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(Radiology. 2001;220:231-235.)
© RSNA, 2001

Emergency Radiology

Scaphoid Fractures: Evaluation with High-Spatial-Resolution US—Initial Results1

Andreas M. Herneth, MD, Alexander Siegmeth, MD, Till R. Bader, MD, Ahmed Ba-Ssalamah, MD, Gerhard Lechner, MD, Viktor M. Metz, MD and Florian Grabenwoeger, MD

1 From the Department of Radiology (A.M.H., T.R.B., A.B., G.L., V.M.M., F.G.) and Clinic for Trauma Surgery (A.S.), University of Vienna, Wahringer Gurtel 18-20, AKH-7F, A-1090 Vienna, Austria. From the 1999 RSNA scientific assembly. Received September 22, 2000; revision requested October 27; revision received January 5, 2001; accepted February 6. Address correspondence to A.M.H. (e-mail: andreas.herneth@univie.ac.at).


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
PURPOSE: To evaluate the diagnostic accuracy of high-spatial-resolution ultrasonography (US) in the diagnosis of scaphoid fractures.

MATERIALS AND METHODS: In 72 hours after acute wrist trauma, 15 consecutive patients were examined for possible scaphoid fractures clinically and with conventional radiographs, including scaphoid views. Thereafter, high-spatial-resolution US was performed by two experienced radiologists blinded to the results of the previously performed investigations. High-spatial-resolution US of the scaphoid bones was performed from the palmar, lateral, and dorsal directions in the longitudinal and transverse planes. US findings indicative of a scaphoid fracture were cortical discontinuity and/or periosteal elevation. Finally, magnetic resonance (MR) images (short inversion time inversion-recovery, T1- and T2*-weighted) (ie, the standard) of the affected wrist were obtained and evaluated for a possible scaphoid fracture by two radiologists in consensus.

RESULTS: Nine of 15 patients had scaphoid fractures. Seven (78%) of nine patients had positive findings at high-spatial-resolution US and five (56%) had such findings at conventional radiography (ie, four occult scaphoid fractures), with an accuracy of 87% and 73%, respectively. Two (50%) of four radiographically occult scaphoid fractures were depicted with high-spatial-resolution US. Sonographic findings of scaphoid fractures were either cortical discontinuity (n = 4), periosteal elevation (n = 2), or a combination of these two findings (n = 1).

CONCLUSION: High-spatial-resolution US is a reliable diagnostic tool for the evaluation of occult scaphoid fractures and should be considered an adequate alternative diagnostic tool prior to computed tomography or MR imaging.

Index terms: Wrist, fractures, 4331.41 • Wrist, MR, 4331.121411, 4331.121412, 4331.121413 • Wrist, radiography, 4331.11 • Wrist, US, 4331.12989


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Fractures of the carpal bones are common after distal forearm or wrist trauma (1,2). Among these fractures, scaphoid fractures are by far the most frequently observed and may lead to long-lasting sequelae. Early diagnosis of these fractures is crucial to initiate adequate therapy, which may help to prevent complications such as delayed healing, nonunion, pseudarthrosis, avascular necrosis, and arthrosis of the wrist (2–5).

The diagnosis of a scaphoid fracture can usually be established with clinical presentation and conventional radiographs. In cases of negative or equivocal findings, additional projections (ie, scaphoid views) and/or magnification views have been reported (1,6–8) to increase sensitivity. However, immediately after injury, up to 65% of scaphoid fractures remain radiographically occult. Thus, in patients with proved scaphoid fractures and those suspected of having scaphoid fractures (ie, occult scaphoid fractures), the wrist should be placed in a scaphoid cast for at least 10 days, until the scaphoid fracture is ruled out with follow-up radiographs (1,7–13). This strategy, however, means that some patients without a fracture would have their wrist immobilized for several days, which is inappropriate and results in both a reduction in the quality of life and an increase in health care costs (14–16).

