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

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.

Background: Morton’s Neuroma is most likely a mechanically induced degenerative neuropathy, presenting as forefoot pain.

Methods: The authors retrospectively reviewed clinical notes, imaging and histology from 71 consecutive patients (75 feet) treated operatively for Morton’s Neuroma between January 2006 and April 2009 and a control group of 20 patients (20 feet) undergoing MRI for other forefoot pathology. 7 feet were excluded from the surgical group due to recurrent disease or missing data.

Results: 84% of the surgical group were female. Mean age was 52. 97.4% of the surgical group presented with pain. 50% described pain in the plantar aspect of the forefoot and 85% reported that their pain was worse in shoes. Web space tenderness was positive in 95%, foot squeeze test 88%, plantar percussion 61% and toe tip sensation deficit 67%. Any two tests were positive in 92% of this group. In the control group any two tests were positive in only 39% – this difference was statistically significant (p< 0.0001 chi-squared test). MRI identified a neuroma in 97% of the surgical group (mean size 8mm) and 50% of the control group (mean size 6mm). 68% were in the 3rd web space; the remainder were in the 2nd web space. Histology confirmed neuroma in 99%.

Discussion: This cohort is larger than any other published series and is further strengthened by both the consistency of clinical testing and the independence of radiological and histological assessment.

Conclusion: We found that diagnosis of Morton’s neuroma was accurate. MRI correctly identified the neuromata in 97% and at least two clinical tests were present in 92%.