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OTHER PEDIATRIC CARPAL FRACTURES (NON-SCAPHOID)

Introduction

Fracture Nomenclature for Other Pediatric Carpal Fractures (Non-Scaphoid)

Hand Surgery Resource’s Diagnostic Guides describe fractures by the anatomical name of the fractured bone and then characterize the fracture by the Acronym:

In addition, anatomically named fractures are often also identified by specific eponyms or other special features.

For the Other Pediatric Carpal Fractures (Non-Scaphoid), the historical and specifically named fractures include:

Scaphocapitate fracture syndrome

Lunate and perilunate dislocation and fracture-dislocation

By selecting the name (diagnosis), you will be linked to the introduction section of this Diagnostic Guide dedicated to the selected fracture eponym.

Carpal fractures are rare in the pediatric population. As with adults, fractures of the scaphoid represent the majority of these injuries, accounting for ~0.45% of all upper limb fractures and ~2.9% of all hand and wrist fractures in children. Fractures of the capitate appear to be most common of non-scaphoid carpal fractures, while incidence rates for the other carpals are not well documented due to their low frequency.  The rarity of pediatric non-scaphoid carpal fractures is primarily due to the cartilaginous nature of these bones during ossification, as considerable forces are required to injure the unossified or partially ossified carpals. Consequently, multiple carpal fractures are more likely than isolated fractures. Most of these fractures result from forced dorsiflexion wrist injuries—often from a fall on an outstretched hand (FOOSH)—although direct blows causing axial loading of the wrist may also be responsible. A significant number of these injuries are missed upon initial evaluation because plain radiographs often fail to identify them, which is why high clinical suspicion is warranted. Treatment for pediatric non-scaphoid carpal fractures is predominantly conservative and should consist of cast immobilization, while surgery is reserved for displaced fractures and patients approaching skeletal maturity.1-4

Definitions

  • A pediatric non-scaphoid carpal fracture is a disruption of the mechanical integrity of one of the non-scaphoid carpals.
  • A pediatric non-scaphoid carpal fracture produces a discontinuity in carpal contours that can be complete or incomplete.
  • A pediatric non-scaphoid carpal fracture is caused by a direct force that exceeds the breaking point of the bone. 

Hand Surgery Resource’s Fracture Description and Characterization Acronym

SPORADIC

S – Stability; P – Pattern; O – Open; R – Rotation; A – Angulation; D – Displacement; I – Intra-articular; C – Closed

S - Stability (stable or unstable)

  • Universally accepted definitions of clinical fracture stability is not well defined in the hand surgery literature.5-7
  • Stable: fracture fragment pattern is generally nondisplaced or minimally displaced. It does not require reduction, and the fracture fragment’s alignment is maintained with simple splinting. However, most definitions define a stable fracture as one that will maintain anatomical alignment after a simple closed reduction and splinting. Some authors add that stable fractures remain aligned, even when adjacent joints are put to a partial range of motion (ROM).
  • Unstable: will not remain anatomically or nearly anatomically aligned after a successful closed reduction and simple splinting. Typically unstable pediatric non-scaphoid carpal fractures have significant deformity with comminution, displacement, angulation, and/or shortening.
  • The incidence of unstable and displaced fractures of the non-scaphoid carpals is less frequent in the pediatric population than in adults because the injury etiology is typically less severe and involves fewer high-velocity mechanisms.8

