The Association Between Socioeconomic Factors and the Clinical Course of Nonoperatively Treated Pediatric Scaphoid Fractures

Abstract

Background

There is a higher incidence of scaphoid fractures in children with lower socioeconomic status (SES), who may be more likely to underutilize health care resources. This study investigated the association between socioeconomic factors and the clinical course of nonoperatively treated pediatric scaphoid fractures. We hypothesized that lower SES would be associated with delayed and prolonged treatment.

Methods

This retrospective study included patients <21 years old who presented to a single institution with an acute scaphoid fracture between 2012 and 2024. Demographic and clinical information were obtained from the electronic health record. SES factors included insurance status, household composition, Child Opportunity Index (COI), Area Deprivation Index (ADI), and Social Vulnerability Index (SVI). Descriptive statistics, nonparametric tests, and regression analyses examined the relationship between SES and clinical course.

Results

The study included 736 patients (mean age, 13.6 ± 2.5 years; 69% male). The median time from injury to rigid immobilization was 4.0 days (interquartile range [IQR], 2.0-7.3), and that to orthopaedic specialist presentation was 5.0 days (IQR, 2.0-9.0). The median duration of immobilization was 38.0 days (IQR, 28.0-43.0), with longer immobilization observed in patients with lower SES per COI (national, P < .001; state, P < .001), ADI (national, P < .001; state, P = .002), and SVI (P < .001). Children in the lowest COI national quintile presented to an orthopaedic specialist 4.5 days later (P = .024) and underwent immobilization 7.4 days longer (P < .001) than other patients. Publicly insured patients were immobilized 7.4 days longer than children with private insurance (P < .001). Children living with both biological parents were immobilized 4.4 days fewer than those in other household configurations (P < .001). SES factors were not associated with scaphoid nonunion or progression to surgery.

Conclusions

In pediatric scaphoid fractures, lower SES is associated with delayed orthopaedic specialist presentation and prolonged rigid immobilization although not nonunion or progression to surgery. Treatment delays may be due to barriers that limit access to orthopaedic specialists or prevent timely follow-up. Further research is needed in this population to elucidate the relationship between SES and health care access and to understand the consequences of treatment delays.

Key Concepts

• (1)Lower socioeconomic status (SES) is associated with delayed orthopaedic specialist presentation and prolonged rigid immobilization in children with acute, nonoperatively treated scaphoid fractures.
• (2)Delays in care may be due to barriers that limit access to orthopaedic specialists after injury and prevent timely follow-up after initiation of rigid immobilization.
• (3)These disparities are concerning as delays in rigid immobilization and prolonged rigid immobilization may negatively impact clinical outcomes, school performance, sports participation, and social engagement.
• (4)SES was not associated with increased risk of nonunion or failed nonoperative treatment and progression to surgery.
• (5)Further research is needed to fully elucidate the relationship between SES and health care access in pediatric scaphoid fractures and to understand the consequences of delayed or prolonged treatment in this population.

Level of Evidence

III, Retrospective Cohort Study

Introduction

Although pediatric scaphoid fractures have a relatively low incidence at 1.47 per 100,000 person-years, they are the most common carpal bone fracture in children [1,2]. The typical mechanism of injury (MOI) is a fall onto an outstretched hand causing forced hyperextension of the wrist [3,4]. With proper immobilization, union rates of acute nondisplaced scaphoid fractures exceed 90% [5]. However, treatment delays are associated with increased rates of failed immobilization and nonunion [6,7]. The consequences of scaphoid fracture nonunion may be severe and include osteonecrosis of the proximal pole, scaphoid nonunion advanced collapse, and radiocarpal osteoarthritis [5]. Therefore, timely management of scaphoid fractures is essential for optimizing patient outcomes.

Patients at highest risk for acute scaphoid fractures are males aged 10-24 years [1]. Additionally, children from lower socioeconomic backgrounds sustain scaphoid fractures at nearly twice the rate of their more affluent peers [8]. Historically, patients with lower socioeconomic status (SES) have been shown to underutilize health care resources, particularly specialist services [9,10]. Within orthopaedics, Hispanic, Black, low-income, less-educated, and non–privately insured patients often have substantially lower odds of pursuing outpatient musculoskeletal care [11]. Furthermore, in pediatric orthopaedics, patients with lower SES experience longer wait times from injury to the initial orthopaedic evaluation, attend fewer follow-up appointments, and are less likely to return to sports after injury [12,13]. In the context of pediatric scaphoid fractures, patients with lower SES may face greater risk of complications from delayed presentation and prolonged treatment. However, the extent of this relationship has not been previously explored. Therefore, the primary aim of this study was to investigate the association between SES factors and the clinical course of nonoperatively treated pediatric scaphoid fractures. We hypothesized that lower SES would be associated with both delayed and prolonged treatment.

