Current Reviews in Musculoskeletal Medicine (2022) 15:465–473

https://doi.org/10.1007/s12178-022-09784-1

INJURIES IN OVERHEAD ATHLETES (J DINES AND C CAMP, SECTION EDITORS)

Common Upper Extremity Injuries in Pediatric Athletes

Rhonda A. Watkins 1,2,3 & Celina De Borja 1,2 & Faustine Ramirez 2

Accepted: 21 June 2022 / Published online: 1 August 2022

# The Author(s) 2022

Abstract
Purpose of Review The aim of this study is to review the most recent literature on common upper extremity injuries in pediatric
athletes and discuss their diagnosis, management, and outcomes. We also highlight ultrasound as a tool in their evaluation.
Recent Findings Shoulder conditions presented include little league shoulder, glenohumeral rotation deficit, acute traumatic
shoulder dislocation, and multidirectional shoulder instability. Elbow conditions include capitellar OCD, medial epicondyle
avulsion fracture, and medial epicondylitis. We also review scaphoid fractures and gymnast wrist. Not all physeal injuries lead
to long-term growth disruption. Ultrasound has been shown to be useful in the diagnosis of scaphoid fracture, medial epicondyle
avulsion fractures, and capitellar OCD. It can also be helpful in assessing risk for shoulder and elbow injuries in overhead
athletes.
Summary There is a rising burden of upper extremity injuries among pediatric athletes. Knowledge of their sport specific
mechanics can be helpful in diagnosis. As long-term outcome data become available for these conditions, it is clear, proper
diagnosis and management are critical to preventing adverse outcomes. We highlight many of these injuries, best practice in care,
and controversies in care in hopes of improving outcomes and preventing injury for pediatric athletes.

Keywords Pediatric sport . Elbow injuries . Shoulder injuries . Wrist injuries . Diagnostic ultrasound

Introduction these sports, overhead sports like baseball and basketball have
been reported as most popular. Increased sport participation
Pediatric athletes are at increased risk for sport-related injuries has led to increased rates of sport-related injuries with a rising
due to intrinsic factors like the impact of chronic repetitive burden of upper extremity injuries [7–11]. This paper will
stress on their physes and extrinsic factors such as improper review some of the common injuries seen in the shoulder,
sport-related technique and sport-specific kinematics [1–3]. elbow, wrist, and hand of pediatric athletes with a focus on
Prior to the 2020 pandemic, there was an estimated 60 million diagnosis, management and outcomes. We also highlight use
kids aged 6 through 18 years participating in organized sport of ultrasound as a diagnostic tool for these conditions.
yearly [4]. Participation was steadily increasing with trends
toward earlier participation in youth sport [5, 6•]. Among

Little League Shoulder

This article is part of the Topical Collection on Injuries in Overhead
Athletes
Little league shoulder (LLS) is an overuse injury caused by
* Rhonda A. Watkins repetitive microtrauma from torque or tractional forces on the
[email protected] proximal humeral physis [12–14]. Skeletally immature ath-
letes between 11 and 16 years old (mean age 13) present with
1
Department of Orthopedic Surgery, Division of Pediatric
insidious onset shoulder pain associated with overhead activ-
Orthopedics, University of California San Francisco, San ities, such as baseball, tennis, swimming, gymnastics, volley-
Francisco, CA, USA ball, football, or cricket. In advanced cases, symptoms may
2
Department of Pediatrics, University of California San Francisco, affect activities of daily living or even be present at rest. Other
San Francisco, CA, USA symptoms may include shoulder fatigue or weakness, me-
3
UCSF Benioff Children’s Hospitals, 747 52nd Street, chanical symptoms, or secondary elbow pain [12, 13].
Oakland, CA 94609, USA Physical exam reveals tenderness over the lateral aspect of
466 Current Reviews in Musculoskeletal Medicine (2022) 15:465–473

