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BILATERAL PROXIMAL RADIAL AND SCAPHOID FRACTURES IN A CHILD
BILATERAL PROXIMAL RADIAL AND SCAPHOID FRACTURES IN A CHILD R. M. KAY and S. H. KUSCHNER From the University of Southern California School of Medicine, Los Angeles CA, USA
A 13-year-old boy fell and suffered concomitant bilateral fractures of the proximal radius and scaphoid. Ipsilateral fractures of the proximal radius and scaphoid have been reported only once previously in a child, and never bilaterally. This article reviews paediatric proximal radial fractures and scaphoid fractures and their associated injuries. This report underlines the importance of examining for other injuries when a child presents with an apparently isolated upper extremity fracture. Journal of Hand Surgery (British and European Volume, 1999) 24B: 2: 255–257 Fractures of the proximal radius account for approximately 1% of all paediatric fractures and 5% to 14% of paediatric elbow fractures (Boyd and Altenberg, 1944; Henrikson, 1969; Landin, 1997; Landin and Danielsson, 1986; O’Brien, 1965). Though these injuries often result from low-energy trauma, associated injuries have been reported in 19% to 78% of cases in many series of fractures of the proximal radius (D’Souza et al., 1993; Fowles and Kassab, 1986; Jeffery, 1950; Newman, 1977; Steinberg et al., 1988, Vahvanen and Gripenberg, 1978). Scaphoid fractures account for 0.3% to 1.7% of all paediatric fractures in large series (Christodoulou and Colton, 1986; Greene et al., 1986; Landin, 1997; Vahvanen and Westerlund, 1980; Wulff and Schmidt, 1998). Associated injuries have been reported in 3% to 9% of cases of paediatric scaphoid fractures (Christodoulou and Colton, 1986; Vahvanen and Westerlund, 1980). We report the case of a 13-year-old boy who fell and suffered bilateral proximal radial and bilateral scaphoid fractures. His only complaint at the time of injury was bilateral elbow pain. This case reinforces the importance of careful examination for concomitant injuries following upper extremity fractures in children, even those which result from low-energy trauma.
patient in this case initially complained of bilateral elbow pain only. Clinical examination localized the scaphoid fractures, which were also evident radiographically. Many paediatric scaphoid fractures involve the distal pole and may heal uneventfully even if unrecognized. However, middle third fractures account for up to 36% of paediatric scaphoid fractures and may lead to nonunion (Christodoulou and Colton, 1986; Southcott and Rosman, 1977; Vahvanen and Westerlund, 1980; Wulff and Schmidt, 1998). The importance of physical examination cannot be overemphasized since 3% to 13% of radiologically-confirmed scaphoid fractures are not evident on initial plain radiographs and snuffbox tenderness is reported to be 100% sensitive for scaphoid fractures in children (Christodoulou and Colton, 1986; Vahvanen and Westerlund, 1980; Wulff and Schmidt, 1998). Fractures of the proximal radius are among the most common paediatric elbow fractures and account for 5% to 14% of elbow fractures in children. Concomitant injuries have been reported in up to 78% of cases, and these have generally been located around the elbow as well (Lindham and Hugosson, 1979; Steinberg et al., 1988; Tibone and Stoltz, 1981). The most frequent associated injuries are fractures of the olecranon, medial epicondyle and ulna and dislocation of the elbow (Steinberg et al., 1988). Associated scaphoid fracture has been reported only once previously in a child (Jeffery, 1950). An adult has also been reported with a fracture of the proximal radius in association with fractures of the entire proximal carpal row (Tiel-Van Buul et al., 1991). Scaphoid fractures account for 0.3% to 1.7% of all fractures in children (Christodoulou and Colton, 1986; Greene et al., 1986; Landin, 1997; Vahvanen and Westerlund, 1980; Wulff and Schmidt, 1998). Unlike scaphoid fractures in adults, paediatric scaphoid fractures involve the distal pole in 59% to 87% of cases, the middle pole in 12% to 36%, and the proximal pole in 0% to 2% (Christodoulou and Colton, 1986; Vahvanen and Westerlund, 1980; Wulff and Schmidt, 1998). The fractures are usually evident on initial radiographs, though follow-up radiographic studies at 1 to 2 weeks after injury have been used to diagnose these fractures in 3% to 13% of cases (Christodoulou and Colton, 1986; Southcott and Rosman, 1977; Vahvanen and Westerlund, 1980; Wulff
CASE REPORT A 13-year-old boy fell from a height of nearly 2 m and injured his arms. He was taken to a local emergency room with complaints of bilateral elbow pain and bilateral fractures of the proximal radius were diagnosed. The following day, clinical and radiographic examination demonstrated that, in addition to the proximal radial fractures, he also had bilateral minimally-displaced fractures of the distal pole of the scaphoid (Fig 1). He was treated in bilateral long arm thumb spica casts for 1 week followed by 3 weeks in bilateral short arm thumb spica casts. At the time of cast removal there was no residual tenderness and he resumed full activity. DISCUSSION The current case serves as a reminder to examine the entire patient, including the entire injured extremity. The 255
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THE JOURNAL OF HAND SURGERY VOL. 24B No. 2 APRIL 1999
a
b
c
d
Fig. 1
Radiographs on initial presentation demonstrate bilateral proximal radial fractures (a,b: right and left upper extremities, respectively) and bilateral scaphoid fractures (c,d: right and left, respectively).
