Dr. Anz is Resident, Department of Orthopaedic Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, NC. Dr. Bushnell is Fellow, Orthopaedic Sports Medicine, Steadman Hawkins Clinic, Denver, CO. Dr. Bynum is Professor of Hand Surgery, Department of Orthopaedic Surgery, University of North Carolina Hospitals, Chapel Hill, NC. Dr. Chloros is Research Fellow, Department of Orthopaedic Surgery, Wake Forest University Baptist Medical Center. Dr. Wiesler is Associate Professor, Department of Orthopaedic Surgery, Wake Forest University Baptist Medical Center.
None of the following authors or a member of their immediate families has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Anz, Dr. Bushnell, Dr. Bynum, Dr. Chloros, and Dr. Wiesler.
Reprint requests: Dr. Anz, Department of Orthopaedic Surgery, Wake Forest University Baptist Medical Center, Medical Center Boulevard, Box 1070, Winston- Salem, NC 27157-1070. J Am Acad Orthop Surg 2009;17: 77-87
Copyright 2009 by the American Academy of Orthopaedic Surgeons.
Adam W. Anz, MD
Brandon D. Bushnell, MD
Donald K. Bynum, MD
George D. Chloros, MD
Ethan R. Wiesler, MD
Abstract
Fractures of the immature carpal scaphoid can be challenging to
manage. The diagnosis may be missed or delayed because of
absent or minimal symptoms. Once diagnosed, most pediatric
scaphoid fractures can be successfully treated with cast
immobilization. However, this is inadequate for difficult and unique
cases. Nonunion may occur as a result of a missed diagnosis or
delayed presentation as well as in patients who receive appropriate
treatment. Because the natural history in children remains
incompletely characterized, the optimal treatment of established
pediatric scaphoid nonunions is controversial. Surgical intervention
should be considered for displaced fractures in patients who are at
or near skeletal maturity or in those in whom nonsurgical treatment
has failed.
Anatomy and Development of the Scaphoid
The scaphoid resides on the radial aspect of the proximal carpal row and has four articular surfaces: a convex articulation with the radius, a flat articulation with the lunate, a convex articulation with the trapezoid and trapezium, and a concave articulation with the capitate. The blood supply to the scaphoid arises from the radial artery as two main vessels. A dorsal branch off the radial artery enters the scaphoid along its dorsal ridge. Upon entry into the scaphoid, this branch divides into multiple longitudinal interosseous branches and supplies the proximal 70% to 80%. Another branch off the radial artery, a volar vessel, is responsible for supplying the distal aspect of the scaphoid1,2 (Figures 1 and 2).
Enchondral ossification of the scaphoid begins with the appearance of an ossific nucleus in the first decade of life and continues to completion in the second decade. On average, this process begins for males at 5 years 9 months and concludes at 15 years 3 months. In females, the average onset is at 4 years 5 months, and completion is at 13 years 4 months3.This approximately 9-year period is a time of flux in the physical nature of the scaphoid. Fractures occurring at different points along this timeline thus behave differently according to the developmental status of the bone. Because of the variability of this development, it is important to base decisions regarding treatment of the scaphoid on radiographic bone age rather than chronologic age. Bipartite scaphoid has been observed in a small number of documented cases4 (Figure 3). It is unknown whether this radiographic appearance is a normal variation or whether it represents an undocumented fracture that has progressed to asymptomatic nonunion. Evidence exists to support each theory. Louis et al5 found no cases of atraumatic congenital bipartite scaphoid in their review of 11,280 pediatric hand radiographs and 196 human fetus dissections. Pick and Segal6 documented asymptomatic nonunion after trauma despite 19 weeks of immobilization in an 8-year-old child whose plain radiographs indicated a bipartite scaphoid. Documented cases also exist of bilateral, biparite scaphoid in the absence of trauma.4,7
The vasculature of the scaphoid originates from a dorsal vessel and a volar
vessel, both of which are branches of the radial artery. MCI = first
metacarpal, R = radius, S = scaphoid, Tz = trapezium. (Reproduced from
Trumble TE, Salas P, Barthel T, Robert KQ III: Management of scaphoid
nonunions. J Am Acad Orthop Surg 2003;11:380-391.)
Pathomechanics and Incidence of Injury
Scaphoid fractures most commonly occur during a fall on an outstretched hand8-15. Other reported causes include punching activities and direct crush injuries. Injury to the scaphoid can result via two mechanisms: a direct compression force on the scaphoid or an indirect lurching moment caused by forced dorsiflexion. Direct blows can cause an impaction fracture anywhere along the length of the scaphoid, whereas forced dorsiflexion of the wrist typically results in a displaced distal third, waist, or proximal third scaphoid fracture.
