SMaRT trial

Clinical and cost implications of using immediate MRI in the management of patients with a suspected scaphoid fracture and negative radiographs results from the SMaRT trial

Rua T, Malhotra B, Vijayanathan S, et al. The bone & joint journal 2019 · PMID 31362557 · doi:10.1302/0301-620x.101b8.bjj-2018-1590.r1

Question

In patients with a clinically suspected scaphoid fracture and normal initial radiographs, does immediate MRI change costs and clinical management compared with standard care?

Design

Pragmatic randomised controlled trial with an embedded economic evaluation, recruiting from the emergency department.

Patients

Patients attending the emergency department with a suspected scaphoid fracture and negative initial radiographs.

Intervention

Immediate MRI of the wrist

Comparison

Standard care with no further imaging in the emergency department (immobilisation and clinical review)

Primary outcome

Total cost impact at three months (secondary: six-month costs, diagnoses, diagnostic accuracy, satisfaction)

Key result

Immediate MRI was associated with lower mean costs per patient; the saving was not statistically significant at three months but became significant at six months. MRI also picked up significantly more fractures other than the scaphoid and had higher diagnostic accuracy than standard care.

Limitations

Modest sample from a single trial setting, so cost findings may not generalise to hospitals with different MRI capacity or tariffs.

Impact on practice

Supports moving to early MRI for suspected scaphoid fractures with normal radiographs in UK emergency pathways, as it need not add cost and clarifies the diagnosis sooner.