A Multi-Institutional Radiographic Evaluation of Pediatric Scapholunate Distance

A Multi-Institutional Radiographic Evaluation of Pediatric Scapholunate Distance | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A Multi-Institutional Radiographic Evaluation of Pediatric Scapholunate Distance M. Mirza Mujadzic, Peter K. Firouzbakht, Tarik Mujadzic, Riley A. Schlubb, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4903357/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Scapholunate (SL) dissociation is the most frequent form of carpal instability. X-ray is the first diagnostic tool for an SL injury. The adult scapholunate distance is well established, however there remains a paucity of literature on the pediatric scapholunate distance. The purpose of this study is to define a standard range of pediatric SL distances. Objective We hypothesize that there will be an inverse relationship of SL distance with age. Materials and Methods A retrospective review was conducted evaluating patients that underwent bone age hand X-rays between 2005 and 2020. Variables collected included chronologic age, bone age, gender, and scapholunate distance. Results 4038 total X-rays were included for analysis. Scapholunate distance was inversely proportional to chronological age between the ages of 4 to 17 years. The scapholunate distances were shorter for females compared to males of the same age. The average SL distance for males started at 9.49 mm at 4 years of age and decreased to 1.93 mm by age 17. The average SL distance for females started at 7.82 mm and decreased to 1.72 mm for the same age range. SL distance decreased to the normal adult distance at ages 16 and 17 for females and males, respectively. Conclusion Pediatric scapholunate distance is inversely proportional to chronological age. Female patients have a significantly shorter distance at each age compared to males. This study may serve as a reference for pediatric scapholunate distances when evaluating a wrist X-ray for potential scapholunate ligament injuries. Figures Figure 1 Figure 2 Introduction The scapholunate ligament is one of the intrinsic ligaments of the wrist that connects the proximal pole of the scaphoid and lunate and is considered by many to be the most important stabilizer of the entire hand [ 1 , 2 ]. Scapholunate (SL) dissociation is the most frequent form of carpal instability, with common etiology being a fall on an outstretched hand [ 3 ]. X-ray is the first diagnostic tool used to evaluate for an SL injury [ 4 ]. The normal adult scapholunate distance of less than 2 mm as measured on a standard hand X-ray is well established [ 5 ]. A distance greater than 3 mm is suggestive of underlying scapholunate dissociation and usually complete ligament tear, which requires ligamentous repair or reconstruction to avoid further progression to osteoarthritis and a scapholunate advanced collapse (SLAC) wrist [ 4 , 6 ]. No studies have proven a significant difference in SL distance when stratified by gender to date. While the adult SL distance is well established, there remains a paucity of literature on the normal pediatric SL distance ranges. Wrist fractures are frequently reported as some of the most common fractures in children and the prevalence of wrist pain is increasing [ 7 , 8 ]. Despite this, pediatric SL ligament injuries are underdiagnosed [ 9 ]. The process of pediatric wrist ossification complicates radiographic evaluation and diagnosis of potential scapholunate injuries, which overall leads to delayed diagnosis, treatment, and ultimately worse outcomes [ 7 ]. The wide range of age of skeletal maturity leads to a varied ossification pattern in children over time. This, in combination with poorly established pediatric scapholunate distance guidelines, adds to the difficulty of pediatric scapholunate injury diagnosis. Therefore, the importance of understanding normal pediatric SL anatomy cannot be understated. Previous studies have noted an inverse relationship of SL distance with age [ 8 – 10 ]. However, to our knowledge, this is the largest study to date analyzing more than four thousand pediatric wrists with previous studies having much smaller cohorts numbering in hundreds [ 9 ]. The purpose of this study is to define a standardized range of pediatric SL distances for each age (ages 4 to 17 years old) through a large, multi-institutional radiographic study. We hypothesize that the SL distance will be inversely proportional to age. We hope that by establishing a reference range of SL distances in pediatric patients, this study will be able to provide objective ranges that can enhance screening ability and improve diagnostic detection of pediatric wrist pathology. Methods Institutional Review Board approvals were obtained prior to performing this study. A retrospective review was conducted evaluating patients that underwent bone age hand X -rays at ) and between the years 20 05 and 2020. Inter- and intra- rater reliabilit y, along with a kappa calculation, were obtained through assistance of the Department of Statistics prior to data collection to ensure interobserver reliability. A total of 4452 atraumatic bone age pediatric hand X -rays (PA view) were evaluated. Inclusion criteria included pediatric patients with sufficient carpal bone ossification and adequate X -ray quality. Exclusion criteria eliminated X-ray studies with no scaphoid and/or lunate ossification, poor image quality, improper