In children younger than age 15 years, the annual incidence of scaphoid fracture has been reported at 0.6 per 10,000.15 Scaphoid fractures account for 0.39% of all pediatric fractures,15 0.45% of pediatric upper extremity fractures,15 and 3% of pediatric fractures of the hand and wrist.16 However, the scaphoid is the most often fractured carpal bone, in both the skeletally immature and mature wrist. The youngest patient to sustain a scaphoid fracture is believed to have been a 4-year-old child who was involved in a motor vehicle accident; however, this fracture was not radiographically documented until the patient reached age 11 years.17 The earliest radiographically confirmed fracture occurred in a child aged 5 years 9 months who sustained a crush injury.18 Fractures start to appear more commonly at 6 years and increase in frequency with each subsequent year, peaking at age 15 years.16,19
Photograph demonstrating the branch of the radial artery that enters along the dorsal ridge and supplies the proximal 70% to 80% of the scaphoid (1) and the volar vessel that supplies the distal aspect (2). (Reproduced with permission from Gelberman RH, Menon J: The vascularity of the scaphoid bone. J Hand Surg [Am] 1980;5:508-513.)
Posteroanterior radiograph demonstrating a bipartite appearance of the scaphoid in a 13-year-old girl with no history of trauma. (Reproduced with
permission from Doman AN, Marcus NW: Congenital bipartite scaphoid. J Hand Surg [Am]
1990;15:869-873.)
Classification of Fractures
The scaphoid experiences a period of maturation from age 6 to 15 years, altering its physical properties during this time. Thus, patient age, degree of ossification, and fracture location are interrelated; these factors are important for determining fracture type, classification, and treatment. D’Arienzo14 proposed a three-part classification system based on the age of the child and the presumed degree of ossification (Figure 4).
Type 1 lesions occur in children younger than age 8 years. In these lesions, the fracture line may be purely chondral or may involve part of the ossific nucleus. These fractures are more rare and difficult to diagnose, often requiring advanced imaging modalities such as magnetic resonance imaging (MRI).8-10,12,14,18 (Figure 5).
Type 2 are osteochondral fractures and occur in patients aged 8 to 11 years. Type 3 lesions are the most common fractures and occur in adolescents aged ≥12 years. At this age, the scaphoid is almost completely ossified, and these fractures behave similarly to those in the adult population.
Pediatric scaphoid fractures also may be classified according to anatomic location: tuberosity, transverse distal pole, avulsion distal pole, waist, and proximal pole13,14,20,21 (Figures 6 and 7). In children, fractures of the distal third of the scaphoid are the most common; this includes transverse distal pole fractures, avulsions of the distal pole, and tubercle fractures. Waist fractures account for approximately one fourth of scaphoid fractures; fractures of the proximal pole are extremely rare in children 8-15 (Table 1).
Two type 1 scaphoid fractures. A, A boy aged 5 years 9 months sustained a crush injury. Initial radiographs revealed a normal-appearing ossific nucleus of the scaphoid. Physical therapy for wrist range of motion was begun following 1 month of immobilization. Three months later, stiffness persisted. This anteroposterior radiograph, taken 3 months after the initial injury, revealed absorption of the radial edge of the ossific nucleus (arrow). This represented a type 1 scaphoid fracture. Regimented therapy was stopped, and the patient was allowed to progress at his own rate. Eventually, he developed an asymptomatic scaphoid nonunion (B).18 C, Fracture through the ossific nucleus in a boy aged 6 years 4 months. He progressed to complete asymptomatic union following 4 months of immobilization.12 (Panels A and B reproduced with permission from Larson B, Light TR, Ogden JA: Fracture and ischemic necrosis of the immature scaphoid. J Hand Surg [Am] 1987;12:122-127. Panel C reproduced with permission from Greene MH, Hadied AM, LaMont RL: Scaphoid fractures in children. J Hand Surg [Am] 1984;9:536-541.)
Radiographic representations of four types of scaphoid fracture based on anatomic location. A, Anteroposterior radiograph demonstrating distal third transverse fracture (arrow). B, Anteroposterior radiograph demonstrating waist fracture. C, Anteroposterior radiograph demonstrating avulsion fracture of the distal pole. D, Posteroanterior radiograph taken at 20° to 40° of supination demonstrating fracture of the tuberosity. (Panels A and B reproduced with permission from D’Arienzo M: Scaphoid fractures in children. J Hand Surg [Br] 2002;27:424-426. Panel C reproduced with permission from Beatty E, Light TR, Belsole RJ, Ogden JA: Wrist and hand skeletal injuries in children. Hand Clin 1990;6:723-738. Panel D reproduced with permission
from Böhler L, Trojan E, Jahana H: The results of treatment of 734 fresh, simple fractures of the scaphoid. J Hand Surg [Br] 2003;28:319-331.)
