Reconstruction of scaphoid non-union and total scaphoid avascular necrosis in a pediatric patient: a case report

Use of a Free Vascularized Medial Femoral Condyle Flap for Revision Surgery in a Pediatric Patient with Congenital Pseudarthrosis of the Clavicle

The most common surgical treatment for congenital pseudarthrosis of the clavicle (CPC) is resection of the pseudarthrosis, placement of an autologous bone graft, and Kirschner wire or plate fixation. However, in some cases, bone fusion cannot be achieved at the first surgery, and an additional surgery is required. We present a case report of a boy with a right CPC who failed radiographic bone union after the first surgery. He subsequently underwent revision surgery with resection of the pseudarthrosis, plate fixation, and establishment of a vascularized medial femoral condyle (MFC) flap to ensure bone union. Three months after the revision surgery, a radiographic bone union was achieved, and no symptoms were observed for one year after the operation. There have been no previous reports of the use of a vascularized MFC flap as a treatment for CPC. We believe that this technique effectively ensures bone union during revision surgery for CPC.

Pediatric Scaphoid Nonunions: A Case Series, Review of the Literature, and Evidence-Based Guidelines

Background  Scaphoid fractures represent less than 3% of hand and wrist fractures in the pediatric population. Nonunions are very rare. We present a case series ( n  = 18) of nonunions in skeletally immature children and adolescents. We further present a review of the literature on pediatric scaphoid nonunions. Materials and Methods  We reviewed the literature by searching the main databases on pediatric scaphoid nonunions, but to identify factors that lead to nonunion, we also searched for databases on scaphoid fractures. Seventy articles were found for the period between 1961 and 2019, all with level 4/5 evidence. Results  The nonunion rate of pediatric scaphoid fractures in the literature is on average 1.5%, occurring mostly as a result of missed or underdiagnosed injuries, similar to our presented case series. Half ( n  = 9) of the injuries in our case series were missed initial injuries, leading to scaphoid nonunions and half developed nonunions after initial treatment. We found excellent outcomes and with surgical and nonoperative management, with few complications. Not surprisingly, the duration of immobilization is longer with nonoperative management. Conclusions  Based on the literature, we recommend a period of nonoperative management before surgery in undisplaced nonunions. In displaced nonunions, open reduction and internal fixation ± bone grafting is necessary. In pediatric scaphoid fractures, similar to adult cases, we identified that suspicious scaphoid fractures should be considered for initial immobilization, and repeat X-rays and early magnetic resonance imaging (MRI) or computed tomography (CT) scans should be considered at follow-up. Immobilization time and type of plaster should be appropriate in relation to the fracture site, similar to the adult scaphoid fracture. Level of Evidence  This is a Level IV study.