PA view, bone ages > 2 standard deviations from Greulich and Pyle standards as read by radiologists. A total of 4038 (2171 female, 1869 male) X -rays were included for measurement and analysis after applying exclusion criteria. Variables collected included chronologic age, bone age, gender, and scapholunate distance (distance between the mid-cortices of scaphoid and lunate) (Fig. 1 ). The average scapholunate distances were calculated for each age and stratified by gender. The ages included were chronological ages 4 through 17. To ensure no effect of bone age variability, a ratio between chronological and bone age was generated as a covariate in a model evaluating the effect of chronological age and sex on scapholunate distance. Multiple linear regression analysis and ANOVA were performed to evaluate the effect of patients’ chronological age and gender on scapholunate distance. Results No significant intraobserver or interobserver error (κ) was noted among the X-ray reviewers. The average scapholunate distances calculated based on chronological ages for all patients (male and female) were 7.96 mm for 4 year olds, decreasing in distance to 1.86 mm at 17 year olds. The average scapholunate distances for males alone were 9.49 mm at 4 years of age, decreasing to 1.93 mm at 17 years of age. For females the SL distance began with 7.82 mm at 4 years and decreased to 1.72 mm at 17 years of age. When comparing males and females, females had shorter scapholunate distances at each respective age (Table 1 , Fig. 2 ). Table 1 Table 1 Mean scapholunate distance in millimeters (mm) for chronological and bone ages 4 through 17. Distance sorted by gender and then combined. YEARS SLD (mm) CA MALE FEMALE ALL 4 9.493 7.823 7.959 5 9.191 6.265 6.830 6 7.688 4.996 5.532 7 7.002 4.290 4.931 8 6.878 3.586 4.668 9 5.889 3.106 4.279 10 5.132 2.877 4.117 11 4.456 2.503 3.593 12 3.415 2.370 2.970 13 2.823 2.168 2.550 14 2.353 2.099 2.277 15 2.123 2.073 2.113 16 2.041 1.905 2.007 17 1.928 1.718 1.860 When considering all patients and their age, a scapholunate distance of less than or equal to 5mm was reached by age 7, less than or equal to 4 mm by approximately age 10.5, less than or equal to 3 mm by age 12, and adult scapholunate distance of approximately 2 mm by age 16. Looking at male and female patients separately, females reached these milestones drastically earlier; less than or equal to 5 mm by age 6 (approximately 10.5 for males), less than or equal to 4 mm by age 7.5 (11.5 in males), less than or equal to 3 mm by age 10 (13 in males), with the adult distance of less than or equal to 2 mm reached by females at age 16 and males at age 17 (Table 1 , Fig. 2 ). Using an ANOVA test, scapholunate distance was found to be significantly affected by chronological age and by sex. Specifically, chronological age had a significant relationship with SL distance (p < 0.0001), as did sex (p < 0.0001), but there was also a significant interaction between age and sex in relation to scapholunate distance. Performing multiple linear regression with the ratio of chronological and bone age as a covariate, we found that all effects remained significant in terms of age and sex affecting scapholunate distance (p < 0.0001). Discussion This study represents the largest sample size analysis of pediatric scapholunate distance by bone and chronologic age. The results provide an age and gender specific reference for expected normal scapholunate distance in children and adolescents, which may be useful in the radiographic assessment of traumatic injuries and wrist pain. The scapholunate distance was found to be inversely proportional to age, however female patients reached the scapholunate distance milestones at an earlier age for all milestones. The age difference for reaching these milestones decreased with increasing age, approximately equalizing as males and females approached adulthood. Although earlier skeletal maturation of female children has been shown in multiple previous studies, scapholunate distance has not been previously studied as a related variable of age in large scale studies [ 8 , 9 ]. One of the primary goals of this study was to increase the potential utility of X-ray imaging in assisting in the diagnosis of pediatric scapholunate injuries. MRI imaging and MR arthrography are the two other imaging techniques commonly employed by hand surgeons to establish a diagnosis of a scapholunate injury, especially when a partial tear is suspected or if the clinical picture is not clear. Although MRI/MRA is considered the gold standard in diagnosing wrist ligament pathology due to their high sensitivity and specificity, they also unfortunately are more difficult to obtain than a simple radiograph in most medical centers in the USA. Whereas an X-ray takes minutes to obtain in the ER or office setting, MRIs require insurance preauthorization and a specialized imaging center, often leading to weeks of diagnostic delay for the patient. Secondly, MRI and MR arthrography take hours to actually image while the patient is in the MR machine which often requires giving sedation to the developing pediatric population in order to eliminate motion artifact and obtain useful images. Lastly, MRI studies are on average ten times more costly than a wrist X-ray with one study quoting an average cost of $ 3,213 for MRI compared to $ 360 for the average cost for a wrist X-ray in USA [ 11 , 12 ]. While an X-ray may not be enough