Diagnostic Imaging Pathways - Wrist Fracture (Suspected)
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This pathway provides guidance on the imaging of adult patients with a suspected scaphoid fracture.
Date reviewed: July 2018
Date of next review: July 2021
Published: March 2019
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The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
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None | 0 |
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Minimal | < 1 millisieverts |
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Low | 1-5 mSv |
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Medium | 5-10 mSv |
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High | >10 mSv |
Images
Image GalleryNote: These images open in a new page | ||
|---|---|---|
| 1 |  |
Scaphoid Fracture Image 1 (Plain Radiograph): Fracture of the scaphoid bone. |
| 2 |  |
Scaphoid Fracture Image 2 (Plain Radiograph): Undisplaced fracture of the scaphoid bone (arrows). |
| 3 |  |
Scaphoid Fracture Image 3 (Plain Radiograph): Non-union of scaphoid fracture. Note sclerosis at fracture line. |
| 4 |  |
Scaphoid Fracture Image 4 (Computed Tomography): Coronal image of the wrist showing fracture though the proximal waist of scaphoid (arrows). |
Teaching Points
Teaching Points
- Early identification of a fracture and the degree of displacement is important to prevent adverse complications such as avascular necrosis, non-union and osteoarthritis. The scaphoid, capitate and lunate are the carpal bones most vulnerable to avascular necrosis. 1 Scaphoid fractures account for 80% of all carpal fractures 2
- The initial diagnostic modality for suspected wrist fractures is plain radiography, 3 but a proportion of fractures are radiographically occult at the time of presentation. In particular, up to 20-30% of scaphoid fractures are initially missed by plain radiographs 4
- Early MRI is the preferred investigation for detecting occult scaphoid and distal radius fractures, and has the advantage of simultaneously evaluating bone marrow abnormalities and surrounding soft tissue injuries 3
- If early MRI is unavailable or contraindicated, CT is an alternative 3
- Depending on local resources, presumptive casting and repeat plain radiography remains an option for suspected scaphoid and distal radius fractures. If follow-up radiographs do not show a fracture but symptoms persist, further imaging with MRI is recommend to investigate for scaphoid fracture or other cause of symptoms 3
- Imaging modality choice will depend on availability and patient factors including age of the fracture, preference, hand dominance and activity level 3
- If CT and MRI resources are limited, use of advanced imaging may be reserved for specific cases where an early answer is required
- Early imaging is preferred as it results in faster identification of fractures and other injuries and reduces unnecessary immobilisation. Early advanced imaging may also be cost-effective compared to immobilisation and repeat radiographs 5,6
- Evaluation of the diagnostic performance of different imaging modalities is limited by the lack of a consensus reference standard
- There is currently a lack of evidence to guide the imaging of suspected scaphoid fractures in children so most current guidelines are based on findings in adults 7
xray
Plain Radiography
- Initial investigation of choice for evaluating clinically suspected wrist fractures 3
- 20-30% of scaphoid fractures are radiographically occult at the time of presentation 4,8,9
- Plain radiographs are specific (95-99.5%) but may miss wrist fractures, with sensitivity of 45-70% for scaphoid fractures, up to 41-60% for other carpal bone fractures and 67-80% for fractures of the proximal metacarpus, distal ulna and radial fractures 4,8,10
- Traditionally, suspected scaphoid fractures have been treated with immobilisation for 7-10 days followed by repeat radiographs, although the exact time frame may vary 11
