Is there a specific type of X-ray (X-ray) for Fall On Outstretched Hand (FOOSH) injuries or suspected scaphoid fractures?

Imaging Protocol for FOOSH Injuries and Suspected Scaphoid Fractures

Yes, there is a specific radiographic protocol: begin with a minimum 4-view X-ray series that includes posteroanterior (PA), lateral, 45° semipronated oblique, and a dedicated "scaphoid view" (PA in ulnar deviation), as this increases diagnostic yield for both distal radius and scaphoid fractures compared to standard 3-view series. 1, 2

Initial Radiographic Protocol

The American College of Radiology establishes that standard wrist trauma evaluation requires more than just 2 views, which are inadequate for detecting fractures. 2 The recommended approach includes:

• Posteroanterior (PA) view in neutral position and rotation 2
• Lateral view with wrist neutral to demonstrate malalignments and soft-tissue swelling 2, 3
• 45° semipronated oblique view 1, 4
• Dedicated scaphoid view (PA in ulnar deviation) - this fourth projection significantly increases diagnostic yield for scaphoid injuries that would otherwise be missed 1, 2

The scaphoid view is critical because it may reveal an otherwise radiographically occult fracture by elongating the scaphoid and improving visualization. 1 Survey data shows that 64.3% of hospitals perform four views for suspected scaphoid fractures, with the lateral neutral and PA ulnar deviation views considered most useful by both orthopedic surgeons (87.8% and 51.5% respectively) and radiologists (84.2% and 52.6% respectively). 3

When Initial X-rays Are Negative But Clinical Suspicion Remains High

If the 4-view X-ray series is negative but you have high clinical suspicion (positive anatomic snuffbox tenderness, scaphoid tubercle tenderness, or positive Kanawel sign), proceed directly to MRI without IV contrast rather than casting and waiting 10-14 days for repeat X-rays. 1, 4

Why MRI is Preferred Over Traditional "Cast and Wait" Approach:

• MRI without IV contrast has the highest sensitivity (94.2%) and specificity (97.7%) for detecting radiographically occult scaphoid fractures 1, 2, 4
• MRI detects bone marrow edema, bone bruises, and concomitant ligamentous injuries (particularly scapholunate ligament tears) that may affect surgical treatment 5, 1, 4
• Cross-sectional imaging reduces time to diagnosis from 24.1 ± 17.2 days (with serial X-rays) to 9.8 ± 5.8 days, minimizing unnecessary immobilization 6
• The traditional approach of casting for 10-14 days and repeating radiographs results in delayed diagnosis, which may lead to functional impairment 5

Alternative Advanced Imaging Options:

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

• Provides high-detail imaging of bone cortex and trabeculae 1, 4
• Shorter acquisition times than MRI 1, 4
• Easier to perform in patients who are already casted 1
• Particularly useful for suspected hook of hamate fractures 1, 4
• However, unlike MRI, CT cannot evaluate concomitant ligamentous injuries 5

Bone scintigraphy can be considered if MRI/CT unavailable:

• High sensitivity for excluding occult scaphoid fractures 1, 4
• Lower specificity compared to CT and MRI due to uptake from bone contusions and osteoarthritis 4, 7
• May be reasonable for claustrophobic patients 1
• Long-term follow-up shows no cases of nonunion when managed according to bone scan results 7

Critical Pitfalls to Avoid

Do not rely on only 2 views - this is inadequate for detecting wrist fractures and will miss significant pathology. 2 Even standard 3-view series can miss scaphoid fractures without the dedicated scaphoid view. 1

Do not use ultrasound for early diagnosis - despite one study showing 98.04% accuracy 8, the American College of Radiology reports only 47% sensitivity and 61% specificity, concluding that ultrasound is not suitable for early diagnosis of scaphoid fracture. 5 Another study showed moderate sensitivity (81.5%) and lower specificity (77.4%). 1

Do not order CT or MRI with IV contrast - there is no evidence to support the use of IV contrast in acute hand and wrist trauma, and it provides no added benefit. 5, 1

Look for associated injuries on initial radiographs:

• Scapholunate diastasis >4 mm suggests dorsal intercalated segmental instability 5, 4
• Dorsal tilt of lunate >10° indicates instability 5, 4
• Fracture displacement >1-2 mm indicates unstable fracture requiring different management 4, 9

Proposed Efficient Protocol

For patients with worsening pain despite negative initial X-rays, or when clinical suspicion remains high after proper 4-view series, obtain MRI immediately rather than waiting weeks in a cast. 2, 6 One proposed protocol suggests two episodes of X-ray separated by 7 days, followed by a single MRI if clinical suspicion remains, to minimize unnecessary immobilization while being cost-conscious. 6