Pediatric Radial Neck Fractures: Which Ones Can Be Successfully Closed Reduced in the Emergency Department?

BACKGROUND: The purpose of this study is to examine pediatric patients with a radial neck fracture and determine the factors associated with a failed closed reduction (CR) in the emergency department (ED). METHODS: A total of 70 patients with acute radial neck fractures were retrospectively reviewed. Inclusion criteria were: age 18 years or younger at time of injury, diagnosis of radial neck fracture without other associated elbow fractures, an attempt at CR with manipulation in the ED or immediate surgery, open proximal radial physis, and appropriate imaging to categorize the injury. Charts were reviewed and demographic data was obtained. Initial injury films were reviewed and the Judet classification was used to define fracture types/categories. RESULTS: CR was attempted on 41 patients. Twenty-nine patients went straight to surgery without a CR attempt. Compared with patients that had an attempted CR in the ED, patients that went straight to surgery had longer mean time from injury to ED presentation (5.6 d; P=0.0001), greater mean fracture angulation (55.0 degrees; P=0.001), and greater fracture translation (46.2%; P=0.001). When analyzing the patients that had a CR attempted in the ED, univariate statistical analysis demonstrated that ≥Judet 4 classification (P=0.03), greater amounts of fracture angulation (P=0.003), and a treatment delayed >24 hours from injury (P=0.007) were significant risk factors for failure of CR in the ED. Zero (0/10) patients with fracture angulation ≥60 degrees had a successful CR. Only 1/14 patients presenting >24 hours after injury had a successful CR in the ED. CONCLUSIONS: Circumventing sedation in the ED, and instead splinting for a planned surgical intervention may be a more efficient treatment method for pediatric radial neck fractures that present to the ED>24 hours after injury and/or have angulations ≥60 degrees. Adopting this new strategy may save time, reduce costs, and avoid possible harm/complications associated with sedation in the ED. LEVEL OF EVIDENCE: Level III-prognostic.

Improving Quality in the Treatment of Pediatric Forearm Fractures: Minimizing the Need for Repeat Intervention With Long-arm Extension Casting.

PURPOSE: Repeat intervention for pediatric forearm fractures after closed manipulation is as high as 46% with flexed elbow (FE) long-arm casts. Casting with the elbow extended (EE) has been advocated as an alternative technique. We documented outcomes of patients treated with closed manipulation and casting with EE long-arm casts for displaced, diaphyseal both-bone forearm fractures. METHODS: We retrospectively reviewed charts for patients who had sedated manipulations and casting for closed, diaphyseal forearm fractures. Open fractures, immediate surgical intervention, metabolic bone disease, recurrent fractures, and Monteggia injuries were excluded. Closed manipulations were performed by orthopaedic residents assisted by cast technicians, with sedation provided by emergency department physicians. Radiographic angulation and displacement of the radius and ulna on immediate postreduction radiographs and all follow-up radiographs were recorded. Patients requiring repeat intervention were compared with those who did not by using the Mann-Whitney U and Fisher exact tests. RESULTS: Of 86 patients (7.2±2.8 y) available for analysis, 82 (95.3%) completed treatment after a single-sedated manipulation and placement of an EE long-arm cast. There were no malunions or nonunions. The average follow-up was 50 days. Four (4.7%) patients required repeat interventions (2 had surgery, 1 had a repeat sedated manipulation, and 1 had a nonsedated manipulation). There were no statistically significant differences in age, sex, laterality, fracture position in the diaphysis, or immediate postreduction angulation of the radius or ulna. A literature review showed average repeat intervention rates of 14.9% (range, 0% to 45.9%) for FE casts and 3.3% (range, 0% to 15%) for EE casts. CONCLUSIONS: There was a low rate of repeat interventions (4.7%) in patients with EE casts compared with historical rates for FE casts. Improving the quality of health care involves identifying and implementing practices that provide the best outcomes at the lowest costs. The use of EE long-arm casts following closed manipulation of pediatric forearm fractures may decrease the rate of repeat manipulation or surgery compared with conventional FE casts. LEVEL OF EVIDENCE: Level IV-case series.

