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SCAPHOID FRACTURE PEDIATRIC

Introduction

Fracture Nomenclature for Scaphoid Fracture Pediatric

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 Scaphoid Fracture Pediatric, the historical and specifically named fractures include:

Scaphocapitate fracture syndrome

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 generally considered rare in the pediatric population. As is the case in adults, fractures of the scaphoid represent the majority of these injuries, and they account for ~0.5% of all upper limb fractures and ~3% of hand and wrist fractures in children. While common for the pediatric carpals, the incidence of scaphoid fractures is relatively low compared to adults. The usual mechanism of injury is a forced dorsiflexion wrist injury—often resulting from a fall on an outstretched hand (FOOSH)—although a direct blow or axial loading of the wrist may also be responsible. Treatment for pediatric scaphoid fractures is predominantly conservative and consists of cast immobilization; surgery is reserved for displaced fractures and patients approaching skeletal maturity.1-4

Definitions

  • A pediatric scaphoid fracture is a disruption of the mechanical integrity of the scaphoid.
  • A pediatric scaphoid fracture produces a discontinuity in the scaphoid contours that can be complete or incomplete.
  • A pediatric scaphoid 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 scaphoid fractures have significant deformity with comminution, displacement, angulation, and/or shortening.
  • The incidence of unstable and displaced fractures of the scaphoid and other carpals is less frequent in the pediatric population because the injury etiology is typically less severe and involves fewer high-velocity mechanisms.3

P - Pattern

  • Scaphoid tubercle: typically caused by direct impact with the hand in dorsifexion, ulnar deviation, and pronation, leading to a fragment avulsion by the radial collateral ligament, capsular attachments, or transverse carpal ligament8
  • Scaphoid distal pole: the most common fracture location, with incidence rates ranging from 59-87% of all pediatric scaphoid fractures9  Includes transverse and avulsion fractures of the distal pole.2
  • Scaphoid waist: transverse, vertical oblique, horizontal oblique, coronal, and/or comminuted; can be complete or incomplete.  Less common than in the adult population: only account for ~25% of all pediatric scaphoid fractures2
  • Scaphoid proximal pole: the rarest fracture location in pediatrics2  These are unstable fractures that are difficult to treat and easily missed on plain radiographs. 10,11
  • The usual mechanism of injury is a forced dorsiflexion wrist injury—most commonly a FOOSH with a pronated and ulnarly deviated hand, and the wrist typically in wrist hyperextension.  This causes longitudinal loading of the scaphoid and a subsequent fracture as the volar cortex fails in tension.2,10,11  Other possible injury mechanisms include a direct blow and axial loading with the wrist in neutral flexion-extension.10,11  Direct blows can also cause an impaction fracture anywhere along the length of the scaphoid, while forced dorsiflexion of the wrist typically results in a displaced distal third, waist, or proximal third scaphoid fracture.2 
  • Scaphoid fractures in children and adults differ in their location within the scaphoid, as most (~70%) adult scaphoid fractures occur at the waist in the middle third, while the majority of pediatric fractures occur at the distal third. Adolescents also show injury patterns that are more similar to those seen in adults.1 
  • A 3-part classification system based on the child’s age and presumed degree of ossification has been proposed:
    • Type 1: lesions occurring in children ≤8 years in which the fracture line is purely chondral or may involve part of the ossific nucleus; these fractures are more rare and difficult to diagnose
    • Type 2: osteochondral fractures in patients aged 8-11 years
    • Type 3: most common type, occurring in adolescents aged ≥12 years; fractures at this age behave similar to the adult population because the scaphoid is almost completely ossified12

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 the pediatric scaphoid require antibiotics with surgical irrigation and wound debridement.5,13,14
  • Open fractures of the scaphoid may require surgical exploration to determine if articular surfaces are involved. After irrigation and debridement, these wounds are generally left open if severely contaminated and further treatment is typically delayed until the wound shows no sign of infection.15,16
  • Open pediatric scaphoid fractures are also more likely to result in nonunion.17

R - Rotation

  • Scaphoid fracture deformity can be caused by rotation of the distal fragment on the 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°.18,19
  • Opposing rotational moments on the proximal and distal poles cause dorsal angulation in scaphoid fractures.20 

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
  • In pediatric scaphoid fractures, fracture angulation in the sagittal plane with a lateral intrascaphoid angle >45° or a height-to-length ratio >0.65 is often considered an indication for surgery.2
  • Very little published information exists concerning the treatment of acute displaced carpal fractures in children.2

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
  • Most pediatric scaphoid fractures are nondisplaced fractures of the distal pole.1

