• Martin Davey, Ian Feeley, Joshua Hayes, Marc Grant-Freemantle, Muhammad Gaafar, Leo Pauzenberger, Ann Maria Byrne, and Hannan Mullett.
• Department of Trauma & Orthopaedics, Beaumont Hospital, Dublin 9, Ireland. martindavey@rcsi.ie.
• Ir J Med Sci. 2020 Aug 1; 189 (3): 949-952.

BackgroundA clinical examination finding of anatomical snuffbox tenderness (AST) with plain film radiographs alone yields low sensitivity and specificity in diagnosing scaphoid fractures. International guidelines suggest immediate referral for magnetic resonance imaging (MRI) following one non-diagnostic radiograph in such patients. Perceived cost, high demand and limited capacity of MRI scanners have resulted in few suspected fractures following this pathway in our institution.AimsOur study aimed to audit cost-effectiveness of immediate MRI referral following one non-diagnostic radiograph in the patient with AST versus current local practice.MethodsRetrospective analysis of all patients with suspected scaphoid fractures referred from the ED to the orthopaedic service over a six-month period was performed. Mean pricing per radiograph, casting, MRI and fracture clinic presentation was obtained from our hospital's Finance department.ResultsNinety-seven patients were identified; 26 had scaphoid fractures (26.8%). Seventy-one patients with no fractures cost a mean €82,111.50 (IQR: €55,025, €98,335) having a mean of 3.1 clinic visits, 4.6 radiographs and 4.7 weeks casted, versus €40,115 for early MRI referral as per guidelines (p > 0.05).ConclusionsIn conclusion, when compared with current local practice, immediate referral of the patient with AST for MRI following one non-diagnostic ED radiograph is potentially cost-effective in establishing efficient diagnosis of scaphoid fractures. We recommend the implementation of published international guidelines in the investigation of query scaphoid fractures as a pragmatic and cost-effective practice.

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