Role of MRI in Scaphoid Injuries: The Scaphoid Magnetic Resonance Imaging in Trauma (SMaRT) Trial

Purpose: To evaluate the role of magnetic resonance imaging (MRI) in scaphoid injuries via the Scaphoid Magnetic Resonance Imaging in Trauma (SMaRT) trial. The clinical and cost implications of immediate MRI in the management of patients with suspected scaphoid fractures and negative radiographs were evaluated. The study was achieved under our institutional initiative Transforming Outcomes and Health Economics Through Imaging (TOHETI).

Methods and Materials: We conducted a single-center randomized nonblinded prospective study evaluating the use of MRI for patients presenting to the emergency department (ED) with suspected scaphoid fractures and negative findings on initial radiographs. The performance of immediate wrist MRI as an add-on test during the initial ED visit was compared against standard of care, the use of radiographs only during the initial ED visit. The primary outcome assessed was total cost at 3 months after recruitment. Secondary outcomes were total cost at 6 months, assessment of clinical findings, diagnostic accuracy, and the satisfaction levels of the participants. The study ran for 23 months (17 months to enroll all required participants and 6 months to follow up the final participant recruited and imaged). A total of 136 adult patients were recruited (68 patients in each arm).

Results: The mean cost at 3 months after recruitment per participant was £542.4 (standard deviation [SD] £855.2) for the control cohort as compared with £368.4 (SD £338.6) for the MRI cohort, with an estimated cost difference of £174 (95% confidence interval [CI], − £30 to £378; p = 0.094). The difference in cost per participant at 6 months increased to £266 (95% CI, £3.3–£528; p = 0.047). Overall, 6.2% (4/65, control group) and 10% (7/67, MRI group) of participants had sustained scaphoid fractures (p = 0.37). A total of 7.7% (5/65, control group) and 22% (15/67, MRI group) of participants had other fractures diagnosed (p = 0.019), and other fractures were detected (7.7% in the control group and 22.4% in the MRI group). The use of MRI was associated with higher diagnostic accuracy both in the diagnosis of scaphoid fracture (100.0% versus 93.8%) and other fractures (98.5% versus 84.6%).

Patterns of injuries (soft tissue and bone) were demonstrated in both cohorts with the added benefit of early MRI imaging in these scenarios. A total of 44 MRIs had no significant clinical findings (i.e., two thirds of the MRIs were negative). The intervention group had fewer secondary care appointments that had positive societal implications for the patients and was a more efficient use of health care resources.

Conclusion: The use of immediate MRI in the management of patients with suspected scaphoid fracture and negative radiographs has led to significant cost savings while improving the pathway’s diagnostic accuracy and patient satisfaction. This procedure has now been incorporated into our clinical practice and has led to changes in our standard of care pathway.