Wrist Fracture (Suspected)

Pathway

Images

Image Gallery Note: These images open in a new page
1		Scaphoid Fracture Image 1 (Plain Radiograph): Fracture of the scaphoid bone.
2		Scaphoid Fracture Image 2 (Plain Radiograph): Undisplaced fracture of the scaphoid bone (arrows).
3		Scaphoid Fracture Image 3 (Plain Radiograph): Non-union of scaphoid fracture. Note sclerosis at fracture line.
4		Scaphoid Fracture Image 4 (Computed Tomography): Coronal image of the wrist showing fracture though the proximal waist of scaphoid (arrows).

Teaching Points

Teaching Points

• Early identification of a fracture and the degree of displacement is important to prevent adverse complications such as avascular necrosis, non-union and osteoarthritis. The scaphoid, capitate and lunate are the carpal bones most vulnerable to avascular necrosis. 1 Scaphoid fractures account for 80% of all carpal fractures 2
• The initial diagnostic modality for suspected wrist fractures is plain radiography, 3 but a proportion of fractures are radiographically occult at the time of presentation. In particular, up to 20-30% of scaphoid fractures are initially missed by plain radiographs 4
• Early MRI is the preferred investigation for detecting occult scaphoid and distal radius fractures, and has the advantage of simultaneously evaluating bone marrow abnormalities and surrounding soft tissue injuries 3
• If early MRI is unavailable or contraindicated, CT is an alternative 3
• Depending on local resources, presumptive casting and repeat plain radiography remains an option for suspected scaphoid and distal radius fractures. If follow-up radiographs do not show a fracture but symptoms persist, further imaging with MRI is recommend to investigate for scaphoid fracture or other cause of symptoms 3
• Imaging modality choice will depend on availability and patient factors including age of the fracture, preference, hand dominance and activity level 3
• If CT and MRI resources are limited, use of advanced imaging may be reserved for specific cases where an early answer is required
• Early imaging is preferred as it results in faster identification of fractures and other injuries and reduces unnecessary immobilisation. Early advanced imaging may also be cost-effective compared to immobilisation and repeat radiographs 5,6
• Evaluation of the diagnostic performance of different imaging modalities is limited by the lack of a consensus reference standard
• There is currently a lack of evidence to guide the imaging of suspected scaphoid fractures in children so most current guidelines are based on findings in adults 7