Operative treatment of torsional humeral shaft fractures in throwers leads to an earlier return to sport: a survey of expert shoulder and elbow surgeons.

PURPOSE: To determine the management of torsional humeral shaft fractures in a group of expert shoulder and elbow surgeons and analyse the rate of return to sport of these throwing athletes. METHODS: A survey was sent to all physician members of two prominent sports medicine professional associations: the American Shoulder and Elbow Surgeons and the Herodicus Society. Due to the rare nature of this injury, a historical survey of management and return to play was performed to allow analysis of trends in treatment and return to play after both non-operative and operative management. RESULTS: The survey was emailed to 858 physician members. Out of the 95 respondents, 35 surgeons indicated they had treated ≥ 1 torsional humeral shaft fractures in throwing athletes (average 1.7 per surgeon). A total of 72 fractures were recorded with an average age of 20.4 years and the majority being male (68/72). Eighty-one percent (58/72) of the fractures were classified as simple spiral. Sixty-one percent (44/72) of the fractures were treated non-operatively, while 35% (25/72) of the fractures were treated by open reduction and internal fixation (ORIF). Patient age, return to sport rate and level, type of fracture, and fracture healing time did not significantly differ based on treatment type. Average time to return to sport was significantly shorter for patients who underwent ORIF compared to non-operative treatment (p = 0.001). Overall, 48 (92.3%) of the 52 athletes returned to sport, with 84% (36/43) returning to the same level of play. CONCLUSION: Torsional humeral shaft fractures in throwers are most commonly seen in young men and can be treated both operatively and non-operatively with overall similar results for healing time, rate of non-union, and return to sport. The only significant difference in the groups was an earlier return to sports in those fixed surgically, however, operative intervention also yielded a higher complication rate. Regardless of the treatment method, the overall rate of return to play was moderate. These finding are clinically relevant and can assist physicians with decision making for treatment and can help when advising throwers of appropriate expectations for recovery after this injury. LEVEL OF EVIDENCE: IV.

BET 1: Functional treatment is non-inferior to below the knee cast in adults with acute closed proximal fifth metatarsal fractures.

A short cut review was carried out to establish whether functional treatment is better than conservative treatment with a below knee cast at decreasing time to functional recovery and fracture union in adults with an acute closed proximal fifth metatarsal fracture. Four papers presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. It is concluded that in proximal (zone 1 and 2) fractures of the fifth metatarsal functional treatment with immediate mobilisation is at least non-inferior to immobilisation in a cast.

The Effectiveness of Mini-C-Arm Fluoroscopy for the Closed Reduction of Distal Radius Fractures in Adults: A Randomized Controlled Trial.

PURPOSE: Most distal radius (DR) fractures are initially managed with closed reduction and orthosis application. Mini-C-arm fluoroscopy provides assessment of reduction quality in real time. Our null hypothesis was that there would be no difference in the reduction quality of DR fractures in the emergency department when using mini-C-arm fluoroscopy during reduction compared with standard reduction techniques (evaluating reduction quality with orthogonal radiographs taken in an orthosis). METHODS: Sixty-three consecutive patients with closed DR fractures requiring reduction between April 2015 and April 2017 were prospectively randomized to standard versus fluoroscopically aided reductions. Reductions were performed by orthopedic surgery residents. The primary outcome measurement was reduction quality (radial height, radial inclination, ulnar variance, and volar tilt) as measured on postreduction radiographs. RESULTS: Standard reductions were performed in 34 patients and fluoroscopically aided reductions in 29 patients. The 2 groups were similar in regards to all potential confounders that were analyzed. No differences in postreduction radial height, radial inclination, ulnar variance, or volar tilt were noted. Overall reduction attempts and subjective difficulty of fracture reduction were increased when using fluoroscopy. The rate of initial operative management did not differ between groups. CONCLUSIONS: The use of mini-C-arm fluoroscopy during the initial closed reduction of adult DR fractures results in equivalent postreduction radiographic parameters when compared with conventional reduction techniques. Additional research regarding time spent in the emergency department and overall cost could elucidate potential benefits of fluoroscopically aided DR fracture reduction. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Calcaneus Fractures: A Possible Musculoskeletal Emergency.