I - Intra-articular involvement

  • Fractures that enter a joint with one or more of their fracture lines.
  • Pediatric scaphoid fractures can have fragment involvement with the radius or any of its intercarpal joint 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 scaphoid fractures: named fractures, fractures with eponyms and other special fractures

Scaphocapitate fracture syndrome

  • Rare but complex injury typically considered a manifestation of the perilunate injury pattern.21,22
  • Consists of simultaneous fractures of the scaphoid and capitate neck with a 90-180° rotation of the proximal capitate fragment.19
  • Most commonly occurs in young men between ages 20-30, and is very rarely seen and not well documented in children.23,24 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°.19
  • 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.23
  • Can be either isolated or associated with a perilunate dislocation, but a substantial force is usually required to cause a dislocation.23

Imaging

  • Plain radiographs may not show the extent of the damage to the carpus. 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.18,22  This is why a high index of clinical suspicion is needed in order to avoid misdiagnosis and ensure appropriate treatment.19,24
  • If plain radiography does not lead to a satisfactory diagnosis, a CT scan may be needed, especially if a complex carpal lesion is suspected.18,23

Treatment

  • The treatment of this injury pattern is controversial, particularly due to its low incidence.22
  • 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.19,22,24
  • Open reduction and internal fixation (ORIF) is generally considered the 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.19,24,25  K-wires or compression screws are typically recommended to achieve fixation and reduce the risk for nonunion.18,23,24  According to the literature, it is recommended that reduction of the capitate precedes reduction of the scaphoid.18

Complications

  • Infection
  • Avascular necrosis
  • Nonunion

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.19
  • Literature is lacking on outcomes after surgical treatment in pediatrics, but in adults, one study in 15 patients reported that ORIF yielded better results than nonoperative treatment.26

Related Anatomy

  • The scaphoid consists of a distal tubercle, a distal pole, a medial waist, and a proximal pole. It articulates distally with the trapezium and trapezoid, medially with the capitate, ulnarly with the lunate, and proximally with the radius at the scaphoid fossa. Derived from the Greek term “skaphe,” meaning skiff or boat, the scaphoid is approximately the size and shape of a medium cashew and is the largest and most radial of the proximal carpals, where it functions as a mechanical link between the proximal and distal carpal rows.10,20 In children, ossification of the scaphoid begins at an average age of 6 for boys and 4 for girls, and concludes at 15 for boys and 13 for girls. This approximately 9-year period is a time of flux in the physical nature of the scaphoid, and fractures occurring at different points behave differently depending on developmental status of the bone.2 The relatively low rate of scaphoid fractures in children may be attributed to the more cartilaginous nature of the bone during ossification, since cartilage provides a cushioning effect in the typically low-impact falls children generally encounter.4
  • Ligamentous attachments of the scaphoid include the radioscaphocapitate, long radiolunate, radioscapholunate, scapholunate interosseous, dorsal radiocarpal, dorsal intercarpal, scaphotrapezium-trapezoid, scaphocapitate, and transverse carpal ligaments. The existence of several other possible ligamentous attachments, including the radial collateral and volar scaphotriquetral ligaments, is still debated.27
  • The scaphoid has no tendinous insertions.

Incidence and Related injuries/conditions

  • Carpal fractures are generally uncommon in the pediatric population, but the scaphoid is by far the most frequently affected of these bones. Scaphoid fractures account for ~0.45% of all upper limb fractures28 and 2.9% of hand and wrist fractures in children.29 The annual incidence of scaphoid fractures in children under age 15 is reported to be 0.6 per 10,000.28 The incidence of scaphoid fractures in pediatric and adolescent patients is believed to be rising, partially due to the growing popularity of contact sports and extreme sports like motocross, snowboarding, and skateboarding.4
  • Most pediatric scaphoid fractures occur between ages 11-13. These injuries are less common in children under the age of 11, and are extremely rare at ≤8 years.4,29