the proximal humerus with decreased range of motion (ROM) lead to increased external rotation (ER) and decreased internal
or strength [12, 14]. In a retrospective study by Heyworth rotation (IR), resulting in a loss of total shoulder ROM or asym-
et al. in 2016, 30% of athletes with LLS had decreased total metry between dominant and nondominant shoulder. GIRD has
arc of motion from glenohumeral internal rotation deficit been implicated with increased risk for shoulder and elbow
(GIRD) [12]. injuries [12, 17–19]. However, a meta-analysis by Keller et al.
Diagnosis can be made clinically, but radiographs of the in 2018 revealed that although shoulders with GIRD favored
shoulder (AP view in external rotation), may reveal physeal injury, it did not yield statistical significance [18].
widening, increased sclerosis or demineralization, cystic Athletes with GIRD present with nonspecific posterior
changes, metaphyseal calcification, or fragmentation. shoulder pain in the late cocking phase, shoulder stiffness,
Radiographs may be normal up to 10 days from onset of and loss of throwing velocity [19]. Diagnosis is made clini-
symptoms and may only be remarkable after 3 weeks. cally by measuring shoulder ER and IR passively while the
Obtaining radiographs of the contralateral side may help de- athlete is supine with the humerus abducted at 90° and elbow
tect subtle changes. Magnetic resonance imaging (MRI) may flexed at 90°. Total shoulder ROM or arc of motion is the sum
be used to confirm the diagnosis if radiographs are inconclu- of shoulder IR and ER. Athletes with GIRD may also present
sive. MRI findings consistent with LLS include physeal wid- with scapular dyskinesia on physical exam [19, 20].
ening with increased signal intensity, metaphyseal bone mar- Radiographs are usually unremarkable, and in some cases
row edema, adjacent periosteal edema, and subchondral cysts may show a posterior glenoid osteophyte (Bennet’s lesion)
[7, 12, 14]. Ultrasound evaluation can be performed to assess [19]. MRI may be obtained to evaluate for concomitant pa-
humeral retroversion, which refers to adaptive changes that thology such as RTC (supraspinatus and infraspinatus) partial
restrict physiologic derotation of the humeral head in skeletal- tears, bony cystic changes to posterosuperior humeral head,
ly immature athletes who participate in overhead activities. thickened appearance of posterior band of the inferior
Humeral retroversion has been reported in dominant extrem- glenohumeral ligament (IGHL), glenoid chondral wear, and
ities of baseball players and may be associated with increased labral pathology [19].
risk for shoulder or elbow injuries [12, 15, 16]. Dynamic assessment through ultrasound may help differ-
Management of LLS includes rest from overhead activities entiate between bony factors (humeral retroversion) versus
until the patient is asymptomatic, physical therapy (PT) focused soft tissue factors (pathologic contracture of posterior capsule)
on alleviating posterior capsule tightness in athletes with GIRD, that may contribute to GIRD [20]. GIRD in the setting of an
periscapular and rotator cuff (RTC) strengthening, and throw- injury is managed through PT focused on improving the cap-
ing mechanics. According to Heyworth et al., the average time sular or muscular adaptations from chronic overhead activi-
to full resolution and return to full competition were 2.6 months ties. Posterior capsule/RTC stretching such as the sleeper
and 4.2 months, respectively [12]. Gradual return to sports and stretch and cross body stretch are associated with favorable
emphasis on pitching guidelines are essential in preventing re- outcomes. Arthroscopic interventions may be indicated if
currence [12, 14]. In the same study, recurrence of LLS was symptoms persist despite conservative measures [19, 20].
seen in 7% of athletes at an average of 7.6 months and was
more likely if the athlete had GIRD [12].
Natural course for LLS is considered benign or self- Shoulder Instability
limiting; however, symptoms can wax and wane and sig-
nificantly affect an athlete’s ability to participate in sports. Acute traumatic shoulder instability refers to dislocation of the
Potential complications include physeal closure, which is humeral head from the glenoid. Anterior dislocation being the
worrisome because the proximal physis contributes to 80% most common will be the focus of this discussion. It may lead
of overall humeral growth; however, these are extremely to soft tissue injuries such as avulsion of the anterior labrum
rare [12, 13]. In a 14-year retrospective study, there were and anterior inferior band of the IGHL (Bankart lesion), hu-
no cases of physeal closure, humeral length discrepancy, meral avulsion of glenohumeral ligament (HAGL lesion), or
or angular deformity reported as well as no differences in anterior labral periosteal sleeve avulsion (ALPSA), and con-
outcomes between athletes who had positive or negative comitant bony injuries including fracture of anterior inferior
radiographic findings, or those treated with (PT) versus glenoid rim (bony Bankart lesion) with corresponding impac-
those who were not [12]. tion fracture of the posterior superior humeral head (Hill-
Sachs defect), or fractures involving the proximal humerus
physis [21]. These injuries are usually sustained through a fall
Glenohumeral Internal Rotation Deficit or a collision while the athlete’s shoulder is abducted and
externally rotated [21, 22]. Previous history may include sub-
Glenohumeral internal rotation deficit (GIRD) refers to adap- jective feeling of instability or prior traumatic subluxation or
tive changes to dominant shoulders of overhead athletes, that complete dislocation events.
Current Reviews in Musculoskeletal Medicine (2022) 15:465–473 467

