Management of Possible Scaphoid (Anatomical Snuffbox) Injury in a 10-Year-Old
Immobilize the wrist immediately in a thumb spica splint or cast and obtain plain radiographs (anteroposterior, lateral, oblique, and dedicated scaphoid views), then refer to a pediatric orthopedic surgeon or pediatric plastic surgeon for definitive management if fracture is confirmed or clinical suspicion remains high despite normal initial imaging. 1, 2
Initial Clinical Assessment
Perform specific clinical tests to assess fracture probability:
- Scaphoid compression test (longitudinal compression of the thumb) is the most accurate clinical indicator with 100% sensitivity and 80% specificity in detecting scaphoid fractures 3
- Anatomical snuffbox tenderness with wrist in ulnar deviation is highly sensitive but not specific, leading to many false positives 2, 4, 3
- Scaphoid tubercle tenderness is more specific than snuffbox tenderness alone 2, 4
- Pronation with ulnar deviation test producing snuffbox pain has 100% negative predictive value—if negative, fracture is effectively ruled out 5
Use the Clinical Scaphoid Score (CSS) to guide decision-making:
- Snuffbox tenderness with ulnar deviation = 3 points
- Scaphoid tubercle tenderness = 2 points
- Longitudinal thumb compression pain = 1 point
- CSS ≥4 indicates high fracture probability and warrants advanced imaging; CSS <4 has 96% negative predictive value 4
Assess for significant wrist swelling, as marked swelling raises suspicion for fracture even with normal initial radiographs 3
Imaging Protocol
Obtain initial plain radiographs including anteroposterior, lateral, oblique, and dedicated scaphoid views 2
If initial radiographs are normal but clinical suspicion remains high (CSS ≥4):
- MRI is the preferred advanced imaging modality and should be obtained within 1-2 days of injury 4
- Bone scintigraphy is an alternative if MRI is unavailable 2
Immobilization Strategy
Immobilize immediately in a well-molded thumb spica cast or splint while awaiting definitive diagnosis, even if initial radiographs are normal but clinical examination is concerning 2
- Standard of care includes thumb immobilization, though this may not be absolutely necessary for all nondisplaced distal fractures 2
- Continue immobilization for 10-14 days minimum if initial radiographs are normal but clinical suspicion exists, then repeat clinical examination and imaging 2, 6
Specialist Referral
Refer to a pediatric orthopedic surgeon or pediatric plastic surgeon for:
- Any confirmed scaphoid fracture 1, 7
- Proximal, medial, or displaced fractures (these warrant immediate orthopedic subspecialist referral) 2
- Persistent clinical findings despite normal imaging 1, 2
The American Academy of Pediatrics explicitly recommends that children with hand trauma involving bone injuries should be referred to a pediatric plastic surgeon, with pediatric orthopedic surgeons as an appropriate alternative 1, 7
Pediatric-Specific Considerations
Scaphoid fractures are rare in children under age 9 years and account for only 0.4% of all pediatric emergency department attendances in the 8-12 year age group 6
At age 10, this patient is at the lower end of typical scaphoid fracture risk, but the injury should still be taken seriously given the potential for complications including avascular necrosis if missed 6
Most pediatric scaphoid fractures occur from falls onto an outstretched hand 6
Nondisplaced distal fractures in children generally heal well with appropriate immobilization, and avascular necrosis is rare when properly managed 2, 6
Critical Pitfalls to Avoid
- Do not rely solely on anatomical snuffbox tenderness, as this has poor specificity and leads to overtreatment 4, 6, 3
- Do not discharge without immobilization if clinical examination suggests possible fracture, even with normal initial radiographs 2, 4
- Do not delay advanced imaging (MRI) beyond 1-2 days if CSS ≥4, as early diagnosis improves outcomes 4
- Do not manage displaced or proximal fractures without orthopedic subspecialist involvement, as these require specialized treatment 2