What type of X-ray (X-ray) should be ordered for scaphoid and thumb fracture evaluation?

Recommended X-ray Views for Scaphoid and Thumb Fracture Evaluation

For scaphoid fractures, order a minimum 4-view series including posteroanterior (PA), lateral, 45° semipronated oblique, and a dedicated scaphoid view; for thumb fractures, order a standard 3-view series with PA, lateral, and oblique views of the affected digit. 1, 2

Scaphoid Fracture Imaging Protocol

Initial Radiographic Series

• The American College of Radiology recommends a 4-view series as the standard initial imaging for suspected scaphoid fractures, which includes:

  • Posteroanterior (PA) view in neutral position 1
  • Lateral view in neutral position to demonstrate malalignments and soft-tissue swelling 1
  • 45° semipronated oblique view 1
  • Dedicated scaphoid view (PA in ulnar deviation), which increases diagnostic yield and may reveal otherwise occult fractures 1, 3

• Relying on only 2 views is inadequate, and even 3-view series can miss important pathology 1

Critical Pitfall to Avoid

• Up to 30% of acute scaphoid fractures are missed on initial conventional radiographs 4
• If clinical suspicion remains high despite negative initial radiographs (positive anatomic snuffbox tenderness, positive scaphoid compression test), do not stop at plain films 3

Thumb Fracture Imaging Protocol

Standard Radiographic Views

• A standard 3-view examination is necessary for phalangeal injuries including the thumb, consisting of:

  • Posteroanterior (PA) view 2
  • Lateral view 2
  • Oblique view 2

• Some centers include a PA examination of the entire hand, while others limit the examination to the injured digit 2

• An internally rotated oblique projection in addition to the standard externally rotated oblique increases diagnostic yield for phalangeal fractures 2

When Initial Radiographs Are Negative But Clinical Suspicion Remains High

For Scaphoid Injuries

Proceed directly to MRI without IV contrast rather than presumptive casting and repeat radiographs, as recommended by the American College of Radiology 3

Advanced Imaging Options (in order of preference):

1. MRI without IV contrast (preferred): Highest sensitivity (94.2%) and specificity (97.7%) for radiographically occult scaphoid fractures, can detect bone bruises and concomitant ligament injuries 3, 5

2. CT without IV contrast (alternative): High-detail imaging of bone cortex and trabeculae, shorter acquisition times, easier in casted patients, particularly useful for hook of hamate fractures 6, 3

3. Bone scan (less preferred): Can reliably exclude occult scaphoid fractures but has lower specificity than CT and MRI; may be reasonable for claustrophobic patients 6, 3

For Thumb Fractures

• If initial radiographs are negative but clinical suspicion remains high, options include short arm cast with repeat radiographs in 10-14 days, or MRI without IV contrast 2
• CT is usually not indicated during acute metacarpal and digital fractures 2

Key Clinical Implications

• Missed scaphoid fractures lead to significant morbidity including nonunion, avascular necrosis, and post-traumatic arthritis 1
• IV contrast does not add diagnostic value for acute fracture evaluation and is usually not appropriate 6, 3
• Only one advanced imaging test (either MRI or CT) needs to be performed for a given patient 3