P - Pattern

  • Capitate: head, waist, or body; body fractures may be oblique, transverse, or comminuted9,10
    • Generally regarded as second most commonly fractured carpal bone in pediatrics.1
    • Typically associated with other injuries—especially scaphoid fractures—and rarely occurs in isolation.11
    • The most common mechanism of injury is a FOOSH, with high-energy trauma being necessary to produce scaphocapitate syndrome.12
  • Hamate: body or hook of hamate; body fractures may be oblique, transverse, coronal, and/or comminuted
    • Body fractures generally result from a FOOSH onto the ulnar border of the hand, while hook fractures are typically due to a direct blow to the ulnar border.
    • Body fractures may be associated with injury at the hamate-metacarpal articulation, which often involves an avulsion and displacement at the base of the ring and little metacarpals.1
  • Lunate: dorsal pole, volar pole, or body; body fractures may be sagittal, coronal, transverse, and/or comminuted
    • Extremely rare, and often fall under the umbrella of perilunate injuries: most are associated with a lunate or perilunate dislocation or fracture-dislocation.1
    • Typically result from wrist hyperextension in which the ulnarly-deviated carpus impinges on the distal ulna.13
  • Pisiform: proximal pole, distal pole, or body; body fractures may be sagittal, parasagittal, coronal, transverse, and/or comminuted
    • Extremely rare, as the pisiform is the last carpal to ossify.1
    • Pisiform dislocations appear to be more likely than fractures, and can result from direct trauma on the hypothenar eminence or from an indirect mechanism like lifting a heavy object or a FOOSH.1,14
  • Trapezium: trapezial ridge or body; body fractures may be horizontal, vertical, sagittal, coronal, and/or comminuted
    • Rare fractures in children.1
    • May occur due to axial loading of the adducted thumb and consequent dorsal impaction of trapezial-metacarpal articulation.9
  • Trapezoid: dorsal rim or body; may be sagittal, coronal, and/or comminuted
    • Rare fractures in children.1
    • Usually occur secondary to direct trauma that axially loads a flexed index metacarpal.9
  • Triquetrum: dorsal ridge (chip fractures) or body; body fractures may be sagittal, oblique, transverse, and/or comminuted
    • High incidence in 11-13-year-olds.
    • These injuries rarely occur in isolation.1
    • Dorsal chip fractures—which are far more common than body fractures—are often caused by the impact of the ulnar styloid process on the dorsal part of the triquetrum in a FOOSH.3

O - Open

  • Open: a wound connects the external environment to the fracture site. The wound provides a pathway for bacteria to reach and infect the fracture site. As a result, there is always a risk for chronic osteomyelitis. Therefore, open fractures of any pediatric non-scaphoid carpal require antibiotics with surgical irrigation and wound debridement but these injuries are extremely rare in children. 5,15,16
  • Open fractures of the non-scaphoid carpals may require surgical exploration to determine if articular surfaces are involved. After irrigation and debridement, these wounds are generally left open and further treatment is typically delayed until the wound shows no sign of infection.17,18
  • Open pediatric non-scaphoid carpal fractures are also more likely to result in nonunion.19

R - Rotation

  • Fracture deformity of any of the pediatric non-scaphoid carpals can be caused by rotation of the bone’s distal fragment on its proximal fragment.
  • Degree of malrotation of the fracture fragments can be used to describe the fracture deformity.
  • Scaphocapitate fracture syndrome consists of concomitant fractures of the scaphoid and capitate with a rotation of 90-180° of the proximal fragment of the capitate. Although possible in children, this injury is extremely rare, and no cases have been documented in which the capitate fragment rotates 180°.20,21
  • The pisiform typically moves distally after direct trauma and proximally after indirect mechanisms. It may also rotate significantly after injury, up to a completely inverted position.14 

A - Angulation (fracture fragments in relationship to one another)

  • Angulation is measured in degrees after identifying the direction of the apex of the angulation.
  • Straight: no angulatory deformity
  • Angulated: bent at the fracture site

D - Displacement (Contour)

  • Displaced: disrupted cortical contours
  • Nondisplaced: fracture line defining one or several fracture fragments; however, the external cortical contours are not significantly disrupted
  • Very little published information exists concerning the treatment of acute displaced carpal fractures in children.22
  • Displacement is another risk factor for nonunion in pediatric carpal fractures.19
  • Most pediatric capitate fractures are minimally displaced and therefore only require conservative treatment.1

I - Intra-articular involvement

  • Fractures that enter a joint with one or more of their fracture lines.
  • Pediatric non-scaphoid carpal fractures can have fragment involvement with any of their metacarpal, intercarpal, or radial articulations.
  • If a fracture line enters a joint but does not displace the articular surface of the joint, then it is unlikely that this fracture will predispose to posttraumatic osteoarthritis. If the articular surface is separated or there is a step-off in the articular surface, then the congruity of the joint will be compromised and the risk of posttraumatic osteoarthritis increases significantly.