In cases of clinically suspected scaphoid fractures with negative or equivocal findings on conventional radiographs obtained immediately after trauma, other diagnostic tools such as scintigraphy, computed tomography (CT), intrasound vibration (ie, transcutaneous application of audible vibrations by using a 200–8,500-Hz probe placed on the snuff box, which is reported to cause pain in patients with a scaphoid fracture), and sonography have been proposed as second-line diagnostic tools (17–24). Because of its excellent sensitivity (95%–100%) and specificity (100%), magnetic resonance (MR) imaging has been advocated as the imaging modality of choice in these patients (4,14,18,25–27).

High-spatial-resolution ultrasonography (US), however, may be an alternative imaging modality in patients with occult scaphoid fractures. Technical improvements in sonography have led to higher spatial resolution of this diagnostic tool, and, thus, high-spatial-resolution US may depict subtle posttraumatic changes of the cortex and/or periosteum, which may already be present immediately after the injury but which are not depicted on conventional radiographs (28). Furthermore, high-spatial-resolution US, compared with MR imaging, is more readily accessible, less time-consuming, and considerably less expensive.

The purpose of this prospectively designed study was to determine the diagnostic accuracy of high-spatial-resolution US in the detection of occult scaphoid fractures in patients after acute wrist trauma.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Fifteen consecutive patients (eight women, seven men; median age, 23.5 years; age range, 15.8–55.2 years) were prospectively examined for a possible scaphoid fracture with clinical examination, conventional radiography, high-spatial-resolution US, and MR imaging, in 72 hours after acute wrist trauma.

Scaphoid fracture was clinically suspected if pain, swelling, restriction of wrist motion, and tenderness at the anatomic snuff box were present (1,5,6,16,29). At our institution, the standard protocol for radiologic work-up of a possible scaphoid fracture consists of the acquisition of several conventional radiographs as follows: posteroanterior view, lateral view, semipronated oblique scaphoid view, radial oblique scaphoid view, and posteroanterior view with the wrist in ulnar deviation (1,7,9,20,24,30). The conventional radiographs were read in consensus by a trauma surgeon (A.S.) and a radiologist (F.G.).

After written informed consent was obtained, high-spatial-resolution US of the scaphoid bone was performed by one of two radiologists (A.M.H., T.R.B.) who were blinded to the results of the clinical investigation and the initially obtained conventional radiographs. According to our national and institutional guidelines for ethical review, institutional review board approval was not necessary, since ionizing radiation, contrast media application, or an invasive technique was not included in the study design.

Finally, an MR image of the injured wrist was obtained, which was used as the standard (26,27,31). The MR images were evaluated in consensus by two radiologists (V.M., A.B.) experienced in musculoskeletal radiology.

US of the scaphoid bones was performed with a US system (HDI 3000; ATL, Bothell, Wash) by using a high–spatial-resolution 10-5-MHz probe (compact linear array; ATL). For the US investigation, the patients were seated upright in front of the radiologist, with the wrist placed on a cushion (Fig 1). A standard 10-mm standoff pad (Sonar Aid; Ed Geistlich Pharma, Wolhusen, Switzerland) was placed over the wrist, and the scaphoid bone was scanned in the longitudinal and transverse planes from the dorsal, lateral, and palmar directions. The cortex of the scaphoid bone is seen as thin continuous echogenic line. In cases of cortical fractures, a discontinuity of this line is visible (32). In several patients with a scaphoid fracture, an additional echogenic line parallel to the cortex of the scaphoid bone was visible; this line is most likely an elevated periosteum with subperiosteal fluid collection due to posttraumatic edema and/or hematoma (33). Changes in the US appearance of the cortex and/or the periosteum were evaluated and documented, and a scaphoid fracture was suspected if either one or a combination of these changes were present at high-spatial-resolution US.



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  		Figure 1. Photograph of the US probe shows the optimal position for scanning the scaphoid bone from the dorsal direction in the longitudinal plane. Note the transparent 10-mm standoff pad placed over the wrist to increase spatial resolution.