Work-up Options

  • Pediatric scaphoid fractures can be difficult to diagnose, as they often have subtle findings on radiographs upon initial presentation.31
  • Routine and special X-rays
    • The sensitivity of plain radiographs varies significantly in the pediatric literature from 21-97%, and one study found that ~13% of fractures do not appear radiographically until 1-2 weeks after injury. Therefore, these images cannot be considered reliable and tend to only be useful for confirming a fracture and following healing progression.2
    • The standard radiographic evaluation of the scaphoid should consist of anteroposterior (AP), lateral, oblique, and scaphoid views.
  • The scaphoid view involves placing the wrist in maximal pronation, dorsiflexion, and ulnar deviation, and is especially useful for visualizing avulsion fractures.2
  • Patients with clinical symptoms of scaphoid fractures but negative radiographs should be either placed in a thumb spica short arm cast and then followed up with radiographs or advanced imaging 10-21 days later, or be evaluated with advanced imaging immediately to rule out a scaphoid fracture.10,31
  • CT scan:  More cost-effective, but less effective for diagnosing occult fractures than MRI. The radiation dose it delivers and lack of evidence justifying its accuracy and reliability make CT scan a less desirable advanced imaging modality for children.2,20
  • MRI:  Advanced imaging modality-of-choice in pediatrics for initial evaluation and follow-up of suspected fractures.2  Especially useful in diagnosing proximal pole fractures.20
  • Ultrasound:  May be useful, but is highly user-dependent.2
  • Bone scan:  May be effective for diagnosing occult fractures within 72 hours.2
ICD-10 Codes

  • FRACTURE, SCAPHOID

    Diagnostic Guide Name

    FRACTURE, SCAPHOID

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    FRACTURE CARPAL BONE SCAPHOID/NAVICULAR    
    DISTAL POLE OF SCAPHOID    
    - DISPLACED S62.012_S62.011_ 
    - NONDISPLACED S62.015_S62.014_ 
    MIDDLE THIRD OF SCAPHOID    
    - DISPLACED S62.022_S62.021_ 
    - NONDISPLACED S62.025_S62.024_ 
    PROXIMAL THIRD OF SCAPHOID    
    - DISPLACED S62.032_S62.031_ 
    - NONDISPLACED S62.035_S62.034_ 

    Instructions (ICD 10 CM 2020, U.S. Version)

    THE APPROPRIATE SEVENTH CHARACTER IS TO BE ADDED TO EACH CODE FROM CATEGORY S62
     Closed FracturesOpen Type I or II or OtherOpen Type IIIA, IIIB, or IIIC
    Initial EncounterABC
    Subsequent Routine HealingDEF
    Subsequent Delayed HealingGHJ
    Subsequent NonunionKMN
    Subsequent MalunionPQR
    SequelaSSS

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Symptoms
History of trauma
Fracture pain, deformity and swelling
Impaired wrist ROM
It is important to recognize that not all patients have pain over the scaphoid, and symptoms may be vague or even nonexistent in some cases.2,30
Typical History

A typical patient is a 13-year-old -year-old, right-handed boy who injured his left wrist during a skateboarding accident. The boy was skating down an inclined street and picking up speed when he failed to notice a small pothole in the asphalt. One of his front wheels caught the pothole and sent him flying forward with both hands outstretched. His ulnarly deviated left wrist took the brunt of the impact when he landed.  The wrist was forced into dorsiflexion and this resulted in a fracture of the scaphoid.

Positive Tests, Exams or Signs
Work-up Options
Images (X-Ray, MRI, etc.)
Scaphoid Fracture
  • Teenager with scaphoid tuberosity fracture (arrow)
    Teenager with scaphoid tuberosity fracture (arrow)
Treatment Options
Treatment Goals
  • When treating closed pediatric scaphoid fractures, the treating surgeon has 4 basic goals:5,14
    1. A scaphoid with a normal appearance. The X-ray may not need to be perfect, but the scaphoid should have no obvious deformity (ie, the scaphoid looks normal!)
    2. Avoid stiffness by maintaining a normal functional ROM (ie, the wrist works!)
    3. The scaphoid is not painful (ie, the scaphoid does not hurt!)
    4. Congruent joint surface with none-to-minimal joint surface irregularities (ie, the joints associated with the scaphoid do not develop early posttraumatic arthritis!)
    5. Fracture care should minimize the risk for infection and osteomyelitis.
Conservative

