Pediatric scaphoid fractures are relatively uncommon. The mechanism is similar in children and adults. Previously, the adult literature has reported that if the initial x-rays are negative there is a low rate of subsequent fracture. However, similar work has not been done in children. The purpose of this study was to (1) determine how many clinical suspected pediatric scaphoid fractures later become radiographically evident and; (2) to identify physical examination findings that suggest a scaphoid fracture when present at initial evaluation.
The study consisted of a retrospective and prospective arm. Both cohorts were designed to assess the incidence of radiographically evident fractures after clinical suspicion but negative x-rays. The prospective cohort also looked at a variety of physical examination findings to determine their predictive value in assessing a fracture.
The treatment for a suspected fracture involved immobilization in short arm splint and referral to local pediatric orthopaedist. The physical examinations recorded included (1) pain with active wrist range of motion; (2) snuffbox tenderness; (3) volar tenderness over the scaphoid; (4) pain with axial loading of the thumb; (5) pain with radial deviation; (6) pain with ulnar deviation; and (7) pain with resisted supination. The entire cohort consisted of 104 wrists with no initial radiographic evidence of fracture, but clinical suspicion. At follow-up, 31 (30%) had fracture. Of the 31 wrists with true scaphoid fracture, 14 were identified at the first office visit, 12 were identified at the second office visit, and 5 were identified at the third office visit. No scaphoid fracture required surgery. When assessing the predictive signs, the following were predictive of subsequent scaphoid fracture: (1) volar scaphoid tenderness (2) pain with radial deviation; and (3) pain with active wrist range of motion. Anatomic snuffbox tenderness was a common finding in both groups and therefore not predictor.
This study supports immobilization of suspected pediatric scaphoid fractures. Remarkably, 30% subsequently developed a fracture, which is higher than the adult literature. The clinical findings of volar scaphoid tenderness, pain with radial deviation, and pain with active wrist range of motion are all predictors.