Initial Assessment of Acute Scaphoid Wrist Fracture
Radiographic Evaluation
- The American College of Radiology recommends beginning with standard 3-view wrist radiographs, including posteroanterior, lateral, and 45° semipronated oblique "scaphoid view", and if negative but clinical suspicion remains high, proceeding directly to MRI or CT without contrast rather than empiric casting 1, 2
- A standard 3-view radiographic series is mandatory as the first-line examination, looking specifically for scapholunate diastasis >4 mm, dorsal tilt of lunate >10°, and intra-articular extension into the radiocarpal joint 1, 2
Advanced Imaging Options
- MRI without IV contrast is the preferred next study, highly sensitive for occult fractures through detection of bone marrow edema, and detects concomitant soft tissue injuries including scapholunate ligament tears that may affect treatment 1, 3, 4, 5, 6
- CT without IV contrast is an acceptable alternative, superior for visualizing bone cortex and trabeculae, with shorter acquisition times than MRI, and preferred for specific fractures like hook of hamate 3, 4
- Bone scintigraphy is a reasonable alternative if MRI/CT is unavailable, with high sensitivity, but lower specificity due to uptake from bone contusions and osteoarthritis 3, 4, 5, 6
Fracture Classification
- Unstable/displaced fractures have >1-2 mm displacement, scapholunate angle abnormalities, and associated carpal malalignment, while stable/undisplaced fractures have minimal to no displacement and no carpal instability 1
Assessment for Complications
- Ligamentous injuries, particularly scapholunate and lunotriquetral ligaments, should be evaluated, as well as distal radius fractures, looking for intra-articular extension and "longhorn sign" 1, 2
- Proximal pole fractures and displaced fractures are risk factors for non-union, with concerns for blood supply and higher risk of avascular necrosis 7