Conservative

  • Most experts generally agree that conservative treatment is indicated for nondisplaced and minimally displaced (<1 mm) pediatric scaphoid fractures, especially if the distal pole or tubercle are involved.  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.1,9
  • Short-arm casting may be preferable in incomplete or avulsion fractures, while long-arm casting is indicated in active individuals since it maximizes immobilization.2  Tubercle or avulsion fractures should be immobilized in a short- or long-arm thumb spica cast for 3-4 weeks, while distal pole fractures may require up to 5 weeks and waist fractures up to 7-8 weeks.1
  • Waist fractures require special consideration, since they are most likely to progress to nonunion. In these cases, immobilization should be continued until healing is verified on plain radiographs or an MRI in questionable cases. If problems occur, surgery may be indicated.2
  • For patients with a suspected scaphoid fracture but no obvious radiographic findings, some experts also advocate cast immobilization before repeat imaging 10-21 days later; however, casting makes excluding fractures and determining union more difficult, which is why others instead recommend subsequent CT scan or MRI for suspected fractures.10,20  Fractures that are initially missed on radiographs but later diagnosed through advanced imaging should also be treated conservatively unless it is a proximal pole fracture.10
Operative
  • Surgical treatment of pediatric scaphoid fractures must always be an individualized therapeutic decision. However, surgical scaphoid 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 4 treatment goals of fracture care.
    2. There is a significantly displaced scaphoid fracture fragment involving one of its associated joints. Surgical fracture care may be required in these cases.
    3. Open scaphoid fractures require surgical care in the form of irrigation and debridement to prevent chronic infection.
  • In addition to the above indications, surgery is also strongly recommended for proximal pole fractures, cases of established scaphoid nonunion, patients at or near skeletal maturity, and those who are seeking an early return to sports or physical activity.2,3  Extended periods of immobilization may also prove to be intolerable for the child and lead them to evaluate surgical options.2  Proximal pole fractures have a greater chance of developing nonunion and/or avascular necrosis than those of the waist or distal pole, and are therefore often managed surgically.2,10,11
  • The two primary surgical options for pediatric scaphoid fractures are ORIF and closed reduction and percutaneous pinning (CRPP).
    • The approach used should be based on the fracture pattern, deformity, chronicity, bone loss, vascularity of the proximal pole, the surgeon's personal experience, and patient needs and expectations.10,11  ORIF appears to be most effective for proximal pole fractures, as it allows for an early return of wrist movement and higher rate of union.10,20
    • CRPP limits the risk of devascularizing fracture fragments and protects the ligaments and volar capsule, but is not feasible if the fracture is displaced or not reducible by closed means.20
  • For cases of nonunion, surgical options include CRPP, ORIF, autogenous bone graft (with or without K-wire or screw fixation), iliac bone graft with Herbert screw fixation, and vascularized bone graft with internal fixation.2
Hand Therapy
  • The care and precautions related to immobilization devices for the scaphoid fracture 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.
  • Pain should be managed with properly fitting splints, reassurance, elevation, ice in the initial post-fracture period, and mild pain medications. 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 3 months depending on the surgical intervention used and the healing of the fracture.2
  • If an infection does occur, management should focus on eradicating sepsis with thorough debridement, appropriate antibiotics (eg, cephalosporin, penicillin), and fracture stabilization, followed by obtaining fracture union and regaining a functional extremity.15
  • Patients should be instructed to carefully exercise all uninjured 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 relatively common in adults, it’s believed to be rare in children. Acute scaphoid fractures correctly treated with prompt immobilization have a very low (0.8%) nonunion rate, which is usually attributed to delayed or missed diagnosis.1,9  Despite this, some authors believe that nonunion in pediatrics may be more common than clinicians believe.17  Risk factors for nonunion in children include severe fracture, high body mass index, smoking, vitamin D deficiency, and prescription opioid use.17  The vast majority of reported nonunion cases occur in children aged 9-15 years.2
  • Osteonecrosis of the scaphoid proximal pole is also another possible complication, but its occurrence is rare in the pediatric population.2
Outcomes
  • In general, the pediatric population has been found to experience superior outcomes and higher rates of union after scaphoid fractures compared to adults, through both conservative and surgical treatment methods. This disparity is primarily due to a number of important anatomic and physiologic advantages in the younger population.2,3,9
  • In one study, union occurred in 97.0% of pediatric patients with scaphoid fractures treated with a thumb spica cast, and clinical union—defined by complete resolution of symptoms—occurred at a mean of 7.1 weeks.9
  • In another trial, excellent union rates were achieved regardless of the type of immobilization and whether patients were treated through surgical or conservative modalities.3
  • Careful evaluation is required for patients who are close to skeletal maturity, but the literature indicates that cast immobilization is effective in this population, with several series identifying successful outcomes.2
Key Educational Points
  • Underlying pathological conditions such as bone tumors—like enchodromas—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 scaphoid fractures.
  • Clinicians should be aware of the possibility of a congenital bipartite scaphoid, which is usually an incidental radiographic finding made after a FOOSH. One way to identify this condition is that it usually occurs bilaterally.1
  • Since the carpus remains predominantly cartilaginous until late childhood and adolescence, mechanisms that normally produce bony wrist injuries in mature adults produce forearm fractures in young children. These fractures of the pediatric scaphoid and other carpals are usually associated with other fractures but rarely with ligamentous injuries, and adolescents generally tend to have injury patterns similar to adults.31
  • While guidelines for treating adult scaphoid fractures have been well described, they are not as well established for pediatrics, and the management of these injuries varies significantly across providers without clear indications for surgical intervention.3
  • Conservative treatment 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.3
  • The clinical presentation of pediatric scaphoid fractures does not differ significantly from that of adults, but the misdiagnosis rate is higher due to their rarity in childhood and because the index of suspicion is low.1  Presentation also tends to be more difficult to interpret in children, as anatomical snuffbox tenderness is not always obvious and young patients often find it difficult to differentiate the location of pain on the radial side of the wrist and carpus.32
References

