Mateusz Gładysz FESSH prep

FESSH prep Wrist trauma Scaphoid imaging

Scaphoid fracture diagnosis and imaging

Last reviewed v2.0

FESSH-026Wrist trauma●●○ intermediate

Regarding the clinical assessment and imaging of suspected acute scaphoid fractures in adults:

  1. 1.Anatomical snuffbox tenderness is sensitive but non-specific for scaphoid fracture in isolation; combining it with scaphoid tubercle tenderness and longitudinal thumb compression substantially improves predictive value.

  2. 2.CT is the gold-standard imaging modality for detecting radiographically occult scaphoid fractures.

  3. 3.Among MRI, CT and bone scintigraphy, MRI offers the best balance of sensitivity and specificity for detecting radiographically occult scaphoid fracture.

  4. 4.Bone scintigraphy reliably detects scaphoid fractures within 24 hours of injury.

  5. 5.If initial radiographs are negative, wrist immobilisation should be discontinued pending advanced imaging.

FESSH marking: +1 per correct statement, 0 for blank, −1 for incorrect. Click the same TRUE/FALSE button twice to clear it.

Question ID
FESSH-026
First published
Last reviewed
Version
v2.0
Answer key and explanations — open after answering

  1. 1. Anatomical snuffbox tenderness is sensitive but non-specific for scaphoid fracture in isolation; combining it with scaphoid tubercle tenderness and longitudinal thumb compression substantially improves predictive value.

    True

    Mallee and colleagues' meta-analysis confirmed that each clinical sign in isolation is sensitive but non-specific. Duckworth and colleagues identified four independent predictors of true fracture — male sex, sports mechanism, snuffbox pain on ulnar deviation within 72 hours, and tubercle tenderness at two weeks; with all four present the post-test probability of fracture rose to 91%, while absence of snuffbox pain on ulnar deviation within 72 hours had a perfect negative predictive value in their cohort.

    • Mallee WH, Henny EP, van Dijk CN, Kamminga SP, van Enst WA, Kloen P. Clinical diagnostic evaluation for scaphoid fractures: a systematic review and meta-analysis. J Hand Surg Am. 2014;39(9):1683-1691.e2. PMID 25091335
    • Duckworth AD, Buijze GA, Moran M, Gray A, Court-Brown CM, Ring D, et al.. Predictors of fracture following suspected injury to the scaphoid. J Bone Joint Surg Br. 2012;94(7):961-968. PMID 22733954

  2. 2. CT is the gold-standard imaging modality for detecting radiographically occult scaphoid fractures.

    False

    MRI, not CT, is the contemporary first-line imaging modality after negative radiographs in suspected occult fracture. NICE NG38 advises clinicians to consider MRI as first-line imaging on cost-effectiveness grounds, since early definitive diagnosis avoids prolonged unnecessary immobilisation. CT is reserved for assessing displacement, fracture morphology and union once a fracture is known.

    • National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. NICE guideline NG38. National Institute for Health and Care Excellence. 2016.
    • Clementson M, Björkman A, Thomsen NOB. Acute scaphoid fractures: guidelines for diagnosis and treatment. EFORT Open Rev. 2020;5(2):96-103. PMID 32175096

  3. 3. Among MRI, CT and bone scintigraphy, MRI offers the best balance of sensitivity and specificity for detecting radiographically occult scaphoid fracture.

    True

    The Mallee Cochrane review reported pooled summary sensitivity and specificity of 0.88 and 1.00 for MRI versus 0.72 and 0.99 for CT, with bone scintigraphy more sensitive (0.99) but considerably less specific (0.86). The over-treatment rate associated with scintigraphy makes it an inferior gatekeeper for a low-prevalence presentation, leaving MRI the practical first-line modality.

    • Mallee WH, Wang J, Poolman RW, Kloen P, Maas M, de Vet HCW, 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;2015(6):CD010023. PMID 26045406
    • Yin ZG, Zhang JB, Kan SL, Wang XG. Diagnostic accuracy of imaging modalities for suspected scaphoid fractures: meta-analysis combined with latent class analysis. J Bone Joint Surg Br. 2012;94(8):1077-1085. PMID 22844049

  4. 4. Bone scintigraphy reliably detects scaphoid fractures within 24 hours of injury.

    False

    Bone scintigraphy requires 48–72 hours post-injury to achieve high sensitivity and has lower specificity than MRI in the Cochrane pooled evidence. It has therefore been displaced from contemporary occult-fracture pathways in favour of MRI.

    • Mallee WH, Wang J, Poolman RW, Kloen P, Maas M, de Vet HCW, 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;2015(6):CD010023. PMID 26045406

  5. 5. If initial radiographs are negative, wrist immobilisation should be discontinued pending advanced imaging.

    False

    BSSH/GIRFT standards stipulate a four-view scaphoid radiograph series at presentation followed by structured clinical reassessment, with thumb-spica or below-elbow immobilisation maintained until advanced imaging excludes a fracture. NICE NG38 advises MRI as first-line advanced imaging when suspicion persists; immobilisation continues until the imaging is performed.

    • British Society for Surgery of the Hand. BSSH Trauma Standards: Management of Scaphoid Fractures. British Society for Surgery of the Hand (in partnership with Getting It Right First Time). 2024.
    • National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. NICE guideline NG38. National Institute for Health and Care Excellence. 2016.