C - Closed

  • Closed: no associated wounds; the external environment has no connection to the fracture site or any of the fracture fragments.5-7

Pediatric non-scaphoid carpal fractures: named fractures, fractures with eponyms and other special fractures

Scaphocapitate fracture syndrome

  • Rare but complex injury that is typically considered a manifestation of the perilunate injury pattern.10,23
    • Consists of simultaneous fractures of the scaphoid and capitate neck with a 90-180° rotation of the proximal capitate fragment.21
  • Most commonly occurs in young men between ages 20-30, and is very rarely seen and not well documented in children.24,25
    • In children, this injury pattern may be associated with other, more obvious fractures.
    • It does not appear that any cases of scaphocapitate fracture syndrome have occurred in a child in which the proximal capitate fragment was rotated to 180°.21
  • The most recognized mechanism of injury is a volar-applied force to a hyperextended wrist, such as from a fall from a height or vehicular accident.24
  • Can be either isolated or associated with a perilunate dislocation, but a substantial force is usually required to cause a dislocation or fracture/dislocation.23

Imaging

  • Plain radiographs may not show the extent of the damage to the carpus, in part because the carpal bones may not yet be completely ossified. This, combined with the rarity and complexity of these injuries, may cause the diagnosis to be initially missed or incorrectly labelled as a simple scaphoid fracture.20,2  This is why a high index of clinical suspicion is needed in order to avoid misdiagnosis and ensure appropriate treatment.21,25
  • If plain radiography does not lead to a satisfactory diagnosis, a CT scan may be needed, especially if a complex carpal lesion is suspected.20,24

Treatment

  • The treatment of this injury pattern is controversial, particularly due to its low incidence.23
  • As in adults, conservative treatment—consisting of closed reduction and cast immobilization—may be appropriate for some nondisplaced injuries, but it appears that surgery is often needed in more complex patterns.21,23,25
  • Open reduction and internal fixation (ORIF) is generally considered the operative treatment-of-choice in children, particularly for displaced and/or comminuted fractures.
    • A dorsal approach is most commonly used, while a volar approach is usually reserved for when decompression of the median nerve is necessary.21,25,26
    • K-wires or compression screws are typically recommended to achieve fixation and reduce the risk for nonunion.20,24,25
    • According to the literature, it is recommended that reduction of the capitate precedes reduction of the scaphoid.20

Complications

  • Infection
  • Loss of range opf motion
  • Avascular necrosis
  • Nonunion
  • Carpal bone growth disturbance

Outcomes

  • Conservative treatment was found to elicit good outcomes in a small series of children with scaphocapitate fracture syndrome in which the capitate fracture was not displaced.21
  • Literature is lacking on outcomes after surgical treatment in pediatrics, but in adults, one study on 15 patients reported that ORIF yielded better results than nonoperative treatment.27

Lunate and perilunate dislocation and fracture-dislocation

  • Pediatric dislocations of the lunate are typically divided into perilunate and lunate varieties.28
  • Although the two entities should be viewed and addressed separately, it is generally agreed that lunate and perilunate dislocations and fracture-dislocations are different stages of the same injury pattern.28,29
    • In lunate dislocations, the lunate is displaced and rotated volarly, while the rest of the carpal bones are in a normal anatomic position in relation to the radius. In perilunate dislocations, the radiolunate articulation is preserved and the rest of the carpus is displaced dorsally.29
    • These types of injuries are extremely rare in children, as only a fraction of pediatric carpal injuries involve the perilunate area.30,31
    • The mechanism of injury is usually high-energy impact on an outstretched wrist in ulnar deviation, which leads to forced hyperextension.30
  • Tran-scaphoid perilunate fracture-dislocations are frequently associated with triquetral fractures.13

Imaging

  • Standard wrist posteroanterior (PA) and lateral radiographs are most useful, but a CT scan may be needed if any clinical doubt remains and in order to avoid a delay in diagnosis.
  • MRI is effective for identifying intercarpal ligamentous ruptures and occult fractures or bone bruises.29

Treatment

  • The optimal management protocol for pediatric lunate and perilunate dislocations and fracture-dislocations is not clearly established because these injuries are so rare. As a result, most treatment recommendations are based on adults.1,30
  • In general, it appears that a surgical approach is preferred in most cases over a conservative approach.
  • Pure lunate fracture-dislocations can be managed with early closed reduction and percutaneous pinning (CRPP), in which K-wires are used for fixation on any associated fracture(s).30
  • Trans-scaphoid perilunate fracture-dislocations can be treated with ORIF through a volar approach.30
  • Perilunate dislocations are particularly challenging to manage, and it has been suggested that only surgical treatment can obtain a positive outcome.32