New and Cited Articles

  1. Goddard, N. Carpal fractures in children. Clin Orthop Relat Res 2005, 73-6. PMID: 15738806
  2. 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
  3. 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
  4. Jauregui, J. J., Seger, E. W., Hesham, K., et al. Operative Management for Pediatric and Adolescent Scaphoid Nonunions: A Meta-analysis. J Pediatr Orthop 2017 [Epub] PMID: 29252909
  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. Prosser, A. J., Brenkel, I. J. and Irvine, G. B. Articular fractures of the distal scaphoid. J Hand Surg Br 1988;13:87-91. PMID: 3361215
  9. Wulff, R. N. and Schmidt, T. L. Carpal fractures in children. J Pediatr Orthop 1998;18:462-5. PMID: 9661853
  10. Fowler, J. R. and Hughes, T. B. Scaphoid fractures. Clin Sports Med 2015;34:37-50. PMID: 25455395
  11. Winston, M. J. and Weiland, A. J. Scaphoid fractures in the athlete. Curr Rev Musculoskelet Med 2017;10:38-44. PMID: 28251560
  12. D'Arienzo, M. Scaphoid fractures in children. J Hand Surg Br 2002;27:424-6. PMID: 12367553
  13. 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
  14. Meals, C. and Meals, R. Hand fractures: a review of current treatment strategies. J Hand Surg Am 2013;38:1021-31. PMID: 23618458
  15. 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.
  16. Weinstein LP, Hanel DP. Metacarpal fractures. J Hand Surg Am 2002; 2(4):168–180
  17. 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
  18. 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
  19. 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
  20. Cheung, J. P., Tang, C. Y. and Fung, B. K. Current management of acute scaphoid fractures: a review. Hong Kong Med J 2014;20:52-8. PMID: 24323670
  21. Shah MA, Viegas SF. Fractures of the carpal bone excluding the scaphoid. J Hand Surg Am 2002; 2(3): 129-140.
  22. 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
  23. 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
  24. Sawant, M. and Miller, J. Scaphocapitate syndrome in an adolescent. J Hand Surg Am 2000;25:1096-9. PMID: 11119668
  25. 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
  26. 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
  27. Buijze, G. A., Lozano-Calderon, S. A., Strackee, S. D., et al. Osseous and ligamentous scaphoid anatomy: Part I. A systematic literature review highlighting controversies. J Hand Surg Am 2011;36:1926-35. PMID: 22051230
  28. Christodoulou, A. G. and Colton, C. L. Scaphoid fractures in children. J Pediatr Orthop 1986;6:37-9. PMID: 3941178
  29. Mussbichler, H. Injuries of the carpal scaphoid in children. Acta radiol 1961;56:361-8. PMID: 14477567
  30. Kawamura, K. and Chung, K. C. Treatment of scaphoid fractures and nonunions. J Hand Surg Am 2008;33:988-97. PMID: 18656779
  31. Carson, S., Woolridge, D. P., Colletti, J., et al. Pediatric upper extremity injuries. Pediatr Clin North Am 2006;53:41-67, v. PMID: 16487784
  32. Jorgsholm, P., Thomsen, N., Besjakov, J., et al. MRI shows a high incidence of carpal fractures in children with posttraumatic radial-sided wrist tenderness. Acta Orthop 2016;87:533-7. PMID: 27436058

Reviews

  1. Gillon H. Scaphoid injuries in children. Accid Emerg Nurs 2001;9(4):249-56. PMID: 11855765
  2. Hamdi MF, Khelifi A. Operative management of nonunion scaphoid fracture in children: a case report and literature review. Musculoskelet Surg 2011;95(1):49-52. PMID: 21190098

Classics

  1. Macrosson KI. Sprain fracture of the carpal scaphoid in children. Lancet 1946;1(6393):341. PMID: 21017402
  2. Grundy M. Fractures of the carpal scaphoid in children. A series of eight cases. Br J Surg 1969;56(7):523-4. PMID: 5794969
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