- Presumptive casting and follow-up radiographs, when resorption at the fracture line may make previously occult fractures visible, has an estimated pooled 91.1% sensitivity and 99.8% specificity in the diagnosis of suspected scaphoid fractures on meta-analysis. 12 Reported sensitivities vary considerably, possibly due to poor interobserver agreement of follow-up radiograph findings. 12,13 The meta-analysis included studies with follow-up radiographs performed between 10 days and one year later. The false negative rate was similar (6% vs 7%) between studies with repeat radiographs at more and less than six weeks
- The main disadvantage of presumptive casting is that a number of people will undergo unnecessary immobilisation. When the cost of lost productivity is taken into account, there is evidence that early advanced imaging may be more cost effective 5,6
- While useful if positive, follow-up radiographs cannot exclude fracture and further evaluation with MRI is recommended if there are persistent symptoms 12,13
ct
Computed Tomography (CT)
- In two meta-analyses, the sensitivity and specificity of CT for scaphoid fractures were 72-85.2% and 99.0-99.5% respectively, which was slightly inferior but comparable to MRI 12,14
- May be used for suspected radiographically occult scaphoid fracture as an alternative when MRI is contraindicated or unavailable 3,8
- Preferred to MRI to evaluate suspected occult hook of hamate fractures 3
- Useful in
- Depicting occult scaphoid and other fractures of the wrist, where it is superior to plain radiographs 8,9,15
- Detecting scaphoid fracture displacement. CT is 77-80% sensitive for scaphoid displacement 10,16 This is important given it affects the decision to proceed to surgery over conservative management, and the risk of non-union 17
- Demonstrating distal radio-ulnar joint involvement 15 and other carpal joint instability 18
- Surgical planning of complex fractures 19
- Diagnosis of union; trabecular bone bridging on CT is currently the best way to evaluate scaphoid union 20,21
- Unlike MRI, CT involves exposure to ionising radiation although the dose for imaging the wrist is very low at 0.03-0.1mSv 9,22
mri
Magnetic Resonance Imaging (MRI)
- MRI is considered the best advanced imaging modality for suspected radiographically occult scaphoid and distal radius fractures 3,8,12,23
- Two meta-analyses estimated a pooled sensitivity of 88- 97.7% and specificity approaching 100% with excellent reliability for the diagnosis of suspected scaphoid fractures, more sensitive than CT or follow-up radiography 12,14
- There is mounting evidence that early MRI is cost effective compared to conventional management with immobilisation and reassessment and may reduce the potentially large societal cost of unnecessary immobilisation, but is influenced by local availability of scanning resources 5,6,24
- Hospitals with the facilities to implement early MRI have found it to have a high clinical impact 8,25,26
- Can evaluate bony and soft tissue injuries in one test without ionising radiation, including: 25-27
- Occult scaphoid and other carpal bone fractures
- Accompanying soft tissue injuries, a minority of which have the potential for significant morbidity, such as triangular fibrocartilage injuries and scapholunate ligament injuries 27-29
- Bone marrow abnormalities, such as avascular necrosis, and bone marrow oedema or ‘bruising’, which was reported to have a 2% risk of occult fracture development in one prospective study 30,31
- Preoperative gadolinium-enhanced MRI can be used to evaluate the vascularity of the proximal pole in scaphoid non-unions which can help inform surgical decision to use a vascularised rather than standard non-vascularised bone graft. 32,33 However, it is relatively insensitive compared to intra-operative assessment as the gold standard and cannot reliably predict prognosis in these patients. 34 Contrast enhanced MRI is also useful in post-operative monitoring 35
- Disadvantages compared to CT include
- Inferior to CT in depicting cortical involvement in occult scaphoid fractures 36
- Longer scanning time needed; is difficult for some patients where claustrophobia or pain may lead to increased risk of movement artefact
- Bone scintigraphy has also been shown to be accurate for diagnosing occult scaphoid fractures,14 but it does not have the same soft tissue resolution as MRI and is not routinely used as it is time consuming and involves considerable ionising radiation, about 4mSv 37
References
References
Date of literature search: April-July 2018