Complications

  • Median nerve dysfunction
  • Hand or wrist weakness
  • Tendon ruptures/dysfunction
  • Residual carpal instability
  • Infection
  • Nonunion
  • Malunion

Outcomes

  • Although positive outcomes have been identified in several case reports, it’s difficult to determine if the pediatric wrist will eventually return to completely normal finction in the long term.13,30,32

Related Anatomy

  • The carpus is composed entirely of cartilage at birth and remains predominantly cartilaginous until late childhood and adolescence. The ossification schedule of these bones affects the likelihood of fracture, fracture pattern, and diagnostic accuracy, depending on the ossification stage.
    • The capitate is the first carpal to begin ossification at 1-3 months of age, with the hamate closely following ~1 month later.
    • Ossification then proceeds in a clockwise manner, with the triquetrum beginning to ossify between 2-3 years of age, the lunate between 2-4 years, the scaphoid between 4-6 years, and the trapezoid and trapezium around 6 years.2
    • The pisiform is the last carpal to ossify, with its center of ossification appearing between 7.5-10 years and usually completing development by age 12. Before this age, the pisiform may be fragmented because of multiple centers.33
  • A spherical growth plate circumferentially surrounds the entire ossific center of each carpal during development, which protects the bone and offers resistance to fracture. This continues until a critical bone-to-cartilage ratio is reached at some point in adolescence, at which point carpal fractures start becoming more common.  The characteristics of carpal fractures in adolescents approaching skeletal maturity also more closely resemble parallel injuries in adults.9

Incidence and Related injuries/conditions

  • Carpal fractures are generally uncommon in the pediatric population, but the scaphoid is by far the most frequently involved of these bones. Scaphoid fractures account for ~0.45% of all upper limb fractures34 and 2.9% of hand and wrist fractures in children.35
    • After the scaphoid, the capitate is generally regarded as the next most commonly fractured carpal, although some studies have also identified the triquetrum in this position. Data on incidence rates beyond this are scarce due to the rarity of these injuries.1,4,36
  • The incidence of pediatric non-scaphoid carpal fractures increases with age and appears to be highest between ages 11-13, while the occurrence at ≤8 years is far less common.1

Work-up Options

  • Pediatric carpal fractures are difficult to diagnose because initial radiographs often fail to reveal the fracture line. Clinicians must therefore have a high index of suspicion when evaluating wrist injuries in children.1
  • Routine X-rays
    • Usually sufficient for trapezium and triquetrum fractures, with a lateral view being particularly helpful for visualizing dorsal chip fractures of the triquetrum.3
    • The key finding on lateral images is a disrupted radius-lunate-capitate axis, while on the PA view, any 1 of the 3 Gilula’s lines can be disrupted.9
  • Special radiographic views
    • Carpal tunnel and 20° supination oblique views are often required for detecting pediatric hamate fractures.9
    • A carpal tunnel view and lateral view of the extended wrist with forearm supination at 30-45° are recommended for diagnosing suspected pisiform fractures and dislocations.14
    • For suspected triquetrum fractures, a 45° oblique view is recommended.3
    • A Robert or true axial view of the thumb carpometacarpal (CMC) joint may help to supplement routine radiographs for visualizing trapezium fractures.9
  • CT scan, MRI, or ultrasound
    • May be necessary for suspected fractures not identified on initial radiographs and to visualize associated soft tissue damage.3

Trapezoid fractures are particularly difficult to identify through imaging.9

Symptoms
History of trauma
Fracture pain, deformity, ecchymosis and swelling
Impaired wrist ROM
Typical History

A typical patient is a 12-year-old, left-handed boy who recently experienced a severe wrist injury while riding his dirt bike. The boy attempted to do a back flip with his bike on a self-made jump but could not complete the rotation and had to bail on the bike. He landed with both his hands outstretched and wrists ulnarly deviated, and consequently suffered a fractured capitate in his left wrist.

