VIRTUAL FRACTURE CLINIC TRIAGE AND SELECTIVE USE OF MRI: A HYBRID MODEL FOR MANAGING SUSPECTED SCAPHOID FRACTURES

Abstract

In current practice in the UK there are three main approaches to investigating suspected scaphoid fractures not seen on initial plain film x-rays.

1. Early MRI of all cases

2. Review all cases in clinic at two weeks with repeat x-rays

3. Hybrid model. Virtual Fracture Clinic (VFC) triage to reduce those who are seen in clinic at two weeks by:

   1. ∘

      Organising early MRI for those with high-risk presentation.

   2. ∘

      Discharging those with an alternative more likely diagnosis.

Our unit uses the VFC model. We aimed to evaluate its efficiency, safety, clinical outcomes and economic viability.

All patients attending the emergency department with either a confirmed or suspected scaphoid fracture between March and December 2020 were included (n=305). Of these 297 were referred to the VFC: 33 had a confirmed fracture on x-ray and 264 had a suspected fracture.

Of the suspected fractures reviewed in VFC 14% had an MRI organised directly owing to a high-risk presentation, 79% were brought for fracture clinic review and 17% discharged with an alternative diagnosis such as osteoarthritis.

Of those subsequently reviewed in fracture clinic at two weeks: 9% were treated as scaphoid fractures (based on clinical suspicion and repeat x-rays), 17% had MRI or CT imaging organised, 5% did not attend and 69% were discharged.

Overall, 17% of cases initially triaged, had further imaging – 41 MRIs and 5 CTs. MRI detected: 5% scaphoid fracture, 17% other fracture, 24% bone contusion, complete ligament tear 10%, partial ligament tear 39% and normal study 10%. The results of MRI minimally affected management. 3 patients were taken out of plaster early, 1 patient was immobilized who was not previously and no patients underwent operative management.

In the following 12-month period one patient re-presented with a hand or wrist issue.

This approach avoided 218 MRIs, equating to £24000 and 109 hours of scanner time.

VFC triage and selective use of MRI scanning is a safe, efficient and cost-effective method for the management suspected scaphoid fractures. This can be implemented in units without the resource to MRI all suspected scaphoid fractures from the emergency department.