True scaphoid fractures of the wrist are difficult to diagnose in children. In 5–40% of cases, a scaphoid fracture may not be detectable on initial X-ray, some fractures may take up to six weeks to become evident. Since missing a scaphoid fracture may have serious implications, many children with a suspected or “clinical” scaphoid fracture, but normal radiographs, may be over-treated. The purpose of this study was to identify predictors of true scaphoid fractures in children.

A retrospective cohort study was performed using electronic medical records for all patients over a two-year period presenting to a tertiary paediatric hospital with hand or wrist injury. Charts were identified by ICD-10 diagnostic codes and reviewed for pre-specified inclusion and exclusion criteria. Patients with either a clinical or true scaphoid fracture were included. When a scaphoid fracture was suspected, but imaging was negative for fracture, the diagnosis of a clinical scaphoid fracture was made. True scaphoid fractures were diagnosed when a fracture was evident on any modality of medical imaging (X-ray, CT, MRI) at any time post-injury.

Over the two-year study period, 148 patients (60 scaphoid fractures, 88 non-fractures) met inclusion and exclusion criteria for review. Mean (±SD) age was 13±2 years and 52% were male. The left wrist was injured in 61% of cases. Of the 60 true scaphoid fractures, mean age was 14±2 years, and 69% were male. Fracture location was primarily at the waist (48%) or distal pole (45%) of the scaphoid. Sports were the prevailing mechanism of injury. Six (11%) underwent surgery. Multivariate logistic regression demonstrated that older age, male gender, and right-sided injury were predictors of scaphoid fracture with odds ratios of 1.3 (95% CI: 1.1–1.6, p=0.005), 2.8 (95% CI: 1.3–6, p=0.007), and 2.4 (95% CI: 1.1–5.2, p=0.025).

Older age, male gender, and right-sided injury may be predictors of scaphoid fractures in children. Further evidence to support this may enable the formulation of clinical guidelines or rules to reduce the overtreatment of children presenting with a clinical scaphoid fracture.

The diagnosis of a clinical scaphoid fracture is made when a scaphoid fracture is suspected, but radiographs are normal. Standard treatment in this scenario involves immobilization and repeat x-rays in 10–14 days. When repeat x-rays are also normal but a scaphoid fracture is still suspected clinically, the optimal management in children is unknown. Our objective was to characterize these patients and evaluate their management and outcomes.

A retrospective study was performed of all patients presenting to a tertiary paediatric center over a two year period with a diagnosis of wrist or hand pain. Charts were identified by ICD-10 diagnostic codes and reviewed for inclusion and exclusion criteria. Patients were included if they had clinical suspicion of a scaphoid fracture but two sets of x-rays negative for fracture within 14 days of injury.

Ninety-one children (mean age 13.2 years, SD: 2.2) were identified with a clinical scaphoid fracture. Mean follow-up was 7.1 weeks. Most patients (60%) were injured either from a fall while ambulating or from sports. Sixteen (18%) patients received CT or MRI at an average of 8.4 weeks post-injury (95%CI:5–15.3). All patients were immobilized for a mean of 5.4 weeks. No patients underwent surgery. Five patients (5.5%) were found to have a scaphoid fracture diagnosed by X-ray or CT at a mean of 5.7 weeks post-injury (range 4.3–6.6). Other carpal fractures or ligamentous injuries were identified in three patients (3%) by MRI or CT. Seventy percent of patients healed within 6 weeks of injury.

The majority of children presenting with clinical suspicion of a scaphoid fracture but 2 sets of X-rays negative for fracture healed with immobilization. While the incidence of true scaphoid fracture may be low in children, MRI or CT may be warranted for patients where clinical suspicion persists.