A normal radiograph does not exclude it. Say that plainly, because the missed scaphoid fracture is the classic avascular necrosis.
Orient first
- The scaphoid has a RETROGRADE blood supply entering distally, so a proximal fracture risks avascular necrosis of the proximal pole. That is why a missed scaphoid fracture matters far more than its size suggests.
- Up to a quarter of scaphoid fractures are invisible on the initial radiograph. A negative film in a patient with anatomical snuffbox tenderness means immobilise and re-image, not discharge.
- The waist is the commonest site and carries intermediate risk; the proximal pole carries the highest.
Acquire the study
- Dedicated SCAPHOID SERIES, not a standard wrist series: PA, lateral, and two obliques, with a PA in ulnar deviation which elongates the scaphoid and opens the waist.
- If films are negative and suspicion persists: MRI is the most sensitive early test and can be done within days; CT best shows displacement, angulation and union.
- Compare with the opposite side only if there is a genuine question of a variant.
The manoeuvre
- Trace the entire cortical outline of the scaphoid on every view — a fracture line may be visible on only one.
- Assess the three carpal (Gilula) arcs for continuity; a step or break indicates carpal malalignment.
- Measure the SCAPHOLUNATE interval; widening beyond about 3 mm (the Terry Thomas sign) indicates ligament injury.
- Look for the fat pad / soft-tissue changes over the radial aspect.
- If a fracture is present, state its SITE (proximal pole, waist, distal pole or tubercle) and whether it is DISPLACED — over 1 mm displacement changes management.
- Assess for humpback deformity and increased intrascaphoid angle on the lateral or on CT.
- Look for associated injuries: distal radius fracture, perilunate dislocation, other carpal fractures.
What confirms it
- A lucent fracture line crossing the scaphoid cortex, ideally on more than one view.
- On MRI, marrow oedema with a fracture line on T1 confirms an occult fracture.
What licenses you to exclude it
- ⚠️ A NORMAL RADIOGRAPH DOES NOT EXCLUDE A SCAPHOID FRACTURE. The report must say this explicitly and recommend immobilisation with repeat imaging or MRI — a bare "no fracture seen" on this specific bone is a clinically dangerous report.
- A normal MRI performed after a few days does effectively exclude it.
The classic misread
- Reporting "no fracture" without the caveat.
- Reading a standard wrist series as if it were a scaphoid series.
- Missing a perilunate dislocation by looking only at the scaphoid — check the arcs.
- Missing proximal pole sclerosis indicating established avascular necrosis on a later film.