History and Physical Examination
Clinical history of a fall on an outstretched hand, punching activity, crushing blow, or other appropriate mechanism of injury should raise suspicion for scaphoid injury. Symptoms may be vague or nonexistent. On examination, the most common sign of injury to the scaphoid is pain on palpation in the anatomic snuffbox. Other less sensitive physical examination findings include pain during range of motion, snuffbox swelling, and pain with axial loading. 9 Trapping the scaphoid through coupled palpation at the snuffbox and at the volar side near the tubercle may aid in localizing pain to the scaphoid bone.Radiographic Imaging
The standard plain radiographic evaluation of the scaphoid should comprise anteroposterior, lateral, oblique, and scaphoid views34 (Figure 8). Positioning for the scaphoid view involves placing the wrist in maximal pronation, dorsiflexion, and ulnar deviation. This view is especially useful in the visualization of avulsion fractures.16 Soft-tissue signs, including exudation into the joint capsule recess, dorsal swelling of the wrist, and obliteration of a scaphoid fat stripe, may aid in the detection of occult scaphoid fractures; however, these should not be used to confirm or refute a diagnosis.35 The sensitivity of plain radiographs varies to such an extent within the pediatric literature (21% to 97%) that these images cannot be considered reliable for fracture exclusion.8,9,36 Christodoulou and Colton15 found that approximately 13% of fractures do not appear radiographically until 1 to 2 weeks after injury. As such, plain radiographs tend to be useful only for confirming a fracture and following healing progression. Bone age radiographs may also be obtained to guide treatment decisions, especially when a large discrepancy exists between bone age and chronologic age.
In the acute setting, computed tomography, ultrasonography, and bone scintigraphy may be used when plain radiographs prove to be negative or equivocal.Both computed tomography and bone scintigraphy have demonstrated high sensitivity and specificity for making a diagnosis in the adult population.37-39 However, the radiation dose delivered, combined with the lack of evidence justifying accuracy and reliability in the pediatric population, makes these modalities less desirable for evaluating the immature wrist. Ultrasonography may prove to be useful, but it is highly user-dependent. In adult studies, its sensitivity ranges from 50% to 78%, with specificity ranging from 89% to 91%.40-42
| Study | No. of Fractures | Age Range (Yr) | Distribution (%) |
|---|---|---|---|
| Christodoulou and Colton15 | 64 | 8-14 | 21 tuberosity (33), 17 distal (27), 24 waist (37), 2 proximal (3) |
| D'Arienzo14 | 39 | 8-15 | 5 tuberosity (13), 31 distal (79), 3 waist (8) |
| Fabre et al8 | 23 | 6-17 | 5 avulsion distal (22), 17 middle and distal (74), 1 proximal (4) |
| Greene et al12 | 9 | 6-14 | 1 tuberosity (11), 5 distal (56), 3 waist (33) |
| Grundy11 | 8 | 10-15 | 2 tuberosity (25), 3 distal (38), 3 waist (37) |
| Mussbichler16 | 100 | 8-15 | 52 avulsion distal (52), 33 distal (33), 15 waist (15) |
| Vahvanen and Westerlund10 | 108 | 6-14 | 41 avulsion distal (38), 53 distal (49), 13 waist (12), 1 avulsion proximal (1) |
| Wulff and Schmidt9 | 33 | 7-16 | 4 avulsion distal (12), 17 distal (52), 12 waist (36) |
Illustration demonstrating five of the common anatomic sites of scaphoid fracture. A, Proximal
pole. B, Waist. C, Distal transverse. D, Tuberosity. E, Avulsion of the distal pole.
MRI can be useful in the initial evaluation of pediatric scaphoid fractures. Johnson et al 36 studied 57 patients (mean age, 12 years 5 months) who were evaluated with plain radiography and MRI within 10 days of injury (Table 4). In all patients, correct diagnosis was made possible with the use of MRI scans. Furthermore, 75% of the patients with a scaphoid fracture proven on MRI scan had a negative initial plain radiograph. These authors posit that a negative MRI scan can eliminate the need for additional follow-up and radiographs in 58% of patients with suspected scaphoid fracture. These findings are echoed by those of Cook et al,35 who found that a normal initial MRI scan as early as 2 days after injury carried a negative predictive value of 100% (18 patients [age range, 8 to 15 years]). In the immature scaphoid, MRI scans offer the best option for definitive imaging evaluation.