The search methodology is available on request. Email
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Kaewlai R, Avery LL, Asrani AV, Abujudeh HH, Sacknoff R, Novelline RA. Multidetector CT of carpal injuries: anatomy, fractures, and fracture-dislocations. Radiographics. 2008;28(6):1771-84. (Review article). View the reference
- Arsalan-Werner A, Sauerbier M, Mehling IM. Current concepts for the treatment of acute scaphoid fractures. European journal of trauma and emergency surgery : official publication of the European Trauma Society. 2016;42(1):3-10. (Review article). View the reference
- American College of Radiology. ACR appropriateness criteria. Acute hand and wrist trauma. 2013. (Guideline). View the reference
- Balci A, Basara I, Cekdemir EY, Tetik F, Aktas G, Acarer A, et al. Wrist fractures: sensitivity of radiography, prevalence, and patterns in MDCT. Emergency radiology. 2015;22(3):251-6. (Level II-III evidence). View the reference
- Karl JW, Swart E, Strauch RJ. Diagnosis of occult scaphoid fractures: a cost-effectiveness analysis. J Bone Joint Surg Am. 2015;97(22):1860-8. (Level III evidence). View the reference
- Yin ZG, Zhang JB, Gong KT. Cost-effectiveness of diagnostic strategies for suspected scaphoid fractures. J Orthop Trauma. 2015;29(8):e245-52. (Level II-III evidence). View the reference
- Offiah AC, Burke D. The diagnostic accuracy of cross-sectional imaging for detecting acute scaphoid fractures in children: a systematic review. Br J Radiol. 2018:20170883. (Level I-II evidence). View the reference
- Jorgsholm P, Thomsen NO, Besjakov J, Abrahamsson SO, Bjorkman A. The benefit of magnetic resonance imaging for patients with posttraumatic radial wrist tenderness. The Journal of hand surgery. 2013;38(1):29-33. (Level II evidence). View the reference
- Behzadi C, Karul M, Henes FO, Laqmani A, Catala-Lehnen P, Lehmann W, et al. Comparison of conventional radiography and MDCT in suspected scaphoid fractures. World Journal of Radiology. 2015;7(1):22-7. (Level II-III evidence). View the reference
- Buijze GA, Jorgsholm P, Thomsen NO, Bjorkman A, Besjakov J, Ring D. Diagnostic performance of radiographs and computed tomography for displacement and instability of acute scaphoid waist fractures. J Bone Joint Surg Am. 2012;94(21):1967-74. (Level II evidence). View the reference
- Suh N, Grewal R. Controversies and best practices for acute scaphoid fracture management. J Hand Surg Eur Vol. 2018;43(1):4-12. (Review article). View the reference
- Yin ZG, Zhang JB, Kan SL, Wang XG. Diagnostic accuracy of imaging modalities for suspected scaphoid fractures: meta-analysis combined with latent class analysis. J Bone Joint Surg Br. 2012;94(8):1077-85. (Level I evidence). View the reference
- Low G, Raby N. Can follow-up radiography for acute scaphoid fracture still be considered a valid investigation? Clin Radiol. 2005;60(10):1106-10. (Level II evidence). View the reference
- Mallee WH, Wang J, Poolman RW, Kloen P, Maas M, de Vet HC, et al. Computed tomography versus magnetic resonance imaging versus bone scintigraphy for clinically suspected scaphoid fractures in patients with negative plain radiographs. Cochrane Database Syst Rev. 2015(6):Cd010023. (Level I evidence). View the reference
- Arora S, Grover SB, Batra S, Sharma VK. Comparative evaluation of postreduction intra-articular distal radial fractures by radiographs and multidetector computed tomography. J Bone Joint Surg Am. 2010;92(15):2523-32. (Level II-III evidence). View the reference
- Lozano-Calderon S, Blazar P, Zurakowski D, Lee SG, Ring D. Diagnosis of scaphoid fracture displacement with radiography and computed tomography. Diagnosis of scaphoid fracture displacement with radiography and computed tomography. View the reference
- Singh HP, Taub N, Dias JJ. Management of displaced fractures of the waist of the scaphoid: meta-analyses of comparative studies. Injury. 2012;43(6):933-9. (Level I evidence). View the reference
- Suzuki D, Ono H, Furuta K, Katayama T, Akahane M, Omokawa S, et al. Comparison of scapholunate distance measurements on plain radiography and computed tomography for the diagnosis of scapholunate instability associated with distal radius fracture. J Orthop Sci. 2014;19(3):465-70. (Level III evidence). View the reference