Materials and methods

Inclusion and exclusion criteria

This institutional review board–approved retrospective study included all patients <21 years old who presented to an outpatient orthopaedic clinic affiliated with a single, pediatric, level 1 trauma center with an acute scaphoid fracture between 2012 and 2024. Patients with scaphoid fractures were identified from the electronic health record (EHR) using International Classification of Diseases codes. Patients were excluded if they (1) underwent surgery without an initial trial of immobilization, (2) did not undergo rigid immobilization, or (3) were lost to follow-up at any point throughout the clinical course.

Patient characteristics

Patient demographics, including age, sex, race, and ethnicity, were collected from the EHR. Injury characteristics obtained from the EHR included injury laterality and MOI. MOIs were categorized as low-energy falls from standing, high-energy falls from height, sport-related direct blow, non-sport-related direct blow, operating/passenger in a body-powered vehicle or motor vehicle, or not specified.

For each patient, the clinical timeline was constructed using the following time points: date of injury, initiation of rigid immobilization, first orthopaedic specialist visit (physician, Doctor of Medicine), discontinuation of rigid immobilization, pain resolution, sports clearance, and final orthopaedic specialist visit. From these dates, the following time interval variables were calculated: time from injury to rigid immobilization, time from injury to specialist presentation, duration of rigid immobilization, time from injury to pain resolution, time from injury to sports clearance, and total duration of follow-up. Rigid immobilization was defined as a nonremovable cast or splint. Clinic notes and radiographs were reviewed at each office visit for evidence of bony union which was determined by the presence of bridging callus.

Several sociodemographic and socioeconomic factors were collected using information available in the EHR, including individual and community-level measures [14]. Individual-level measures included insurance coverage (private, public, other) and household composition. Household composition was categorized as both biological parents, single biological parent (mother or father), single biological parent (mother or father) with ≥1 other adult, relative(s), or other (group home, juvenile services, foster care, or unknown). Community-level measures of SES included the Child Opportunity Index (COI), Area Deprivation Index (ADI), and Social Vulnerability Index (SVI); these indices quantify socioeconomic conditions, access to resources, and community vulnerability, respectively, to generate standardized scores that can be compared to state and national averages and are frequently used to assess disparities in health and opportunity [[15], [16], [17]]. COI national (COIn), COI state (COIs), and ADI national (ADIn) scores range from 0 to 100, with higher COI scores and lower ADIn scores representing higher SES [15,16]. COIn uses the following quintile-based cutoffs to stratify individuals into 5 levels of opportunity: 0-20 (“very low”), 21-40 (“low”), 41-60 (“moderate”), 61-80 (“high”), and 81-100 (“very high”) [18]. ADI state (ADIs) scores range from 0 to 10, with lower scores representing higher SES [15]. Lastly, the SVI uses a percentile ranking system from 0 to 1, with lower scores indicating higher SES [19]. National and state averages for the COI, ADI, and SVI correspond to approximately the midpoint (50th percentile) of each respective index [[20], [21], [22]].

Statistical analysis

Descriptive statistics were used to summarize patient demographics, SES variables, injury characteristics, and clinical timeline and included mean and standard deviation (SD), median and interquartile range (IQR), and counts and percentages where appropriate. The relationship between SES and clinical course was analyzed using nonparametric tests (Wilcoxon rank-sum and Kruskal-Wallis tests) and univariate linear regressions. For 2-group comparisons, an a priori power analysis determined that 67 patients were required per group, assuming a medium effect size. Two-group comparisons were made between the lowest COIn quintile and all other patients. Furthermore, according to Greene’s rule, a minimum of 105 patients was required to adequately power the cohort for linear regression analyses [23]. Patients who transitioned from nonoperative to operative management at any point during the follow-up period were excluded from analyses involving the following variables: duration of rigid immobilization, time from injury to pain resolution, time from injury to sports clearance, and total duration of follow-up. All statistical analyses were performed in R (Version 4.5.1, Vienna, Austria), with statistical significance set to a P value <.05 [24].