Positive Tests, Exams or Signs
Work-up Options
Treatment Options
Treatment Goals
  • When treating closed pediatric non-scaphoid carpal fractures, the treating surgeon has 4 basic goals:5,16
    1. A carpal bone with a normal appearance. The X-ray may not need to be perfect, but the bone should have no obvious deformity (ie, the carpal looks normal!)
    2. Avoid stiffness by maintaining a normal functional ROM (ie, the wrist works!)
    3. The carpal is not painful (ie, the carpal does not hurt!)
    4. Congruent joint surface with none-to-minimal joint surface irregularities (ie, the joints associated with the carpal do not develop early posttraumatic arthritis!)
    5. Fracture care for open fractures  should minimize the risk for infection and osteomyelitis.
Conservative
  • No universal management standards have been established due to the scarcity of these injuries, but it appears most experts agree that conservative treatment is indicated for the majority of non-scaphoid carpal fractures, especially those that are nondisplaced or minimally displaced (<1 mm).1,4
    • Immobilization is typically accomplished with a short- or long-arm thumb spica cast and should be initiated as early as possible to reduce complication risk.1,4
    • A forearm cast is recommended for triquetrum fractures, with dorsal chip fractures typically requiring 2-4 weeks immobilization and body fractures 4-6 weeks.3
  • Conservative treatment is also recommended for isolated pisiform dislocations and should consist of closed reduction and cast immobilization for 3-4 weeks.1
    • Reduction maneuvers usually include direct pressure on the pisiform accompanied by wrist flexion and forearm pronation.14
Operative
  • Surgical treatment of pediatric non-scaphoid carpal fractures must always be an individualized therapeutic decision. However, surgical carpal fracture care is most frequently recommended when:
    1. Closed reduction fails or the simple splint or cast immobilization does not maintain the reduction. For these irreducible or unstable fractures, operative treatment is recommended to achieve the four treatment goals of fracture care (noted above).
    2. There is a significantly displaced non-scaphoid carpal fracture fragment involving one of its associated joints. Surgical fracture care may be required in these cases.
    3. Open non-scaphoid carpal fractures require surgical care in the form of irrigation and debridement to prevent chronic infection.
  • ORIF
    • Appears to be operative treatment-of-choice for severely displaced carpal fractures.
    • Either percutaneous K-wires or absorbable pins.  Conventional screws can be used for fixation but these devices may complicate the outcome in a growing child.1,14
  • Pisiform excision
    • May be indicated when conservative treatment of pisiform dislocation fails and/or redislocation occurs, as removal of the bone does not appear to interfere with normal wrist function.14
Hand Therapy
  • The care and precautions related to immobilization devices for non-scaphoid carpal fractures must be carefully reviewed with the patient. Patients should be educated regarding care and precautions. Patients should know that pain, especially increasing pain, numbness, tingling, skin irritation, splint loosening, or excessive splint tightness are red flags and should be reported to the surgeon or his team immediately.
  • Pain should be managed with properly fitting splints, reassurance, elevation, ice in the initial post-fracture period, and mild pain medications that are appropriate for the patient's age and weight. Patients should be encouraged to discontinue pain medication as soon as possible. Opioid use should be kept to a minimum.
  • The recommended period of immobilization after surgery varies from 4 weeks to 8 weeks depending on the surgical intervention used.22
  • If an infection does occur, management should focus on eradicating sepsis with thorough debridement, appropriate antibiotics, and fracture stabilization, followed by obtaining fracture union and regaining a functional extremity.17
  • Patients should be instructed to carefully exercise all joints in the injured hand, wrist, and arm that do not require immobilization. Patients usually can exercise on their own; however, signs of generalized finger or hand stiffness are indications for referral to hand therapy (PT or OT).
Complications
  • While nonunion is quite common in adults, it’s generally believed to be rare in pediatric non-scaphoid carpal fractures.1,4
    • Some authors believe that nonunion in pediatrics may be more common than is currently estimated.19
    • Most cases are due to delayed or missed diagnosis, while additional risk factors include severe fracture, high body mass index, smoking, vitamin D deficiency, and prescription opioid use.19
    • The vast majority of reported nonunion cases occur in children aged 9-15 years.22
  • Other possible complications include malunion, osteonecrosis, and posttraumatic osteoarthritis.
    • Comminuted capitate fractures have an increased risk for malunion.9
    • Triquetrum fractures may lead to pisotriquetral osteoarthritis in some cases.3
Outcomes
  • In one study of 10 children with a median age of 13, 8 patients were treated conservatively and 2 surgically.
    • At the median follow-up of 3.4 months, all pediatric patients achieved functional ROM, whereas 48% of the 43 adults in the same study also achieved this outcome.37
  • Pediatric pisiform dislocations appear to have good long-term outcomes with minimal residual symptoms, but there can be a risk of multiple redislocations, with associated chronic pain, reduced ROM, and eventual posttraumatic osteoarthritis in some cases.14
  • Triquetrum fractures generally have an excellent prognosis if diagnosed and treated early, but late presentation and missed diagnoses can lead to degenerative wrist changes with pain during movement, stiffness, and reduced function.3
Key Educational Points
  • Underlying pathological conditions such as bone tumors—like enchondromas—and osteoporosis should be expected in fractures that occur from trivial trauma.
  • The functional needs of each patient must be considered when recommending treatment for pediatric non-scaphoid carpal fractures.
  • Children’s bones differ from adult bones in several ways, and these differences contribute to age-specific injury manifestations—like growth plate development—that must be acknowledged: with more cartilage and collagen than adult bones, the pediatric skeleton is relatively weaker but has greater elasticity, which leads to a higher likelihood of fracture but a decreased likelihood of its propagation.9
  • Conservative treatment of pediatric non-scaphoid carpal fractures offers the advantage of avoiding the negative effects of surgery in childhood, such as exposure to anesthesia, placement of permanent hardware, possible growth restriction, and risk of infection, among other complications.8
References

