Practice Rational Imaging

Investigating suspected scaphoid fracture

BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f1370 (Published 27 March 2013) Cite this as: BMJ 2013;346:f1370
  1. Randall L Baldassarre, medical student,
  2. Tudor H Hughes, professor of radiology; vice chair of education; radiology residency program director
  1. 1Department of Radiology, University of California, San Diego Medical Center, 200 West Arbor Drive, San Diego, CA 92103-8756, USA
  1. Correspondence to: T H Hughes thughes{at}ucsd.edu

The choice of imaging modality for suspected scaphoid fracture depends on factors such as age, patient activity, cost, and availability of services

Learning points

  • Initial evaluation for suspected acute scaphoid fracture requires radiography, but this modality misses 15-20% of fractures

  • Occult scaphoid fractures may be examined by repeat radiography after casting, magnetic resonance imaging, computed tomography, bone scintigraphy, or ultrasonography

  • The American College of Radiology recommends magnetic resonance imaging or repeat radiography after 10-14 days of casting as the second line investigations of choice

  • The choice of imaging modality for occult scaphoid fracture depends on factors such as age, hand dominance, patient activity, cost, and availability of services

A 26 year old previously healthy woman presented to the emergency department immediately after being involved in a road traffic incident. After clinical examination, scaphoid injury was suspected. A radiograph of the left wrist was obtained and found to be equivocal (fig 1).

Fig 1 Posteroanterior radiograph of the wrist showing an incomplete lucency at the waist of scaphoid suspicious for a fracture but not definitive (arrow)

What is the next investigation?

Scaphoid fractures should be suspected with trauma involving the hand and/or wrist, particularly falls onto an outstretched hand and road traffic incidents. Such fractures most commonly occur among men aged 20-30 years, with about 10% presenting with an associated fracture.1 Less than 20% of patients with a clinically suspected scaphoid fracture have a true fracture.2 In most of the patients with true scaphoid fracture, the fracture is diagnosed with wrist radiography, the initial examination recommended by the …

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