for a definitive diagnosis or to rule out a partial scapholunate injury in all cases, it remains an excellent initial method of screening for complete scapholunate tears requiring repair. While our study does not intend to prove that X-ray is a better diagnostic tool than MRI for known pathologic wrists, we believe that by establishing normative values it can be a more useful screening and, at times, diagnostic tool. Although this study consisted of a large sample size, it does contain certain limitations. The use of bone age XR studies has the potential to cause confounding effects as these studies are done for evaluating pediatric skeletal maturation which can be delayed, within normal limits or precocious. Although we excluded patients whose bone age significantly differed from their chronological age, some variability in bone age and chronological age remained. To ensure the validity of our data and trends, we performed statistical analysis with both chronological and bone age as covariates in multiple linear regression analysis, and found statistical significance in their relation to scapholunate distance and gender. An additional limitation of the study is an inability to account for possible racial differences in skeletal development due to unavailable data. There are known racial differences in bone density, with African-American patients having statistically greater density than Caucasian patients [ 13 , 14 ]. A previous study conducted in 2008 aimed to evaluate the racial differences on skeletal development using the Greulich and Pyle Atlas method and found that bone age was significantly overestimated in Asian and Hispanic children, regardless of gender [ 15 ]. While this does suggest a limitation to the external validity of the data, it also highlights a weakness of the Atlas method to measure bone age. Further study and stratification of bone age by race would be beneficial to provide a more accurate atlas for reference. Scapholunate ligament injury in the pediatric population is an infrequently diagnosed injury with limited data in the literature. This poses a challenge to further study of this subject. The authors feel that future research on this topic would be beneficial to examine known pathologic wrists and compare to non-pathologic wrists, with the goal of further refining diagnostic criteria for pediatric SL ligament injuries stratified by age. Furthermore, the prevalence of young adult SLAC wrist, potentially due to undiagnosed pediatric SL injury, could further be elucidated in future studies. The authors believe that this study can serve as a reference for standard pediatric scapholunate distances when evaluating a wrist X-ray for potential scapholunate ligament injuries. This reference may aid in the diagnosis of pediatric scapholunate injuries through X-ray alone when possible, helping to decrease the cost and burden of diagnosis and reduce treatment delay with associated long term sequelae of SL injuries. Conclusion Pediatric scapholunate distance is inversely proportional to chronological age. Female patients have a significantly shorter distance at each age compared to males. This study may serve as a reference for pediatric scapholunate distances when evaluating a wrist X-ray for potential scapholunate ligament injuries. Declarations Data Availability Statement The data that support the findings of this study are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request. References Haug LCP, Adler T, Bignion D, Voegelin E. Radio-luno-triquetral bone-ligament transfer as an additional stabilizer in scapholunate-instability. Arch Orthop Trauma Surg . 2021;141(2):341-347. doi:10.1007/s00402-020-03690-2 Totterman SM, Miller RJ. Scapholunate ligament: normal MR appearance on three-dimensional gradient-recalled-echo images. Radiology . 1996;200(1):237-241. doi:10.1148/radiology.200.1.8657918 Scott W. Wolfe, William C. Pederson, Scott H. Kozin, Mark S. Cohen. Green’s Operative Hand Surgery, 8th Edition . Vol 1. 8th edition. Elsevier Rachunek K, Springer F, Barczak M, Kolbenschlag J, Daigeler A, Medved F. An algorithmic diagnostic approach to scapholunate ligament injuries based on comparison of X-ray examinations and arthroscopy in 414 patients. J Plast Reconstr Aesthet Surg . 2022;75(9):3293-3303. doi:10.1016/j.bjps.2022.04.083 Özkan S, Kheterpal A, Palmer WE, Chen NC. Dorsal Extrinsic Ligament Injury and Static Scapholunate Diastasis on Magnetic Resonance Imaging Scans. J Hand Surg . 2019;44(8):641-648. doi:10.1016/j.jhsa.2019.03.003 Kuo CE, Wolfe SW. Scapholunate Instability: Current Concepts in Diagnosis and Management. J Hand Surg . 2008;33(6):998-1013. doi:10.1016/j.jhsa.2008.04.027 van Kampen RJ, Fox PM, Baltzer HL, Moran SL. Long-term Outcomes following Operative Management of Pediatric Scapholunate Ligament Injuries. J Wrist Surg . 2023;12(1):56-62. doi:10.1055/s-0042-1757779 Kaawach W, Ecklund K, Di Canzio J, Zurakowski D, Waters PM. Normal ranges of scapholunate distance in children 6 to 14 years old. J Pediatr Orthop . 2001;21(4):464-467. Shaver TB, Hogarth DA, Case AL, May CC, Abzug JM. Radiographic Scapholunate Interval in the Pediatric Population Decreases in Size as Age Increases. Hand N Y N . Published online February 13, 2023:15589447231153166. doi:10.1177/15589447231153166 Yerli M, Bayraktar TO, Yüce A, Erkurt N, Saygili MS, Ocak O. Normal values of scapholunate distance in Turkish children aged 5–14 years. J Pediatr Orthop B . Published online August 7, 2023. doi:10.1097/BPB.0000000000001112 Greenfield PT, Spencer CC, Dawes A, Wagner ER, Gottschalk MB, Daly CA. The Preoperative Cost of Carpal Tunnel Syndrome. J Hand Surg . 