 
MR imaging of the wrist was performed with a 1.0-T unit (Gyroscan T10-NT; Philips, Best, the Netherlands) with a circular surface coil (C3; Philips, 14 cm external and 11 cm internal diameter). In all cases, short inversion time inversion-recovery sequences (1,200/16/130 [repetition time msec/echo time msec/inversion time msec], 2.4-mm section thickness, 0.3-mm intersection gap, four signals acquired), coronal T1-weighted spin-echo sequences (500/20 [repetition time msec/echo time msec], 2.4-mm section thickness, 0.3-mm intersection gap, four signals acquired), and a transverse T2*-weighted three-dimensional gradient-echo sequence (60/17, 20° flip angle, 1 signal acquired, with an effective section thickness of 1.5 mm) were obtained (14). In all sequences, a 256 x 256 matrix was used, and the field of view of 10–14 cm was adjusted to cover the wrist and carpal bones. At MR imaging, a scaphoid fracture was diagnosed if perifocal bone marrow edema, cortical or trabecular fracture lines, or a combination of these signals were evident (27,31).

Finally, the results of the clinical, conventional radiographs, and high-spatial-resolution US investigations were compared with those of the standard (MR imaging), and possible causes of false-positive results were evaluated.

Sensitivity, specificity, accuracy, and positive and negative predictive values were calculated with a commercially available PC-based software package (SYSTAT; SPSS, Chicago, Ill).


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
At MR imaging, nine (60%) of the 15 patients with acute wrist trauma had scaphoid fractures. At high-spatial-resolution US, seven (78%) of those nine patients with proved scaphoid fractures had positive results, with no false-positive results and two (22%) false-negative results (Table 1). Conventional radiographs, including scaphoid views, depicted scaphoid fractures in five (56%) of nine patients, with no false-positive results but four (44%) false-negative results (ie, four patients with occult scaphoid fractures). At clinical examination, eight (89%) of nine patients had clinical signs of scaphoid fractures, three (50%) of six had false-positive results, and one (11%) of nine had false-negative results.


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  		TABLE 1. Positive and Negative Predictive Values in the Detection of Scaphoid Fractures

 
The accuracy (87%) of high-spatial-resolution US in depicting scaphoid fractures was substantially higher compared with the accuracy of conventional radiographs, including scaphoid views (73%), and the clinical examination (73%) (Table 2). The sensitivity of high-spatial-resolution US in depicting scaphoid fractures was 78%, and the specificity was 100%, compared with 56% and 100% obtained for conventional radiographs and 89% and 50% obtained for clinical examination. The positive predictive value of high-spatial-resolution US, conventional radiography, and clinical examination was 100%, 100%, and 73%, respectively. The negative predictive value of high-spatial-resolution US was 75% versus 60% for conventional radiography and 75% for clinical examination.


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  		TABLE 2. Accuracy, Sensitivity, Specificity, and Predictive Values in the Diagnosis of Scaphoid Fractures

 
At high-spatial-resolution US, four patients had cortical discontinuity (Fig 2), two had periosteal elevation (Fig 3), and one had a combination of these two findings (Fig 4). High-spatial-resolution US depicted two of four occult scaphoid fractures: one with cortical discontinuity and one with periosteal elevation.



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  		Figure 2a. (a) Conventional radiograph obtained in a 22-year-old man with acute trauma of the right wrist is suggestive of a scaphoid fracture (arrows). (b) Longitudinal high-spatial-resolution sonogram obtained in the lateral direction clearly shows cortical discontinuity (arrows), indicating a scaphoid fracture. Circle = distal scaphoid pole, star = proximal scaphoid pole. (c) Short inversion time inversion-recovery MR image (1,200/16/130) obtained immediately after high-spatial-resolution US shows diffuse high-signal-intensity alteration of the bone marrow of the scaphoid (straight arrows) and discontinuity of the cortex (curved arrow).

 


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  		Figure 2b. (a) Conventional radiograph obtained in a 22-year-old man with acute trauma of the right wrist is suggestive of a scaphoid fracture (arrows). (b) Longitudinal high-spatial-resolution sonogram obtained in the lateral direction clearly shows cortical discontinuity (arrows), indicating a scaphoid fracture. Circle = distal scaphoid pole, star = proximal scaphoid pole. (c) Short inversion time inversion-recovery MR image (1,200/16/130) obtained immediately after high-spatial-resolution US shows diffuse high-signal-intensity alteration of the bone marrow of the scaphoid (straight arrows) and discontinuity of the cortex (curved arrow).

