Scaphoid Radiography

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Introduction
The fall onto an outstretched hand (FOOSH) is a common mechanism of bony injury and the scaphod fracture is a common result. This page considers all aspects of
scaphoid radiography.

Anatomy
The carpal bones can be thought of as being arranged in two rows- a proximal row and a distal row. The lunate and scaphoid occupy the proximal row and articulate with
the radius. The row theory is based on the fact that the proximal and distal rows work as 2 separate functional units. This model has been challenged/modified by the
proposition that the two rows are stabilized by the scaphoid which could be considered to be part of both rows. There is also an alternate column theory.

Surface Anatomy
The scaphoid position centrepoint is
most easily determined by locating the
surface anatomy feature known as the
anatomical snuff box. This is a void
at the base of the thumb best
demonstrated when the thumb is
abducted (hitch-hiking position). This
triangular depression is defined by the
extensor and abductors of the thumb,
and is easily visible when the wrist is
partially ulnar deviated and the thumb
abducted and extended.
http://www.aafp.org/afp/20040901/879.html

adapted from http://www.flickr.com/photos/data_op/2211821511/

"- scaphoid receives majority of its blood supply via dorsal vessels at
or just distal to waist area;
- these vessels perfuse the proximal pole in a retrograde fashion;
- most important vascular branches of radial artery enter scaphoid
thru foraminae along its dorsal ridge;
- it supplies 70-80% of bone, including entire proximal pole;
- second group of vessels, arise from palmar & superficial palmar
branches of radial artery & enter carpal
scaphoid in region of its distal tubercle;
- it perfuses distal 20-30 % of bone, including tuberosity"
quoted from
http://www.wheelessonline.com/ortho/vascular_anatomy_of_scaphoid
Mechanism of Injury
Scaphoid fractures are almost invariably caused by a fall onto an outstretched hand.
This is useful for the radiographer to know. It is good practice to ask the patient
about their mechanism of injury in cases of acute injury to help assess the likelihood
that the patient may have sustained a scaphoid fracture. A history of a fall onto an
outstretched hand and acute localised pain in the anatomical snuff box suggests a
high probability of a scaphoid fracture (base of thumb fractures - Bennett, Rolando,
other- are common clinical misdiagnoses). Scaphoid fractures are most common in
males 15 to 30 years of age and are rare in young children and infants.
http://www.aafp.org/afp/20040901/879.html

adapted from source: unknown

The Scaphoid View (PA with Ulnar Deviation and Tube angulation)
This is the commonly performed "scaphoid view" that is an essential inclusion in any scaphoid series. This view provides an often elongated image of the scaphoid
that can reveal a fracture that is not evident in any of the other views. The scaphoid fat pad is also demonstrated best with the wrist in ulnar deviation.

Radiographic Technique
The hand and wrist are placed on the IR with the palmar/volar aspects of the hand and wrist in contact with the IR. The wrist is ulnar deviated and the tube angled
20 - 30 degrees towards the patient's elbow. In an acute injury case, collimate to include the proximal metacarpals and the distal radius- this will potentially
demonstrate base of thumb fractures and distal radius fractures which are sometimes clinically misdiagnosed as scaphoid fractures. In a follow-up of a previously
diagnosed scaphoid fracture, inclusion of the metacarpals and distal radius is not essential.
Zero Degree Tube Angle 20 Degrees Tube Angle 30 Degrees Tube Angle

modified from http://www.aafp.org/afp/20040901/879.html modified from http://www.aafp.org/afp/20040901/879.html

modified from http://www.aafp.org/afp/20040901/879.html

This demonstrates the positioning for a scaphoid view
with no tube angle. The wrist is positioned for a PA wrist
view then moved into an ulnar deviated position. Note
that the wrist position is not sufficiently ulnar deviated in
this photograph- a good guide is when the first
metacarpal lines up with the longaxis of the radius.
Centre the X-ray beam immediately medial to the
anatomical snuff-box.
A tube angle of 20 degrees is applied as shown above. Some centres employ a 30 degree tube angle which
The tube angle is an approximation of the angle of the tends to elongate the scaphoid, often to good effect.
scaphoid to achieve an en face image of the scaphoid.
The perfect angle will vary between patients and with
the degree of ulnar deviation.
Why Angle the Beam?
The scaphoid view can be performed with no beam angulation. This will almost invariably produce a foreshortened image of the scaphoid. It is preferable to produce
an image of the scaphoid that is either en face or elongated slightly. The reason for using beam angulation is clear when you consider the orientation of the scaphoid
in the wrist as shown below
If the positioning objective is to image the scaphoid en face, the beam
should in theory be angled at 90 degrees to the long axis of the
scaphoid.

The scaphoid long axis shows considerable variability in the angle of its
long axis. This suggests that the scaphoid angle will always be an
approximation of the scaphoid angle.

Why Ulnar Deviation?

Ulnar deviation of the patient's wrist is important for the following reasons
1. Ulnar Deviation rotates the scaphoid parallel to the long axis of the forearm and moves it away from the radius
2. Ulnar deviation rotates the scaphoid marginally in a palmar direction reducing the angle required to achieve an en face image.

1. Ulnar Deviation rotates the scaphoid parallel to the long axis of the forearm
Radial Deviation Ulnar Deviation The radial deviation wrist position (left image)
positions the scaphoid in closer proximity to
the radius (undesirable in terms of
superimposition). Conversely, the ulnar
deviated position pulls the scaphoid away from
the radius. In doing so, ulnar deviation also
orientates the long axis of the scaphoid such
that a tube angled towards the patent's elbow
will not be angled across the scaphoid.