2022;47(8):752-761.e1. doi:10.1016/j.jhsa.2021.07.027 Shoulder, Elbow, or Wrist MRI Costs | NH Health Cost. Accessed October 21, 2023. https://nhhealthcost.nh.gov/costs/medical/result/shoulder-elbow-or-wrist-mri Seeman E, D. M. Growth in Bone Mass and Size—Are Racial and Gender Differences in Bone Mineral Density More Apparent than Real? J Clin Endocrinol Metab . 1998;83(5):1414-1419. doi:10.1210/jcem.83.5.4844 Ettinger B, Sidney S, Cummings SR, et al. Racial Differences in Bone Density between Young Adult Black and White Subjects Persist after Adjustment for Anthropometric, Lifestyle, and Biochemical Differences*†. J Clin Endocrinol Metab . 1997;82(2):429-434. doi:10.1210/jcem.82.2.3732 Zhang A, Sayre J, Vachon L, Liu B, Huang H. Racial Differences in Growth Patterns of Children Assessed on the Basis of Bone Age. Radiology . 2008;250:228-235. doi:10.1148/radiol.2493080468 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4903357","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":347740087,"identity":"d2b98243-d91d-4471-86da-4eeae6e48fd7","order_by":0,"name":"M. 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Plikaitis","email":"","orcid":"","institution":"Division of Plastic and Reconstructive Surgery, Department of Surgery, Saint Louis University School of Medicine. 1008 South Spring Avenue, St. Louis, MO 63110","correspondingAuthor":false,"prefix":"","firstName":"Christina","middleName":"M.","lastName":"Plikaitis","suffix":""},{"id":347740098,"identity":"50ba3a80-2886-492f-9b56-61d98c18cc70","order_by":11,"name":"Mirsad Mujadzic","email":"","orcid":"","institution":"Prisma/USC Division of Plastic and Reconstructive Surgery, University of South Carolina School of Medicine, Two Medical Park Road, Suite 302, Columbia, SC 29203","correspondingAuthor":false,"prefix":"","firstName":"Mirsad","middleName":"","lastName":"Mujadzic","suffix":""}],"badges":[],"createdAt":"2024-08-13 01:50:58","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4903357/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4903357/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":66377766,"identity":"86d9c5a3-d047-4a59-8fe7-4ead8dcf8c67","added_by":"auto","created_at":"2024-10-11 06:24:00","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":203437,"visible":true,"origin":"","legend":"\u003cp\u003eExamples of scapholunate (SL) distance measurements from left to right: an 8 year old female, a 9 year old male, and a 13 year old male.\u003c/p\u003e","description":"","filename":"PedsSLFigure1.tiff.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4903357/v1/5d9da8269fef637f2aaa59fe.jpg"},{"id":66377765,"identity":"4a3a4a83-ae09-484c-b178-ce2b4b8e7a60","added_by":"auto","created_at":"2024-10-11 06:24:00","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":196821,"visible":true,"origin":"","legend":"\u003cp\u003eGraphical representation of Table 1. The figure displays the average scapholunate distance (mm) for each age group from 4 to 17 years old. Age listed in chronologic age. The figure shows females (pink line), males (blue line), and all patients combined (orange line).\u003c/p\u003e","description":"","filename":"PedsSLFigure2.tiff.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4903357/v1/ff03d2880f483224d5c15940.jpg"},{"id":66378864,"identity":"b4406ff9-64c4-4ab4-914e-7f754c4d362c","added_by":"auto","created_at":"2024-10-11 06:40:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":712768,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4903357/v1/13865f71-dbbf-4730-bf85-10ad2fe754e8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Multi-Institutional Radiographic Evaluation of Pediatric Scapholunate Distance","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe scapholunate ligament is one of the intrinsic ligaments of the wrist that connects the proximal pole of the scaphoid and lunate and is considered by many to be the most important stabilizer of the entire hand [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Scapholunate (SL) dissociation is the most frequent form of carpal instability, with common etiology being a fall on an outstretched hand [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eX-ray is the first diagnostic tool used to evaluate for an SL injury [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The normal adult scapholunate distance of less than 2 mm as measured on a standard hand X-ray is well established [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. A distance greater than 3 mm is suggestive of underlying scapholunate dissociation and usually complete ligament tear, which requires ligamentous repair or reconstruction to avoid further progression to osteoarthritis and a scapholunate advanced collapse (SLAC) wrist [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. No studies have proven a significant difference in SL distance when stratified by gender to date.