores (not significant) with comparable time off work and sporting activities.

Conclusion Early MRI in occult scaphoid fractures is marginally cost saving compared with conventional management and may reduce potentially large societal costs of unnecessary immobilisation. It enables early detection and appropriate treatment of scaphoid and other injuries.


  • Competing interests None.

  • Ethics approval Ethics approval was provided by the West London Research Ethics Committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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Among patients with minor TBI (GCS 13-15) getting CT scans ≥ 24 hours after injury, what proportion have a traumatic finding?


0.5% - 43% response rate
3% - 41% response rate
10% - 16% response rate

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