Scaphoid Fracture

With acute paediatric trauma, standard radiographs remain the predominant imaging modality, with MRI being used as an adjunct. MRI is useful in detecting some acute injuries such as scaphoid fractures. In other circumstances it is of limited value, being relatively insensitive in detecting small os-sific fragments within a joint and when there is a considerable amount of metallic hardware within the bone. 

Fig. 5.10. Oblique coronal STIR image of the scaphoid. There is extensive marrow oedema with fluid around the carpal bones, features in keeping with a scaphoid fracture. Radiographs were normal.

Avascular necrosis can potentially complicate any fracture but is thankfully relatively rare in the younger child. In the older teenager with a scaphoid or femoral head fracture, dislocation then avascular necrosis is a more significant risk. 

Jaramillo D, Shapiro E et al. (1990) Post-traumatic growth-plate abnormalities MR imaging of bony-bridge formation in rabbits. Radiology 175 767-773 Johnson KJ, Haigh SP et al. (2000) MRI in the management of scaphoid fractures in skeletally immature patients. Pediatr Radiol 30 685-688... 

Fig. 19.33. Scaphoid views of the wrist performed in a 12-year-old boy show a dorsal buckle fracture of the radius...

The ossific nucleus of the scaphoid appears around 4-6 years of age, and ossification is complete at 13-15 years. As in adults, the scaphoid is the most frequently injured carpal hone. The incidence of fractures is extremely low in the first decade, thereafter rising to a peak in the late teens to mid twenties (Grad 1986). Unlike adults, fractures of the distal pole are more common than of the waist (Fig. 19.34). These fractures represent ligamentous avulsion injuries, with failure through the bone rather than the stronger soft tissues. Middle third fractures occur in older children and adolescents, whilst proximal pole fractures are rare. Many fractures are the result of direct trauma to the wrist rather than a fall on the outstretched hand (Vahvanen and Westerlund 1980). 

Fractures of the other carpals are very rarely seen in children (Goddard 2005). The capitate maybe injured in isolation, or more typically, in conj unction with other carpals, particularlythe scaphoid (Anderson 1987). Rare cases of lunate dislocations have been reported, usually associated with other injuries (Giddins and Shaw 1994) (Fig. 19.35). Open reduction and repair of the intercarpal hgaments is advised. 

A1 Qattan MM (2002) Juxta-epiphyseal fractures of the base of the proximal phalanx of the fingers in children and adolescents. J Hand Surg [Br] 27 24-30 Anderson WJ (1987) Simultaneous fracture of the scaphoid and capitate in a child. J Hand Surg [Am] 12 271-273 Barton NJ (1979) Fractures of the phalanges of the hand in children. Hand 11 134-143... 

Christodoulou AG, Colton CL (1986) Scaphoid fractures in children. J Pediatr Orthop 6 37-39 Chung KC, Spilson SV (2001) The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg [Am] 26 908-915... 

Cook PA, Yu JS, Wiand W, Cook AJ, Coleman CR, Cook AJ (1997) Suspected scaphoid fractures in skeletally immature patients application of MRI. J Comput Assist Tom-ogr 21 511-515... 

Vahvanen V, Westerlund M (1980) Fracture of the carpal scaphoid in children. A clinical and roentgenological study of 108 cases. Acta Orthop Scand 51 909-913 Valencia J, Leyva F, Gomez-Bajo GJ (2005) Pediatric hand trauma. Clin Orthop Relat Res (432) 77-86 Waters PM (2001) Fractures and dislocations of the hand and carpus in children. In Beaty JH, Kasser JR (eds) Rock-wood and Wilkins Fractures in children, 5th edn. Lippincott Williams and Wilkins, Philadelphia, pp 381-442 Weiss AP, Hastings H (1993) Distal unicondylar fractures of the proximal phalanx. J Hand Surg [Am] 18 594-599 Wyatt JP, Beattie TF (1995) Paediatric injuries on an artificial ski slope. Injury 26 87-88... 

The hand and wrist are commonly fractured in falls on the outstretched arm. The ulna, the radius, or both are prone to break as an individual attempts to catch oneself when falling. Blows to the forearm or hand may result in fractures. A fracture of the scaphoid at the base of the anatomic snuffbox is one that is slow to heal or may result in non-union and must be watched carefully. 

Ezquerro F et al. (2007) The influence of wire positioning upon the initial stability of scaphoid fractures fixed using Kirschner wires A finite element study. Medical Engineering Physics 29 652-660... 

Herneth AM, Siegmeth A, Bader TR et al (2001) Scaphoid fractures evaluation with high-spatial-resolution US initial results. Radiology 220 231-235 Herzenberg JE, Goldner JL, Martinez S et al (1986) Computerized tomography of talocalcaneal tarsal coalition. Foot Ankle 6 273-288... 

Hodgkinson DW, Nicholson DA, Stewart G et al (1993) Scaphoid fracture a new method of assessment. Clin Radiol 48 398-401... 

Senall JA, Failla JM, Bouffard JA et al (2004) Ultrasound for the early diagnosis of clinically suspected scaphoid fracture. J Hand Surg [Am] 29 400-405... 

The scaphoid is the most common site of occult fractures in the wrist area, with up to 20-25% of cases unnoticed at the initial evaluation (Waizenegger et al. 1994). When the diagnosis is delayed, scaphoid fi actures have high rates of complications such as pseudoarthrosis, avascular necrosis of the proximal pole of the bone and secondary radiocarpal osteoarthritis with chronic pain and impaired function. A variety of diagnostic modalities, such as additional radiographic views, bone scan, CT and MR imaging, have been advocated for early detection of scaphoid fractures. The choice between an addi-... 

Fig. 10.80 a-c. Scaphoid fracture, a Coronal 12-5 MHz US image over the lateral aspect of the wrist with corresponding b diagram and c anteroposterior radiographic correlation displays a fracture of the waist of the scaphoid as a step-off deformity of the hyperechoic cortical line (open arrow). Note a perilesional hypoechoic halo (arrowheads) surrounding the fracture site, consistent with a local hematoma. Rad, radius... 

Dias JJ, Hui AC, Lamont AC (1994) Real time ultrasonography in the assessment of movement at the site of a scaphoid fracture non-union. J Hand Surg [Br] 19 498-504 Duncan 1, Sullivan P, Lomas F (1999) Sonography in the diagnosis of carpal tunnel syndrome. AJR Am J Roentgenol 173 681-683... 

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