On exam, the athlete will present with gross deformity or analysis revealed that re-dislocation was highest among those
shoulder asymmetry, holding the injured arm to the side with who underwent arthroscopic Bankart repair, in contrast to
limited ROM. If the athlete presents after the joint reduction, those who had open Bankart repair or Latarjet procedures
special maneuvers such as the load and shift, hyperabduction, [27]. Socioeconomic factors such as insurance status may also
apprehension/relocation tests, and sulcus sign may be used to affect outcomes after acute shoulder dislocations. A retrospec-
provoke symptoms or assess laxity. Radiographs of the shoul- tive review by Hung et al. revealed that publicly-insured indi-
der including AP, scapular Y, and axillary views should be viduals take longer to receive medical evaluation, MRI, and
obtained following these injuries to assess proper joint reduc- surgery; have higher number of previous dislocations before
tion and evaluate for concomitant bony injuries. The AP view their initial consult; are associated with secondary bony inju-
may show bony Bankart lesions with accompanying Hill- ries; and have higher rates of recurrent instability post-
Sachs deformity or fractures of the proximal humerus, while operatively [25].
the axillary view best visualizes concentric reduction. MRI Multidirectional instability (MDI) refers to anterior or pos-
may be utilized to evaluate the extent of soft tissue damage terior with inferior shoulder instability from chronic repetitive
to the joint capsule, glenohumeral ligaments, labrum, and car- microtrauma in overhead sports [17, 21]. Athletes usually
tilage [21]. present with gradual onset subjective feeling of shoulder in-
Multiple techniques have been described for closed reduc- stability especially with overhead activities. Prior history of
tion after anterior shoulder dislocation. Principle methods in- traumatic shoulder subluxation/dislocation may be present.
clude traction-countertraction, leverage techniques, and scap- Physical exam includes similar provocative maneuvers dis-
ular manipulation. The best technique is still up for debate. A cussed in acute traumatic anterior shoulder instability.
meta-analysis revealed that traction-countertraction may pro- Beighton score may help assess overall ligamentous laxity
vide least pain, but leverage techniques may be quickest to [17]. Diagnosis is made clinically, although ultrasound evalu-
perform [23]. Ultimately, gentle manipulation is essential to ation can be utilized for dynamic assessment. A study of ul-
avoid further iatrogenic injuries. Pain control is crucial while trasound findings in individuals with hypermobile type Ehlers
performing the procedure and sedation may be necessary for Danlos syndrome with MDI revealed a larger subacromial
the pediatric population [21, 23]. Shoulder immobilization area with inferior humeral head subluxation compared to the
through an arm sling and activity modifications are recom- control group. Their findings suggest that symptoms from
mended immediately following the injury. Proper rehabilita- MDI may not be from impingement, and instead result from
tion includes PT focused on periscapular and RTC inferior humeral head displacement and loss of shoulder
strengthening. ROM, and should be considered when designing rehabilita-
An athlete may return to sport once full ROM, strength, and tion programs [28].
ability to perform sport specific maneuvers without pain, dis- Management includes activity modifications and PT focused
comfort or apprehension are achieved [21]. Recurrence of on stabilizing the shoulder through RTC and periscapular
traumatic shoulder dislocations after nonoperative treatment strengthening, which have shown favorable outcomes [17]. A
is around 95% in individuals under 25 years old and can be as systematic review by Longo et al revealed 60% of athletes were
high as 100% in skeletally immature athletes. Boys between able return to sports at the same level while 34% returned at a
14 and 18 years old are more likely to re-dislocate [21, 22, lower level. Overall, only 21% of patients required surgery due
24–26]. Rates for return to sport are 41% and 95% for those to persistence of symptoms despite conservative treatment.
who are treated nonoperatively and surgically, respectively Recurrence of MDI in those who were managed surgically
[26]. Due to concern for recurrent injuries leading to more were lowest among those who underwent open capsular shift
extensive surgical management, degenerative arthropathy, (7.5%) and arthroscopic plication (7.8%) [29].
and less favorable outcomes with regards to return to sport,
there has been some discussion regarding earlier surgical in-
tervention in recent literature [22, 26, 27]. Elbow
Absolute surgical indications for first time anterior shoul-
der dislocations include open injuries, irreducible joints, or Medial Epicondyle Apophysitis
fracture/dislocation. Relative indications for first time injuries
may include bony Bankart lesions with Hill-Sachs deformity, Medial epicondyle apophysitis, frequently referred to as
injuries sustained by overhead athletes, glenolabral articular “Little League elbow,” arises in the skeletally immature
disruption (GLAD), or ALPSA. Surgical interventions are athlete with open physes, typically under the age of 10.
commonly done through arthroscopic techniques and focused [7–10]. The developing apophysis and adjacent physis are
on joint stabilization and repairing injuries to the capsule and structurally weaker than the flexor-pronator mass that orig-
labrum [21]. Recurrence of anterior shoulder instability post- inates at the medial elbow, and thus are particularly sus-
operatively varies depending on surgical technique. A meta- ceptible to injury due to repetitive valgus stress and traction
468 Current Reviews in Musculoskeletal Medicine (2022) 15:465–473