Treatment
Most pediatric scaphoid fractures are amenable to nonsurgical treatment with cast immobilization. Surgical intervention should be considered for displaced scaphoid fractures in patients who are at or near skeletal maturity and in patients with established scaphoid nonunion.
Immobilization should be initiated at the time of injury in all patients with the appropriate history and physical examination findings, regardless of initial plain radiographic results, until an MRI scan can be obtained (as needed) for definitive evaluation. A negative MRI evaluation warrants no further treatment,23,35,36 but a limited period (2 to 4 weeks) of clinical follow-up is appropriate. Initial management with a long arm thumb spica cast should be considered as it maximizes immobilization in a population known to be active. Short arm spica casting may be used as initial treatment of incomplete or avulsion fractures. Immobilization also should be the initial treatment method in the patient with late presentation or diagnosis because multiple clinical reports have shown progression to union with proper immobilization, even with delayed diagnosis.7-10,12,25,30
At the initial 2-week follow-up visit, immobilization with a long arm thumb spica may be continued, or the patient may be transitioned to a short arm thumb spica cast. Waist fractures require special consideration as these are the fractures that most commonly progress to nonunion. For patients with such fractures, continuation of long arm casting may be beneficial; however, surgical treatment may be indicated. Immobilization should be continued until healing is verified on plain radiographs or, in questionable cases, MRI scans. Healing times based on fracture location have been reported 10,11,13,14,16 (Table 3). MRI is often required to determine healing in patients with pure chondral lesions or smaller osteochondral fractures that are not reliably visualized on plain radiographs.
| Study | No. of Nonunions | Distribution |
|---|---|---|
| Mussbichler16 | 2 | Not reported |
| Southcott and Rosman22 | 8 | Waist |
| Vahvanen and Westerlund10 | 1 | Waist |
| Maxted and Owen23 | 2 | Waist |
| Onuba and Ireland24 | 2 | Waist |
| Pick and Segal5 | 1 | Waist |
| Greene et al12 | 2 | 1 waist, 1 distal pole |
| Christodoulou and Colton15 | 1 | Waist |
| Larson et al18 | 1 | Waist |
| Wilson-MacDonald25 | 1 | Not reported |
| De Boeck et al30 | 1 | Waist |
| Littlefield et al29 | 2 | Waist |
| Mintzer and Waters32 | 13 | Waist |
| Fabre et al8 | 2 | Not reported |
| Garcia-Mata31 | 4 | 2 waist |
| Waters and Stewart33 | 3 | Proximal pole |
| Henderson and Letts28 | 20 | Waist |
| Toh et al19 | 46 | 44 waist, 1 distal pole, 1 proximal pole |
| Duteille and Dautel27 | 11 | 11 waist, 2 distal pole |
| Study | Distribution | Healing Time (Wk) |
|---|---|---|
| D'Arienzo14 | 5 tuberosity | 3-4 |
| 31 distal | 5 | |
| 3 waist | 7-8 | |
| Gamble and Simmons13 | 2 waist | 10 |
| Grundy11 | 2 tuberosity | 3 |
| 3 distal | 5-6 | |
| 3 waist | 5-6 | |
| Mussbichler16 | 52 distal avulsion | 3-6 |
| 33 distal | 4-7 | |
| 15 waist | 4-7 | |
| Vahvanen and Westerlund10 | 41 distal avulsion | 3 |
| 53 distal | 4-8 | |
| 13 waist | 4-16 | |
| 1 proximal avulsion | 3 |
A fracture that does not heal within 6 months must be classified as a nonunion and managed accordingly. Very little published information exists concerning treatment of displaced fractures in the acute setting in children. There is one case report of a 9-year-old girl with a displaced waist fracture who underwent open reduction and internal fixation with a Herbert screw.43 This patient progressed to an asymptomatic, anatomic union.
Careful evaluation is required for the patient who is close to skeletal maturity (as judged by physeal closure and/or bone age radiographs). The literature indicates that cast immobilization has proved to be effective in this population. Clinical series include those of Christodoulou and Colton,15 who reported success with immobilization in 64 patients aged 8 to 14 years (one nonunion required surgery), D’Arienzo,14 who reported success with immobilization in 31 patients older than age 12 years, and Grundy,11 who reported success with immobilization in eight fractures in patients aged 10 to 15 years. The historical success reported in the literature must be balanced with the documented propensity toward nonunion in the young adult population and the success of early surgical intervention in this group.
