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What is the Risk of Scaphoid Fracture in Children with Suspected Fracture but Negative Screening Radiographs?
Simon Blanchard, BS, Stone R. Streeter, BS, Dev Laungani, BA, Sayaka Mori, BA, Sulagna Sarkar, MS; Apurva S. Shah, MD, MBA
Children's Hospital of Philadelphia, Philadelphia, PA
Introduction:In adults, the rate of occult scaphoid fractures in patients with suspected fracture but negative screening radiographs is estimated to be around 21.8%, but there is limited research on occult scaphoid fractures in children. A majority of pediatric scaphoid fractures have excellent outcomes following adequate immobilization. However, due to the difficulty of detecting scaphoid fractures on radiographs, the effectiveness of non-operative management, and the serious potential consequences of nonunion, pediatric patients with suspected scaphoid fractures are typically immobilized even in the absence of radiographic evidence. The lack of clear data on incidence of occult scaphoid fractures in pediatric patients may lead to over-immobilization of patients with suspected scaphoid fracture and increased healthcare cost burden. This study aims to characterize the incidence and risk factors of having a scaphoid fracture in children with suspected scaphoid fractures but negative screening radiographs.
Materials & Methods:A retrospective cohort study was performed at a single institution on patients <21 years old who presented for a suspected scaphoid fracture. Patients were included if a scaphoid fracture was not seen on initial radiographs but was identified on advanced imaging (MRI or CT) or follow-up radiographs obtained ?14 days after injury. Patients with inadequate follow-up were excluded. Data were analyzed using Fisher's exact tests, chi-squared tests, and logistic regression where appropriate.
Results: 346 children (mean age 11.9±2.7, 58% male) presented with a suspected scaphoid fracture but no radiographic evidence of scaphoid fracture on initial imaging. In this cohort, 162 (46.8%) eventually had an occult scaphoid fracture diagnosed with advanced imaging or on follow-up radiographs. Risk factors for having an occult fracture were younger age at injury (mean age 9.5 vs 11.3 years, p<0.001), open distal radial physis (85.1% vs 74.2%, p=0.001), open first metacarpal physis (73.1% vs 58.5%, p<0.001), higher BMI (mean 22 vs 21 kg/m², p<0.001), and a lack of tenderness at the distal radius (73.7% vs 56.6%, p<0.001).
Conclusions: In pediatric patients with clinically suspected scaphoid fractures but no signs of fracture on initial radiographs, nearly 50% developed signs of an occult scaphoid fracture that were detected on subsequent imaging. This is more likely to occur in patients who are younger and skeletally-immature, who are overweight/obese, and who have focal tenderness. Patients with these risk factors warrant close follow-up and likely benefit from immobilization despite negative initial imaging.
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