at the medal epicondyle [8, 10, 11]. This injury occurs Fracture displacement is often used to determine the opti-
almost exclusively in throwing athletes such as baseball mal treatment. However, controversy remains about its clini-
players, during the cocking phases of throwing when val- cal significance and the most accurate diagnostic approach to
gus stress on the medial elbow is maximal [8, 10, 11]. determine the degree of displacement [41, 44]. Obtaining con-
Approximately 20–50% of youth baseball players report tralateral elbow radiographs can be beneficial to distinguish
elbow pain, and recent radiographic assessments of the me- between acute avulsion from anatomic variation, due to the
dial elbow using ultrasonography and MRI have reported variable age of fusion of the medial epicondyle ossification
medial epicondyle abnormalities ranging from 10 to 50% center [9, 41]. Fragment displacement is typically anterior and
on the throwing side [2, 3, 30•, 31–36]. distal, so the displacement may be underestimated by an iso-
Patients present with insidious onset of medial elbow pain lated anteroposterior radiograph [41]. Several studies have
with throwing. Physical examination reveals focal tenderness shown that internal oblique radiographs at 45° and distal hu-
to palpation over the medial epicondyle with possible medial meral axial views may improve accuracy in measuring maxi-
elbow swelling, limited elbow extension, and stiffness [8, 11, mal displacement, as CT and MRI are typically not helpful in
37]. Diagnosis is clinical, but radiographs should be obtained evaluating these injuries [41, 45–47].
to evaluate for widening of the medial epicondyle physis, Optimal management of pediatric medial epicondyle frac-
possible fragmentation, ragged appearance, sclerosis, or tra- tures continues to be an area of debate, especially with regards
becular thickening [7, 37, 38]. On MRI, widening of the to surgical indications. Non-displaced or minimally displaced
physis can be noted with varying levels of inflammation and fractures can be treated non-operatively. Generally accepted
increased periphyseal bone marrow edema [7, 37, 38]. Several absolute indications for operative intervention include incar-
studies have examined the role of ultrasonography as a screen- cerated fragments, open fracture, and ulnar nerve entrapment
ing tool for the early detection of medial epicondyle injuries in [41, 42]. Relative indications include elbow instability and
youth baseball players and have found it effective at detecting significant displacement. These indications are controversial
early medial epicondyle lesions including bony cortical dis- however as there is no agreement regarding the definition of
continuity or fragmentation [32, 33, 39, 40]. significant displacement (ranges from 2 to 10 mm), in addition
The management of medial epicondyle apophysitis is con- to the aforementioned measurement controversies [41, 42,
servative, involving complete cessation of all throwing activ- 44]. The concern about valgus instability resulting from
ities for a minimum of 4–6weeks and initiation of PT, with a higher rates of nonunion or malunion observed in patients
focus on core, hip, and lower body strengthening and mobility treated non-operatively has led to a trend toward operative
[2, 15, 19]. Limited data is available on outcomes and prog- fixation of avulsion fractures in competitive upper-extremity
nosis following conservative treatment. Once full, pain-free athletes who rely on elbow stability for their sport, including
mobility and strength have been regained and medial elbow baseball and gymnastics [41, 42, 44, 48].
tenderness to palpation has resolved, supervised gradual re- Studies comparing operative to non-operative management
turn to throwing can be initiated. This involves progression demonstrate similar outcomes and ability to return to sport,
from light tosses to maximum effort pitching over 4–8 weeks although hardware removal is a frequently cited complication
[2, 15, 19]. On average, the total time to return to competitive in the operative group and reported time to return to sports
pitching is 8–12 weeks [2, 15, 19]. varies from 3 to 7 months [5, 43, 48–52]. In a recent study of
matched operative and non-operative moderately displaced
fractures in adolescent upper-extremity athletes, Axibal and
Medial Epicondyle Avulsion Fracture colleagues reported no significant difference in the proportion
of subjects who returned to the same sport (92.9% in each
Medial epicondyle avulsion fractures occur secondary to val- group), performance at pre-injury level of competition, range
gus stress at the elbow with increased risk as the athlete nears of motion limitations, complications, or median time to return
skeletal maturity and the apophysis begin to fuse [8, 10, 41]. It to play [50]. However, non-operative patients tended to return
typically affects baseball pitchers ages 9–14 years [8, 10, 41]. to play sooner than those in the operative group (3 vs. 5.5
They present acutely in an athlete with sudden pain and/or months, non-significant) [50].
popping sensation during a single throwing motion, resulting
in swelling, tenderness to palpation over the medial Osteochondritis Dissecans of The Capitellum
epicondyle, and reduced range of motion [41–43]. This injury
may be associated with valgus instability and ulnar nerve Osteochondritis dissecans (OCD) of the humeral capitellum
symptoms [41–43]. Presence of symptoms preceding the results from compressive forces at the immature chondral sur-
avulsion is variable, with recent reports suggesting that the face of the radiocapitellar joint in the setting of excessive
majority of athletes report pre-existing medial elbow pain pri- valgus stress or axial loading which puts the subchondral bone
or to their acute injury [5]. at risk for localized ischemia from a limited vascular supply,
Current Reviews in Musculoskeletal Medicine (2022) 15:465–473 469