New and Cited Articles

  1. Goddard, N. Carpal fractures in children. Clin Orthop Relat Res 2005, 73-6. PMID: 15738806
  2. Carson, S., Woolridge, D. P., Colletti, J., et al. Pediatric upper extremity injuries. Pediatr Clin North Am 2006;53:41-67, v. PMID: 16487784
  3. Horras, N., Barthlen, W. and Wildbrett, P. A rare case of an isolated triquetrum body fracture in a 14-year-old boy. Afr J Paediatr Surg 2012;9:157-8. PMID: 22878769
  4. Wulff, R. N. and Schmidt, T. L. Carpal fractures in children. J Pediatr Orthop 1998;18:462-5. PMID: 9661853
  5. Cheah, A. E. and Yao, J. Hand Fractures: Indications, the Tried and True and New Innovations. J Hand Surg Am 2016;41:712-22. PMID: 27113910
  6. Nesbitt, K. S., Failla, J. M. and Les, C. Assessment of instability factors in adult distal radius fractures. J Hand Surg Am 2004;29:1128-38. PMID: 15576227
  7. Walenkamp, M. M., Vos, L. M., Strackee, S. D., et al. The Unstable Distal Radius Fracture-How Do We Define It? A Systematic Review. J Wrist Surg 2015;4:307-16. PMID: 26649263
  8. Shaterian, A., Santos, P. J. F., Lee, C. J., et al. Management Modalities and Outcomes Following Acute Scaphoid Fractures in Children: A Quantitative Review and Meta-Analysis. Hand (N Y) 2017 [Epub]. PMID: 29078712
  9. Little, J. T., Klionsky, N. B., Chaturvedi, A., et al. Pediatric distal forearm and wrist injury: an imaging review. Radiographics 2014;34:472-90. PMID: 24617692
  10. Shah MA, Viegas SF. Fractures of the carpal bone excluding the scaphoid. J Hand Surg Am 2002; 2(3): 129-140
  11. Obdeijn, M. C., van der Vlies, C. H. and van Rijn, R. R. Capitate and hamate fracture in a child: the value of MRI imaging. Emerg Radiol 2010;17:157-9. PMID: 19468765
  12. Young, T. B. Isolated fracture of the capitate in a 10-year-old boy. Injury 1986;17:133-4. PMID: 3770903
  13. Ji, J. H., Shafi, M., Moon, C. Y., et al. Trans-scaphoid perilunate dislocation with fractured carpal bones in a child. Chir Main 2010;29:32-5. PMID: 20106703
  14. Hurni, Y., Fusetti, C. and de Rosa, V. Fracture dislocation of the pisiform bone in children: a case report and review of the literature. J Pediatr Orthop B 2015;24:556-60. PMID: 26163866
  15. Ketonis, C., Dwyer, J. and Ilyas, A. M. Timing of Debridement and Infection Rates in Open Fractures of the Hand: A Systematic Review. Hand (N Y) 2017;12:119-126. PMID: 28344521
  16. Meals, C. and Meals, R. Hand fractures: a review of current treatment strategies. J Hand Surg Am 2013;38:1021-31. PMID: 23618458
  17. Day CS. Fractures of the Metacarpals and Phalanges. In: Green DP, ed. Green's Operative Hand Surgery. Seventh ed. Philadelphia: Elsevier; 2016, pp. 231-77.
  18. Weinstein LP, Hanel DP. Metacarpal fractures. J Hand Surg Am 2002; 2(4):168–180.
  19. Zura, R., Kaste, S. C., Heffernan, M. J., et al. Risk factors for nonunion of bone fracture in pediatric patients: An inception cohort study of 237,033 fractures. Medicine (Baltimore) 2018;97:e11691. PMID: 30075567
