This is Barry Bellosis, one of the musculoskeletal radiology fellows at Stanford University. 20 year old male with acute right wrist pain after diving practice concerned for scaphoid fracture. The patient in this case presented with this wrist radiograph. Here we can see an honor deviated PA radiograph of the scaphoid showing no displaced fracture. On the oblique view we can see a subtle lucency traversing the proximal waist of the scaphoid concerning for a non-displaced fracture. The patient did underwent MRI showing edema about the proximal scaphoid with associated hypo-intensity or linear band here consistent with a non-displaced fracture. This is in a different patient, a 14 year old gymnast with snuffbox tenderness. So in patients with suspected scaphoid fracture, in addition to the three standard views of the wrist, a dedicated honor deviated PA radiograph of the scaphoid which fully extends the scaphoid is recommended. However, in the event of a negative radiograph with suspicion for scaphoid fracture, a follow-up two to six weeks radiograph has been suggested as a strategy based on the theory that bone resorption at the fracture site will become more visible over time confirming or excluding the presence of a fracture. In this case, two weeks later, we do see this linear lucency in the proximal waist of the scaphoid consistent with a scaphoid fracture. The patient in this case, however, did undergo MRI without contrast. MRI remains the gold standard for the diagnosis of occult scaphoid fractures. So in here, we can see this linear band of hypo-intensity, the waist of the scaphoid and in our coronal fluid sensitive images, we can see that there is surrounding edema in the scaphoid consistent with scaphoid waist fracture. CT has been used in the acute setting when fracture is radiographically visible or for surgical planning. However, if there is an option between CT or MRI, MRI is favored as the second test of assessment for radiographically occult scaphoid fractures. These are on the different patients with scapholunate advanced collapse and also a scaphoid non-eugenic advanced collapse. Here on our slack, it is a complication of undiagnosed or untreated scapholunate dissociation and it refers to a pattern of wrist malalignment that has been attributed to post-traumatic or spontaneous osteoarthritis. In here, we can see that there is widening of the scapholunate interval. The patient did not undergo any treatment and here we can see that there is continued widening of the scapholunate interval. The pattern that we see on slack is a progressive osteoarthritis affecting initially the radius scaphoid articulation, typically the radius thyloid and the scaphoid, and progressed to the whole scaphoid and lastly, it can affect most of the intercarpal articulation, particularly the lunate and the capitate articulation as we can see here. Scaphoid non-union advanced collapse essentially have the same sequela of wrist injury as slack. So in here, we can see this non-united scaphoid fracture at the waist, also here on a different patient and more proximally. On the resultant or end-stage osteoarthritis, we can see that there is complete collapse of the radius scaphoid articulation and migration of the capitate as we can see here, which are both seen on slack and snag and we can see this radius scaphoid and intercarpal osteoarthritis.

2nd Edition, CASE 16

2nd Edition

Hand and Wrist

scaphoid fractures

MRI diagnosis

wrist injuries

scapholunate advanced collapse

osteoarthritis