References

References

Date of literature search: April-July 2018

The search methodology is available on request. Email

References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document

1. Kaewlai R, Avery LL, Asrani AV, Abujudeh HH, Sacknoff R, Novelline RA. Multidetector CT of carpal injuries: anatomy, fractures, and fracture-dislocations. Radiographics. 2008;28(6):1771-84. (Review article). View the reference
2. Arsalan-Werner A, Sauerbier M, Mehling IM. Current concepts for the treatment of acute scaphoid fractures. European journal of trauma and emergency surgery : official publication of the European Trauma Society. 2016;42(1):3-10. (Review article). View the reference
3. American College of Radiology. ACR appropriateness criteria. Acute hand and wrist trauma. 2013. (Guideline). View the reference
4. Balci A, Basara I, Cekdemir EY, Tetik F, Aktas G, Acarer A, et al. Wrist fractures: sensitivity of radiography, prevalence, and patterns in MDCT. Emergency radiology. 2015;22(3):251-6. (Level II-III evidence). View the reference
5. Karl JW, Swart E, Strauch RJ. Diagnosis of occult scaphoid fractures: a cost-effectiveness analysis. J Bone Joint Surg Am. 2015;97(22):1860-8. (Level III evidence). View the reference
6. Yin ZG, Zhang JB, Gong KT. Cost-effectiveness of diagnostic strategies for suspected scaphoid fractures. J Orthop Trauma. 2015;29(8):e245-52. (Level II-III evidence). View the reference
7. Offiah AC, Burke D. The diagnostic accuracy of cross-sectional imaging for detecting acute scaphoid fractures in children: a systematic review. Br J Radiol. 2018:20170883. (Level I-II evidence). View the reference
8. Jorgsholm P, Thomsen NO, Besjakov J, Abrahamsson SO, Bjorkman A. The benefit of magnetic resonance imaging for patients with posttraumatic radial wrist tenderness. The Journal of hand surgery. 2013;38(1):29-33. (Level II evidence). View the reference
9. Behzadi C, Karul M, Henes FO, Laqmani A, Catala-Lehnen P, Lehmann W, et al. Comparison of conventional radiography and MDCT in suspected scaphoid fractures. World Journal of Radiology. 2015;7(1):22-7. (Level II-III evidence). View the reference
10. Buijze GA, Jorgsholm P, Thomsen NO, Bjorkman A, Besjakov J, Ring D. Diagnostic performance of radiographs and computed tomography for displacement and instability of acute scaphoid waist fractures. J Bone Joint Surg Am. 2012;94(21):1967-74. (Level II evidence). View the reference
11. Suh N, Grewal R. Controversies and best practices for acute scaphoid fracture management. J Hand Surg Eur Vol. 2018;43(1):4-12. (Review article). View the reference
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13. Low G, Raby N. Can follow-up radiography for acute scaphoid fracture still be considered a valid investigation? Clin Radiol. 2005;60(10):1106-10. (Level II evidence). View the reference
14. Mallee WH, Wang J, Poolman RW, Kloen P, Maas M, de Vet HC, et al. Computed tomography versus magnetic resonance imaging versus bone scintigraphy for clinically suspected scaphoid fractures in patients with negative plain radiographs. Cochrane Database Syst Rev. 2015(6):Cd010023. (Level I evidence). View the reference
15. Arora S, Grover SB, Batra S, Sharma VK. Comparative evaluation of postreduction intra-articular distal radial fractures by radiographs and multidetector computed tomography. J Bone Joint Surg Am. 2010;92(15):2523-32. (Level II-III evidence). View the reference
16. Lozano-Calderon S, Blazar P, Zurakowski D, Lee SG, Ring D. Diagnosis of scaphoid fracture displacement with radiography and computed tomography. Diagnosis of scaphoid fracture displacement with radiography and computed tomography. View the reference
17. Singh HP, Taub N, Dias JJ. Management of displaced fractures of the waist of the scaphoid: meta-analyses of comparative studies. Injury. 2012;43(6):933-9. (Level I evidence). View the reference
18. Suzuki D, Ono H, Furuta K, Katayama T, Akahane M, Omokawa S, et al. Comparison of scapholunate distance measurements on plain radiography and computed tomography for the diagnosis of scapholunate instability associated with distal radius fracture. J Orthop Sci. 2014;19(3):465-70. (Level III evidence). View the reference
19. Kleinlugtenbelt YV, Madden K, Groen SR, Ham SJ, Kloen P, Haverlag R, et al. Can experienced surgeons predict the additional value of a CT scan in patients with displaced intra-articular distal radius fractures? Strategies in Trauma and Limb Reconstruction. 2017;12(2):91-7. (Level III evidence). View the reference
20. Ecker J. Scaphoid union: the role of wrist arthroscopy. Hand Clin. 2017;33(4):677-86. (Review article). View the reference
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22. Biswas D, Bible JE, Bohan M, Simpson AK, Whang PG, Grauer JN. Radiation exposure from musculoskeletal computerized tomographic scans. J Bone Joint Surg Am. 2009;91(8):1882-9. (Level II evidence). View the reference
23. Carpenter CR, Pines JM, Schuur JD, Muir M, Calfee RP, Raja AS. Adult scaphoid fracture. Acad Emerg Med. 2014;21(2):101-21. (Review article). View the reference
24. Patel NK, Davies N, Mirza Z, Watson M. Cost and clinical effectiveness of MRI in occult scaphoid fractures: a randomised controlled trial. Emerg Med J. 2013;30(3):202-7. (Level III evidence). View the reference
25. Khalid M, Jummani ZR, Kanagaraj K, Hussain A, Robinson D, Walker R. Role of MRI in the diagnosis of clinically suspected scaphoid fracture: analysis of 611 consecutive cases and literature review. Emerg Med J. 2010;27(4):266-9. (Level II evidence). View the reference
26. Brydie A, Raby N. Early MRI in the management of clinical scaphoid fracture. Br J Radiol. 2003;76(905):296-300. (Level II evidence). View the reference
27. McCullough NP, Smith FW, Cooper JG. Early MRI in the management of the clinical scaphoid fracture. Eur J Emerg Med. 2011;18(3):133-6. (Level II-III evidence). View the reference
28. Magee T. Comparison of 3-T MRI and arthroscopy of intrinsic wrist ligament and TFCC tears. AJR Am J Roentgenol. 2009;192(1):80-5. (Level II evidence). View the reference
29. Jorgsholm P, Thomsen NO, Bjorkman A, Besjakov J, Abrahamsson SO. The incidence of intrinsic and extrinsic ligament injuries in scaphoid waist fractures. The Journal of hand surgery. 2010;35(3):368-74. (Level II-III evidence). View the reference
30. Thavarajah D, Syed T, Shah Y, Wetherill M. Does scaphoid bone bruising lead to occult fracture? A prospective study of 50 patients. Injury. 2011;42(11):1303-6. (Level III evidence). View the reference
31. La Hei N, McFadyen I, Brock M, Field J. Scaphoid bone bruising--probably not the precursor of asymptomatic non-union of the scaphoid. J Hand Surg Eur Vol. 2007;32(3):337-40. (Level III evidence). View the reference
32. Cerezal L, Abascal F, Canga A, Garcia-Valtuille R, Bustamante M, del Pinal F. Usefulness of gadolinium-enhanced MR imaging in the evaluation of the vascularity of scaphoid nonunions. AJR Am J Roentgenol. 2000;174(1):141-9. (Level II-III evidence). View the reference
33. Schmitt R, Christopoulos G, Wagner M, Krimmer H, Fodor S, van Schoonhoven J, et al. Avascular necrosis (AVN) of the proximal fragment in scaphoid nonunion: is intravenous contrast agent necessary in MRI? Eur J Radiol. 2011;77(2):222-7. (Level II evidence). View the reference
34. Megerle K, Worg H, Christopoulos G, Schmitt R, Krimmer H. Gadolinium-enhanced preoperative MRI scans as a prognostic parameter in scaphoid nonunion. J Hand Surg Eur Vol. 2011;36(1):23-8. (Level III evidence). View the reference
35. Dailiana ZH, Zachos V, Varitimidis S, Papanagiotou P, Karantanas A, Malizos KN. Scaphoid nonunions treated with vascularised bone grafts: MRI assessment. Eur J Radiol. 2004;50(3):217-24. (Level III evidence). View the reference
36. Memarsadeghi M, Breitenseher MJ, Schaefer-Prokop C, Weber M, Aldrian S, Gabler C, et al. Occult scaphoid fractures: comparison of multidetector CT and MR imaging--initial experience. Radiology. 2006;240(1):169-76. (Level III evidence). View the reference
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