\u003c/p\u003e \u003cp\u003eWhile the adult SL distance is well established, there remains a paucity of literature on the normal pediatric SL distance ranges. Wrist fractures are frequently reported as some of the most common fractures in children and the prevalence of wrist pain is increasing [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Despite this, pediatric SL ligament injuries are underdiagnosed [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The process of pediatric wrist ossification complicates radiographic evaluation and diagnosis of potential scapholunate injuries, which overall leads to delayed diagnosis, treatment, and ultimately worse outcomes [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The wide range of age of skeletal maturity leads to a varied ossification pattern in children over time. This, in combination with poorly established pediatric scapholunate distance guidelines, adds to the difficulty of pediatric scapholunate injury diagnosis. Therefore, the importance of understanding normal pediatric SL anatomy cannot be understated.\u003c/p\u003e \u003cp\u003ePrevious studies have noted an inverse relationship of SL distance with age [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, to our knowledge, this is the largest study to date analyzing more than four thousand pediatric wrists with previous studies having much smaller cohorts numbering in hundreds [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe purpose of this study is to define a standardized range of pediatric SL distances for each age (ages 4 to 17 years old) through a large, multi-institutional radiographic study. We hypothesize that the SL distance will be inversely proportional to age. We hope that by establishing a reference range of SL distances in pediatric patients, this study will be able to provide objective ranges that can enhance screening ability and improve diagnostic detection of pediatric wrist pathology.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eInstitutional Review Board\u003c/span\u003e approvals were \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eobtained prior to performing this study. A retrospective review was conducted evaluating patients that underwent bone age hand\u003c/span\u003e X\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e-rays at\u003c/span\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e)\u003c/span\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eand between the years 20\u003c/span\u003e05 \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eand 2020.\u003c/span\u003e Inter- and intra-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003erater reliabilit\u003c/span\u003ey, along with a kappa calculation, were \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eobtained through assistance of the\u003c/span\u003e Department of Statistics \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eprior to data collection\u003c/span\u003e to ensure interobserver reliability. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eA total of\u003c/span\u003e 4452 atraumatic bone age pediatric hand X\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e-rays (PA view) were evaluated. Inclusion criteria included pediatric patients with sufficient carpal bone ossification and adequate\u003c/span\u003e X\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e-ray quality. Exclusion criteria\u003c/span\u003e eliminated X-ray studies with no scaphoid and/or lunate ossification, poor image quality, improper PA view, bone ages\u0026thinsp;\u0026gt;\u0026thinsp;2 standard deviations from Greulich and Pyle standards as read by radiologists. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eA total of 4038 (2171 female, 1869 male)\u003c/span\u003e X\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e-rays were included for measurement and analysis after applying exclusion criteria. Variables collected included chronologic age, bone age, gender, and scapholunate distance\u003c/span\u003e (distance between the mid-cortices of scaphoid and lunate) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe average scapholunate distances were calculated for each age and stratified by gender. The ages included were chronological ages 4 through 17. To ensure no effect of bone age variability, a ratio between chronological and bone age was generated as a covariate in a model evaluating the effect of chronological age and sex on scapholunate distance. Multiple linear regression analysis and ANOVA were performed to evaluate the effect of patients\u0026rsquo; chronological age and gender on scapholunate distance.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eNo significant intraobserver or interobserver error (κ) was noted among the X-ray reviewers. The average scapholunate distances calculated based on chronological ages for all patients (male and female) were 7.96 mm for 4 year olds, decreasing in distance to 1.86 mm at 17 year olds. The average scapholunate distances for males alone were 9.49 mm at 4 years of age, decreasing to 1.93 mm at 17 years of age. For females the SL distance began with 7.82 mm at 4 years and decreased to 1.72 mm at 17 years of age. When comparing males and females, females had shorter scapholunate distances at each respective age (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMean scapholunate distance in millimeters (mm) for chronological and bone ages 4 through 17. Distance sorted by gender and then combined.