and altered biomechanics [8, 41, 53–55]. It occurs primarily in Indications for operative management include failure of
children and adolescents aged 10–16 years who participate in conservative management, unstable lesions, pain during daily
overhead throwing and axial loading activities, including activities, presence of mechanical symptoms, and/or loose
baseball and gymnastics [41, 53–56]. Prevalence ranges from bodies [63, 67]. Various surgical options exist, including ret-
1 to 4% among youth baseball players, with an increased risk rograde drilling, internal fixation, loose body removal and
in males, athletes with a longer duration of competitive play, microfracture, osteochondral autograft, and osteochondral al-
and those who began to play at earlier ages[41–44]. lograft [53, 56]. The respective indications and differential
Patients typically present with insidious onset, progressively outcomes of these various surgical techniques have been de-
worsening lateral elbow pain during activity in the dominant scribed elsewhere [53, 56, 57, 63, 73, 74]. In a recent system-
arm, with stiffness, loss of mobility, inability to perform at the atic review of return to sport rates following surgical manage-
previous level of sport, and possible mechanical symptoms or ment of elbow OCD lesions, Cohen and colleagues reported a
swelling [8, 53, 55, 57]. They commonly have tenderness to pooled rate of return to any level of sport of 98% in a mean
palpation over the radiocapitellar joint or capitellum, and may duration of 6 months, a pooled rate of return to preinjury level
also have effusions or loss of extension, pronation, and/or su- of sports of 79%, and a post-operative improvement in all
pination [8, 11, 53, 55, 57]. Radiographs of the elbow in early functional outcome scores [74]. The most common complica-
stages may be normal, or demonstrate subtle changes including tion was revision surgery for loose body removal [74].
a faint subchondral lucency on the anterolateral aspect of the
capitellum [7, 58, 59]. Advanced lesions may display increased
lucency, sclerosis, and fragmentation of the capitellum, and Wrist and Hand
possible loose bodies [7]. In addition to anteroposterior, lateral,
and oblique views, anteroposterior views with the elbow in 45° Gymnast Wrist
of flexion should be obtained to aid in visualization, especially
in radiographs with less elbow flexion or full extension among Gymnast wrist is an overuse stress injury of the distal radius
gymnasts [7, 54, 58]. physis. It is most often seen in gymnasts as they bear a signif-
Ultrasonography may be a better initial screening tool, es- icant amount of their weight on their wrists at a young age
pecially for early stage lesions, and has been used extensively leaving them subject to large compressive loads over time and
in the evaluation and early detection of capitellar OCD le- susceptible to injury [75]. This area is at risk for increased
sions, with reported positive predictive values ranging from susceptibility due to the proportionally greater axial loads on