BACKGROUND: Calcaneal fractures are commonly seen and treated in the emergency department. There are subsets of calcaneal fractures that pose a high risk to the adjacent soft tissue of the heel and can result in full-thickness tissue necrosis. OBJECTIVE: To identify which calcaneal fractures need to be managed within hours and triaged to the orthopedic team and which can be temporized in a neutral or plantarflexed ankle splint and seen in an outpatient setting. DISCUSSION: Tongue-type calcaneal fractures and tuberosity fractures must be triaged appropriately within the first few hours of presentation to prevent skin compromise. This requires the emergency physician to understand the radiographic morphology of the fracture as well as the clinical signs of skin compromise. Communication with the orthopedic surgery service is essential and splinting in a specific manner is important to stabilize the soft tissue envelope. CONCLUSION: Recognizing the calcaneal injury pattern and implementing the correct treatment strategy is paramount to having successful patient outcomes. A delay or error in treatment can turn a closed fracture into an open fracture.

A prospective multi-center study of intramedullary nailing vs casting of stable tibial shaft fractures.

BACKGROUND: The purpose of this study was to determine optimal treatment of stable tibial shaft fractures using intramedullary nailing (IMN) or casting. MATERIALS AND METHODS: We performed a multi-center prospective study cohort. Patients with stable tibia shaft fractures meeting Sarmiento's criteria (isolated closed fractures with less than 12 mm of shortening and 10° of angulation) were enrolled prospectively and treated with either a reamed IMN with static interlocking screws or closed reduction followed by long-leg casting. Both groups were weight bearing following surgery. Radiographs were taken until union, and range of motion of knee and ankle joints was assessed. Malalignment (>5°) and malunion (>10°) were determined. Functional outcome measures using short musculoskeletal assessment scores (SMFA) and a knee pain score were scheduled at 6 weeks, 3 months and 6 months. RESULTS: At 3 months, differences between the casting and IMN groups were noted in return to work (6/15 vs 3/17, P < 0.05); ankle dorsiflexion (7° vs 12°, P < 0.05); plantar flexion (28° vs 39°, P < 0.05); and SMFA domains of Dysfunction Index, Bother Index, daily activities, emotional status, and arm/hand function (P < 0.05). The SMFA mobility function demonstrated a significant trend (P = 0.065). At 6 months, malalignment was present in 3/15 in the casting group and in 1/17 in the IMN group (P = 0.02). Malunion was present in 1/15 in the cast group. One fracture in the casting group went on to nonunion and required late IMN placement at 7 months and eventually healed. There were no differences in ankle motion, SMFA scores, or return to work. There was no difference in knee pain between the groups as measured by VAS and Court-Brown pain scale at 6 months. CONCLUSIONS: Patients with stable tibia fractures treated with intramedullary nailing have improved clinical and functional outcomes at 3 months compared with those treated with casting, but there are no differences in any other outcome measure. Patients treated in a cast may have a higher incidence of malalignment or malunion. LEVEL OF EVIDENCE: Level-II prognostic.

Ultrasound-guided pediatric forearm fracture reductions in a resource-limited ED.