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"15\" rowspan=\"16\"\u003e \u003cp\u003eYEARS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eSLD (mm)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMALE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFEMALE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eALL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.493\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.823\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.959\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.191\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.265\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.830\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.688\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.996\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.532\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.290\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.931\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.878\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.586\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.668\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.889\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.106\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.279\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.132\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.877\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.117\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.456\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.503\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.593\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.415\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.370\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.970\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.823\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.168\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.550\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.353\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.099\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.277\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.123\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.073\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.113\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.041\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.905\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.007\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.928\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.718\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.860\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWhen considering all patients and their age, a scapholunate distance of less than or equal to 5mm was reached by age 7, less than or equal to 4 mm by approximately age 10.5, less than or equal to 3 mm by age 12, and adult scapholunate distance of approximately 2 mm by age 16. Looking at male and female patients separately, females reached these milestones drastically earlier; less than or equal to 5 mm by age 6 (approximately 10.5 for males), less than or equal to 4 mm by age 7.5 (11.5 in males), less than or equal to 3 mm by age 10 (13 in males), with the adult distance of less than or equal to 2 mm reached by females at age 16 and males at age 17 (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eUsing an ANOVA test, scapholunate distance was found to be significantly affected by chronological age and by sex. Specifically, chronological age had a significant relationship with SL distance (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), as did sex (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), but there was also a significant interaction between age and sex in relation to scapholunate distance. Performing multiple linear regression with the ratio of chronological and bone age as a covariate, we found that all effects remained significant in terms of age and sex affecting scapholunate distance (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study represents the largest sample size analysis of pediatric scapholunate distance by bone and chronologic age. The results provide an age and gender specific reference for expected normal scapholunate distance in children and adolescents, which may be useful in the radiographic assessment of traumatic injuries and wrist pain. The scapholunate distance was found to be inversely proportional to age, however female patients reached the scapholunate distance milestones at an earlier age for all milestones. The age difference for reaching these milestones decreased with increasing age, approximately equalizing as males and females approached adulthood. Although earlier skeletal maturation of female children has been shown in multiple previous studies, scapholunate distance has not been previously studied as a related variable of age in large scale studies [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOne of the primary goals of this study was to increase the potential utility of X-ray imaging in assisting in the diagnosis of pediatric scapholunate injuries. MRI imaging and MR arthrography are the two other imaging techniques commonly employed by hand surgeons to establish a diagnosis of a scapholunate injury, especially when a partial tear is suspected or if the clinical picture is not clear. Although MRI/MRA is considered the gold standard in diagnosing wrist ligament pathology due to their high sensitivity and specificity, they also unfortunately are more difficult to obtain than a simple radiograph in most medical centers in the USA. Whereas an X-ray takes minutes to obtain in