Management of Negative Initial X-ray After FOOSH Injury

Rationale for Advanced Imaging Over Repeat Radiography

• The American College of Radiology recommends proceeding directly to MRI without IV contrast rather than repeating radiographs in 10-14 days for patients with a FOOSH injury and negative initial radiographs but persistent clinical suspicion for fracture, as this prevents delayed diagnosis and unnecessary immobilization 1
• MRI without IV contrast has excellent sensitivity for detecting occult fractures of the distal radius and carpal bones and can change diagnosis in 55% of patients and management in 66% of patients when initial radiographs are normal but clinical suspicion remains high 1
• Certain high-risk fractures can lead to nonunion, avascular necrosis, and long-term disability if diagnosis is delayed, highlighting the importance of timely diagnosis 1

Clinical Decision Algorithm

• Suspected intra-articular involvement or ligamentous injury is an indication to proceed directly to MRI 1

Common Pitfalls to Avoid

• A minimum of 3 views is necessary for wrist evaluation, including posteroanterior, lateral, and 45° semipronated oblique views, as 2-view examinations are inadequate for detecting fractures 1, 2

Summary of Imaging Modality Selection

• MRI without IV contrast is the preferred next study after negative initial radiographs because it detects occult fractures with excellent sensitivity, evaluates concomitant ligamentous injuries, and prevents delayed diagnosis and unnecessary immobilization 1
• CT without IV contrast can be used as an alternative when MRI is contraindicated or unavailable, and is particularly useful for confirming or excluding suspected wrist fractures when radiographs are equivocal 1