Results

This study included 736 patients with an acute scaphoid fracture (mean age, 13.6 ± 2.5 years; 69% male). Sixty-nine percent of patients were White (508/736), and 93.9% were non-Hispanic or Latino (691/736). Most patients were privately insured (74.2%, 546/736) and lived with both biological parents (66.7%, 491/736). Across the study population, the median COI, ADI, and SVI scores were above the 50th percentile at both the national and state levels. Regarding the clinical timeline, the median time from injury to rigid immobilization was 4.0 days (IQR, 2.0-7.3 days), while the median time from injury to orthopaedic specialist presentation was 5.0 days (IQR, 2.0-9.0 days). Patients underwent rigid immobilization for a median of 38.0 days (IQR, 28.0-43.0) and were followed up for 42.0 days (IQR, 28.0-56.3 days). Patients reported pain resolution at a median of 41.0 days after injury (IQR, 32.0-49.0 days) and were cleared to return to sport at a median of 60.0 days after injury (IQR, 46.0-78.5 days). Thirty-four patients (4.6%) experienced nonunion and 48 patients (6.5%) underwent surgery due to suboptimal or delayed healing after rigid immobilization. A comprehensive summary of patient demographics, SES variables, injury characteristics, and clinical timeline is shown in Table 1. SES characteristics for patients who developed nonunion and those who underwent surgical intervention after failing nonoperative management with rigid immobilization are displayed in Table 2.

Table 1.

Patient demographics, socioeconomic status variables, injury characteristics, and clinical timeline.

Total number of patients, n	736
Age at the date of injury, years, mean ± SD	13.6 ± 2.5
Sex, n (%)
Male	510 (69.3%)
Female	226 (30.7%)
BMI, kg/m2, mean ± SD	21.2 ± 4.8
Race, n (%)
White	508 (69.0%)
Black or African American	124 (16.8%)
Asian	17 (2.3%)
Other	87 (11.9%)
Ethnicity, n (%)
Non-Hispanic or Latino	691 (93.9%)
Hispanic or Latino	35 (4.8%)
Not indicated	10 (1.3%)
Insurance type, n (%)
Private	546 (74.2%)
Public	141 (19.2%)
Other	49 (6.6%)
Socioeconomic status indices, median (IQR)
Child Opportunity Index
National rank	85.0 (59.0-95.0)
State rank	74.0 (40.0-91.0)
Area Deprivation Index
National rank	30.0 (16.0-49.0)
State rank	3.0 (1.0-6.0)
Social Vulnerability Index	0.28 (0.10-0.56)
∗Child opportunity index national quintile-based cutoffs, n (%)
0-20	70 (9.9)
20-40	51 (7.2)
40-60	61 (8.6)
60-80	136 (19.2)
80-100	391 (55.1)
Household information, n (%)
Both biological parents	491 (66.7%)
Single biological mother	151 (20.5%)
Single biological father	26 (3.5%)
Biological mother and ≥1 other adult	40 (5.4%)
Biological father and ≥1 other adult	6 (0.8%)
Single relative	4 (0.5%)
Multiple relatives	7 (1.0%)
Other (group home, juvenile services, foster care, unknown)	11 (1.6%)
Injury etiology, n (%)
Sport	260 (35.3%)
Low-energy fall (from standing)	206 (28.0%)
High-energy fall (from height)	35 (4.8%)
Operating/passenger in a body-powered vehicle	166 (22.6%)
Operating/passenger in a motor vehicle	17 (2.3%)
Direct blow (non-sport-related)	41 (5.6%)
Unknown	10 (1.4%)
Clinical timeline characteristics, days, median (IQR)
Injury to specialist presentation	5.0 (2.0-9.0)
Injury to rigid immobilization	4.0 (2.0-7.3)
Duration of rigid immobilization	38.0 (28.0-43.0)
Injury to pain resolution	41.0 (32.0-49.0)
Injury to sports clearance	60.0 (46.0-78.5)
Duration of follow-up	42.0 (28.0-56.3)

SD, standard deviation; IQR, interquartile range; BMI, body mass index.

“Other” race includes American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, Indian, multiracial, and unknown race.

^∗There were 710 patients with available Child Opportunity Indexnational data.

Table 2.

Socioeconomic characteristics of patients who developed nonunion or underwent surgical intervention after failed nonoperative management with rigid immobilization.