| Radiographic Findings (No. of Pts) | Magnetic Resonance Imaging Findings (No. of Pts) |
|---|---|
| No fracture (44) | Normal (27), scaphoid fracture (9), scaphoid fracture and other injury (2), carpal injury (6) |
| Equivocal (10) | Normal (6), scaphoid fracture (2), carpal/radial injury (2) |
| Scaphoid fracture (3) | Scaphoid fracture (3) |
| Fracture displacement ≥1.0 mm |
| Fracture comminution |
| Any proximal pole fracture |
| Delay in diagnosis and initial treatment |
| Fracture angulation in the sagittal plane with a lateral intrascaphoid angle >45° or a height-to-length ratio >0.65 |
| Poor patient compliance as evaluated from the patient interview |
Scaphoid Nonunion
Even in cases of appropriately managed pediatric scaphoid fractures, nonunion may develop.5,6,15,18,27 In their review of the literature on scaphoid fracture in 371 children, Fabre et al8 reported a 0.8% incidence of nonunion after prompt, adequate immobilization. However, more often, nonunion occurs because the initial fracture has been missed because of the paucity of clinical signs,31 lack of clear radiographic findings, or difficulty in accurately interpreting the immature carpus.10 An unknown percentage of the missed initial fractures will ultimately develop a scaphoid nonunion, whereas others will heal spontaneously and pass undetected.Thus, in general, a nonunion may be discovered in one of the three following circumstances: (1) After an acute injury that was misdiagnosed, neglected, or for which treatment failed. In this instance, there is a clear history of injury, and symptoms are usually present.15,22,24-29,31,32,44 (2) Incidentally, from radiographs performed for another indication. The patient may have no clear history of previous injury.23,27,44 (3) In the context of poorly defined chronic wrist pain or discomfort.11,12,22,27,44 There may be a history of multiple falls during contact sports or playing with other children, but usually no single specific incident has occurred that would account for the injury.44Incidence
Because of the reliable healing power of the pediatric skeleton, nonunions of the scaphoid are fairly rare.22,25-30 Most reported cases of nonunion involve the scaphoid waist;8,9,11,12,15,21-24,26,28-32,44 nonunions of the distal19,25 and proximal6,19,33 poles are rarer in children6,8,10,12,15-18,22-31 (Table 2). Nonunions have been reported almost exclusively in children aged 9 to 15 years.15,19,22,24-27,29,31-33,44 A boy aged 5 years 9 months who sustained a crushing blow to his hand is the youngest documented patient to have a scaphoid nonunion; this is the same patient who was the youngest documented case of a scaphoid fracture. 18Natural History
Whereas scaphoid nonunion in the adult population progresses to a predictable model of wrist arthrosis, the natural history of untreated pediatric scaphoid nonunion is unknown. The relation of the scaphoid and the lunate through the scapholunate interosseous ligament provides a vital role concerning overall alignment and support of the carpals. The scaphoid is an important structural bridge between the proximal and distal carpal rows. A fracture in the scaphoid can lead to a break or rift in this structural chain. If this rift persists, such as in cases of nonunion, the proximal lunate and linked proximal scaphoid displace volarly, and as a result, the wrist loses stability. This produces a dorsal intercalated segmental instability (DISI) pattern. In the adult population, if this pattern of deformity becomes permanent, a form of radiocarpal arthritis known as scaphoid nonunion advanced collapse (SNAC) forms. This represents the natural progression of injury in adult patients within 10 years.1,45-47 Although concern exists that this progression may apply to the pediatric population, SNAC wrist has never been demonstrated in the immature skeleton, and the paucity of pediatric cases makes the occurrence of posttraumatic SNAC wrist difficult to determine. There is one documented case of a 19-year-old man who sustained a scaphoid injury in his younger years that progressed to nonunion and eventual SNAC. This patient was treated surgically with a four-bone arthrodesis and reportedly returned to his occupation with good results. However, it is unclear whether his initial injury was to an immature or a mature scaphoid.48| Study | No. of Fractures | Surgical Method (No. of Fractures) | Results |
|---|---|---|---|
| Southcott and Rosman22 | 8 | Autogenous bone graft via an anterior approach | All progressed to union, with 1 patient requiring revision |
| Maxted and Owen23 | 2 | Bone graft via anterior approach and K-wire fixation | Successful union at 16 and 18 wk |
| Onuba and Ireland24 | 2 | AO cancellous screw | Successful union at 24 wk |
| Littlefield et al29 | 2 | Iliac bone wedge and Herbert screw | Successful union at 13 wk |
| Mintzer and Waters32 | 13 | Matti-Russe procedure (4) | Successful union, with 1 patient requiring revision |
| Iliac bone graft and Herbert screw using the Matti-Russe procedure (9) | Successful union; significant decrease in time of postoperative immobilization compared with Matti-Russe alone | ||
| Garcia-Mata31 | 4 | Matti-Russe procedure | Successful union in two at 8 wk and in two at 2 wk |
| Waters and Stewart33 | 3 | Vascularized bone graft and internal fixation | Successful union achieved at 11, 12, and 18 wk |
