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What are the indications for MR imaging in acute skeletal trauma? At present, I fear that the indications for MR imaging after an injury are more political than medical. Are you an important person? Are you a VIP? Are you a member of my family or a friend of mine? Or are you a friend of a referring physician? Or are you a varsity or professional athlete? Or are you just insistent enough? If so, you are fortunate and may undergo MR imaging. However, if the answer is no, you are not likely to receive an MR examination. You are then left to your own devices.
We know now that MR imaging has a place in the evaluation of otherwise obscure or inapparent hip fractures and certain spinal injuries. But is there a role for MR imaging in the assessment of acute skeletal trauma at other sites?
This question is brought to mind by Dorsay et al. [1] who explore the role of MR imaging in the assessment of suspected scaphoid fractures. These researchers find, as have others [2,3,4], considerable value in the immediate use of MR imaging in this setting. Read the article. I am certain it will give you something to think about, just as it did for me.
It is now standard procedure to perform MR imaging in patients with a strong clinical suspicion of hip fracture but unrevealing or equivocal radiographs. This answers the question, "Is there a fracture or dislocation?" The answer has immediate impact on the care of the patient—if yes, the patient is hospitalized and treated appropriately; if no, the patient may be safely sent home, sparing the expense of hospitalization. In this setting, MR imaging saves money and is therefore considered warranted and appropriate by third-party payers.
The impact of MR imaging in assessing skeletal trauma at other sites is likely less dramatic and more arguable. True, a fracture may be identified, thus establishing the source of the patient's symptoms and confirming the clinical diagnosis, but the ramifications of confirming the diagnosis are likely less profound than with a patient having a potential hip fracture.
Given that radiographs of a patient can be unrevealing or equivocal, the majority of fractures then revealed by MR imaging will very likely be nondisplaced and will be treated by closed casting that requires neither hospitalization nor surgery. In truth, the patient may have received the same treatment based on the clinical diagnosis and negative radiographs without incurring the expense of MR imaging. One major difference, however, is that the addition of MR imaging leads to diagnostic certainty and thus reassures the treating physician. The "hooker" is that third-party payers are not enthralled by the prospect of paying for the elimination of diagnostic uncertainty when the information obtained does not determine or change the patient's treatment.
On the other hand, the added information obtained on MR imaging may also, with equal certainty, exclude the clinical suspicion of a fracture of the bone in question and, with the same certainty, exclude fractures of adjacent bones. The exclusion of significant injury allows early mobilization and eliminates the morbidity attendant with unnecessary casting of an injured extremity.
Add to the preceding the fact that MR imaging is enormously more sensitive than radiography, MR imaging offers an all-encompassing view of the musculoskeletal system instead of the limited view afforded by the window of radiography. MR imaging reveals the soft-tissue supporting structures of the skeleton: ligaments, tendons, and joint cartilage as well as labri and menisci, which are, of course, invisible and undetectable on radiography.
In patients with clinically suspected fractures of the scaphoid and unrevealing radiographs, MR imaging has been shown to confirm the clinically suspected injury in 15-20% of patients; reveal contusions or fractures of other bones or other significant injuries of adjacent ligaments, tendons, or muscles in another 20-30% of patients; and show no serious injury in the remaining 50% of patients [2,3,4]. Are these results significant? Such matters are subject to interpretation. Opinions may vary. However, to me, these results of MR imaging are significant and should encourage more frequent use of MR imaging in this setting.
What about the role of MR imaging in acute skeletal trauma at other sites? There are no clear-cut, agreed on, and scientifically validated indications for MR imaging.
The increased sensitivity of MR imaging allows a significant expansion in the intent of imaging in skeletal trauma. Radiography depicts little more than bone and is restricted to addressing the question, "Has this patient sustained a fracture or dislocation?" On the other hand, MR imaging depicts the entire musculoskeletal system: bones, joint surfaces, ligaments, and muscles—indeed, all anatomic structures. Therefore, with MR imaging, the question addressed can be expanded by a significant order of magnitude to become, "Is there any evidence of injury to the musculoskeletal system?" Or, "Is the integrity of the musculoskeletal system maintained?"
Of course, the ultimate effect—the outcome of failure to diagnose and treat, to neglect injuries of ligaments, tendons, joint surfaces, menisci, and joint labri at the time of initial injury—remains unknown. The results of such injuries are often insidious. The final result may be secondary degenerative arthritis and joint instability. Could this be prevented? Would it be better to identify and treat such injuries when they occur? Here again, opinions vary. What are we supposed to say to patients? "Come back when you are disabled"? There is a lot we don't know and much to be learned about the potential role of MR imaging in acute skeletal trauma.
MR imaging shows great promise, but there is much work to be done. Considerable research must be performed before the emergence of more precise indications for MR imaging in the assessment of acute skeletal trauma.
References
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