Children's Hospital Boston, Boston, Massachusetts 02115, USA.
J Bone Joint Surg Am. 2011 Jul 6;93(13):1210-9. doi: 10.2106/JBJS.J.01729.
Historically, scaphoid fractures in children and adolescents have predominantly involved the distal pole, requiring neither surgical care nor extended follow-up. Changing patient characteristics, however, appear to be altering fracture epidemiology and treatment. The purpose of this investigation was to characterize contemporary fracture patterns in children and adolescents and to identify factors influencing time to healing following both nonoperative and operative treatment.
A retrospective analysis of 351 scaphoid fractures that had been treated from 1995 to 2010 was performed to characterize fracture patterns. The mean patient age was 14.6 years (range, seven to eighteen years). Complete clinical and radiographic follow-up data were available for 312 fractures (89%), with 222 fractures presenting acutely and ninety not acutely. Union rates following casting or surgical treatment were determined, and Cox regression analysis was utilized to identify factors influencing both the union rate and the time to union.
Overall, 248 fractures (71%) occurred at the scaphoid waist, eighty-one (23%) occurred at the distal pole, and twenty-two (6%) occurred at the proximal pole. Male sex, high-energy mechanisms of injury, closed physes, and high body-mass index were associated with fractures of the waist or proximal pole. Treatment of acute fractures with casting alone resulted in a 90% union rate. Lower union rates were seen in association with the use of casting alone for the treatment of chronic fractures, displaced fractures, and proximal fractures. Longer time to union was seen in association with older fractures, displaced fractures, proximal fractures, and fractures in patients with osteonecrosis. The union rate following surgery was 96.5% (109 of 113). Increased time to union was seen in association with open physes, fracture displacement, proximal fracture, the type of screw used for surgical fixation, and the use of bone graft at the time of surgery.
With changes in patient characteristics and activities, scaphoid fracture patterns in children and adolescents are now similar to the published patterns in adults. While 90% of acute nondisplaced fractures heal with nonoperative treatment, three months of cast immobilization or more may be required for more proximal injuries. Almost one-third of pediatric patients with scaphoid fractures will present late with chronic nonunions; in these instances, surgical reduction and internal fixation should be considered the primary treatment option.
从历史上看，儿童和青少年的舟状骨骨折主要涉及舟骨远端，既不需要手术治疗也不需要长期随访。然而，患者特征的变化似乎改变了骨折的流行病学和治疗方法。本研究的目的是描述儿童和青少年的当代骨折模式，并确定影响非手术和手术治疗后愈合时间的因素。
对 1995 年至 2010 年期间治疗的 351 例舟状骨骨折进行回顾性分析，以描述骨折模式。患者平均年龄为 14.6 岁（7-18 岁）。312 例骨折（89%）获得完整的临床和影像学随访数据，222 例为急性骨折，90 例为非急性骨折。确定石膏固定或手术治疗后的愈合率，并利用 Cox 回归分析确定影响愈合率和愈合时间的因素。
总体而言，248 例（71%）骨折发生在舟骨腰部，81 例（23%）发生在舟骨远端，22 例（6%）发生在舟骨近端。男性、高能损伤机制、闭合骺板和高身体质量指数与腰部或近端骨折有关。单独使用石膏固定治疗急性骨折的愈合率为 90%。单独使用石膏固定治疗慢性骨折、移位骨折和近端骨折的愈合率较低。愈合时间较长与较陈旧的骨折、移位骨折、近端骨折和伴有骨坏死的骨折有关。手术治疗后的愈合率为 96.5%（109/113）。骺板开放、骨折移位、骨折近端、手术固定用螺钉类型和手术时植骨均与愈合时间延长有关。
随着患者特征和活动的变化，儿童和青少年的舟状骨骨折模式现在与成人的发表模式相似。虽然 90%的急性无移位骨折可以通过非手术治疗愈合，但更靠近近端的损伤可能需要 3 个月或更长时间的石膏固定。近三分之一的儿童舟状骨骨折患者会出现慢性不愈合，在这种情况下，应考虑手术复位和内固定作为主要治疗选择。
