A 53-year-old male presented with left-sided radial wrist pain and swelling following downhill mountainbiking. Clinical examination demonstrated anatomical snuffbox tenderness/volar scaphoid tenderness/restricted wrist movement.
Ultrasound examination from the volar aspect demonstrates a fracture of the scaphoid at the junction between its middle and distal thirds. The fracture line is most clearly visualised using the volar approach.
Fluid and surrounding soft-tissue swelling are present adjacent to the fracture. Additional fluid and reactive soft-tissue swelling are visible at the radiocarpal and [midcarpal/metacarpal] joint regions.
The scapholunate ligament appears intact. Dynamic assessment demonstrates no apparent instability or abnormal widening of the scapholunate joint.
From the dorsal approach, the scaphoid fracture is not, or is only poorly, visualised. Dorsal soft-tissue swelling remains evident.
1. Final diagnosis
Scaphoid fracture at the junction of the middle and distal thirds, most clearly demonstrated using a volar ultrasound approach. Associated peri-fracture fluid, soft-tissue swelling and wrist joint effusion are present.
2. Differential diagnosis
The demonstrated cortical and fracture-line abnormality is consistent with a scaphoid fracture. In less conclusive examinations, differential considerations for focal cortical irregularity include a prominent vascular channel, developmental cortical variation or a previous healed injury. Correlation with radiographs or cross-sectional imaging may help confirm the fracture configuration.
3. Teaching points
A scaphoid fracture may be considerably more conspicuous from the volar than from the dorsal approach. Examination of a clinically suspected scaphoid fracture should therefore include systematic assessment from multiple acoustic windows. Secondary findings such as local fluid, soft-tissue swelling and radiocarpal or midcarpal effusion may support the diagnosis when the fracture line is difficult to visualise.
4. Injury/disease information
Scaphoid fractures commonly follow a fall onto an outstretched hand and may be difficult to detect on initial imaging. Fracture location and displacement are important because they influence vascular risk, stability and healing. Ultrasound can demonstrate cortical interruption and associated soft-tissue changes, but radiography, CT or MRI may be required to fully assess fracture morphology, displacement and healing. In this case, the scapholunate ligament appears intact and there is no sonographic evidence of scapholunate instability.
Marc is founder of, and trainer at, SonoSkills. SonoSkills is an organization dedicated to MSK ultrasound education. He's also an MSK Sonographer at EchoConsult in Roermond, the Netherlands.
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