the ER or office setting, MRIs require insurance preauthorization and a specialized imaging center, often leading to weeks of diagnostic delay for the patient. Secondly, MRI and MR arthrography take hours to actually image while the patient is in the MR machine which often requires giving sedation to the developing pediatric population in order to eliminate motion artifact and obtain useful images. Lastly, MRI studies are on average ten times more costly than a wrist X-ray with one study quoting an average cost of \u003cspan\u003e$\u003c/span\u003e3,213 for MRI compared to \u003cspan\u003e$\u003c/span\u003e360 for the average cost for a wrist X-ray in USA [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. While an X-ray may not be enough for a definitive diagnosis or to rule out a partial scapholunate injury in all cases, it remains an excellent initial method of screening for complete scapholunate tears requiring repair. While our study does not intend to prove that X-ray is a better diagnostic tool than MRI for known pathologic wrists, we believe that by establishing normative values it can be a more useful screening and, at times, diagnostic tool.\u003c/p\u003e \u003cp\u003eAlthough this study consisted of a large sample size, it does contain certain limitations. The use of bone age XR studies has the potential to cause confounding effects as these studies are done for evaluating pediatric skeletal maturation which can be delayed, within normal limits or precocious. Although we excluded patients whose bone age significantly differed from their chronological age, some variability in bone age and chronological age remained. To ensure the validity of our data and trends, we performed statistical analysis with both chronological and bone age as covariates in multiple linear regression analysis, and found statistical significance in their relation to scapholunate distance and gender.\u003c/p\u003e \u003cp\u003eAn additional limitation of the study is an inability to account for possible racial differences in skeletal development due to unavailable data. There are known racial differences in bone density, with African-American patients having statistically greater density than Caucasian patients [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. A previous study conducted in 2008 aimed to evaluate the racial differences on skeletal development using the Greulich and Pyle Atlas method and found that bone age was significantly overestimated in Asian and Hispanic children, regardless of gender [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. While this does suggest a limitation to the external validity of the data, it also highlights a weakness of the Atlas method to measure bone age. Further study and stratification of bone age by race would be beneficial to provide a more accurate atlas for reference.\u003c/p\u003e \u003cp\u003eScapholunate ligament injury in the pediatric population is an infrequently diagnosed injury with limited data in the literature. This poses a challenge to further study of this subject. The authors feel that future research on this topic would be beneficial to examine known pathologic wrists and compare to non-pathologic wrists, with the goal of further refining diagnostic criteria for pediatric SL ligament injuries stratified by age. Furthermore, the prevalence of young adult SLAC wrist, potentially due to undiagnosed pediatric SL injury, could further be elucidated in future studies. The authors believe that this study can serve as a reference for standard pediatric scapholunate distances when evaluating a wrist X-ray for potential scapholunate ligament injuries. This reference may aid in the diagnosis of pediatric scapholunate injuries through X-ray alone when possible, helping to decrease the cost and burden of diagnosis and reduce treatment delay with associated long term sequelae of SL injuries.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePediatric scapholunate distance is inversely proportional to chronological age. Female patients have a significantly shorter distance at each age compared to males. This study may serve as a reference for pediatric scapholunate distances when evaluating a wrist X-ray for potential scapholunate ligament injuries.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHaug LCP, Adler T, Bignion D, Voegelin E. Radio-luno-triquetral bone-ligament transfer as an additional stabilizer in scapholunate-instability. \u003cem\u003eArch Orthop Trauma Surg\u003c/em\u003e. 2021;141(2):341-347. doi:10.1007/s00402-020-03690-2\u003c/li\u003e\n\u003cli\u003eTotterman SM, Miller RJ. Scapholunate ligament: normal MR appearance on three-dimensional gradient-recalled-echo images. \u003cem\u003eRadiology\u003c/em\u003e. 1996;200(1):237-241. doi:10.1148/radiology.200.1.8657918\u003c/li\u003e\n\u003cli\u003eScott W. Wolfe, William C. Pederson, Scott H. Kozin, Mark S. Cohen. \u003cem\u003eGreen\u0026rsquo;s Operative Hand Surgery, 8th Edition\u003c/em\u003e. Vol 1. 