67 to 100% [32, 39, 53, 60–66]. Several classification systems the distal radius (80%) compared to the ulna (20%) during
have been proposed to classify the stability of OCD lesions, weight bearing on the extended wrist [76–78]. In addition,
although there is limited interobserver reliability among these blood flow compromise to the metaphysis and epiphysis
criteria [53, 67, 68]. MRI is helpful when initial radiographs may also be at play here [76, 79].
are negative, and may reveal bone marrow edema, irregulari- Athletes usually present with chronic, dull, dorsal, or radial
ties or fragmentation of the articular cartilage, and possible sided wrist pain without a history of injury. Their pain is
intra-articular bodies in advanced cases [7, 53]. usually exacerbated by activities that load the wrist such as
Radiographs, MRI, CT, and ultrasonography all have a role floor, vaulting and pommel horse. Pain at rest may be seen in
in identifying lesions and assessing lesion instability, which is advanced disease [76]. There may also be associated reports
characterized by any signs of sclerosis or fragmentation and of wrist swelling. On palpation, the pain is usually localized to
helps determine the initial management [53, 63, 66]. the distal radius physis. Pain may be worsened with hyperex-
Stable lesions should be managed non-operatively with rest tension and axial loading of the wrist such as in the plank or L
for 6 weeks, PT, cessation of overhead activities, and reassess- position on the exam table [77].
ment after 3–6 months of conservative therapy [10, 26, 39, 48]. Diagnosis is made with radiographs which typically show
At this time, if the patient has clinical improvement and radio- physeal widening, metaphyseal irregularity such as beaking,
graphic healing, return to sport can be initiated [10, 26, 39, 48]. and sclerosis [75]. MRI imaging is usually not needed for
Good prognostic factors for non-operative treatment include diagnosis but if obtained, T2 images show increased signal
early stage lesions, younger patients with open capitellar intensity of the physis [7]. The literature suggests that radio-
physes, smaller lesions, absence of cyst-like lesions, graphic abnormalities consistent with gymnast wrist can be
radiocapitellar congruity, and compliance to conservative treat- found in 10–85% of gymnasts with and without symptoms
ment [44, 54–57]. Healing rates of 50–90% with non-operative [78]. Treatment usually consists of cessation of weight bear-
management for early stage lesions have been reported in the ing activity for 6–8 weeks. Complete immobilization in a
literature [69–72]. In two recent studies, mean non-operative brace or cast may be helpful for compliance.
treatment duration and mean duration before returning to play Without treatment, athletes are at risk for progression to
were 8.3 and 6.4 months, respectively [69, 70]. premature closure of the physis and a resultant discrepancy
470 Current Reviews in Musculoskeletal Medicine (2022) 15:465–473

