A 30 year old previously healthy man presented to the emergency depament immediately after being involved in a road traffic accident. After clinical examination, scaphoid injury was suspected. A radiograph of the left wrist was obtained and found to be equivocal. What is the best next step?
If initial imaging fails to show a fracture, the hand or wrist is often put in a cast before any fuher imaging, with the presumption that there is a fracture (presumptive casting). The British college recommends magnetic resonance imaging (MRI) as the second line approach, with bone scintigraphy and computed tomography as alternatives. The US college ors MRI or presumptive casting with repeat radiography to detect subsequently formed fracture lines; it also suggests computed tomography as a third line option. Scaphoid fractures should be suspected with trauma involving the hand and/or wrist, paicularly falls onto an outstretched hand and road traffic incidents. Such fractures most commonly occur among men aged 20-30 years, with about 10% presenting with an associated fracture. Less than 20% of patients with a clinically suspected scaphoid fracture have a true fracture. First step: Radiography of wrist, including at least a posteroanterior, lateral, and semi-pronated oblique. The ACR recommends the inclusion of a fouh view: a posteroanterior projection with ulnar detion and/or cephalad tube angulation (scaphoid view) if a scaphoid fracture is suspected. Ref: Investigating suspected scaphoid fracture ; BMJ 2013;346:f1370.
CT Scan
MRI Scan
Presumptive Casting
Bone scintigraphy of wrist