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An audit of the management of suspected scaphoid fractures in the accident and emergency department
Clinical Radiology (2004) 59, 864
2ND PRIZE 2003 RCR AUDIT POSTER An audit of the management of suspected scaphoid fractures in the accident and emergency department Background Scaphoid fracture (S#) is the most common carpal fracture. Early diagnosis is important to prevent complications.1 Multiple radiographs and treatment with immobilization is the standard care in equivocal cases. Bone scanning has been used for S# detection, but has poor specificity and a high false positive rate2 and uses ionising radiation. Magnetic resonance imaging (MR) of the wrist is being increasingly used to reduce delay in the diagnosis of S# and has the advantage of detecting other injuries.3 Outline † Assessment of baseline A&E practice † Establishing protocol for S# detection † Re-audit Baseline A&E practice Data † Audit period: October–December 2001. † 151 A&E patients extracted from Radiology Information System. † A&E database and case notes from fracture clinic reviewed. Results † Of 68 patients with suspected occult S#: † 28 were sent to fracture clinic without definitive S# diagnosis (25 had .2 sets of radiographs.) † 13 of these had no other imaging. † No MRI for suspected S#. † 8 bone scans. Protocol (see flowchart) Aims † To establish definitive presence/absence of S#. † To reduce: † time to detection of occult S# † unnecessary orthopaedic referral † radiation exposure Re-audit Data † Audit period: January–March 2003. † 145 A&E patients. Analysis as for baseline study, with additional review of A&E attendance sheets and MR requests. Results Improvement in A&E practice: † 40.5% of those with ongoing tenderness but negative 2nd radiograph referred for MR. † 23 MRs were done with 11 (47.8%) positive for bony injury. † 5 (21.7%) had occult S# (Comparable to 19% in a previous series.3). † No 3rd radiographs for suspected S#. † Only one bone scan for suspected S#.
Conclusions It is feasible to provide an early MRI examination for suspected scaphoid fracture at our institution. Early MR scaphoid imaging has improved the service by early detection of scaphoid fracture thus reducing unnecessary radiation and immobilization in a young patient group. It has also reduced unnecessary referral to fracture clinic. References 1. Dias JJ, Brenkel IJ, Finlay DB. Patterns of union in fractures of the waist of the scaphoid. J Bone Joint Surg Br 1989;71:307—10. 2. Brismar J. Skeletal scintigraphy of the wrist in suggested scaphoid fracture. Acta Radiol 1988;29:101—7. 3. Brydie A, Raby N. Early MRI in the management of clinical scaphoid fracture. Br J Radiol 2003;76:296—300.
S.P.Suresh, S.J.Jackson Department of Radiology, Salford Royal Hospitals NHS Trust, Hope Hospital, Salford, Manchester, UK
0009-9260/$ - see front matter q 2004 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.crad.2004.05.008
2ND PRIZE 2003 RCR AUDIT POSTER An audit of the management of suspected scaphoid fractures in the accident and emergency department Background Scaphoid fracture (S#) is the most common carpal fracture. Early diagnosis is important to prevent complications.1 Multiple radiographs and treatment with immobilization is the standard care in equivocal cases. Bone scanning has been used for S# detection, but has poor specificity and a high false positive rate2 and uses ionising radiation. Magnetic resonance imaging (MR) of the wrist is being increasingly used to reduce delay in the diagnosis of S# and has the advantage of detecting other injuries.3 Outline † Assessment of baseline A&E practice † Establishing protocol for S# detection † Re-audit Baseline A&E practice Data † Audit period: October–December 2001. † 151 A&E patients extracted from Radiology Information System. † A&E database and case notes from fracture clinic reviewed. Results † Of 68 patients with suspected occult S#: † 28 were sent to fracture clinic without definitive S# diagnosis (25 had .2 sets of radiographs.) † 13 of these had no other imaging. † No MRI for suspected S#. † 8 bone scans. Protocol (see flowchart) Aims † To establish definitive presence/absence of S#. † To reduce: † time to detection of occult S# † unnecessary orthopaedic referral † radiation exposure Re-audit Data † Audit period: January–March 2003. † 145 A&E patients. Analysis as for baseline study, with additional review of A&E attendance sheets and MR requests. Results Improvement in A&E practice: † 40.5% of those with ongoing tenderness but negative 2nd radiograph referred for MR. † 23 MRs were done with 11 (47.8%) positive for bony injury. † 5 (21.7%) had occult S# (Comparable to 19% in a previous series.3). † No 3rd radiographs for suspected S#. † Only one bone scan for suspected S#.
Conclusions It is feasible to provide an early MRI examination for suspected scaphoid fracture at our institution. Early MR scaphoid imaging has improved the service by early detection of scaphoid fracture thus reducing unnecessary radiation and immobilization in a young patient group. It has also reduced unnecessary referral to fracture clinic. References 1. Dias JJ, Brenkel IJ, Finlay DB. Patterns of union in fractures of the waist of the scaphoid. J Bone Joint Surg Br 1989;71:307—10. 2. Brismar J. Skeletal scintigraphy of the wrist in suggested scaphoid fracture. Acta Radiol 1988;29:101—7. 3. Brydie A, Raby N. Early MRI in the management of clinical scaphoid fracture. Br J Radiol 2003;76:296—300.
S.P.Suresh, S.J.Jackson Department of Radiology, Salford Royal Hospitals NHS Trust, Hope Hospital, Salford, Manchester, UK
0009-9260/$ - see front matter q 2004 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.crad.2004.05.008