Scaphoid Injury Workup
- Author: Scott R Laker, MD; Chief Editor: Stephen Kishner, MD, MHA more...
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No laboratory studies are indicated for the diagnosis of scaphoid fracture.
When a scaphoid fracture is suggested on physical examination, a scaphoid series (including a posteroanterior [PA] view with the wrist in ulnar deviation) should be ordered, because routine wrist anteroposterior (AP), lateral, and oblique views may not show the fracture. Based on retrospective studies and cadaveric review, the most sensitive radiographic evaluation includes 4 views: PA, lateral, pronated oblique (60° pronated oblique), and ulnar deviated oblique (also described as 60° supinated oblique).[2, 3]
Comparison views of the contralateral wrist may be necessary. Importantly, as many as 25% of scaphoid fractures are not evident on initial radiographs. Much research has been performed to determine if this conventional wisdom still holds true.
If the radiographs are equivocal and it is important for an athlete to return to competition without waiting 7-14 days for repeated radiographs, a bone scan may be obtained after 24 hours, which almost always settles the issue.
A study by Hannemann et al indicated that in terms of revealing the union of nondisplaced scaphoid waist fractures after 6 weeks of cast immobilization, conventional radiography has an average sensitivity and specificity of 65% and 67%, respectively, as well as positive and negative predictive values of 93% and 22%, respectively.
Tibrewal et al conclude that magnetic resonance imaging (MRI) is the most effective imaging tool for diagnosing a clinically suspected scaphoid fracture.[6, 7]
A prospective, noncontrolled study by Bervian et al indicated that in cases of scaphoid fracture nonunion, the presence of marked low signal intensity on T1-weighted MRI scans and the absence intraoperatively of punctate bone bleeding strongly suggest osteonecrosis of the proximal fragment.
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If a diagnosis still cannot be confirmed with confidence on routine films, a technetium-99m ( 99m Tc) bone scan or a magnetic resonance imaging (MRI) scan of the wrist is recommended, in that order of preference. [4, 9]
One prospective study found that bone scans performed 3-7 days postinjury are 92% sensitive and 87% specific. Another prospective study found minimal interobserver and intraobserver variability. 
MRI is increasingly used because it offers several distinct advantages; specifically, the modality is noninvasive and readily available, and it can assess bone healing and evaluate for bone contusions and ligamentous injuries. [11, 12]
A British study looked into the cost effectiveness of MRI and found that the direct cost of the modality did not significantly increase health care costs; additionally, when accounting for productivity losses incurred by unnecessary casting, MRI was found to be much more cost effective.  MRI sensitivity and specificity have been reported as 100% and 96.3%, respectively, in the acute setting of suspected scaphoid fracture.  Several articles suggest that MRI is a very reasonable next step in cases in which fracture is highly suspected despite initial negative radiographic findings.
Computed tomography (CT) scanning has very good interobserver and intraobserver reliability, although fractures with less than 1 mm of displacement are often not detected.  Its sensitivity and specificity are estimated to be 100% when used 5-10 days postinjury. Bone scanning sensitivity was noted to be 78% in this study.
High-resolution ultrasonography is also being investigated for the diagnosis of scaphoid fracture, but it relies heavily on the technical skill of the examiner. 
Intrasound vibration examination also has been used to detect the occult, undiagnosed scaphoid fracture. 
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