  20. Dailiana, Z. H., Papatheodorou, L. K. and Malizos, K. N. Scaphocapitate Fracture: Two Cases with Follow-Up over 5 Years. J Wrist Surg 2015;4:174-8. PMID: 26261742
  21. Mazur, K., Stevanovic, M., Schnall, S. B., et al. Scaphocapitate syndrome in a child associated with a distal radius and ulna fracture. J Orthop Trauma 1997;11:230-2. PMID: 9181510
  22. Anz, A. W., Bushnell, B. D., Bynum, D. K., et al. Pediatric scaphoid fractures. J Am Acad Orthop Surg 2009;17:77-87. PMID: 19202121
  23. Kim, Y. S., Lee, H. M. and Kim, J. P. The scaphocapitate fracture syndrome: a case report and literature analysis. Eur J Orthop Surg Traumatol 2013;23 Suppl 2:S207-12. PMID: 23412323
  24. Hamdi, M. F. The scaphocapitate fracture syndrome: report of a case and a review of the literature. Musculoskelet Surg 2012;96:223-6. PMID: 21373909
  25. Sawant, M. and Miller, J. Scaphocapitate syndrome in an adolescent. J Hand Surg Am 2000;25:1096-9. PMID: 11119668
  26. Wong, W. Y. and Ho, P. C. Minimal invasive management of scaphoid fractures: from fresh to nonunion. Hand Clin 2011;27:291-307. PMID: 21871352
  27. Milliez, P. Y., Dallaserra, M. and Thomine, J. M. An unusual variety of scapho-capitate syndrome. J Hand Surg Br 1993;18:53-7. PMID: 8436864
  28. Rawlings, I. D. The management of dislocations of the carpal lunate. Injury 1981;12:319-30. PMID: 7263037
  29. Stanbury, S. J. and Elfar, J. C. Perilunate dislocation and perilunate fracture-dislocation. J Am Acad Orthop Surg 2011;19:554-62. PMID: 21885701
  30. Khan, S. A., Van Velze, M. and Pearse, A. A rare case of an acute lunate dislocation in a child. BMJ Case Rep 2017;2017. PMID: 28978611
  31. Sharma, H., Azzopardi, T., Sibinski, M., et al. Volar lunate dislocation associated with a Salter-Harris Type III fracture of the distal radial epiphysis in an 8 year-old child. J Hand Surg Eur Vol 2007;32:77-9. PMID: 17045369
  32. Tomaszewski, R. Rare Perilunate Injury as a Result of Chronic Trauma in 3-Year-Old Girl. European J Pediatr Surg Rep 2015;3:94-7. PMID: 26788457
  33. Mancini, F., De Maio, F. and Ippolito, E. Pisiform bone fracture-dislocation and distal radius physeal fracture in two children. J Pediatr Orthop B 2005;14:303-6. PMID: 15931038
  34. Christodoulou, A. G. and Colton, C. L. Scaphoid fractures in children. J Pediatr Orthop 1986;6:37-9. PMID: 3941178
  35. Mussbichler, H. Injuries of the carpal scaphoid in children. Acta radiol 1961;56:361-8. PMID: 14477567
  36. Light, T. R. Carpal injuries in children. Hand Clin 2000;16:513-22. PMID: 11117042
  37. Kadar, A., Morsy, M., Sur, Y. J., et al. Capitate Fractures: A Review of 53 Patients. J Hand Surg Am 2016;41:e359-e366. PMID: 27524693

Reviews

  1. Goddard, N. Carpal fractures in children. Clin Orthop Relat Res 2005, 73-6. PMID: 15738806
  2. Wulff, R. N. and Schmidt, T. L. Carpal fractures in children. J Pediatr Orthop 1998;18:462-5. PMID: 9661853

Classic

  1. Nafie SA. Fractures of the carpal bones in children. Injury 1987;18(2):117-9. PMID: 3508159
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