| Henderson and Letts28 | 20 | Bone graft and screw fixation (11), K-wire fixation and bone graft (2), bone graft (6), screw fixation (1) | Successful union, with 1 patient requiring removal of Herbert screw |
| Toh et al19 | 44 | Closed reduction and percutaneous screw fixation (4), open reduction and screw fixation (5), bone graft and screw fixation (35) | Successful union, with 2 patients requiring revision |
| Duteille and Dautel27 | 11 | Bone graft via anterior approach and K-wire fixation | Successful union at a mean of 6.2 wk |
Nonsurgical Treatment
Although excellent healing and functional outcomes of pediatric scaphoid nonunion with immobilization have been reported,6,8,12,25,30 some patients eventually require surgical intervention.15,23,31 Extended periods of immobilization may prove to be intolerable for the child or the family, and few guidelines exist to indicate when enough is enough. The decision to proceed to surgical intervention should be made only after having a thorough discussion of risks and benefits with the child’s caretakers.Surgical Treatment
A variety of surgical treatments has been described for pediatric scaphoid nonunion19,22-29,31,33 (Table 6). Southcott and Rosman22 documented the first successful series involving autogenous bone graft via an anterior approach. All but one patient progressed to union without the need for revision surgery. Maxted and Owen23 reported on two patients in whom Kirschner wire fixation was used in addition to bone graft. Techniques have since progressed to include the use of screw fixation, including Herbert and AO instrumentation. The Matti-Russe procedure has also had documented success within this patient population. Mintzer et al26 presented a series that compared the Matti-Russe procedure with Herbert screw and iliac grafting. The latter method required a significantly decreased period of postoperative immobilization to achieve healing. In general, regardless of the method used, excellent results with surgical treatment have been reported, with a union rate close to 100%, good to excellent range of motion, and absence of pain.8,18,19,22,23,25-32,43 A small number of patients have experienced light, intermittent discomfort at the extremes of motion or with strenuous activities.18,19,28,44
In cases in which the first operation did not result in union or in which reduction was subsequently lost, 100% union was achieved following a second operation using the same or another fixation method along with bone grafting.18,19,22 These data indicate that different techniques yield similar good results, and thus, that the prognosis in children with pediatric scaphoid waist nonunion is favorable. Another issue that can affect treatment selection is the duration of the period of immobilization after sursurgery. In adults, one of the advantages of using Herbert screws or other fixation devices is the abbreviated period of immobilization after surgery. The applicability of this same concept to the pediatric population remains unclear. The recommended period of immobilization after surgery varies from 4 weeks to 3 months depending on the type of surgical treatment.19,22,26-29,31,32,44
Complications Following Scaphoid Fracture
Osteonecrosis of the proximal pole of the scaphoid in the immature skeleton is possible but is rarely reported. In fact, there has been only one report of osteonecrosis. This report involved three adolescent boys (mean age, 14.5 years).33 Each patient was treated with a vascularized bone graft from the distal radius that was secured with Kirschner wires. At a minimum follow-up of 5 years, the patients were pain-free and had unrestricted activities, but they experienced a moderate loss of wrist dorsiflexion and radial deviation. Plain radiographs showed union, no evidence of degenerative joint disease, and absence of the preoperative proximal scaphoid lucency.In cases of surgical treatment, obvious concern exists regarding the possible disturbance of growth of the cartilaginous scaphoid with use of a Herbert screw. Use of this screw has been reported only in children aged 11 years and older.18,19,26,32,44 One case has been noted in which proximal migration of a Herbert screw to the distal radius caused pain, requiring screw removal at 14 months. This had no effect on fracture union, but the patient identified some discomfort at follow-up.28
Summary
Considering the known complications in the adult population and the nuances of the pediatric population, traumatic injuries to the immature wrist can be daunting. A low threshold must be set for initiating immobilization in the patient with suspected scaphoid fracture. An MRI scan is beneficial and recommended in all pediatric patients with wrist pain and suspected scaphoid fracture to ensure adequate diagnosis and subsequent treatment. Fresh and chronic scaphoid fractures both have great healing potential with nonsurgical treatment. Thus, ample immobilization should serve as the foundation of treatment in all cases of acute fracture and nonunion. Excellent results have been achieved with surgical management.References
Evidence-based Medicine: Level I/II randomized, prospective studies include references 35-42. Reference 49 is a level III case report. Several level IV casecontrol cohort series (references 5, 8-12, 15, 16, 19, 20, 22, 26-28, 31-34, and 44-47) and level V expert opinion reports (references 1, 4, 6, 7, 13, 14, 17, 18, 21, 23-25, 29, 30, 43, and 49) are cited.Citation numbers printed in bold type indicate references published within the past 5 years.