8th edition. Elsevier\u003c/li\u003e\n\u003cli\u003eRachunek K, Springer F, Barczak M, Kolbenschlag J, Daigeler A, Medved F. An algorithmic diagnostic approach to scapholunate ligament injuries based on comparison of X-ray examinations and arthroscopy in 414 patients. \u003cem\u003eJ Plast Reconstr Aesthet Surg\u003c/em\u003e. 2022;75(9):3293-3303. doi:10.1016/j.bjps.2022.04.083\u003c/li\u003e\n\u003cli\u003e\u0026Ouml;zkan S, Kheterpal A, Palmer WE, Chen NC. Dorsal Extrinsic Ligament Injury and Static Scapholunate Diastasis on Magnetic Resonance Imaging Scans. \u003cem\u003eJ Hand Surg\u003c/em\u003e. 2019;44(8):641-648. doi:10.1016/j.jhsa.2019.03.003\u003c/li\u003e\n\u003cli\u003eKuo CE, Wolfe SW. Scapholunate Instability: Current Concepts in Diagnosis and Management. \u003cem\u003eJ Hand Surg\u003c/em\u003e. 2008;33(6):998-1013. doi:10.1016/j.jhsa.2008.04.027\u003c/li\u003e\n\u003cli\u003evan Kampen RJ, Fox PM, Baltzer HL, Moran SL. Long-term Outcomes following Operative Management of Pediatric Scapholunate Ligament Injuries. \u003cem\u003eJ Wrist Surg\u003c/em\u003e. 2023;12(1):56-62. doi:10.1055/s-0042-1757779\u003c/li\u003e\n\u003cli\u003eKaawach W, Ecklund K, Di Canzio J, Zurakowski D, Waters PM. Normal ranges of scapholunate distance in children 6 to 14 years old. \u003cem\u003eJ Pediatr Orthop\u003c/em\u003e. 2001;21(4):464-467.\u003c/li\u003e\n\u003cli\u003eShaver TB, Hogarth DA, Case AL, May CC, Abzug JM. Radiographic Scapholunate Interval in the Pediatric Population Decreases in Size as Age Increases. \u003cem\u003eHand N Y N\u003c/em\u003e. Published online February 13, 2023:15589447231153166. doi:10.1177/15589447231153166\u003c/li\u003e\n\u003cli\u003eYerli M, Bayraktar TO, Y\u0026uuml;ce A, Erkurt N, Saygili MS, Ocak O. Normal values of scapholunate distance in Turkish children aged 5\u0026ndash;14 years. \u003cem\u003eJ Pediatr Orthop B\u003c/em\u003e. Published online August 7, 2023. doi:10.1097/BPB.0000000000001112\u003c/li\u003e\n\u003cli\u003eGreenfield PT, Spencer CC, Dawes A, Wagner ER, Gottschalk MB, Daly CA. The Preoperative Cost of Carpal Tunnel Syndrome. \u003cem\u003eJ Hand Surg\u003c/em\u003e. 2022;47(8):752-761.e1. doi:10.1016/j.jhsa.2021.07.027\u003c/li\u003e\n\u003cli\u003eShoulder, Elbow, or Wrist MRI Costs | NH Health Cost. Accessed October 21, 2023. https://nhhealthcost.nh.gov/costs/medical/result/shoulder-elbow-or-wrist-mri\u003c/li\u003e\n\u003cli\u003eSeeman E, D. M. Growth in Bone Mass and Size\u0026mdash;Are Racial and Gender Differences in Bone Mineral Density More Apparent than Real? \u003cem\u003eJ Clin Endocrinol Metab\u003c/em\u003e. 1998;83(5):1414-1419. doi:10.1210/jcem.83.5.4844\u003c/li\u003e\n\u003cli\u003eEttinger B, Sidney S, Cummings SR, et al. Racial Differences in Bone Density between Young Adult Black and White Subjects Persist after Adjustment for Anthropometric, Lifestyle, and Biochemical Differences*\u0026dagger;. \u003cem\u003eJ Clin Endocrinol Metab\u003c/em\u003e. 1997;82(2):429-434. doi:10.1210/jcem.82.2.3732\u003c/li\u003e\n\u003cli\u003eZhang A, Sayre J, Vachon L, Liu B, Huang H. Racial Differences in Growth Patterns of Children Assessed on the Basis of Bone Age. \u003cem\u003eRadiology\u003c/em\u003e. 2008;250:228-235. doi:10.1148/radiol.2493080468\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4903357/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4903357/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eScapholunate (SL) dissociation is the most frequent form of carpal instability. X-ray is the first diagnostic tool for an SL injury. The adult scapholunate distance is well established, however there remains a paucity of literature on the pediatric scapholunate distance. The purpose of this study is to define a standard range of pediatric SL distances.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe hypothesize that there will be an inverse relationship of SL distance with age.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials and Methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA retrospective review was conducted evaluating patients that underwent bone age hand X-rays between 2005 and 2020. Variables collected included chronologic age, bone age, gender, and scapholunate distance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e4038 total X-rays were included for analysis. Scapholunate distance was inversely proportional to chronological age between the ages of 4 to 17 years. The scapholunate distances were shorter for females compared to males of the same age. The average SL distance for males started at 9.49 mm at 4 years of age and decreased to 1.93 mm by age 17. The average SL distance for females started at 7.82 mm and decreased to 1.72 mm for the same age range. SL distance decreased to the normal adult distance at ages 16 and 17 for females and males, respectively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePediatric scapholunate distance is inversely proportional to chronological age. Female patients have a significantly shorter distance at each age compared to males. This study may serve as a reference for pediatric scapholunate distances when evaluating a wrist X-ray for potential scapholunate ligament injuries.\u003c/p\u003e","manuscriptTitle":"A Multi-Institutional Radiographic Evaluation of Pediatric Scapholunate Distance","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-11 06:23:56","doi":"10.21203/rs.3.rs-4903357/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"72fd8795-21f5-4cf7-8e7f-971cacccb5f5","owner":[],"postedDate":"October 11th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-10-11T06:23:58+00:00","versionOfRecord":[],"versionCreatedAt":"2024-10-11 06:23:56","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4903357","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4903357","identity":"rs-4903357","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}