BACKGROUND: Pediatric forearm fractures are a common presentation in emergency departments in Papua New Guinea. Often these children undergo "blind" closed reduction with reduction adequacy assessed by standard radiographs. This study aims to demonstrate the safety and efficacy of ultrasound (US) in guiding closed reduction of pediatric forearm fractures in a resource-limited setting. METHODS: We recruited consecutive children with closed forearm fractures requiring reduction. A US scanner was used to visualize and aid fracture reductions. The outcome measures were the rate of successful reductions (ie, adequate alignment without the need for a second procedure or further surgical intervention), length of stay in hospital, and adverse events during each procedure and at follow-up after 6 weeks. RESULTS: Of 47 children recruited, there were 44 (94%) successful reductions, whereas 3 (6%) required repeated reduction. The mean (SD) length of stay in hospital of the successful cases was 8.77 (3.66) hours. Two patients had tight plaster casts during early follow-up which were immediately addressed. Of the 44 successful cases, only 38 were retrieved for the final review. No further adverse events were observed in the latter. CONCLUSIONS: This small-scale study has demonstrated the safe and efficacious use of US-guided close reduction of pediatric forearm fractures in a low-resource setting. Using US, real-time visualization of reduction efforts can reassure the clinician in decision making, thus reducing the rate of repeated reductions and allowing shorter hospital stay.

Distal radial fractures in children: risk factors for redisplacement following closed reduction.

BACKGROUND: Distal radial fractures represent one of the most common fractures in children with the majority treated by closed reduction and cast application. Redisplacement after manipulation can occur resulting in potential poor outcome. We performed a prospective study of children undergoing closed reduction of distal radial fracture and evaluated a range of possible risk factors contributing to loss of reduction. METHODS: The prospective study included 135 displaced distal radial fractures. There were 48 girls (36%) and 87 boys (64%), with a mean age of 9.9 years (range, 3 to 17 y). The risk factors for redisplacement, which were evaluated, were age, sex, location of the fracture, preoperative fracture displacement, presence of ulna fracture, grade of surgeon, quality of reduction, quality of plaster, and residual postreduction displacement. RESULTS: Redisplacement occurred in 39 of 135 cases (28.8%). Initial complete displacement was the most important risk factor for loss of reduction (odds ratio, 6.94; P=0.001). Completely displaced fractures were 7 times more likely to redisplace than fractures with some bony contact or no translation. Achievement of anatomic reduction decreases the risk of redisplacement (odds ratio, 0.29; P=0.046). Ten of the 39 fractures that lost position needed a second procedure (7.4%). CONCLUSIONS: Completely displaced distal radial fractures that cannot be anatomically reduced have a high risk of redisplacement after closed reduction. Only a small number of fractures that lose reduction will require a second intervention. LEVEL OF EVIDENCE: Level II.

Treatment trends in adolescent clavicle fractures.

BACKGROUND: Controversy continues with regard to decision making for operative treatment of adolescent clavicle fractures, while the literature continues to support operative treatment for select middle third fractures in adults. The purpose of our study was to evaluate the recent trends in nonoperative and operative management of adolescent clavicle fractures in the United States. METHODS: Data were derived from a publicly available database of patients, PearlDiver Patient Records Database. The database was queried for ICD-9 810.02 (closed fracture of shaft of clavicle), with the age restriction of either 10 to 14 or 15 to 19 years old, along with CPT-23500 (closed treatment of clavicular fracture) and CPT-23515 (open treatment of clavicular fracture) from 2007 to 2011. The χ analysis was used to determine statistical significance with regard to procedural volumes, sex, and region. The Student t test was used to compare average charges between groups. RESULTS: A significant increase in the number of adolescent clavicle fractures managed operatively (CPT-23510, ages 10 to 19 y) from 309 in 2007 to 530 in 2011 was observed (P<0.0001). There was a significantly greater increase in operative management of clavicle fractures in the age 15 to 19 subgroup compared with the age 10 to 14 subgroup (P<0.0001). In the operative group, there was a trend toward a higher number of males being managed with operative intervention. The overall average monetary charge for both nonoperatively and operatively managed adolescent clavicle fractures increased significantly in the study period. A statistically significant increase in normalized incidence of operatively managed adolescent clavicle fractures was noted in the midwest, south, and west regions with the greatest increase in west region where the incidence increased over 2-fold (P<0.0001). CONCLUSIONS: Adolescent clavicle fractures seem to be being treated increasingly with open reduction and internal fixation recently, especially in the 15 to 19 age group. Nevertheless, there remains of lack of high-level studies comparing outcomes of operative and conservative treatment specifically for the adolescent population to justify this recent trend. LEVEL OF EVIDENCE: Level IV-retrospective database analysis.

