How to report wrist injuries, and not to miss scaphoid fractures

Image showing scaphoid Stripe sign

Scaphoid fractures are among the most frequently missed injuries in emergency and radiology departments. Their subtle presentation and limitations of standard imaging contribute to diagnostic challenges. (Medscape)

Scaphoid fractures are the most commonly missed carpal bone fractures. Studies indicate that up to 25% of scaphoid fractures are not visible on initial plain radiographs . Factors contributing to missed diagnoses include inadequate imaging views and subtle fracture lines.(imj.ie, NCBI, Wikipedia)

Standard wrist radiographs typically include posteroanterior (PA) and lateral views. However, these may not adequately visualize the scaphoid. Dedicated scaphoid views, such as PA with ulnar deviation and oblique projections, are essential for optimal assessment . Clinicians should specify the need for scaphoid views when scaphoid injury is suspected.(ScienceDirect, MDPI)

Even with appropriate views, scaphoid fractures may remain occult on initial imaging. Estimates suggest that up to 25% of scaphoid fractures are not evident on initial plain radiographs . This underscores the importance of clinical vigilance and consideration of follow-up imaging when suspicion persists.(AAFP, NCBI)

To improve detection of scaphoid fractures:

• Image Magnification: Zooming in on the scaphoid region can reveal subtle cortical disruptions.(Medscape)
• Edge Enhancement: Adjusting window settings may enhance visualization of fracture lines.
• Soft Tissue Assessment: Evaluate for signs such as the scaphoid fat stripe sign, which may indicate underlying injury.(PubMed)

The scaphoid fat stripe sign is a radiological indicator of potential scaphoid fracture. It appears as a linear lucency adjacent to the scaphoid on PA and oblique views. Displacement or obliteration of this stripe suggests underlying pathology. In pediatric populations, the sign has shown a sensitivity of 86% and specificity of 58% .(MDPI)

When interpreting wrist radiographs:

• Standard Views: If only PA and lateral views are available, and clinical suspicion remains, recommend dedicated scaphoid views. Suggested statement: "If clinical suspicion for scaphoid fracture persists, dedicated scaphoid views are recommended."
• Negative Scaphoid Views: If dedicated scaphoid views are negative but suspicion remains, suggest further imaging. Suggested statement: "If clinical suspicion for scaphoid fracture persists despite negative scaphoid views, repeat radiographs in 7–10 days, or advanced imaging with CT or MRI, are recommended based on local protocols."

Accurate diagnosis of scaphoid fractures requires a combination of appropriate imaging techniques and clinical awareness. By utilizing dedicated scaphoid views, enhancing image evaluation, and recognizing subtle signs such as the scaphoid fat stripe, clinicians can reduce the risk of missed diagnoses and improve patient outcomes.(SAGE Journals)