and Schmidt, 1998). Associated injuries have been reported in 3% to 9% of cases of paediatric scaphoid fractures in large series, and most commonly involve the ipsilateral hand (Christodoulou and Colton, 1986; Vahvanen and Westerlund, 1980; Wulff and Schmidt, 1998). Scaphoid nonunion in children is reported to be 0% to 3% in large series, and has been seen in patients who have undergone treatment as well as in those who have not (Christodoulou and Colton, 1986; Southcott and Rosman, 1977; Vahvanen and Westerlund, 1980; Wulff and Schmidt, 1998). In the largest series of scaphoid nonunion in children, all eight cases resulted from fractures of the scaphoid waist (Southcott and Rosman, 1977). Four of the eight nonunions were in patients whose fractures were diagnosed and treated acutely, while the other four were first diagnosed after nonunion was already established. Early recognition and treatment are the keys to avoidance of such complications. This case serves as a reminder of the importance of careful physical examination in patients with apparently “isolated” fractures of the proximal radius.
REFERENCES Boyd HB, Altenberg AR (1944). Fractures about the elbow in children. Archives of Surgery, 49: 213–224. Christodoulou AG, Colton CL (1986). Scaphoid fractures in children. Journal of Pediatric Orthopaedics, 6: 37–39. D’Souza S, Vaishya R, Klenerman L (1993). Management of radial neck fractures in children: a retrospective analysis of one hundred patients. Journal of Pediatric Orthopaedics, 13: 232–238. Fowles JV, Kassab MT (1986). Observations concerning radial neck fractures in children. Journal of Pediatric Orthopaedics, 6: 51–57. Greene MH, Hadied AM, LaMont RL (1986). Scaphoid fractures in children. Journal of Hand Surgery, 9A: 536–541. Henrikson B (1969). Isolated fractures of the proximal end of the radius in children: epidemiology, treatment and prognosis. Acta Orthopaedica Scandinavica, 40: 246–260. Jeffery CC (1950). Fractures of the head of the radius in children. Journal of Bone and Joint Surgery, 32B: 314–324. Landin LA (1997). Epidemiology of children’s fractures. Journal of Pediatric Orthopaedics, 6B: 79–83. Landin LA, Danielsson, LG (1986). Elbow fractures in children: an epidemiological analysis of 589 cases. Acta Orthopaedica Scandinavica, 57: 309–312. Lindham S, Hugosson C (1979). The significance of associated lesions including dislocation in fractures of the neck of the radius in children. Acta Orthopaedica Scandinavica, 50: 79–83. Newman JH (1977). Displaced radial neck fractures in children. Injury, 9: 114–121. O’Brien PI (1965). Injureis involving the proximal radial epiphysis. Clinical Orthopaedics and Related Research, 41: 51–58. Southcott R, Rosman MA (1977). Non-union of carpal scaphoid fractures in children. Journal of Bone and Joint Surgery, 59B: 20–23.
BILATERAL RADIAL AND SCAPHOID FRACTURES Steinberg EL, Golomb D, Salama R, Wientroub S (1988). Radial head and neck fractures in children. Journal of Pediatric Orthopaedics, 8: 35–40. Tibone JE, Stoltz M (1981). Fractures of the radial head and neck in children. Journal of Bone and Joint Surgery, 63A: 100–106. Tiel-Van Buul MMC, Van Beek EJR, Bakker AJ, Broekhuizen AH (1991). A rare combination of fractures of the upper extremities: a diagnostic problem. Netherlands Journal of Surgery, 43: 189–191. Vahvanen V, Gripenberg L (1978). Fracture of the radial neck in children: a longterm follow-up study of 43 cases. Acta Orthopaedica Scandinavica, 49: 32–38. Vahvanen V, Westerlund M (1980). Fracture of the carpal scaphoid in children: a clinical and roentgenological study of 108 cases. Acta Orthopaedica Scandinavica, 51: 909–913.
