Diagnosis of scaphoid fracture: optimal imaging techniques

Abstract

This review aims to provide an overview of modern imaging techniques for evaluation of scaphoid fracture, with emphasis on occult fractures and an outlook on the possible evolution of imaging; it also gives an overview of the pathologic and anatomic basis for selection of techniques. Displaced scaphoid fractures detected by wrist radiography, with or without special scaphoid views, pose no diagnostic problems. After wrist trauma with clinically suspected scaphoid fracture and normal scaphoid radiography, most patients will have no clinically important fracture. Between 5% and 19% of patients (on average 16% in meta-analyses) will, however, have an occult scaphoid fracture which, untreated, may lead to later, potentially devastating, complications. Follow-up imaging may be done with repeat radiography, tomosynthesis, computed tomography, magnetic resonance imaging (MRI), or bone scintigraphy. However, no method is perfect, and choice of imaging may be based on availability, cost, perceived accuracy, or personal preference. Generally, MRI and bone scintigraphy are regarded as the most sensitive modalities, but both are flawed by false positive results at various rates.

MR imaging of scaphoid fractures. Fat-saturated T2-weighted and Short tau inversion recovery images.

“…Fat suppression, an essential technique in MR imaging is used to improve depiction of bone marrow edema, determining the lipid content by suppressing the bright fat signal on T2 weighted fast spin echo images, thus improving the contrast resolution for resolving the bright fluid signal of bone marrow edema, [1][2][3][4] hereby bone marrow edema appears as a hyper intense area on proton density and T2 weighted sequences. Bone bruise is a term for a bone marrow edema, caused by a traumatic injury (micro-trabecular fractures) sustained from a forceful impact during sports, accidents or a direct hit.…”

“…The best way to help healing is to rest, support, and protect the bone or joint involved, and to apply conventional treatments for trauma. [1][2][3][5][6][7][8][9][10][11][12][13][14] Identifying and locating the bone bruise are important for many reasons, knowing that a bone bruise on a T2 fat saturated image in conjunction with a fracture line on a T1 weighted image will set the diagnose for a fracture (however, a fat saturated sequence cannot stand alone for the diagnosis of a fracture). 3,6 Pseudoarthrosis, osteoarthrosis, avascular necrosis and chronic wrist pain, are potential consequences of undiagnosed fractures.…”

“…3,6 Pseudoarthrosis, osteoarthrosis, avascular necrosis and chronic wrist pain, are potential consequences of undiagnosed fractures. [2][3][4][5][6]8 Therefore, a standardized method for diagnostic and treatment purposes is important. Visualization of bone bruise is not only indispensable for identifying a fracture, it may also be the only pathological finding that explains a patient's symptoms.…”

“…Also, the location and radiation pattern may indicate the point from which the trauma arises. [1][2][3][5][6][7][8][9][10][11][12][13][14] MRI offers a variety of sequences that are appropriate for examining a bone bruise, 4 STIR, FAT SAT, Hybrid and Dixon are some of the most commonly used fat suppression techniques. The use of high-field-strength MRI in musculoskeletal imaging has become increasingly more common, resulting in higher Signal-to-Noise Ratio (SNR) and wider chemical shifts between fat and water signals.…”

“…Articles states the importance of an early MRI and hereby predict bone bruise with help from a fat suppression sequence. [1][2][3]5,[7][8][9][10][11]14 To ensure the best composition for diagnosis, medical professionals should be aware of the advantages and clinical considerations of the various sequences. However, only a limited selection of published articles that compare the various fat suppression techniques, were found.…”