 


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  		Figure 2c. (a) Conventional radiograph obtained in a 22-year-old man with acute trauma of the right wrist is suggestive of a scaphoid fracture (arrows). (b) Longitudinal high-spatial-resolution sonogram obtained in the lateral direction clearly shows cortical discontinuity (arrows), indicating a scaphoid fracture. Circle = distal scaphoid pole, star = proximal scaphoid pole. (c) Short inversion time inversion-recovery MR image (1,200/16/130) obtained immediately after high-spatial-resolution US shows diffuse high-signal-intensity alteration of the bone marrow of the scaphoid (straight arrows) and discontinuity of the cortex (curved arrow).

 


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  		Figure 3a. (a) Conventional radiograph (scaphoid view) obtained in a 48-year-old woman with a scaphoid fracture after acute trauma of the left wrist is unremarkable. (b) However, longitudinal high-spatial-resolution sonogram obtained in the dorsal direction shows clear evidence of an elevation of the periosteum (arrows), which is suggestive of a scaphoid fracture. (c) Short inversion time inversion-recovery MR image (1,200/16/130) depicts bone marrow edema (arrows), which is consistent with a trabecular fracture of the scaphoid.

 


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  		Figure 3b. (a) Conventional radiograph (scaphoid view) obtained in a 48-year-old woman with a scaphoid fracture after acute trauma of the left wrist is unremarkable. (b) However, longitudinal high-spatial-resolution sonogram obtained in the dorsal direction shows clear evidence of an elevation of the periosteum (arrows), which is suggestive of a scaphoid fracture. (c) Short inversion time inversion-recovery MR image (1,200/16/130) depicts bone marrow edema (arrows), which is consistent with a trabecular fracture of the scaphoid.

 


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  		Figure 3c. (a) Conventional radiograph (scaphoid view) obtained in a 48-year-old woman with a scaphoid fracture after acute trauma of the left wrist is unremarkable. (b) However, longitudinal high-spatial-resolution sonogram obtained in the dorsal direction shows clear evidence of an elevation of the periosteum (arrows), which is suggestive of a scaphoid fracture. (c) Short inversion time inversion-recovery MR image (1,200/16/130) depicts bone marrow edema (arrows), which is consistent with a trabecular fracture of the scaphoid.

 


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  		Figure 4. Longitudinal high-spatial-resolution sonogram obtained in the dorsal direction in a 21-year-old man with a scaphoid fracture, which was seen with all imaging modalities, after acute trauma of the left wrist clearly shows elevation of the periosteum (solid arrows) and cortical discontinuity (open arrows).

 
Those three patients with false-positive results at clinical examination had, at MR imaging, either a distal radial fracture, which was seen on all images including high-spatial-resolution US, or a triangular-fibrocartilage-complex tear or soft-tissue edema with no evidence of a fracture.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
Scaphoid fractures are the most common fractures of the carpal bones, with a reported incidence of 46 fractures per 100,000 population per year (3). Scaphoid fractures are complicated because of possible severe and long-lasting sequelae (2,6,7,10,28,34–36). Despite extended radiologic work-up with conventional radiography, two-thirds of scaphoid fractures remain occult, and, thus, the diagnosis of scaphoid fractures remains a challenge for the radiologist (4,6,13,19,23).

In patients with occult scaphoid fractures, fracture-related changes are considered too subtle to be recognized on conventional radiographs obtained immediately after the trauma; however, they may become visible on follow-up images after they become more pronounced (28). Therefore, it has been recommended that these patients should be treated with cast immobilization for at least 10 days, which leads to unnecessary immobilization in about 47% of cases (3,4,33). Thus, early and accurate diagnosis is mandatory to avoid overtreatment and to reduce morbidity, which would result in lower health care costs (14, 37,38). Gaebler and colleagues (4) reported that an immediate and accurate diagnosis of scaphoid fractures with MR imaging in cases with negative or equivocal findings at conventional radiography would save up to $7,200 per 100,000 population per year.

