Treatment of Acute Pediatric Scaphoid Waist Fractures

and Dan A. Zlotolow^{1, 2}

(1)

Christine M. Kleinert Institute for Hand and Microsurgery, Louisville, KY, USA

(2)

Department of Orthopaedics, Temple University School of Medicine and Shriners Hospital for Children Philadelphia, Philadelphia, PA, USA

Dan A. Zlotolow

Email: dzlotolow@yahoo.com

Keywords

Acute pediatric scaphoid waist fracturesPediatric scaphoid waist fractures scaphoid waist fractures in pediatricsCarpal scaphoid fracture nonunion in childrenPercutaneous screw fixation in pediatric scaphoid fractureScrew fixation in pediatric scaphoid fracture

Case Presentation

The patient was a 14-year-old right-hand dominant male who tripped on a tennis ball and landed on his outstretched left hand 1 week prior to presentation . He was evaluated by the emergency room and diagnosed with a scaphoid fracture. Initial treatment consisted of placing him in a removable thumb spica splint. He was then referred to a hand surgeon for additional evaluation and treatment. On presentation to the hand surgeon, he complained of mild-to-moderate intermittent pain. He denied any limitations in his activities of daily living. The patient was an elite tennis player and was eager to resume playing tennis as early as possible.

Physical Assessment

The physical examination was remarkable for mild ecchymosis and swelling over the dorsal radial left wrist and tenderness to palpation over the anatomic snuffbox. He also had diffuse ligamentous laxity, and both patellas were dislocatable .

Diagnostic Studies and Diagnosis

Left-wrist radiographs were significant for a nondisplaced scaphoid waist fracture and skeletal immaturity (Fig. 6.1) . The scaphoid was completely ossified.

Fig. 6.1

Anteroposterior (a), oblique (b), and lateral (c) radiographs obtained shortly after the injury demonstrated a nondisplaced fracture of the scaphoid waist. (Published with kind permission of © Peter R. Letourneau and Dan A. Zlotolow, 2015. All rights reserved)

Management Options

Most acute scaphoid fractures that are minimally displaced or nondisplaced can be successfully treated with cast immobilization in the pediatric population. This patient was adamant about returning to full activity as quickly as possible; his coach was concerned that even a short-arm thumb spica cast would interfere with his ability to serve a tennis ball. Treatment options were reviewed with the family, including casting versus percutaneous screw fixation. The family was informed of the potential risks of percutaneous screw fixation , including injury to branches of the superficial radial nerve, infection, scaphotrapezial and radiocarpal screw prominence, nonunion, malunion, and fracture displacement during percutaneous fixation requiring open reduction and fixation.

Management Chosen

The patient chose to pursue percutaneous fixation because it would allow him the best chance to resume tennis more quickly.

Surgical Technique

Volar percutaneous screw fixation was performed using a modified technique to optimize screw position [1] . Ten pounds of traction was placed on the thumb, thereby facilitating reduction and opening the scaphotrapezial joint. Using a mini fluoroscopy unit to visualize the distal pole of the scaphoid, freehand K-wires were used to draw intersecting lines on the skin overlying the scaphotrapezial joint. A small incision was then made at the base of the thenar eminence over the scaphotrapezial joint, and a 14-gauge angiocatheter needle was placed into the distal pole of the scaphoid, starting within the scaphotrapezial joint. The angiocatheter needle facilitates localizing the starting point, directs the guide wire toward the proximal pole, functions as a lever to translate the trapezium ulnarly, and serves as a soft tissue protector. Proper placement was confirmed using fluoroscopy, and the needle was then gently tapped into position using a mallet. The guide wire was advanced across the fracture so that the wire ended up in the center of the proximal pole . Finally, the bone tunnel was hand-drilled, and a Mini-Acutrak 2 (Hillsboro, OR) screw was placed, making sure that the screw was at least 4 mm shorter than the measured length. Traction was released after the screw crossed the fracture site to allow for compression. Successful compression of the fracture was achieved. Final fluoroscopic images were obtained before the guide wires were removed and after the traction was released (Fig. 6.2). A sterile dressing and short-arm thumb spica splint were then placed .

Fig. 6.2

Intraoperative fluoroscopic anteroposterior (a) and lateral (b) images show the percutaneously placed screw in place. (Published with kind permission of © Peter R. Letourneau and Dan A. Zlotolow, 2015. All rights reserved)

Clinical Course and Outcome

Two weeks after the surgery, the patient was fitted with an over-the-counter thumb spica splint and he began some gentle range of motion exercises. Seven weeks after the surgery, routine X-rays demonstrated fracture healing and he was released to full activities without restrictions. At final follow-up 3 months postoperative, he had full range of motion in his left wrist that was equal to the contralateral side, as well as grip strength that was equal to the right. He denied any deficits in his activities of daily living and was able to resume playing tennis at his previous level of competitiveness.

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