	Nonunion (n = 34)	Surgery (n = 48)
Age at the date of injury, years, mean ± SD	15.2 ± 2.2	15.4 ± 2.2
Sex, n (%)
Male	27 (79.4%)	41 (85.4)
Female	7 (20.6%)	7 (14.6)
Race, n (%)
White	19 (55.9%)	31 (64.6%)
Black or African American	1 (2.9%)	1 (2.0%)
Asian	7 (20.6%)	8 (16.7)
Other	7 (20.6%)	8 (16.7)
Ethnicity, n (%)
Non-Hispanic or Latino	34 (100.0%)	45 (93.8%)
Hispanic or Latino	0 (0.0%)	3 (6.2%)
Not indicated	0 (0.0%)	0 (0.0%)
Insurance type, n (%)
Private	28 (82.4%)	37 (77.1%)
Public	6 (17.6%)	11 (22.9%)
Other	0 (0.0%)	0 (0.0%)
Socioeconomic status indices, median (IQR)
Child Opportunity Index
National rank	92.0 (72.0-95.0)	85.0 (69.0-94.5)
State rank	74.0 (59.0-91.0)	74.0 (54.5-91.0)
Area Deprivation Index
National rank	29.0 (15.0-42.0)	30.0 (16.5-42.0)
State rank	3.0 (1.0-5.0)	3.0 (1.0-4.5)
Social Vulnerability Index	0.13 (0.08-0.39)	0.24 (0.09-0.46)
Household information, n (%)
Both biological parents	24 (70.6%)	32 (66.7%)
Single biological mother	5 (14.7%)	9 (18.8%)
Single biological father	0 (0.0%)	2 (4.2%)
Biological mother and ≥1 other adult	2 (5.9%)	2 (4.2%)
Biological father and ≥1 other adult	1 (2.9%)	1 (1.9%)
Single relative	0 (0.0%)	0 (0.0%)
Multiple relatives	0 (0.0%)	0 (0.0%)
Other (group home, juvenile services, foster care, unknown)	2 (5.9%)	2 (4.2%)

SD, standard deviation; IQR, interquartile range; BMI, body mass index.

“Other” race includes American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, Indian, multiracial, and unknown race.

Socioeconomic variables and clinical timeline

There was no difference in time from injury to initiation of rigid immobilization between patients in the lowest COIn quintile and other patients (8.9 vs 7.7 days; P > .05). However, children in the lowest COIn quintile presented to an orthopaedic specialist an average of 4.5 days later than children in other quintiles (13.0 vs 8.5 days; P = .024) (Fig. 1, Table 3). Lower SES, as measured by COIn (P < .001), COIs (P < .001), ADIn (P < .001), ADIs (P = .002), and SVI (P < .001), was associated with significantly longer rigid immobilization (Table 3). Specifically, children in the lowest COIn quintile underwent rigid immobilization for an average of 7.4 days longer than all other children (45.7 vs 38.3 days; P < .001) (Fig. 1, Table 3). Compared to patients with private insurance, publicly insured patients were immobilized for 7.4 days longer (44.9 vs 37.5 days; P < .001). Children living with both biological parents were immobilized for 4.4 days fewer than those living in other household configurations (37.7 vs 42.1 days; P < .001). Lastly, socioeconomic factors were not associated with time to pain resolution, time to sports clearance, scaphoid nonunion, or failed nonoperative management and progression to surgery.

Figure 1.

Box and whisker plots comparing clinical timeline characteristics among groups stratified by established Child Opportunity Index national (COIn) score quintile-based cutoffs. Forty-eight patients underwent surgery and were not included in the calculations for duration of rigid immobilization. ∗Denotes statistical significance (P < .05).

Table 3.

Socioeconomic status as a predictor of clinical timeline.

		Clinical timeline
		Injury to specialist presentation	Injury to rigid immobilization	Duration rigid immobilization	Injury to pain resolution	Injury to sports	Duration of follow-up
SVI	Coeff	0.306	−1.957	8.385	3.318	3.296	−0.619
	P value	.885	.339	<.001∗	.409	.436	.910
COI national	Coeff	−0.016	0.016	−0.097	−0.016	−0.057	−0.003
	P value	.461	.436	<.001∗	.692	.186	.952
COI state	Coeff	−0.003	0.021	−0.080	−0.001	−0.046	−0.026
	P value	.876	.266	<.001∗	.977	.247	.607
ADI national	Coeff	0.013	−0.012	0.097	0.017	0.087	0.046
	P value	.607	.616	<.001∗	.732	.082	.480
ADI state	Coeff	0.030	−0.133	0.655	0.167	0.764	0.971
	P value	.886	.507	.002∗	.667	.063	.070

SVI, Social Vulnerability Index; COI, Child Opportunity Index; ADI, Area Deprivation Index; Coeff, coefficient.