[Occult fractures of extremities in adults and children. Exemplified by foot and ankle injuries]. / Okkulte Extremitätenfrakturen im Erwachsenen- und Kindesalter. Am Beispiel von Fuß- und Sprunggelenkverletzungen.

BACKGROUND: Occult fractures in children and adults cannot by definition be diagnosed by conventional radiographs. These injuries are usually recognized as bone marrow edema by magnetic resonance imaging (MRI). There are no randomized controlled trials or prospective cohort studies concerning the correct management of occult fractures and, therefore, no evidence-based treatment guidelines can be drafted. OBJECTIVES: This article summarizes the current diagnostic and treatment concepts for occult fractures under special consideration of foot and ankle injuries. METHODS: A selective search of the current literature was performed and also taking own experience into consideration. RESULTS AND CONCLUSION: The clinical prognosis of occult fractures is generally good and there is no evidence that these lesions need specific treatment. Besides forensic applications and problems pursuant to insurance law, MRI examination is only indicated when conventional radiographs are unremarkable, pain persists for an unusually long period of time and when a relevant therapeutic consequence can be expected from the MRI results. Classical pitfalls are combinations of occult fractures with potentially unstable ligamentous injuries and patients with disordered pain perception as in cases of diabetic polyneuropathy, as the common therapeutic concept of weight bearing according to pain is not suitable for these patients and can lead to severe complications.

Open biological reduction and a locking compression plate for distal femoral fractures: a review of 40 cases.

OBJECTIVE: To determine the clinical results of patients with comminuted fractures of the distal femur treated by open biological reduction using an indirect reduction technique and locking compression plate (LCP) without primary bone grafting. MATERIAL AND METHOD: Prospective observation was conducted with 40 patients (24 males and 16 females), average age 48.7 years (range 20-81), with distal femoral fractures AO/OTA types A2 (5), A3 (17), C2 (8) and C3 (10) who were treated using an open indirect reduction technique and fixation with LCP between May 2010 and December 2013. Among the 40 patients, 28 were closed fractures and 12 were open fractures. Clinical results were evaluated using the Neer score six months after surgery. Follow-up periods ranged from 12 to 36 months (average 18.35). RESULTS: Thirty eight (95%) of the fractures healed completely without a secondary procedure. The average time to union was 14.45 weeks (range 12-24). The average knee range of motion was 2° (0-5) to 110° (20-140). Two patients had an implant failure which required revision and secondary iliac bone grafting. There were no varus or valgus deformities, no limb shortening and no deep infections. Neer scores were excellent in 18 cases (45%), good in 14 (35%), fair in 6 (15%) and poor in 2 (5%). The mean Neer score was 83.60 (range 50-100). CONCLUSION: The indirect reduction technique for the treatment of comminuted distal femoral fractures provides satisfactory results when combined with LCP fixation.

Papineau debridement, Ilizarov bone transport, and negative-pressure wound closure for septic bone defects of the tibia.