257 Wulff RN, Schmidt TL (1998). Carpal fractures in children. Journal of Pediatric Orthopaedics, 18: 462–465.
Received: 27 August 1998 Accepted after revision: 12 October 1998 R.M. Kay MD, Pediatric Orthopaedics, Childrens Hospital Los Angeles, 4650 Sunset Boulevard, Mailstop 69, Los Angeles, CA 90027, USA. ©1999 The British Society for Surgery of the Hand Article no. jhsb.1998.0188
A 13-year-old boy fell and suffered concomitant bilateral fractures of the proximal radius and scaphoid. Ipsilateral fractures of the proximal radius and scaphoid have been reported only once previously in a child, and never bilaterally. This article reviews paediatric proximal radial fractures and scaphoid fractures and their associated injuries. This report underlines the importance of examining for other injuries when a child presents with an apparently isolated upper extremity fracture. Journal of Hand Surgery (British and European Volume, 1999) 24B: 2: 255–257 Fractures of the proximal radius account for approximately 1% of all paediatric fractures and 5% to 14% of paediatric elbow fractures (Boyd and Altenberg, 1944; Henrikson, 1969; Landin, 1997; Landin and Danielsson, 1986; O’Brien, 1965). Though these injuries often result from low-energy trauma, associated injuries have been reported in 19% to 78% of cases in many series of fractures of the proximal radius (D’Souza et al., 1993; Fowles and Kassab, 1986; Jeffery, 1950; Newman, 1977; Steinberg et al., 1988, Vahvanen and Gripenberg, 1978). Scaphoid fractures account for 0.3% to 1.7% of all paediatric fractures in large series (Christodoulou and Colton, 1986; Greene et al., 1986; Landin, 1997; Vahvanen and Westerlund, 1980; Wulff and Schmidt, 1998). Associated injuries have been reported in 3% to 9% of cases of paediatric scaphoid fractures (Christodoulou and Colton, 1986; Vahvanen and Westerlund, 1980). We report the case of a 13-year-old boy who fell and suffered bilateral proximal radial and bilateral scaphoid fractures. His only complaint at the time of injury was bilateral elbow pain. This case reinforces the importance of careful examination for concomitant injuries following upper extremity fractures in children, even those which result from low-energy trauma.
patient in this case initially complained of bilateral elbow pain only. Clinical examination localized the scaphoid fractures, which were also evident radiographically. Many paediatric scaphoid fractures involve the distal pole and may heal uneventfully even if unrecognized. However, middle third fractures account for up to 36% of paediatric scaphoid fractures and may lead to nonunion (Christodoulou and Colton, 1986; Southcott and Rosman, 1977; Vahvanen and Westerlund, 1980; Wulff and Schmidt, 1998). The importance of physical examination cannot be overemphasized since 3% to 13% of radiologically-confirmed scaphoid fractures are not evident on initial plain radiographs and snuffbox tenderness is reported to be 100% sensitive for scaphoid fractures in children (Christodoulou and Colton, 1986; Vahvanen and Westerlund, 1980; Wulff and Schmidt, 1998). Fractures of the proximal radius are among the most common paediatric elbow fractures and account for 5% to 14% of elbow fractures in children. Concomitant injuries have been reported in up to 78% of cases, and these have generally been located around the elbow as well (Lindham and Hugosson, 1979; Steinberg et al., 1988; Tibone and Stoltz, 1981). The most frequent associated injuries are fractures of the olecranon, medial epicondyle and ulna and dislocation of the elbow (Steinberg et al., 1988). Associated scaphoid fracture has been reported only once previously in a child (Jeffery, 1950). An adult has also been reported with a fracture of the proximal radius in association with fractures of the entire proximal carpal row (Tiel-Van Buul et al., 1991). Scaphoid fractures account for 0.3% to 1.7% of all fractures in children (Christodoulou and Colton, 1986; Greene et al., 1986; Landin, 1997; Vahvanen and Westerlund, 1980; Wulff and Schmidt, 1998). Unlike scaphoid fractures in adults, paediatric scaphoid fractures involve the distal pole in 59% to 87% of cases, the middle pole in 12% to 36%, and the proximal pole in 0% to 2% (Christodoulou and Colton, 1986; Vahvanen and Westerlund, 1980; Wulff and Schmidt, 1998). The fractures are usually evident on initial radiographs, though follow-up radiographic studies at 1 to 2 weeks after injury have been used to diagnose these fractures in 3% to 13% of cases (Christodoulou and Colton, 1986; Southcott and Rosman, 1977; Vahvanen and Westerlund, 1980; Wulff
CASE REPORT A 13-year-old boy fell from a height of nearly 2 m and injured his arms. He was taken to a local emergency room with complaints of bilateral elbow pain and bilateral fractures of the proximal radius were diagnosed. The following day, clinical and radiographic examination demonstrated that, in addition to the proximal radial fractures, he also had bilateral minimally-displaced fractures of the distal pole of the scaphoid (Fig 1). He was treated in bilateral long arm thumb spica casts for 1 week followed by 3 weeks in bilateral short arm thumb spica casts. At the time of cast removal there was no residual tenderness and he resumed full activity. DISCUSSION The current case serves as a reminder to examine the entire patient, including the entire injured extremity. The 255
256
THE JOURNAL OF HAND SURGERY VOL. 24B No. 2 APRIL 1999
a
b
c
d
Fig. 1
Radiographs on initial presentation demonstrate bilateral proximal radial fractures (a,b: right and left upper extremities, respectively) and bilateral scaphoid fractures (c,d: right and left, respectively).