Linear regressions examining the effect of socioeconomic status on clinical characteristics following acute scaphoid fracture.

Forty-eight patients underwent surgery and were not included in the calculations for the latter 4 clinical variables.

Bolded values are statistically significant.

^∗Denotes statistical significance (P < .05).

Discussion

In this study investigating the clinical course of nonoperatively treated pediatric scaphoid fractures in a large contemporary cohort, we found that socioeconomic factors were associated with delayed presentation to an orthopaedic specialist and prolonged rigid immobilization. In particular, children in the lowest COIn quintile presented to an orthopaedic specialist significantly later than other children. Furthermore, patients with lower SES as measured by COIn, COIs, ADIn, ADIs, SVI, public insurance status, and household composition underwent rigid immobilization for significantly longer than other patients. We found no significant association between community-level socioeconomic factors and time to pain resolution, time to sports clearance, nonunion rates, or failed nonoperative management and progression to surgery.

It is well established that patients from lower socioeconomic backgrounds are less likely to access health care resources [9]. This pattern is particularly pronounced regarding the use of outpatient services, including orthopaedic specialists [10,12]. Furthermore, even when patients have access to care, initiation of services may be delayed. In a study examining the impact of SES on the management of adolescent idiopathic scoliosis, Black patients and those with limited insurance coverage presented to an orthopaedic specialist with greater average curve magnitudes, suggesting delayed care initiation in these patient populations [25]. Outpatient follow-up after the initial presentation can also pose challenges; among children with supracondylar humerus fractures discharged from the emergency department, those with private insurance were 2.78 times more likely to be seen in an outpatient clinic for appropriate follow-up care [26]. Additionally, in a study by Meza et al. [13], higher ADI, Black race, single-parent caregiver status, and Medicaid insurance were found to be associated with suboptimal fracture care compliance, with patients from the most socially deprived regions being significantly more likely to miss scheduled orthopaedic visits.

Our study supports these previous findings that socioeconomic factors are associated with care delays. In our study, children in the lowest COIn quintile presented to an outpatient orthopaedic specialist an average of 4.5 days later than patients in other quintiles. This disparity is concerning as delays in treatment for scaphoid fractures may be associated with an increased risk of poor outcomes, including wrist stiffness, delays in sports clearance, decreased social performance, and critically, nonunion [5]. Fortunately, we did not observe an association between SES and scaphoid nonunion or failed nonoperative management and progression to surgery in this study, likely because there was no significant relationship between SES and time to initiation of rigid immobilization in our cohort (median of 4.0 days after injury). Time to immobilization was shorter than the time from injury to orthopaedic specialist presentation, likely because most patients initially presented to an urgent care facility or emergency department after sustaining acute injury, where rigid immobilization was appropriately applied in a timely fashion, before evaluation by an orthopaedic specialist at an outpatient clinic. While low-SES patients may utilize outpatient specialty orthopaedic care less frequently, they often rely heavily on emergency departments, with lower income associated with 53% higher odds of emergency department utilization for musculoskeletal conditions [11]. Therefore, patients with lower SES may be immobilized promptly but have difficulty accessing an orthopaedic specialist for definitive care. Union rates for acute pediatric scaphoid fractures decline from 97% to 75% when rigid immobilization is delayed more than 3 weeks after injury [6]. In our study, both the time from injury to initiation of rigid immobilization and outpatient orthopaedic specialist evaluation were well below this threshold, which may explain why SES was not associated with nonunion, total duration of follow-up, time to return to sports, or failed nonoperative management and progression to surgery in this study. That being said, delayed access to orthopaedic specialists and prolonged rigid immobilization may have additional consequences that are not fully captured by objective clinical outcomes alone. For example, during the interval between the initial rigid immobilization at an outside facility and evaluation by an orthopaedic specialist, patients and families may experience increased stress related to uncertainty regarding the severity of the injury, treatment plan, and expected recovery. Future prospective studies are needed to evaluate these patient-centered outcomes and better characterize the broader impact of delays in care, which could not be assessed in the current retrospective study design.

