A patient has pain in the anatomic snuffbox after a fall on an outstretched hand. What is the next step in management?

• A. Radiograph of the hand; if normal, thumb spica cast with follow-up
• B. MRI of the hand
• C. CT scan of the hand
• D. Immediate thumb spica cast without imaging

Answer: (C)

Pain in the anatomic snuffbox after a fall on an outstretched hand points strongly to a scaphoid fracture. The scaphoid’s blood supply makes fractures prone to nonunion and avascular necrosis if not diagnosed early, so accurate imaging is crucial even when initial X-rays look normal.

Cross-sectional imaging is the best next step to evaluate the scaphoid promptly. A CT scan provides rapid, high-resolution detail of the bone, allowing detection of occult fractures that radiographs miss and giving precise information about fracture location and displacement. This information directly guides management: if a fracture is present, immobilize in a thumb spica cast and arrange orthopedic follow-up; if the fracture is displaced or unstable, surgery may be needed.

If the CT is negative but your clinical suspicion remains high, MRI can detect occult fractures by showing bone marrow edema, but CT is typically used first in the acute setting because it quickly confirms or excludes a fracture and informs immediate treatment.