Clinically Suspected Scaphoid Fractures in Children

Abstract

Scaphoid fractures are often missed in children because of their rarity and difficulty with radiographic diagnosis. Children are often treated for clinically suspected scaphoid fractures although there is no radiographic evidence for fracture on initial evaluation. The 2-fold purpose of this study is (1) to determine how many clinically suspected pediatric scaphoid fractures later became radiographically evident fractures and (2) to identify physical examination findings that suggest a scaphoid fracture when present at initial evaluation. We performed separate retrospective and longitudinal reviews of children younger than 16 years referred to orthopaedics with traumatic wrist pain from January 1995 to April 2002. A total of 104 cases with high clinical suspicion but no radiographic evidence of scaphoid fracture on initial examination were included. Patients were followed until discharge to determine if they later demonstrated a confirmed fracture. In the longitudinal arm, 7 specific examination findings were recorded. Simple and multiple logistic regressions were used to analyze the data. Thirty-one (30%) of the 104 wrists with no initial radiographic evidence of fracture had a radiographically evident scaphoid fracture at follow-up. In the longitudinal arm (n = 41), the following 3 findings were statistically significant predictors of scaphoid fracture: volar tenderness over the scaphoid (P = 0.010), pain with radial deviation (P = 0.001), and pain with active wrist range of motion (P = 0.015). Presence of any of these findings was associated with a higher likelihood of scaphoid fracture. A high percentage (30%) of clinically suspected scaphoid fractures in children became radiographically evident fractures at follow-up. Volar scaphoid tenderness, radial deviation pain, and pain with active wrist range of motion can be used as signs to increase suspicion for eventual fracture. We recommend that all clinically suspected pediatric scaphoid fractures be immobilized with repeat radiographs and a clinical examination at 2 weeks. II.