Pediatric Scaphoid Nonunions: A Case Series, Review of the Literature, and Evidence-Based Guidelines

Abstract

Background Scaphoid fractures represent less than 3% of hand and wrist fractures in the pediatric population. Nonunions are very rare. We present a case series (n = 18) of nonunions in skeletally immature children and adolescents. We further present a review of the literature on pediatric scaphoid nonunions. Materials and Methods We reviewed the literature by searching the main databases on pediatric scaphoid nonunions, but to identify factors that lead to nonunion, we also searched for databases on scaphoid fractures. Seventy articles were found for the period between 1961 and 2019, all with level 4/5 evidence. Results The nonunion rate of pediatric scaphoid fractures in the literature is on average 1.5%, occurring mostly as a result of missed or underdiagnosed injuries, similar to our presented case series. Half (n = 9) of the injuries in our case series were missed initial injuries, leading to scaphoid nonunions and half developed nonunions after initial treatment. We found excellent outcomes and with surgical and nonoperative management, with few complications. Not surprisingly, the duration of immobilization is longer with nonoperative management. Conclusions Based on the literature, we recommend a period of nonoperative management before surgery in undisplaced nonunions. In displaced nonunions, open reduction and internal fixation ± bone grafting is necessary. In pediatric scaphoid fractures, similar to adult cases, we identified that suspicious scaphoid fractures should be considered for initial immobilization, and repeat X-rays and early magnetic resonance imaging (MRI) or computed tomography (CT) scans should be considered at follow-up. Immobilization time and type of plaster should be appropriate in relation to the fracture site, similar to the adult scaphoid fracture. Level of Evidence This is a Level IV study.

Epidemiology of scaphoid fractures and non-unions: A systematic review

“…Our literature search did not identify any studies describing the incidence of scaphoid non-union among children. However, calculations based on case reports estimated a non-union incidence of 1.5 % [50].…”

“…18 retrospective studies [7,10,17,30,32,33,35,[41][42][43][44][45][46][47][48][49][50][51][52][53][54] including 221 patients were analyzed. All studies were based on conventional radiographs for diagnosis of scaphoid non-union.…”

Outcomes of Pediatric Scaphoid Nonunions Treated With Distal Radius Cancellous Autograft

“…Some authors have defined scaphoid nonunions in adolescents to be displacement of fragments greater than 1 mm on CT scans, with evidence of cystic resorption and sclerosis on radiographs and CT scans >6 weeks from injury 17. Likewise, a recent study12 used the 6 week timepoint; the authors contend that because healing potential is greater in children, a nonunion type of management should be considered at 6 weeks postinjury for the pediatric population. In our study, we used a 12-week timepoint as a minimum, but required radiographic evidence of sclerosis of the fracture fragment borders and cystic formation.…”

“…Similarly, Chloros at al4 reported good union rates in 12 children with scaphoid nonunion managed with open reduction, iliac crest grafting, and Herbert screw fixation. Oestreich et al12 report on a series of 6 pediatric scaphoid nonunions treated with both distal radius and iliac crest bone grafts, although the graft source was not specified for individual patients. There are similar outcomes in terms of union and function with these 2 graft source locations, but the distal radius graft has advantages that include ease of harvest and less donor site morbidity 8,13–15.…”

Pediatric Wrist

“…1,49,53,69 Scaphoid fractures primarily involve adolescents, rarely occurring in children < 8 years of age. 68 They may occur simultaneously with other wrist injuries. Studies indicate that 1 to 4% of individuals with distal radius fractures also have scaphoid fractures.…”