Management of Suspected Scaphoid Fracture with Positive Kanawel Sign

Initial Evaluation and Imaging

The American College of Radiology recommends beginning with standard wrist radiographs, including a dedicated "scaphoid view", which may reveal an otherwise radiographically occult fracture 1, 2
If initial radiographs are negative but clinical suspicion remains high, the American College of Radiology suggests proceeding directly to MRI without IV contrast rather than presumptive casting and repeat radiographs 3, 4

MRI without IV contrast is highly sensitive to changes in bone marrow composition and is the preferred method for identifying radiographically occult scaphoid fractures, with benefits including highest sensitivity (94.2%) and specificity (97.7%) for diagnosing scaphoid fractures, and can detect concomitant ligament injuries that may affect treatment 3, 4, 5
MRI can identify bone bruises and soft tissue injuries, and has no radiation exposure 3

CT without IV contrast can be used if MRI is contraindicated or unavailable, with benefits including high-detail imaging of bone cortex and trabeculae, shorter acquisition times compared to MRI, and easier to perform in patients who are already casted 3, 6
CT is particularly useful for suspected fractures of the hook of the hamate 3

Bone scan can reliably exclude occult scaphoid fractures with high sensitivity, but has lower specificity compared to CT and MRI, and may be a reasonable alternative for claustrophobic patients 1, 2
Ultrasound has limited utility with moderate sensitivity (81.5%) and lower specificity (77.4%), and is not suitable for early diagnosis of scaphoid fracture 5

The American College of Radiology recommends CT without IV contrast for detecting scaphoid nonunion, malunion, osteonecrosis, and wrist osteoarthritis in patients with chronic scaphoid fractures 7, 8
MRI without IV contrast can detect fractures of the distal radius and carpal bones with high sensitivity (94.2%) and specificity (97.7%) in patients with suspected scaphoid fractures, and has the advantage of detecting concomitant ligament injuries that may affect treatment 9
Either CT without IV contrast or MRI without IV contrast is usually appropriate for evaluating suspected scaphoid fractures, but only one of these tests is necessary, according to the American College of Radiology 7, 8
CT is particularly useful for evaluating fracture complications such as nonunion, malunion, or osteonecrosis in patients with scaphoid fractures 8
The use of IV contrast does not provide added benefit in patients with suspected scaphoid fractures and is usually not appropriate, as stated by the American College of Radiology 8