PURPOSE: Ilizarov pioneered bone transport using a circular external fixator. Papineau described a staged technique for the treatment for infected pseudarthrosis of the long bones. This article presents a single-stage Papineau technique and Ilizarov bone transport, and postoperative negative-pressure wound dressing changes for septic bone defects of the tibia. MATERIALS AND METHODS: We studied the files of seven patients (mean age, 32 years) with septic bone defects of the tibia treated with a Papineau technique and Ilizarov bone transport in a single stage, followed by postoperative negative-pressure wound dressing changes. All patients had septic pseudarthrosis and skin necrosis of the tibia. The technique included a single-stage extensive surgical debridement of necrotic bone, open bone grafting with cancellous bone autograft and bone transport, and postoperative negative-pressure wound dressing changes for wound closure. The mean time from the initial injury was 6 months (range, 4-8 months). The mean follow-up was 14 months (range, 10-17 months). RESULTS: All patients experienced successful wound healing at a mean of 29 days. Six patients experienced successful bone regeneration and union at the docking side at a mean of 6 months. One patient experienced delayed union at the docking site, which was treated with autologous cancellous bone grafting. Two patients experienced pin track infection, which was successfully treated with antibiotics and pin site dressing changes. All patients were able to return to their work and previous levels of activity, except one patient who had a stiff ankle joint and had to change his job. No patient experienced recurrence of infection, or fracture of the regenerated or transported bone segment until the period of this study. CONCLUSION: The combined Papineau and Ilizarov bone transport technique with negative-pressure wound closure provides for successful eradication of the infection, reconstruction of the bone defect, and soft-tissue closure. A single-stage surgical treatment is feasible, without any complications.

Skin dimpling after a closed proximal humerus fracture.

BACKGROUND: Skin dimpling, also known as skin puckering, is a rare occurrence after closed proximal humerus fractures. This finding is suggestive of incarceration of the skin at the fracture site and may lead to necrosis and conversion to an open fracture. OBJECTIVES: Our goal is to describe our experience with skin dimpling after a proximal humerus fracture to increase awareness and recognition of this clinical presentation in the Emergency Department (ED). CASE REPORT: We report a case of a 46-year-old woman who presented to the ED with left shoulder pain and swelling after a fall. She was found to have skin dimpling over the anterior aspect of the shoulder on further examination and was diagnosed with a proximal humerus fracture after imaging. CONCLUSION: Skin dimpling is an uncommon sign associated with proximal humerus fractures that can help in diagnosis and determining course of treatment. Devastating soft tissue injury can occur if the fracture is not immediately reduced. Therefore, it is imperative that physicians be able to promptly identify the clinical presentation to prevent unwanted sequelae.

Missed ulnar nerve injury and closed forearm fracture in a child.

Ulnar nerve injury in closed fracture of forearm in children is uncommon.Commonly, neurapraxia is the reason for this palsy but other severe injuries or nerve entrapment has been reported in some cases. The importance of diagnosis concerning the types of the nerve injury lies in the fact that they have totally different management.We present a case of ulnar nerve deficit in a child following a closed fracture of the forearm bones. It is imperative to diagnose exact cause of palsy as it forms the basis for treatment. MRI scan can help diagnosis and accordingly guide the management. Simple nerve contusion should be treated conservatively, and exploration with fixation of the fracture should be done in lacerations and entrapments of the nerve. Surgery is not the treatment of choice in cases that could be managed conservatively.

Occult distal femoral physeal injury with disruption of the perichondrium.

The authors describe a case of distal femoral physeal injury with disruption of the perichondrium in a 9-year-old girl after a sledding accident. The patient presented with knee pain, limited range of motion, and inability to bear weight. Initial radiographs were normal. A magnetic resonance imaging of the knee demonstrated abnormal signal and widening of the distal femoral physis with elevation of the posterior distal femoral periosteum. This case illustrates the main magnetic resonance imaging findings in an occult Salter Harris type I injury: increased physeal thickness and signal intensity on water-sensitive sequences, perichondrial disruption, and intracartilaginous fracture.

Ultrasound-guided femoral nerve block for pain control in an infant with a femur fracture due to nonaccidental trauma.