In our study, patients with lower SES underwent rigid immobilization longer than patients with higher SES, which may reflect difficulties in accessing or attending appointments in a timely manner following treatment initiation. Several studies demonstrate that patients with lower SES exhibit higher rates of missed outpatient appointments and decreased follow-up with orthopaedic care, in part due to transportation challenges [12,13,27]. Pediatric patients may face this barrier to an even greater degree due to their reliance on caregivers for transportation and scheduling appointments around work and school schedules [12]. Our finding that children living with both biological parents were immobilized for 4.4 days fewer than those living in other household configurations suggests that the presence of both biological parents in the household may facilitate attendance at scheduled appointments. In addition to health complications associated with disrupted treatment protocols, prolonged rigid immobilization carries other potential downsides, including negative effects on school performance, sports participation, and social engagement. Short-arm casts typically applied for uncomplicated scaphoid fractures can impair fine motor movements required for writing and using a keyboard or mouse [28]. Restriction of these movements may temporarily affect a student’s ability to complete school assignments on time, leading to stress and decreased performance. Participation in sports is also limited when patients are immobilized, particularly for contact sports or activities requiring use of the upper extremity [29]. Even after discontinuing immobilization, patients may report joint stiffness and reduced grip strength, further delaying their return to sports. Lastly, short-arm casting for scaphoid fractures may temporarily limit social activities, but it has not been shown to have a lasting impairment on social engagement [2,5]. Unfortunately, given our retrospective study design, we did not have access to many clinically relevant variables that we would like to have included, such as functional and patient-reported outcomes that would allow us to entirely quantify the effects of prolonged rigid immobilization on a child’s life. It is possible that even a brief increase in immobilization duration may have meaningful effects. Future prospective studies are warranted to assess patient-centered outcomes and investigate the impact of delays in care among children undergoing rigid immobilization for scaphoid fractures.

In pediatric orthopaedics, patients with lower SES experience delays across the health care spectrum which leads to worse outcomes [12,13,30,31]. Addressing inequities in this patient population requires interventions at multiple levels. At the policy level, insurance status represents a key barrier to timely care. A study by Skaggs et al. [32] found that only 2% of randomly chosen orthopaedic offices in California offered timely appointments to children with Medicaid in comparison to 100% for patients with private insurance. Similarly, another study completed in Ohio, Indiana, and Kentucky reported that following Anterior Cruciate Ligament (ACL) injury, privately insured patients had 57 times the odds of being offered an appointment within 2 weeks of injury compared to Medicaid patients [33]. Shorter intervals from referral to scheduled appointments are associated with improved appointment attendance rates, further highlighting the importance of appointment availability in reducing health care disparities [34]. Reimbursement rates are often a driver of appointment scheduling and health care access disparities, and policy-level changes are needed to address this issue [30,32].

At the individual practice level, targeted interventions can help mitigate disparities. Extending clinic hours to accommodate families whose caregivers work during standard business hours and establishing community partnerships to improve access to reliable, affordable transportation are practical first steps. Transportation challenges affect approximately 4% of pediatric orthopaedic patients, with the greatest impact reported among families identifying as Black or non-English-speaking [35]. Children’s hospitals and community organizations have worked together to address transportation concerns within broader strategies aimed at improving social determinants of health, but data on the efficacy of these strategies within orthopaedics specifically are scarce [[36], [37], [38]]. Effective communication with patients across all socioeconomic backgrounds is also critical, particularly when addressing language barriers [39]. Parental limited English proficiency is associated with worse health care access and quality for children [40]. Multifaceted quality improvement interventions—including staff education, electronic alerts for language needs, and data feedback—have been shown to substantially increase interpreter use and improve associated patient outcomes [41]. In the context of our study, language barriers may have contributed to difficulty scheduling appointments and communicating information regarding timely follow-up, potentially resulting in both a delayed and prolonged treatment timeline. Unfortunately, reliable data regarding interpreter utilization among patients in our study cohort were not consistently available, which limited our ability to further evaluate the potential impact of language barriers on provision of care. Furthermore, interpreter use alone may not fully capture the complex influence of language barriers on health care access in this population as many patients were often bilingual, while their caregivers spoke only 1 language. Accordingly, information regarding language competencies of both the patients and their caregivers would likely provide a more comprehensive assessment of this nuanced concept. This may be an area of investigation worth pursuing in the future. While many initiatives have been undertaken to address health care disparities in pediatric orthopaedics, considerable work remains to address these challenges.

