What X-ray views are recommended for diagnosing a suspected scaphoid fracture?

X-ray Views for Diagnosing Suspected Scaphoid Fractures

For suspected scaphoid fractures, a standard 3-view radiographic examination of the wrist (posteroanterior, lateral, and 45° semipronated oblique view) plus dedicated scaphoid views such as the carpal tunnel or semisupinated oblique projection should be obtained as the initial imaging study. 1, 2

Initial Radiographic Assessment

Standard Views

• Posteroanterior (PA) view
• Lateral view
• 45° semipronated oblique view 1

Dedicated Scaphoid Views

• Carpal tunnel view or "scaphoid view"
• Semisupinated oblique projection 2

These dedicated scaphoid views are critical because the standard 3-view radiographic examination may miss 20-30% of scaphoid fractures due to the complex three-dimensional anatomy of the scaphoid 2.

Rationale for Multiple Views

The American College of Radiology guidelines emphasize that a radiographic examination that includes only 2 views is inadequate for detecting fractures in the wrist 1. This is particularly important for scaphoid fractures, which are notoriously difficult to visualize on standard radiographs due to:

• The curved shape of the scaphoid
• Overlapping carpal bones
• Variable orientation of fracture lines

When Initial X-rays Are Negative

If initial radiographs are negative but clinical suspicion remains high:

1. MRI without contrast should be performed as the preferred advanced imaging modality (highest sensitivity at 19-37% in patients with normal initial X-rays) 2
2. CT without contrast can be used if MRI is unavailable (sensitivity 94.4%, specificity 100%) 2

Common Pitfalls to Avoid

• Relying on insufficient views: Never rely on just 2 views for wrist trauma; always obtain at least 3 standard views plus dedicated scaphoid views 1, 2
• Premature exclusion of fracture: Initial radiographs may miss 20-30% of scaphoid fractures 2
• Delayed advanced imaging: If clinical suspicion remains high despite negative X-rays, proceed promptly to MRI or CT rather than waiting for repeat X-rays 3
• Inadequate immobilization: Maintain immobilization until definitive diagnosis is established 2

Imaging Protocol Algorithm

1. Initial assessment: Standard 3-view wrist radiographs plus dedicated scaphoid views
2. If radiographs are negative but clinical suspicion persists: Proceed to MRI without contrast within 3-5 days 4
3. If MRI is unavailable: CT without contrast with reconstructions in coronal and sagittal planes following the longitudinal axis of the scaphoid 4

This approach minimizes unnecessary immobilization while ensuring accurate and timely diagnosis of scaphoid fractures, which is crucial for preventing complications such as nonunion, avascular necrosis, and long-term functional impairment.