From Diagnosis to Treatment: Challenges in Scaphoid Imaging.

The scaphoid is the largest and most significant bone in the proximal carpal row and is essential for wrist biomechanics and stability. Its intricate anatomy and unique blood supply render it vulnerable to overlooked fractures and postfracture complications, often making for an exceptionally challenging radiologic appraisal. Radiographic diagnosis of a scaphoid fracture is particularly difficult because of the bone's complex geometric structure. Its numerous sulci, apices, ridges, and facets can resemble fractures, which may lead to unnecessary immobilization. A significant portion of the scaphoid is also encased in cartilage that restricts its capacity to develop callus, an imaging clue enduringly relied on in follow-up trauma radiography to confirm a fracture. There is no established agreement on the number of radiographic views. A minimum of three views is recommended, with most institutions adding a fourth. Both CT and MRI provide specific benefits for assessing cortical fractures and trabecular injuries, respectively, and can clarify cases for which clinical suspicion remains high. The scaphoid's distinctive distal-to-proximal blood flow increases the risk of osteonecrosis and abnormal healing following a fracture. Diagnosing osteonecrosis remains the radiologist's greatest challenge when evaluating the scaphoid. There are myriad studies proposing one imaging technique over another, without definite consensus on which is best. Currently, low signal intensity at T1-weighted MRI for osteonecrosis is the only generally accepted criterion. Among all complications, scaphoid osteonecrosis with nonunion is arguably the most difficult to treat. Both nonvascularized and vascularized bone grafts have been proposed, yielding mixed outcomes, and further high-quality randomized trials are necessary to establish which approach is superior. ©RSNA, 2025 Supplemental material is available for this article.