- Kleinlugtenbelt YV, Madden K, Groen SR, Ham SJ, Kloen P, Haverlag R, et al. Can experienced surgeons predict the additional value of a CT scan in patients with displaced intra-articular distal radius fractures? Strategies in Trauma and Limb Reconstruction. 2017;12(2):91-7. (Level III evidence). View the reference
- Ecker J. Scaphoid union: the role of wrist arthroscopy. Hand Clin. 2017;33(4):677-86. (Review article). View the reference
- Buijze GA, Wijffels MM, Guitton TG, Grewal R, van Dijk CN, Ring D. Interobserver reliability of computed tomography to diagnose scaphoid waist fracture union. The Journal of hand surgery. 2012;37(2):250-4. (Level III evidence). View the reference
- Biswas D, Bible JE, Bohan M, Simpson AK, Whang PG, Grauer JN. Radiation exposure from musculoskeletal computerized tomographic scans. J Bone Joint Surg Am. 2009;91(8):1882-9. (Level II evidence). View the reference
- Carpenter CR, Pines JM, Schuur JD, Muir M, Calfee RP, Raja AS. Adult scaphoid fracture. Acad Emerg Med. 2014;21(2):101-21. (Review article). View the reference
- Patel NK, Davies N, Mirza Z, Watson M. Cost and clinical effectiveness of MRI in occult scaphoid fractures: a randomised controlled trial. Emerg Med J. 2013;30(3):202-7. (Level III evidence). View the reference
- Khalid M, Jummani ZR, Kanagaraj K, Hussain A, Robinson D, Walker R. Role of MRI in the diagnosis of clinically suspected scaphoid fracture: analysis of 611 consecutive cases and literature review. Emerg Med J. 2010;27(4):266-9. (Level II evidence). View the reference
- Brydie A, Raby N. Early MRI in the management of clinical scaphoid fracture. Br J Radiol. 2003;76(905):296-300. (Level II evidence). View the reference
- McCullough NP, Smith FW, Cooper JG. Early MRI in the management of the clinical scaphoid fracture. Eur J Emerg Med. 2011;18(3):133-6. (Level II-III evidence). View the reference
- Magee T. Comparison of 3-T MRI and arthroscopy of intrinsic wrist ligament and TFCC tears. AJR Am J Roentgenol. 2009;192(1):80-5. (Level II evidence). View the reference
- Jorgsholm P, Thomsen NO, Bjorkman A, Besjakov J, Abrahamsson SO. The incidence of intrinsic and extrinsic ligament injuries in scaphoid waist fractures. The Journal of hand surgery. 2010;35(3):368-74. (Level II-III evidence). View the reference
- Thavarajah D, Syed T, Shah Y, Wetherill M. Does scaphoid bone bruising lead to occult fracture? A prospective study of 50 patients. Injury. 2011;42(11):1303-6. (Level III evidence). View the reference
- La Hei N, McFadyen I, Brock M, Field J. Scaphoid bone bruising--probably not the precursor of asymptomatic non-union of the scaphoid. J Hand Surg Eur Vol. 2007;32(3):337-40. (Level III evidence). View the reference
- Cerezal L, Abascal F, Canga A, Garcia-Valtuille R, Bustamante M, del Pinal F. Usefulness of gadolinium-enhanced MR imaging in the evaluation of the vascularity of scaphoid nonunions. AJR Am J Roentgenol. 2000;174(1):141-9. (Level II-III evidence). View the reference
- Schmitt R, Christopoulos G, Wagner M, Krimmer H, Fodor S, van Schoonhoven J, et al. Avascular necrosis (AVN) of the proximal fragment in scaphoid nonunion: is intravenous contrast agent necessary in MRI? Eur J Radiol. 2011;77(2):222-7. (Level II evidence). View the reference
- Megerle K, Worg H, Christopoulos G, Schmitt R, Krimmer H. Gadolinium-enhanced preoperative MRI scans as a prognostic parameter in scaphoid nonunion. J Hand Surg Eur Vol. 2011;36(1):23-8. (Level III evidence). View the reference
- Dailiana ZH, Zachos V, Varitimidis S, Papanagiotou P, Karantanas A, Malizos KN. Scaphoid nonunions treated with vascularised bone grafts: MRI assessment. Eur J Radiol. 2004;50(3):217-24. (Level III evidence). View the reference
- Memarsadeghi M, Breitenseher MJ, Schaefer-Prokop C, Weber M, Aldrian S, Gabler C, et al. Occult scaphoid fractures: comparison of multidetector CT and MR imaging--initial experience. Radiology. 2006;240(1):169-76. (Level III evidence). View the reference
- Rhemrev SJ, de Zwart AD, Kingma LM, Meylaerts SA, Arndt JW, Schipper IB, et al. Early computed tomography compared with bone scintigraphy in suspected scaphoid fractures. Clin Nucl Med. 2010;35(12):931-4. (Level II evidence). View the reference
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