A 3-month-old infant girl was transferred to our emergency department (ED) with a subtrochanteric femoral neck fracture due to nonaccidental trauma. She received multiple doses of parenteral analgesics both before arrival and in our ED. We performed an ultrasound-guided femoral nerve block using 2.0 mL of 0.25% bupivicaine (approximately 1.25 mg/kg) before placing the patient in a Pavlik harness. Successful pain control was achieved within 15 minutes of the procedure allowing pain-free manipulation of the affected extremity. The patient required only a single dose of parenteral narcotics during the ensuing 18 hours. To our knowledge, this is the first report of an ultrasound-guided femoral nerve block used in the ED for pain control in a pediatric patient.

Management of simple (types A and B) closed tibial shaft fractures using percutaneous lag-screw fixation and Ilizarov external fixation in adults.

PURPOSE: Although intramedullary fixation of closed simple (type A or B) diaphyseal tibial fractures in adults is well tolerated by patients, providing lower morbidity rates and better mobility, it is associated with some complications. This study evaluated the results of managing these fractures using percutaneous minimal internal fixation using one or more lag screws, and Ilizarov external fixation. METHODS: This method was tested to evaluate its efficacy in immediate weight bearing, fracture healing and prevention of any post-immobilisation stiffness of the ankle and knee joints. This randomised blinded study was performed at a referral, academically supervised, level III trauma centre. Three hundred and twenty-four of the initial 351 patients completed this study and were followed up for a minimum of 12 (12-88) months. Patient ages ranged from 20 to 51 years, with a mean of 39 years. Ankle and knee movements and full weight bearing were encouraged immediately postoperatively. Solid union was assessed clinically and radiographically. Active and passive ankle and knee ranges of motion were measured and compared with the normal side using the Wilcoxon signed rank test for matched pairs. Subjective Olerud and Molander Ankle Score was used to detect any ankle joint symptoms at the final follow-up. RESULTS: No patient showed delayed or nonunion. All fractures healed within 95-129 days. CONCLUSIONS: Based on final clinical and radiographic outcomes, this technique proves to be adequate for managing simple diaphyseal tibial fractures. On the other hand, it is relatively expensive, technically demanding, necessitates exposure to radiation and patients are expected to be frame friendly.

Role of MRI in the diagnosis and management of patients with clinical scaphoid fracture.

PURPOSE: The American College of Radiologists (ACR) recognises the value of magnetic resonance imaging (MRI) as the investigation of choice in patients with a clinically suspected scaphoid fracture but normal plain radiographs. The Royal College of Radiologists (RCR) in the UK produces no similar guidelines, as evidenced by the inconsistent management of such cases in hospitals around the UK. In discussion with our musculoskeletal radiologists, we implemented new guidelines to standardise management of our patients and now report our findings. METHODS: A consecutive series of 137 patients referred to the orthopaedic department with clinically suspected scaphoid fracture but normal series of plain radiographs were prospectively followed up over a two-year period. We implemented the use of early MRI for these patients and determined its incidence of detected scaphoid injury in addition to other occult injuries. We then prospectively examined results of these findings on patient management. RESULTS: Thirty-seven (27%) MRI examinations were normal with no evidence of a bony or soft-tissue injury. Soft-tissue injury was diagnosed in 59 patients (43.4%). Of those, 46 were triangular fibrocartilage complex (TFCC) tears (33.8%) and 18 were intercarpal ligament injuries (13.2 %). Bone marrow oedema with no distinct fracture was discovered in 55 cases (40.4%). In 17 (12.5%) cases, this involved only the scaphoid. In the remainder, it also involved the other carpal bones or distal radius. Fracture(s) were diagnosed on 30 examinations (22.0%). CONCLUSIONS: MRI should be regarded as the gold standard investigation for patients in whom a scaphoid fracture is suspected clinically. It allows the diagnosis of occult bony and soft-tissue injuries that can present clinically as a scaphoid fracture; it also helps exclude patients with no fracture. We believe that there is a need to implement national guidelines for managing occult scaphoid fractures.