and Schmidt, 1998). Associated injuries have been reported in 3% to 9% of cases of paediatric scaphoid fractures in large series, and most commonly involve the ipsilateral hand (Christodoulou and Colton, 1986; Vahvanen and Westerlund, 1980; Wulff and Schmidt, 1998). Scaphoid nonunion in children is reported to be 0% to 3% in large series, and has been seen in patients who have undergone treatment as well as in those who have not (Christodoulou and Colton, 1986; Southcott and Rosman, 1977; Vahvanen and Westerlund, 1980; Wulff and Schmidt, 1998). In the largest series of scaphoid nonunion in children, all eight cases resulted from fractures of the scaphoid waist (Southcott and Rosman, 1977). Four of the eight nonunions were in patients whose fractures were diagnosed and treated acutely, while the other four were first diagnosed after nonunion was already established. Early recognition and treatment are the keys to avoidance of such complications. This case serves as a reminder of the importance of careful physical examination in patients with apparently “isolated” fractures of the proximal radius.
REFERENCES Boyd HB, Altenberg AR (1944). Fractures about the elbow in children. Archives of Surgery, 49: 213–224. Christodoulou AG, Colton CL (1986). Scaphoid fractures in children. Journal of Pediatric Orthopaedics, 6: 37–39. D’Souza S, Vaishya R, Klenerman L (1993). Management of radial neck fractures in children: a retrospective analysis of one hundred patients. Journal of Pediatric Orthopaedics, 13: 232–238. Fowles JV, Kassab MT (1986). Observations concerning radial neck fractures in children. Journal of Pediatric Orthopaedics, 6: 51–57. Greene MH, Hadied AM, LaMont RL (1986). Scaphoid fractures in children. Journal of Hand Surgery, 9A: 536–541. Henrikson B (1969). Isolated fractures of the proximal end of the radius in children: epidemiology, treatment and prognosis. Acta Orthopaedica Scandinavica, 40: 246–260. Jeffery CC (1950). Fractures of the head of the radius in children. Journal of Bone and Joint Surgery, 32B: 314–324. Landin LA (1997). Epidemiology of children’s fractures. Journal of Pediatric Orthopaedics, 6B: 79–83. Landin LA, Danielsson, LG (1986). Elbow fractures in children: an epidemiological analysis of 589 cases. Acta Orthopaedica Scandinavica, 57: 309–312. Lindham S, Hugosson C (1979). The significance of associated lesions including dislocation in fractures of the neck of the radius in children. Acta Orthopaedica Scandinavica, 50: 79–83. Newman JH (1977). Displaced radial neck fractures in children. Injury, 9: 114–121. O’Brien PI (1965). Injureis involving the proximal radial epiphysis. Clinical Orthopaedics and Related Research, 41: 51–58. Southcott R, Rosman MA (1977). Non-union of carpal scaphoid fractures in children. Journal of Bone and Joint Surgery, 59B: 20–23.
BILATERAL RADIAL AND SCAPHOID FRACTURES Steinberg EL, Golomb D, Salama R, Wientroub S (1988). Radial head and neck fractures in children. Journal of Pediatric Orthopaedics, 8: 35–40. Tibone JE, Stoltz M (1981). Fractures of the radial head and neck in children. Journal of Bone and Joint Surgery, 63A: 100–106. Tiel-Van Buul MMC, Van Beek EJR, Bakker AJ, Broekhuizen AH (1991). A rare combination of fractures of the upper extremities: a diagnostic problem. Netherlands Journal of Surgery, 43: 189–191. Vahvanen V, Gripenberg L (1978). Fracture of the radial neck in children: a longterm follow-up study of 43 cases. Acta Orthopaedica Scandinavica, 49: 32–38. Vahvanen V, Westerlund M (1980). Fracture of the carpal scaphoid in children: a clinical and roentgenological study of 108 cases. Acta Orthopaedica Scandinavica, 51: 909–913.
257 Wulff RN, Schmidt TL (1998). Carpal fractures in children. Journal of Pediatric Orthopaedics, 18: 462–465.
Received: 27 August 1998 Accepted after revision: 12 October 1998 R.M. Kay MD, Pediatric Orthopaedics, Childrens Hospital Los Angeles, 4650 Sunset Boulevard, Mailstop 69, Los Angeles, CA 90027, USA. ©1999 The British Society for Surgery of the Hand Article no. jhsb.1998.0188