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Suspected occult scaphoid fracture — MSRA MCQ

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ModerateMRISuspected occult scaphoid fractureMSRA

A 29-year-old right-hand-dominant woman attends an urgent treatment centre 4 hours after falling onto her outstretched right hand while roller-skating. She has radial-sided wrist pain and swelling. Examination shows tenderness in the anatomical snuffbox and over the scaphoid tubercle. Wrist movement is painful, but there is no deformity, neurovascular deficit or open injury. Four-view scaphoid radiographs show no fracture. She has no contraindication to MRI. What is the most appropriate next investigation and initial management plan?

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Correct answer: A — Immobilise the wrist and arrange MRI of the wrist as the first-line definitive investigation

This is a clinically suspected scaphoid fracture: a fall onto an outstretched hand followed by anatomical snuffbox and scaphoid-tubercle tenderness is sufficiently concerning despite normal initial scaphoid radiographs. NICE recommends considering MRI as first-line imaging after thorough clinical examination in people with suspected scaphoid fracture. The wrist should remain immobilised while definitive assessment is arranged. CT is useful where MRI is contraindicated or may be needed for operative planning, but it is not the preferred first-line test in this situation. Repeat radiographs after 10 to 14 days are a traditional pathway, but delay definitive diagnosis and are less sensitive than MRI for occult fracture. Delaying MRI until persistent symptoms likewise prolongs unnecessary immobilisation for people without fracture and may delay diagnosis in those with one. Discharge without further imaging is inappropriate because missed scaphoid fractures can have important longer-term consequences, including non-union and osteoarthritis.

Reference: NICE NG38: Fractures (non-complex): assessment and management, recommendation 1.2.3 (17 February 2016) — https://www.nice.org.uk/guidance/NG38/chapter/recommendations NICE NG38 evidence: Fractures (non-complex), acute-stage assessment and diagnostic imaging (2016) — https://www.nice.org.uk/guidance/ng38/evidence/full-guideline-2358460765