Suspected scaphoid fracture with normal radiographs

ACR AC Acute Hand and Wrist Trauma

Clinical scaphoid tenderness with normal scaphoid-series radiographs. MRI is the definitive next test: it shows the fracture line and the marrow oedema that radiographs cannot, and it either confirms the injury or releases the patient from immobilisation immediately.

Fall on the outstretched hand with anatomical snuffbox or scaphoid tubercle tenderness, and a dedicated scaphoid radiographic series reported as normal.

Referenced decision support — confirm against your local protocol.

Decision support, not a directive. Protocols and timings shown are typical published ones — your local protocol takes precedence, and the vetting radiologist decides.

The request in front of you

Everything is optional. Leave a field alone and the answer assumes nothing — the verdict updates as you go.

Study requested

What the referrer actually asked for. It is evidence of intent, not a constraint on the right answer.

Contrast as written

What the request form says, not what it should say.

Age

Pick a band, or type an exact age if it matters.

years

Pregnancy status

Renal risk factors

The question a vetter can actually answer from the request. An explicit “none known” is a real answer, and it removes checks rather than deferring them.

Previous contrast reaction

The pathway — tap anything already done

Marking a study complete moves the answer on. A patient arrives partway through a pathway far more often than at the start of one.

Accept as requested

MRI Wrist — routine

MRI Wrist and Hand

What we'd amend, and why

MRI detects what radiographs physically cannot: an undisplaced trabecular fracture produces marrow oedema — high signal on the fluid-sensitive sequence, low signal on T1 — long before there is enough cortical disruption or resorption to be visible on a film. It also identifies the bone bruise, the ligament injury and the distal radius fracture that explain the pain when the scaphoid is intact, and it does so on the day rather than at two weeks.

Nothing needs resolving before this goes ahead. Routine checks below are owned downstream.

How was this decided?

pathwayany — All patients
rulerule-mr-device-screening — MR safety screening for implants and foreign bodies; checked by Radiographer at the scanner

Decision support only. Local protocol takes precedence.

Handled at the scanner(1)nothing for you to do

Settled and owned downstream. Each returns to a radiologist only on the stated trigger.

MR safety screening for implants and foreign bodies
Complete the MR safety questionnaire, verify implant labelling and its stated conditions of use against this scanner and this protocol, and ensure no ferromagnetic object enters Zone IV.
Radiographer at the scannerBefore the scan
Flags back if: An implant or retained foreign body that is MR Unsafe, unlabelled, or cannot be identified; or an MR Conditional device whose stated conditions this scanner or the requested protocol cannot satisfy; or a credible unexcluded intraocular metallic foreign body history.
A standard safety questionnaire at attendance covers almost every wrist MRI. If an implant does flag back, CT is a genuinely good substitute for this question — unusually so, because the scaphoid is a small, thin-cortexed bone that thin-section CT depicts well — so the pathway switches modality rather than reverting to a cast and a repeat film.

Pathways

Big forks are separate pathways; the first whose conditions match is the one used.

All patients

Matches your inputsDefault

Role	Study & protocol	Why this answers the question
First line	MRI Wrist and Hand MRI Wrist — routine usually appropriate	MRI detects what radiographs physically cannot: an undisplaced trabecular fracture produces marrow oedema — high signal on the fluid-sensitive sequence, low signal on T1 — long before there is enough cortical disruption or resorption to be visible on a film. It also identifies the bone bruise, the ligament injury and the distal radius fracture that explain the pain when the scaphoid is intact, and it does so on the day rather than at two weeks.
Reasonable alternative	CT Extremity / Musculoskeletal CT Extremity — Unenhanced, Thin Section	Thin-section CT along the scaphoid axis is the alternative where MRI is contraindicated or unavailable, and it is better than MRI for judging displacement, comminution and, later, union. It is less sensitive for the truly occult undisplaced fracture, because it sees cortex rather than marrow.
Second line	Limb radiograph Limb radiograph — two orthogonal views	Delayed repeat radiographs remain the fallback where no cross-sectional imaging is accessible, but they perform poorly: a significant proportion of fractures are still not visible at follow-up, and the strategy keeps a patient immobilised in the meantime. Prefer MRI wherever it can be obtained.

Pitfalls

Treating a normal scaphoid series as excluding a fracture — it does not, which is the entire reason this card exists.
Imaging the wrist with a small field of view centred on the scaphoid and missing the distal radius, triquetral and capitate injuries that account for many of these presentations.
Interpreting isolated marrow oedema without a fracture line as a fracture; bone bruise and fracture are different diagnoses with different management.
Leaving a patient in a cast for weeks waiting for a follow-up radiograph when a short MRI would have answered it the same day.
Missing proximal pole involvement, where the blood supply makes non-union and osteonecrosis far more likely and the surgical decision different.
Discharging the patient out of the splint while the MRI is pending. The whole premise of this card is that a normal radiograph does not exclude the fracture, so the wrist stays immobilised until the study that can exclude it has been done and reported — a same-day scan shortens that immobilisation, it does not replace it.
Reading "wrist radiographs normal" as "scaphoid series normal". Standard wrist views miss scaphoid fractures that a dedicated four-view series shows, and starting the occult-fracture pathway from an incomplete series answers the wrong question — check which views were actually taken before deciding what the negative means.

Priors — what to pull first

Check whether the original radiographs were a dedicated scaphoid series rather than standard wrist views; an incomplete series is a different starting point.
Previous wrist injury or known scaphoid non-union changes the meaning of today’s appearances entirely.

What makes a good request

Roughly the whole point of this pathway is the mismatch between a normal radiograph and a real fracture, because an undiagnosed scaphoid fracture risks non-union and avascular necrosis of the proximal pole.
The alternative to imaging is not "no imaging" — it is several weeks in a cast for a wrist that is usually uninjured. That is the comparison the request should be judged against.
A short, targeted MRI is enough: coronal T1 and a coronal fluid-sensitive sequence answer the question, so scanner time is not a good reason to refuse.

Scoring this once it is done

The classification and risk tools this question ends in.

Ottawa Ankle / Knee / Foot Rules Garden Classification (Femoral Neck Fractures)Salter-Harris Classification (Physeal Fractures)

How these studies are acquired

Contrast, phases and timing for every study on the pathways above.

MRI Wrist — routine CT Extremity — Unenhanced, Thin Section Limb radiograph — two orthogonal views

Confirm locally

MRI Wrist — routine: timings are typical — confirm against local protocol.
Timings, contrast volumes and rates above are typical published values. Your department's protocol, scanner and patient population decide the actual numbers.
Safety thresholds and premedication policy follow local policy where it differs from the cited guidance.

References

Implemented from the cited published sources. Educational and workflow support only; confirm against current guidelines and local policy before clinical use.