1. Trumble TE, Salas P, Barthel T, Robert KQ III : Management of scaphoid nonunions. J Am Acad Orthop Surg 2003;11:380-391.
2. Gelberman RH, Menon J: The vascularity of the scaphoid bone. J Hand Surg [Am] 1980;5:508-513.
3. Stuart HC, Pyle SI, Cornoni J, Reed Onsets, completions and spans of ossification in the 29 bonegrowth centers of the hand and wrist. Pediatrics 1962; 29:237-249.
4. Doman AN, Marcus NW: Congenital bipartite scaphoid. J Hand Surg [Am] 1990;15:869-873.
5. Louis DS, Calhoun TP, Garn SM, Carroll RE, Burdi AR: Congenital bipartite scaphoid: Fact or fiction? J Bone Joint Surg Am 1976;58:1108- 1112.
6. Pick RY, Segal D: Carpal scaphoid fracture and non-union in an eight-yearold child: Report of a case. J Bone Joint Surg Am 1983;65:1188-1189.
7. Dubrana F, Le Nen D, Hu W, Poureyron Y, Pazart F, Lefevre C: Bilateral bipartite carpal scaphoid bone: A congenital disease or unrecognized pseudarthrosis? Discussion a propos of a clinical case [French]. Rev Chir Orthop Reparatrice Appar Mot 1999;85:503-506.
8. Fabre O, De Boeck H, Haentjens P: Fractures and nonunions of the carpal scaphoid in children. Acta Orthop Belg 2001;67:121-125.
9. Wulff RN, Schmidt TL: Carpal fractures in children. J Pediatr Orthop 1998;18: 462-465.
10. Vahvanen V, Westerlund M: Fracture of the carpal scaphoid in children: A clinical and roentgenological study of 108 cases. Acta Orthop Scand 1980;51: 909-913.
11. Grundy M: Fractures of the carpal scaphoid in children: A series of eight cases. Br J Surg 1969;56:523-524.
12. Greene MH, Hadied AM, LaMont RL: Scaphoid fractures in children. J Hand Surg [Am] 1984;9:536-541.
13. Gamble JG, Simmons SC III: Bilateral scaphoid fractures in a child. Clin Orthop Relat Res 1982;162:125-128.
14. D’Arienzo M: Scaphoid fractures in children. J Hand Surg [Br] 2002;27:424- 426.
15. Christodoulou AG, Colton CL: Scaphoid fractures in children. J Pediatr Orthop 1986;6:37-39.
16. Mussbichler H: Injuries of the carpal scaphoid in children. Acta Radiol 1961; 56:361-368.
17. Bloem JJ: Fracture of the carpal scaphoid in a child aged 4. Arch Chir Neerl 1971; 23:91-94.
18. Larson B, Light TR, Ogden JA: Fracture and ischemic necrosis of the immature scaphoid. J Hand Surg [Am] 1987;12: 122-127.
19. Toh S, Miura H, Arai K, Yasumura M, Wada M, Tsubo K: Scaphoid fractures in children: Problems and treatment. J Pediatr Orthop 2003;23:216-221.
20. Böhler L, Trojan E, Jahna H: The results of treatment of 734 fresh, simple fractures of the scaphoid. J Hand Surg [Br] 2003;28:319-331.
21. Beatty E, Light TR, Belsole RJ, Ogden JA: Wrist and hand skeletal injuries in children. Hand Clin 1990;6:723-738.
22. Southcott R, Rosman MA: Non-union of carpal scaphoid fractures in children. J Bone Joint Surg Br 1977;59:20-23.
23. Maxted MJ, Owen R: Two cases of nonunion of carpal scaphoid fractures in children. Injury 1982;13:441-443.
24. Onuba O, Ireland J: Two cases of nonunion of fractures of the scaphoid in children. Injury 1983;15:109-112.
25. Wilson-MacDonald J: Delayed union of the distal scaphoid in a child. J Hand Surg [Am] 1987;12:520-522.
26. Mintzer CM, Waters PM, Simmons BP: Nonunion of the scaphoid in children treated by Herbert screw fixation and bone grafting: A report of five cases. J Bone Joint Surg Br 1995;77:98-100.
