Hiding in Plain Sight: Cone Beam Computed Tomography Exposes the True Spectrum of Carpal Fractures

Physiotherapists are frequently the first point of contact for patients with acute wrist injuries. Initial clinical impressions rely on radiographic (X‑ray) imaging to rule out fracture, yet standard radiography has limited sensitivity for detecting carpal injuries. This study quantified the number of acute radiocarpal fractures missed on initial X‑rays but later identified using cone beam computed tomography (CBCT). It also examined whether fracture location differed between X‑ray and CBCT findings. A retrospective review was undertaken for patients presenting with acute wrist trauma to a specialist fracture clinic between 1 December 2023 and 30 May 2024 (n = 333). Data were extracted from electronic health and imaging records. Descriptive statistics and bivariate analyses assessed fracture location, detection rates, imaging modality, and demographic characteristics. Of the 325 wrist injuries analysed, 186 fractures were identified. X‑rays detected approximately 75% of these, leaving one in four occult. CBCT identified 41 fractures in cases where X‑rays appeared normal, highlighting the limitations of standard radiography. While X‑rays predominantly identified distal radius and scaphoid fractures, CBCT detected a broader spectrum of carpal injuries. Physiotherapists should recognise the limitations of X‑ray imaging in diagnosing radiocarpal fractures, as findings suggest carpal fractures are more common than previously understood and have been historically underdiagnosed. If a wrist injury presents clinically as a fracture despite normal X-rays, therapists should remain aware of the possibility of an occult fracture.