between the length of the radius and ulna [75, 80]. Clinically, Conclusion
this can be seen as deviation of the hand toward the radial side.
The underlying ulnar positive variance that results in this case Rising youth sport participation and early sport specialization
increases the risk for development of other wrist pathologies. in popular sports like baseball, basketball, and gymnastics
Surgical intervention is reserved for symptomatic, partial clo- demand continued knowledge on the diagnosis, management,
sure of the radial physis or if there is progression to clinically and outcomes of common upper extremity injuries seen in
unacceptable malalignment [76]. A recent retrospective ana- pediatric athletes. Furthermore, care of the pediatric athlete
lysis of immature gymnasts diagnosed with gymnast wrist should involve not only special consideration of their skeletal
found a 10% rate of growth disturbance and a 12% rate of immaturity but also of their specific sport. An understanding
reoccurrence [81••]. of sport-specific risks is essential for diagnosis and injury
prevention for these young athletes. Ultrasonography is
Scaphoid Fractures emerging as a useful tool for initial evaluation of upper ex-
tremity injuries such as scaphoid fractures, medial epicondyle
Scaphoid fractures are the most commonly encountered carpal avulsion fracture, and capitellar OCDs. More research is need-
fractures, representing about 70% of all carpal fractures [75, ed to solidify its role in the diagnosis of pediatric upper ex-
76, 82]. They typically occur from a fall onto an outstretched tremity injuries.
hand, and are commonly seen in participants of contact sports
such as football, rugby, or high velocity sports like
skateboarding or rollerblading. In the pediatric population, Funding No funding was received.
these fractures have traditionally occurred most frequently at
the distal pole of the scaphoid but in recent times they have Declarations
been occurring with increased frequency at the waist of the
Conflict of Interest Celina de Borja, Rhonda Watkins, and Faustine
scaphoid as seen in the adult population [7, 83]. This is
Ramirez declare that they have no conflict of interest.
thought to be related to increased body mass index and in-
creased participation in high impact and extreme sports at a
young age. Athletes usually present after trauma with acute Human and Animal Rights and Informed Consent This article does not
wrist pain. On exam, they have tenderness to palpation of the contain any studies with human or animal subjects performed by any of
the authors.
anatomic snuffbox, scaphoid tubercle volarly, and pain with
radial deviation, or pain with active wrist ROM [84]. Open Access This article is licensed under a Creative Commons
Initial diagnostic imaging of choice is plain radiographs in- Attribution 4.0 International License, which permits use, sharing, adap-
cluding scaphoid views which may or may not show a fracture tation, distribution and reproduction in any medium or format, as long as
you give appropriate credit to the original author(s) and the source, pro-
line. In cases with high clinical suspicion and normal plain ra- vide a link to the Creative Commons licence, and indicate if changes were
diographs, advanced imaging with CT or MRI is warranted to made. The images or other third party material in this article are included
rule out scaphoid fracture. Alternatively, repeat plain radiographs in the article's Creative Commons licence, unless indicated otherwise in a
in 10–14 days may show sclerosis or early healing changes. credit line to the material. If material is not included in the article's
Creative Commons licence and your intended use is not permitted by
Ultrasound imaging may be useful for sideline or point of care statutory regulation or exceeds the permitted use, you will need to obtain
evaluation but has thus far shown variable sensitivity for detect- permission directly from the copyright holder. To view a copy of this
ing scaphoid fractures with one study reporting sensitivity of licence, visit http://creativecommons.org/licenses/by/4.0/.
50% [85] and another 77.8–100% [86]. This variability may be
in part due to operator experience. Ultrasonography does seem to
at least be reliably useful early in the disease process with a
recent study showing ultrasound to be superior to radiographs References
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