This study had several limitations. First, the study population consisted of patients who were predominantly White or non-Hispanic, had private insurance, lived with both biological parents, and had higher community-level measure scores. Consequently, the study population may not be representative of all children who sustain scaphoid fractures in the USA. However, since all consecutive patients presenting to our institution with scaphoid fractures during the study period were included, the socioeconomic characteristics of the study cohort are inherent to the patient population treated by our institution. Furthermore, according to the U.S. Census Bureau’s American Community Survey data for 2012 and 2024, the pediatric population of the city where the study institution is located was 38%-41% White and 84%-88% non-Hispanic, so although not an exact match, our cohort’s distribution approximates our city’s racial and ethnic population. Nonetheless, future investigations should consider including patients from multiple institutions in different geographic locations to increase socioeconomic diversity and improve generalizability. Another limitation is that patients who underwent surgery were excluded from certain analyses. This approach was taken to focus on patients with nonoperative scaphoid fractures who followed a typical treatment timeline. In theory, this minimizes the impact of outliers on the results—such as patients who were only immobilized briefly before undergoing surgery for a complex fracture or those with prolonged postoperative follow-up. However, excluding surgical patients may have biased our findings, potentially masking an association between SES and outcomes if certain patients were more or less likely to experience complications requiring more advanced or extended care. Moreover, although this study found no association between SES and important outcomes such as pain resolution, sports clearance, nonunion, and progression to surgery after failed nonoperative management, other clinically relevant outcome measures, such as wrist stiffness, range of motion data, additional functional assessments, and patient-reported outcomes, were not consistently available and therefore were unable to be assessed; it is possible that SES would influence these metrics. Strengths of this study include the large cohort size, the use of both multiple individual- and community-level measures of SES which more comprehensively characterize SES than a single metric, and the inclusion of clinical variables from throughout the clinical course.

In conclusion, this study found that lower SES was associated with delayed orthopaedic specialist presentation and prolonged rigid immobilization in children with nonoperative scaphoid fractures. Treatment delays may be due to barriers that limit access to orthopaedic specialists after injury or prevent timely follow-up after initiation of rigid immobilization. These disparities are concerning as delays in rigid immobilization for scaphoid fractures are associated with poor outcomes and prolonged rigid immobilization may negatively impact school performance, sports participation, and social engagement. However, in this study, delayed specialist presentation and prolonged rigid immobilization were not found to be clinically significant. Although patients with lower SES experienced statistically significant delays throughout the treatment timeline compared with patients with higher SES, these differences were not associated with clinically meaningful differences in outcomes in this study. Nevertheless, we believe these findings remain important as social determinants of health are known to influence health care access and patient outcomes and it is important to report both “positive” and “negative” findings from clinical investigations. We hope this study will encourage further investigation into the impact of social determinants of health on pediatric fracture care. Additional research is needed to further elucidate the relationship between SES and health care access in pediatric scaphoid fractures and to understand the complete spectrum of consequences of delayed or prolonged treatment in this population.

Additional links

• •POSNAcadamy: Pediatric Hand and Wrist Trauma: Scaphoid/Carpus Fractures
• •POSNAcadamy: High Yield Pediatric Orthopaedics for the OITE Part 2 – Upper Extremity Trauma

Author contributions

Stone R. Streeter: Writing – review & editing, Writing – original draft, Methodology, Investigation, Data curation. Simon Blanchard: Writing – review & editing, Methodology, Investigation, Data curation. Dev Laungani: Writing – review & editing, Methodology, Investigation, Data curation. Edward H. Dockery: Writing – review & editing, Methodology, Investigation, Data curation. Sayaka Mori: Writing – review & editing, Methodology, Investigation, Data curation. Sulagna Sarkar: Writing – review & editing, Formal analysis. Apurva S. Shah: Writing – review & editing, Supervision, Project administration, Methodology, Investigation, Data curation, Conceptualization. Mary Claire B. Manske: Writing – review & editing, Supervision, Project administration, Methodology, Investigation, Data curation, Conceptualization.

Ethics approval and consent

The authors declare that no patient consent was necessary as no images or identifying information is included in the article.

Funding

None of the authors received financial support for this study.

Declaration of competing interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.