27. Duteille F, Dautel G: Non-union fractures of the scaphoid and carpal bones in children: Surgical treatment. J Pediatr Orthop B 2004;13:34-38.
28. Henderson B, Letts M: Operative management of pediatric scaphoid fracture nonunion. J Pediatr Orthop 2003;23:402-406.
29. Littlefield WG, Friedman RL, Urbaniak JR: Bilateral non-union of the carpal scaphoid in a child: A case report. J Bone Joint Surg Am 1995;77:124-126.
30. De Boeck H, Van Wellen P, Haentjens P: Nonunion of a carpal scaphoid fracture in a child. J Orthop Trauma 1991;5:370- 372.
31. García-Mata S: Carpal scaphoid fracture nonunion in children. J Pediatr Orthop 2002;22:448-451.
32. Mintzer CM, Waters PM: Surgical treatment of pediatric scaphoid fracture nonunions. J Pediatr Orthop 1999;19: 236-239.
33. Waters PM, Stewart SL: Surgical treatment of nonunion and avascular necrosis of the proximal part of the scaphoid in adolescents. J Bone Joint Surg Am 2002;84:915-920.
34. Russe O: Fracture of the carpal navicular: Diagnosis, non-operative treatment, and operative treatment. J Bone Joint Surg Am 1960;42:759-768.
35. Cook PA, Yu JS, Wiand W, Cook AJ II, Coleman CR, Cook AJ: Suspected scaphoid fractures in skeletally immature patients: Application of MRI. J Comput Assist Tomogr 1997;21:511-515.
36. Johnson KJ, Haigh SF, Symonds KE: MRI in the management of scaphoid fractures in skeletally immature patients. Pediatr Radiol 2000;30:685-688.
37. Beeres FJ, Hogervorst M, den Hollander P, Rhemrev S: Outcome of routine bone scintigraphy in suspected scaphoid fractures. Injury 2005;36:1233-1236.
38. Cruickshank J, Meakin A, Breadmore R, et al: Early computerized tomography accurately determines the presence or absence of scaphoid and other fractures. Emerg Med Australas 2007;19:223-228.
39. Adey L, Souer JS, Lozano-Calderon S, Palmer W, Lee SG, Ring D: Computed tomography of suspected scaphoid fractures. J Hand Surg [Am] 2007;32:61- 66.
40. Senall JA, Failla JM, Bouffard JA, van Holsbeeck M: Ultrasound for the early diagnosis of clinically suspected scaphoid fracture. J Hand Surg [Am] 2004;29: 400-405.
41. Herneth AM, Siegmeth A, Bader TR, et al: Scaphoid fractures: Evaluation with high-spatial-resolution US initial results. Radiology 2001;220:231-235.
42. Munk B, Bolvig L, Kroner K, Christiansen T, Borris L, Boe S: Ultrasound for diagnosis of scaphoid fractures. J Hand Surg [Br] 2000;25:369- 371.
43. Mintzer C, Waters PM: Acute open reduction of a displaced scaphoid fracture in a child. J Hand Surg [Am] 1994;19:760-761.
44. Chloros GD, Themistocleous GS, Wiesler ER, Benetos IS, Efstathopoulos DG, Soucacos PN: Pediatric scaphoid nonunion. J Hand Surg [Am] 2007;32: 172-176.
45. Lindström G, Nyström A: Natural history of scaphoid non-union, with special reference to “asymptomatic” cases. J Hand Surg [Br] 1992;17:697- 700.
46. Mack GR, Bosse MJ, Gelberman RH, Yu E: The natural history of scaphoid nonunion. J Bone Joint Surg Am 1984;66: 504-509.
47. Ruby LK, Stinson J, Belsky MR: The natural history of scaphoid non-union: A review of fifty-five cases. J Bone Joint Surg Am 1985;67:428-432.
48. Tomaino MM, Miller RJ, Cole I, Burton RI: Scapholunate advanced collapse wrist: Proximal row carpectomy or limited wrist arthrodesis with scaphoid excision? J Hand Surg [Am] 1994;19: 134-142.
49. Suzuki K, Herbert TJ: Spontaneous correction of dorsal intercalated segment instability deformity with scaphoid malunion in the skeletally immature. J Hand Surg [Am] 1993;18:1012-1015.
Published in:
Journal of the American Academy of Orthopaedic Surgeons
February 2009, Vol 17, No 2
For additional information on ACL knee injuries, or to learn more about what is involved during ACL reconstruction surgery, please contact the office of orthopedic knee surgeon, Dr. Adam Anz, serving the greater Pensacola, Gulf Breeze, and Gulf Coast communities.
