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Changing Fracture Patterns in Children

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Ecclesiastes is often quoted from the Bible saying, "There is nothing new under the sun." There is still some truth to that idea but in today's modern world, there are,indeed, a few new things under the sun. One of them is the way children engage in extreme sports at an early age resulting in changing fracture patterns. And those children are much larger in size now than they were 30 years ago.

In this report, a particular wrist fracture (of the scaphoid bone) is the focus. Changes in the type of wrist fractures orthopedic surgeons are seeing have changed treatment, too. The scaphoid bone is on the thumb side of the hand. It is located at the end of the forearm with just one small bone (the trapezium) between the scaphoid and the base of the thumb.

The scaphoid is the bone fractured most often in the wrist. It is kidney shaped with three distinct fracture patterns involving the middle of the bone called the waist and the two ends on either side called poles.

The distal pole (thumb side) and the proximal pole (wrist side) make up the two other segments. The bone isn't really divided anatomically into three parts -- it is just shaped in such a way that makes it easy to categorize fractures based on their location in any of these three locations.

One of the changes surgeons have noticed is where scaphoid fractures occur. For example, in a study published in 1980, the majority of scaphoid wrist fractures were in the distal pole. That fracture pattern has shifted now to the waist (middle section) of the scaphoid. Fractures of the proximal pole are still fairly limited (both then and now) but a slight rise in number of proximal pole fractures has been noted.

Treatment of scaphoid fractures has also changed for a couple of reasons. First, proximal fractures (on the forearm side of the scaphoid bone) may require a longer period of time in a cast. Likewise, fractures that aren't diagnosed right away (called late-presenting fractures) also take longer to heal.

High-energy trauma from intense sports such as motocross, extreme soccer, skateboarding, and snowboarding may require more than cast immobilization. High-energy injuries are more likely to cause waist and proximal pole scaphoid fractures. There may be other injuries of the nearby soft tissues and bones associated with the scaphoid fracture.

Surgery with bone grafting and screw or wire fixation may be necessary for the high-energy scaphoid fractures. Sometimes casting is tried but fracture healing doesn't take place. Late-presenting (chronic) fractures are less likely to heal with casting. Any cases of fracture nonunion or malunion will require follow-up with surgery.

With younger children involved in these sports, there is always a concern about the effect of the fracture on the physes (growth plate). A fracture through the growth plate could alter the bone growth and result in a shorter wrist/hand on that side. Distal pole fractures are more common when the growth plate is still open.

The authors also note that their research has been able to uncover factors that affect (increased) time to healing. These include: displacement (separation) of the fracture, location (waist or proximal pole fractures take longer to heal), longer time between injury and treatment, and the presence of osteonecrosis (bone death).

In summary, scaphoid wrist fractures in children can be a complex problem. The open physes (growth plates), presence of scaphoid cartilage that hasn't turned to bone yet, and poor blood supply to this area can make treatment challenging.

Most nondisplaced acute scaphoid fractures in this age group can be treated with cast immobilization. Chronic, late-presenting scaphoid fractures almost always require surgical repair. Children and family members must be advised that the healing process can take longer than the usual six-weeks-in-a-cast that is typical for most other types of fractures. With early diagnosis and proper treatment, treatment results for scaphoid fractures in this age group are favorable.

Reference: J. Joseph Gholson, BS, et al. Scaphoid Fractures in Children and Adolescents: Contemporary Injury Patterns and Factors Influencing Time to Union. In The Journal of Bone and Joint Surgery. July 6, 2011. Vol. 93-A. No. 13. Pp. 1210-1219.

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