While guidelines recommend CT imaging for suspected scaphoid fractures occult to X-ray within three to five days, CT may miss significant scapholunate ligament injuries and may falsely reassure clinicians who may neglect to splint and arrange follow-up for these patients.^12,17 Another imaging strategy option is to obtain a scaphoid cone view X-ray, immobilize the patient’s wrist in a removable splint or radial-gutter plaster splint, and arrange follow-up in 10 to 14 days for re-examination and repeat X-ray if necessary.

Next time you are chatting with a colleague or resident, ask them what they think the most common occult fracture of the wrist is. Chances are they’ll be surprised to learn that the answer is distal radius fracture.

Many thanks to Dr. Arun Sayal and Dr. Matt Distefano for their tag-teamed contributions to the EM Cases podcast which inspired this column.

Dr. Helman is an emergency physician at North York General Hospital in Toronto. He is an assistant professor at the University of Toronto, Division of Emergency Medicine, and the education innovation lead at the Schwartz/Reisman Emergency Medicine Institute. He is the founder and host of Emergency Medicine Cases podcast and website.

References

1. Ferguson R, Riley ND, Wijendra A, et al. Wrist pain: a systematic review of prevalence and risk factors, what is the role of occupation and activity? BMC Musculoskelet Disord. 2019;20(1):542.
2. Abraham MK, Scott S. The emergent evaluation and treatment of hand and wrist injuries. Emerg Med Clin North Am. 2010;28(4):789-809.
3. Dóczi J, Springer G, Renner A, et al. Occult distal radial fractures. J Hand Surg Br. 1995;20(5):614-7.
4. Glickel SZ, Hinojosa L, Eden CM, et al. Predictive power of distal radial metaphyseal tenderness for diagnosing occult fracture. J Hand Surg Am.2017;42(10):835.e1-835.e4.
5. Kazemian GH, Bakhshi H, Lilley M, et al. DRUJ instability after distal radius fracture: a comparison between cases with and without ulnar styloid fracture. Int J Surg. 2011;9(8):648-51.
6. Mirghasemi AR, Lee DJ, Rahimi N, et al. Distal radioulnar joint instability. Geriatr Orthop Surg Rehabil. 2015;6(3):225-9.
7. Mandegaran R, Gidwani S, Zavareh A. Concomitant hook of hamate fractures in patients with scaphoid fracture: more common than you might think. Skeletal Radiol. 2018;47(4):505-10.
8. Kim H, Kwon B, Kim J, et al. Isolated hook of hamate fracture in sports that require a strong grip comprehensive literature review. Medicine (Baltimore).2018;97(46):e13275.
9. Andresen R, Radmer S, Scheufler O, et al. Optimierung von konventionellen Röntgenaufnahmen zur Erkennung von Hamulus ossis hamati Frakturen [Optimization of conventional X-ray images for the detection of hook of hamate fractures]. [German] Rontgenpraxis. 2006;56(2):59-65.
10. Neill A. Anatomy for emergency medicine 018: EM Ireland website. Published June 11, 2012. Accessed February 16, 2024.
11. Dietrich TJ, Toms AP, Cerezal L, et al. Interdisciplinary consensus statements on imaging of scapholunate joint instability. Eur Radiol. 2021;31(12):9446-58.
12. Clementson M, Björkman A, Thomsen NOB. Acute scaphoid fractures: guidelines for diagnosis and treatment. EFORT Open Rev. 2020;5(2):96-103.
13. Parvizi J, Wayman J, Kelly P, et al. Combining the clinical signs improves diagnosis of scaphoid fractures. A prospective study with follow-up. J Hand Surg Br. 1998;23(3):324-7.
14. Duckworth AD, Buijze GA, Moran M, et al. Predictors of fracture following suspected injury to the scaphoid. J Bone Joint Surg Br. 2012;94(7):961-8.
15. Cohen A, Reijman M, Kraan GA, et al. Clinically suspected scaphoid fracture: treatment with supportive bandage or cast? ‘Study protocol of a multicenter randomized controlled trial’ (SUSPECT study). BMJ Open. 2020;10(9):e036998.
16. Carpenter CR, Pines JM, Schuur JD, et al. Adult scaphoid fracture. Acad Emerg Med. 2014;21(2):101-21.
17. Pappou IP, Basel J, Deal DN. Scapholunate ligament injuries: a review of current concepts. Hand (NY). 2013;8(2):146-56.