2. Ulnar deviation rotates the scaphoid marginally in a palmar direction reducing the angle required to achieve an en face image.
Ulnar Deviation Radial Deviation The difference in appearance of the carpal bones between
the two images, particularly evident in the change in
appearance of the scaphoid, suggests that there is a
 flexion/extension movement of the carpal bones associated
with radial/ulnar deviation. During radial deviation, the
proximal carpal row rotates in a palmar direction/flexes.
Conversely, during ulnar deviation the proximal carpal row
(including the scaphoid) rotates in a dorsal direction.

Ulnar Deviation Radial Deviation These saggital CT images demonstrate the position of the
scaphoid in ulnar deviation and radial deviation. The
scaphoid clearly rotates in a dorsal direction during ulnar
deviation. Importantly, this movement mitigates toward a
more en face imaging of the scaphoid when undertaking a
dedicated scaphoid view.

Ulrich Lanz, Rainer Schmitt, Wolfgang Buchberger. Diagnostic Imaging of the Ulrich Lanz, Rainer Schmitt, Wolfgang Buchberger. Diagnostic Imaging of the
Hand. 2008 Hand. 2008
The scaphoid rotates in a dorsal direction during The scaphoid seen here on CT imaging moves in
ulnar deviation. This movement is used to a palmar direction during radial deviation.
advantage in the common PA scaphoid view with
ulnar deviation.

This video demonstrates the movement of the proximal carpal row (scaphoid, This video demonstrates the movement of the carpus in ulnar and radial
lunate triquetrum) in ulnar and radial deviation. deviation.

Click to use Flash Click to use Flash

source: e-hand.com

How Much Tube Angle do I use for the Scaphoid View?

Beware the radiographer who insists on a particular technique but can't explain their viewpoint based on an objective and a balanced appraisal of the advantages and
disadvantages of their technique (with supporting evidence). Many techniques are simply historically based (not that there is anything wrong with that per se). The first
question is what are you trying to achieve with this view? If your answer is an en face projection of the scaphoid (i.e. without distortion/elongation), the 20 degree angle (as
proposed in some textbooks) appears reasonable in a patient who can achieve good ulnar deviation. This is based on the fact that the scaphoid rotates dorsally slightly
during ulnar deviation and is likely to be positioned at about 20 degrees to the coronal plane of the wrist (see CT images above). If you are aiming to demonstrate fractures
of the scaphoid by producing an elongated image of the scaphoid, 30 degrees of tube angle would achieve that objective in most patients who adequately ulnar deviate
their wrists.

Another technique consideration is how much your technique is superimposing the scaphoid over the adjacent bony structures.

Yet another consideration is whether you perform a series of tube angles in patients who have convincing clinical evidence of a scaphoid fracture but no radiographic
evidence on routine views. This is arguably reasonable if there are good diagnostic yield in patients who would otherwise be referred for MRI imaging.
Scaphoid Series
A patient referred for a scaphoid series in an Emergency Department (or other acute care setting) might typically be subject to 4 exposures as follows
1. PA wrist with ulnar deviation
2. Lateral wrist
3. Oblique Wrist
4. Scaphoid View (20 - 30 degrees tube angle)
It should be borne in mind that the clinical diagnosis of scaphoid fracture could easily be incorrect- it is a provisional diagnosis only. It is important therefore to include as
much of the metacarpals and forearm as would be indicated by the particular case. This would typically extend as far as inclusion of all of the metacarpals, and the distal
1/3 of the radius and ulna.
1. PA with Ulnar Deviation 2. Lateral 3. Oblique 4. Scaphoid View

This is over-collimated for an acute injury
case. There is good ulnar deviation
This lateral wrist image is
acceptable but is considered by
some authors to not constitute a
true lateral wrist position.
The oblique view will superimpose the This is a 30 degree tube angle which results
scaphoid in part over the distal radius, in some elongation of the scaphoid.
capitate and lunate. Despite this limitation,
the oblique position does afford good
visualisation of the scaphoid and can be the
best projection for demonstrating scaphoid
tubercle fractures.

What Went Wrong?

This scaphoid view image suffers from underexposure (signal-to-noise ratio is
too low). The central ray is also directed slightly across the scaphoid rather than
along its long axis. This is probably of little consequence but is nevertheless
noteworthy.

This scaphoid view image suffers from underexposure. In addition, and

importantly, the tube angle is too great.
 This patient was referred for scaphoid views from orthopaedic clinic. It was not
clear why this patient was referred for scaphoid view. The following was clear
the patient has a radial metaphysis fracture (probably Salter Harris)
ulnar deviation is not possible
a scaphoid fracture will be difficult to demonstrate with the patient's wrist in
a fibreglass cast
If a patient is referred for scaphoid views whist in an immobilising cast (plaster,
fibreglass or any other artifact producing material) the radiographer should at the
very least ask the referring doctor doctor if he/she had intended for the cast to be
removed prior to the X-ray examination

Comment
Performing a scaphoid view is more meaningful if you understand what you are trying to achieve. There is arguably a case for performing a supplementary scaphoid series
if the patient has strong clinical indicators of having sustained a scaphoid fracture and the fracture is not revealed on routine views. Performing a supplementary scaphoid
series in such patients may facilitate early definitive treatment and avoid the inconvenience and expense of MRI imaging of the wrist.

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Latest page update: made by M.J.Fuller , Feb 17 2010, 8:42 PM EST (about this update - complete history)

Keyword tags: anatomical snuffbox scaphoid ulnar deviation wrist

M.J.Fuller
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