Other diagnostic tools have been evaluated for their accuracy in the early diagnosis of a possible scaphoid fracture. For example, bone scintigraphy is still the subject of some debate because of its limited availability and low spatial resolution, which necessitates further radiologic work-up (18,22–24,39). Intrasound vibration, which might also depict occult scaphoid fractures, requires additional equipment and has been reported (21,40,41) to lack accuracy. MR imaging and CT offer high sensitivity and specificity in the diagnosis of occult scaphoid fractures, which may enable prompt and accurate treatment (6,11,18,20,22–24,27,41). The advantages of these diagnostic tools are not only their high accuracy in depicting bone injuries but also their ability to help in the evaluation of abnormalities of the cartilage layers, ligaments, and adjacent soft tissue (4,6,10,14,42). A limitation of these imaging modalities in the management of occult scaphoid fractures is, however, their limited availability in smaller hospitals and remote areas. Moreover, they are time-consuming investigations and are still considered to be too expensive for the evaluation of simple wrist injuries that may not be fractures (4,16).

US has already been suggested as an alternative diagnostic tool in patients with occult scaphoid fractures. Hodgkinson and colleagues (19) evaluated the scaphoid index of the injured wrist and compared it with the index of the asymptomatic wrist. This index takes into account fracture-related soft-tissue changes that may be compromised if both wrists are injured. Furthermore, these soft-tissue changes may also occur after a mere wrist sprain or with inflammation and may, therefore, lack specificity.

The findings of this study further demonstrate the capability of US to depict cortical discontinuity in fractured bones, which has been described recently (32, 43). However, periosteal changes, which were seen in three (43%) of seven patients with scaphoid fractures, have not yet been reported as a feature of US. Particularly in patients with trabecular scaphoid fractures where no cortical changes are evident on conventional radiographs, periosteal elevation may be the only US finding suggestive of a scaphoid fracture, as depicted in Figure 3. Because these changes are discrete, they may not be visible on conventional radiographs. In this study, high-spatial-resolution US was superior to conventional radiography, because it depicted two of four occult scaphoid fractures and yielded a substantially higher diagnostic accuracy in depicting scaphoid fractures (87% vs 73%).

A limitation of high-spatial-resolution US is that not all occult scaphoid fractures were depicted. This is probably due to the fact that the scapholunate articulating joint may not be reliably imaged with high-spatial-resolution US. Another explanation may be that the scaphoid bone was examined immediately after the injury, prior to the development of changes detectable at US. Thus, in cases with a negative result at high-spatial-resolution US, performing MR imaging should be considered to rule out possible scaphoid fractures, because of the severe sequelae that may occur (1,2,5,6,12,28, 35,36).

A limitation of this study is the relatively small number of occult scaphoid fractures examined. However, the data presented are promising and should be strengthened in future studies.

In conclusion, high-spatial-resolution US seems to be a potential and reliable alternative early diagnostic tool for the evaluation of occult scaphoid fractures because of its high accuracy. This is important because definitive treatment can be initiated promptly, which substantially decreases the rate of complications, increases the quality of life of the patient, and reduces health care costs. On the basis of the excellent predictive value of a positive result at high-spatial-resolution US, one can reliably diagnose a scaphoid fracture if the described periosteal and/or cortical changes, which seem to be specific, are observed. Given these results, the diagnostic strategy in the treatment of clinically suspected scaphoid fractures should consist of conventional radiographs that include scaphoid and/or magnification views as a first-line diagnostic tool. In cases of normal or equivocal findings on conventional radiographs, high-spatial-resolution US should be considered an alternative diagnostic tool prior to CT or MR imaging or if the latter two imaging modalities are not available.


   FOOTNOTES
 
Author contributions: Guarantor of integrity of entire study, A.M.H.; study concepts, A.M.H., V.M.M.; study design, A.M.H., A.S.; literature research, A.M.H., A.S.; clinical studies, A.M.H., A.S., T.R.B.; data acquisition, A.M.H., A.S., T.R.B.; data analysis/interpretation, A.M.H., F.G.; statistical analysis, A.M.H., T.R.B.; manuscript preparation, A.M.H., A.B., T.R.B.; manuscript definition of intellectual content, A.M.H., F.G.; manuscript editing, A.M.H.; manuscript revision/review, V.M.M., G.L.; manuscript final version approval, V.M.M., F.G., G.L.


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 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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