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Hypothesis - In pediatric patients who sustain a scaphoid fracture, cast immobilization will result in successful union at a lower rate in delayed presentation ( > 28 days following injury) of displaced fractures with cystic change than acute, nondisplaced fractures without cystic change after 12 weeks of casting.

Methods - A retrospective analysis of 255 scaphoid fractures treated at a single pediatric hospital between 2010-2020 was performed to characterize: demographic factors, fracture characteristics, amount of cystic change, treatment method, and rate of healing. The primary outcome measure was the rate of healing of scaphoid fractures presenting > 28 days from injury with cast immobilization and compared with those treated surgically. Demographic factors and fracture characteristics were compared using Fisher's exact tests.

Results - Patients presenting in a delayed fashion were more likely male (84.8%, p = 0.02), injured playing sports (63%, p < 0.0001), football players (41.3%, p < 0.0001), and had closed physes (41.3%, p < 0.0001). The fracture characteristics included an increased incidence of a transverse fracture pattern (80.4%, p = 0.037), proximal pole fracture (26.1 %, p < 0.0001), > 1 mm of cystic change (80.4%, p < 0.0001), and > 1 mm of fracture displacement (62.2%, p < 0.0001). Of patients presenting in a delayed fashion, 41.3% were treated with casting alone with a 78.9% union rate compared to 96.1% of acute fractures treated with casting resulting in a 95.5% union rate. The average duration of casting required for healing in the delayed presenting fractures was 63 days (range 53-98). There were no significant demographic differences between the patients with chronic scaphoid fractures treated with casting or surgery initially. However patients treated with casting were less likely to have cystic change > 1 mm (42.1%, p = 0.002), fracture displacement (73.7%, p = 0.0001) or fracture comminution (5.3%, p = 0.031.)

Summary points -

  • Cast immobilization for scaphoid fractures who present > 28 days following injury results in successful union in patients with minimal displacement, < 1 mm cystic change, and no fracture comminution or humpback deformity. These indications for casting mirror the acutely presenting group.

  • Both acute and delayed groups treated with casting healed in an equivalent amount of time.

  • Sports participation, specifically football participation, is a risk factor for delay of presentation of pediatric scaphoid fractures.

  • Delayed presentation of a scaphoid fracture is not independently an indication for surgery in the pediatric and adolescent population.

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Risk Factors For Failure Of Cast Immobilization In Pediatric Scaphoid Fracture Presenting Greater Than 28 Days After Injury