The aim of the Scaphoid Magnetic Resonance Imaging in Trauma (SMaRT) trial was to evaluate the clinical and cost implications of using immediate MRI in the acute management of patients with a suspected fracture of the scaphoid with negative radiographs. Patients who presented to the emergency department (ED) with a suspected fracture of the scaphoid and negative radiographs were randomized to a control group, who did not undergo further imaging in the ED, or an intervention group, who had an MRI of the wrist as an additional test during the initial ED attendance. Most participants were male (52% control, 61% intervention), with a mean age of 36.2 years (18 to 73) in the control group and 38.2 years (20 to 71) in the intervention group. The primary outcome was total cost impact at three months post-recruitment. Secondary outcomes included total costs at six months, the assessment of clinical findings, diagnostic accuracy, and the participants’ self-reported level of satisfaction. Differences in cost were estimated using generalized linear models with gamma errors.Aims
Patients and Methods
The aim of this study was to produce estimates of specificity and predictive value of presenting symptoms and signs of paediatric bone cancer, a rare and frequently misdiagnosed condition, to aid clinical decision-making in primary care. A systematic literature review plus questionnaire to primary care physicians were carried out to determine frequency of bone cancer symptoms in both cancer and the benign conditions as which cancer is misdiagnosed. Literature sources – Ovid MEDLINE (1950-May 2008), EMBASE (1980-May 2008) and AMED (Allied and Alternative Medicine) (1985-May 2008). Literature review methods – We included systematic reviews, cohort studies or case series (where n ≥ 10), reporting frequency of symptoms and signs at initial presentation, as originally recorded in case notes or observed by the authors, in subjects aged 0–18 years. Disease incidence data was taken from retrospective and prospective studies from 1980 onwards which recorded incidence over a defined time period, in a large pre-defined population within Europe, North America or Australia. Questionnaire respondents – 32 general practitioners and paediatric Accident & Emergency physicians throughout Scotland and England. Positive predictive values (PPVs) for bone cancer symptoms range from 0.003 to 0.034% (percentage of children presenting with symptom who have cancer). Specificity (percentage of children without cancer who do not have the symptom) varies considerably between symptoms and ranges from 24% (tenderness) to 95% (weight loss). Specificity can be improved by looking for combinations of symptoms. Weight loss and fever are the features with both highest specificity and highest PPV. Bone cancer symptoms, even those with high specificity for cancer, have low positive predictive value. We suggest that diagnosis based on initial presentation to primary care is intrinsically difficult and that delay in diagnosis is not unreasonable if it is to make use of time as a diagnostic aid.
To test the knowledge of clinicians in Orthopaedic clinics and Emergency departments of the surface anatomical landmarks that should be examined during assessment of foot and ankle injuries. Specifically trained assessors observed 109 clinicians examining 6 anatomical landmarks on uninjured subjects. Each landmark was chosen for their relevance in assessment of foot and ankle injuries. The landmarks were the medial malleolus, lateral malleolus, fibula head, navicular, base of the 5th metatarsal and the anterior talo-fibular ligament (ATFL). Two participants failed to identify a single landmark. Of 109 assessed, 27% correctly identified all 6 landmarks. The average correctly identified by each clinician was 4.1 with a standard deviation of 1.5 and range of 0–6. One hundred and seven clinicians correctly identified the lateral malleolus, the most consistently identified. The most poorly identified landmark was the ATFL, by 45%. The knowledge of surface anatomy overall by junior Orthopaedic and Emergency clinicians was found to be poor and only seems to significantly improve once higher specialty training is reached. Despite the potential for subjectivity and bias the authors believe the methodology is sufficient to demonstrate a lacking in anatomical knowledge amongst clinicians. Poor anatomical knowledge leads to inaccurate examination. This can lead to incorrect diagnoses or even mal-treatment of patients. Clinicians are becoming more reliant on potentially unnecessary and expensive imaging investigations. They have neglected the basic art of physical examination based on sound knowledge of human anatomy. At present, the authors believe that the anatomical teaching in undergraduate medicine is inadequate.
