What X-ray view is recommended for a suspected scaphoid (scaphoid bone) fracture?

Scaphoid Fracture X-Ray Imaging

Initial Radiographic Views

For suspected scaphoid fractures, obtain a standard 3-view wrist radiograph series consisting of posteroanterior (PA), lateral, and a 45° semipronated oblique "scaphoid view" (also called scaphoid-specific view). 1, 2

The dedicated scaphoid view is critical because it may reveal fractures that are otherwise radiographically occult on standard PA and lateral views alone. 1

What to Look For on Initial X-Rays

When reviewing the radiographs, specifically assess for:

• Fracture line visibility through the scaphoid bone 2
• Scapholunate diastasis >4 mm (indicates ligamentous injury) 2
• Dorsal tilt of lunate >10° (suggests carpal instability) 2
• Intra-articular extension into the radiocarpal joint 2

If Initial X-Rays Are Negative But Clinical Suspicion Remains High

The American College of Radiology recommends proceeding directly to MRI without IV contrast rather than empiric casting with repeat radiographs. 1, 2

Why MRI Is Preferred Over Repeat X-Rays:

• MRI without contrast has the highest diagnostic accuracy with 94.2% sensitivity and 97.7% specificity for scaphoid fractures 1, 2
• MRI detects concomitant injuries including scapholunate ligament tears and bone bruises that affect treatment decisions 1, 2
• Avoids prolonged unnecessary immobilization - waiting 10-14 days for repeat X-rays risks keeping patients in casts when no fracture exists 3, 4
• Prevents complications from delayed diagnosis of true fractures, including nonunion, malunion, and avascular necrosis 2, 3

Alternative Advanced Imaging Options:

CT without IV contrast is an acceptable alternative if MRI is contraindicated or unavailable, offering:

• Superior visualization of bone cortex and trabeculae 1, 2
• Shorter acquisition times than MRI 1, 2
• Easier to perform in already-casted patients 1

Bone scintigraphy can be considered if MRI/CT are unavailable, with high sensitivity but lower specificity due to uptake from bone contusions 2, 5

Common Pitfalls to Avoid

• Inadequate radiographic views: A minimum of 3 views is required; obtaining only PA and lateral views misses fractures visible on the scaphoid-specific view 2
• Premature repeat X-rays: Repeating radiographs before 10-14 days has high risk of missing occult fractures that haven't yet become radiographically visible 3
• Relying solely on ultrasound: While ultrasound shows 81.5% sensitivity, its lower specificity (77.4%) makes it unsuitable for early diagnosis 1
• Failing to assess carpal alignment: Missing scapholunate diastasis or lunate tilt changes management from stable to unstable classification 2

Clinical Algorithm

1. Obtain 3-view wrist radiographs (PA, lateral, 45° scaphoid view) for all suspected scaphoid fractures 1, 2
2. If fracture is visible: Classify as stable vs. unstable based on displacement (>1-2 mm), scapholunate angle, and carpal alignment 2
3. If radiographs negative but high clinical suspicion (positive anatomic snuffbox tenderness, scaphoid tubercle tenderness): Proceed directly to MRI without contrast 1, 2
4. If MRI contraindicated: Use CT without contrast as alternative 1, 2
5. Only if advanced imaging unavailable: Immobilize and repeat radiographs at 10-14 days 3