What X-ray (radiograph) should I order for a patient with suspected scaphoid fracture?

Initial Imaging for Suspected Scaphoid Fracture

Order standard wrist radiographs including a dedicated "scaphoid view" (anteroposterior, lateral, oblique, and scaphoid-specific views) as your first-line imaging study. 1, 2

Initial Radiographic Evaluation

• Begin with a four-view radiographic series: anteroposterior, lateral, oblique, and scaphoid view (Stecher's view with the wrist in ulnar deviation) 1, 3
• The dedicated scaphoid view may reveal fractures that are otherwise occult on standard wrist radiographs 1
• Standard radiography detects approximately 70% of scaphoid fractures, meaning up to 30% are initially missed 4

When Initial Radiographs Are Negative But Clinical Suspicion Remains High

If the patient has a positive Kanawel sign (anatomic snuffbox tenderness) or other concerning clinical findings with negative initial radiographs, proceed directly to MRI without IV contrast rather than presumptive casting and repeat radiographs. 1

Clinical Decision-Making Tool

• Consider using a Clinical Scaphoid Score (CSS) to guide advanced imaging decisions 5:
  • Anatomic snuffbox tenderness with wrist in ulnar deviation: 3 points
  • Scaphoid tubercle tenderness: 2 points
  • Pain with longitudinal thumb compression: 1 point
• If CSS ≥4 points (snuffbox pain plus at least one other finding), proceed directly to MRI 5
• A CSS <4 has a 96% negative predictive value, making scaphoid fracture unlikely 5

Advanced Imaging Options (When Initial X-rays Are Negative)

MRI Without IV Contrast (Preferred)

• MRI is the preferred advanced imaging modality with sensitivity of 94.2% and specificity of 97.7% for detecting occult scaphoid fractures 1, 2
• MRI detects bone marrow edema, bone bruises, and concomitant ligament injuries that may affect treatment 1
• No radiation exposure 1
• Common pitfall: MRI can sometimes struggle to differentiate bone contusion from non-displaced fracture 4

CT Without IV Contrast (Alternative)

• Use CT if MRI is contraindicated or unavailable 1
• CT provides superior anatomic detail of bone cortex, trabeculae, and fracture morphology (localization, fragment displacement, comminution) 4
• Sensitivity of 85-95% and specificity of 95-100% 4
• Shorter acquisition time and easier to perform in casted patients 1
• CT is particularly useful for evaluating the hook of the hamate 1

Bone Scan (Less Preferred Alternative)

• High sensitivity but lower specificity compared to CT and MRI 1, 6
• May be reasonable for claustrophobic patients who cannot tolerate MRI 1
• Becomes positive 1-2 weeks before radiographic changes are visible 6

The Traditional "Wait and Repeat" Approach (Generally Not Recommended)

• If advanced imaging is unavailable, immobilize in a thumb spica cast and repeat radiographs in 10-14 days 6
• Critical pitfall: Repeating radiographs too early (less than 10 days) has high risk of missing fractures that remain occult 6
• This approach results in unnecessary immobilization in 76-94% of patients who don't have fractures, leading to lost productivity 7
• The American College of Radiology now recommends proceeding directly to MRI rather than this traditional approach 1

Important Contraindications

• Do not use IV contrast for suspected scaphoid fractures—it provides no added benefit and is not appropriate 1
• Ultrasound has limited utility with only 81.5% sensitivity and 77.4% specificity, and is not suitable for early diagnosis 1