Is a CT (Computed Tomography) of the wrist or hand more recommended for diagnosing a scaphoid fracture?

CT of Wrist is Preferred for Scaphoid Fracture Diagnosis

CT of the wrist is the preferred imaging modality for diagnosing scaphoid fractures, particularly when reformatted along the long axis of the scaphoid. 1

Initial Diagnostic Approach

• Begin with standard wrist radiographs, including a dedicated "scaphoid view," which may reveal an otherwise radiographically occult fracture 2
• If initial radiographs are negative but clinical suspicion remains high, proceed to advanced imaging rather than presumptive casting and repeat radiographs 2

Advanced Imaging Options for Scaphoid Fractures

CT of the Wrist (Recommended)

• CT without IV contrast is historically the most commonly used examination to detect scaphoid nonunion, malunion, osteonecrosis, and wrist osteoarthritis in patients with chronic scaphoid fractures 3
• CT provides high-detail imaging of bone cortex and trabeculae with shorter acquisition times compared to MRI 2
• CT reformations along the long axis of the scaphoid (CT-scaphoid) show better diagnostic performance than reformations in the planes of the wrist (CT-wrist) 1
• CT-scaphoid has shown sensitivity of 67%, specificity of 96%, and accuracy of 91% for diagnosing scaphoid fractures 1
• For optimal visualization, CT should be performed with primary oblique-sagittal layers in the longitudinal axis of the scaphoid 4

MRI as an Alternative

• MRI without IV contrast can detect fractures of the distal radius and carpal bones with high sensitivity (94.2%) and specificity (97.7%) 3, 2
• MRI has the advantage of detecting concomitant ligament injuries that may affect treatment 3, 2
• MRI can identify bone bruises and soft tissue injuries with no radiation exposure 2
• For scaphoid-specific imaging, MRI sequences should be performed with the plane parallel to the longitudinal axis of the scaphoid 5

Clinical Considerations

• 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 3
• CT is particularly useful when:
  • MRI is contraindicated or unavailable 2
  • The patient is already casted, making CT easier to perform 2
  • There is a need to evaluate for fracture complications such as nonunion, malunion, or osteonecrosis 3
• If CT shows no fracture but clinical suspicion persists, an MRI scan should be performed 4

Important Caveats

• Even with thin slice technique, scaphoid fractures can be overlooked if improper CT technique is used 4
• IV contrast does not provide added benefit in these patients and is usually not appropriate 3
• Ultrasound has limited utility with moderate sensitivity (81.5%) and lower specificity (77.4%), and is not suitable for early diagnosis of scaphoid fracture 2
• Bone scan, while sensitive, has lower specificity compared to CT and MRI 2