Pediatric Wrist Pain Dr. Leah Hillier MD CCFP (SEM) May 26th, 2017

Agenda Case Specific Paediatric Considerations Differential Diagnosis History Anatomy/Physical Imaging Questions

Wynonna Rist 10 year old female left-handed gymnast (6 hours per week of gymnastics) presenting with left radial-sided wrist pain insidious onset (no traumatic event), gradually worsening pain primarily when weight bearing on the wrist, though does also have some aching at rest after gymnastics no swelling, not keeping her up at night, not stopping her from participating in gymnastics, but bothering her at times when writing at school The ratio of organized sport : free play time should not be >2:1. Kids should not be participating in more organized sporting hours than their age in years. Single sport specialization before puberty puts athletes at risk of injury. Common to have early sport specialization in gymnastics and dance

pediatric considerations

Pediatric considerations Children’s bones have more cartilage and collagen than adults’ The skeleton is relatively weaker, but has greater elasticity (Frost 2000, Davis 2010) Growth plates are still open The periosteum is more active and promotes rapid healing and remodelling (Dwek 2010) Children tend to have more injuries of epiphyses and apophyses

Pediatric considerations http://bones.getthediagnosis.org

Normal pediatric bone development in the wrist Radiopaedia

Normal pediatric bone development in the wrist radius physeal closure ages 15-18 discuss growth plate arrest postive/negative ulnar variance Age 6 Age 11 Age 9 Age 13 http://bones.getthediagnosis.org

differential diagnosis

Pediatric wrist differential diagnosis TRAUMA Buckle, greenstick, complete, and physeal injuries Galeazzi-equivalent Fractures http://pubs.rsna.org/doi/full/10.1148/rg.342135073

Salter-Harris Classification Buckle fractures

Differential diagnosis of wrist pain Bony Distal radius fracture Acute scaphoid fracture Scaphoid stress fracture Other carpal fractures Carpal dislocation Growth plate injury - distal radial physeal injury (Gymnast’s wrist) Bennett fractures (1st metacarpal fractures) Scaphoid Impaction Syndrome Ulnar stress fracture Osteoarthritis

Differential diagnosis of wrist pain Soft Tissue De Quervain’s tenosynovitis (tenosynovitis of the tendons of the first extensor compartment of the wrist: the abductor pollicis longus and extensor pollicis brevis) UCL injury of the thumb Extensor carpi ulnaris (ECU) tendonitis (overuse injury of the ECU tendon in the wrist) Extensor carpi ulnaris subluxation (rupture to medial wall of the ECU tendon sheath secondary to sudden or repetitive flexion and ulnar deviation, causing subluxation of ECU.) Intersection syndrome: inflammation at the crossing points of the tendons of the first dorsal compartment and the extensor radialis longus and brevis. This point is typically 2–3 in. proximal to the radio-carpal joint. This entity is seen in sports involving repetitive wrist extension. Scapholunate injuries Lunotriquetral injuries Triangular fibrocartilage complex (TFCC) injuries Distal radioulnar joint injury Ganglion

Differential diagnosis of wrist pain Other Carpal tunnel syndrome Wartenberg’s syndrome (nerve entrapment of the cutaneus branch of the radial nerve) Infection/osteomyelitis Crystal arthropathy/gout Inflammatory conditions (RA, psoriatic arthritis, etc) Neoplasm Referred pain from c-spine, brachial plexus, shoulder

History ID: includes dominant hand (in writing? in sport?) CC: Location of pain (could you point to where you feel your discomfort?) HPI: Start of symptoms (acute versus insidious onset) ?trauma ?mechanism of injury ?change in training load Aggravating and relieving factors Allergies/Meds/PMHx/SurgHx/Injuries Activities: Level of training, hours per week, level of competition, plans for the future in sport, other hobbies that involve hand/wrist (?guitar ?piano ?art) Development: Menarche, Growth spurt (how much? over what time period?) SocHx: Work in adults (?manual labour ?jackhammers ?manual dexterity ?repetitive motions) FamHx: ?rheum ?connective tissue, etc Symptoms: pain, swelling, paresthesias, clicking, stiffness, function

Physical Having the patient show you the location of pain as a first step can often help to take a more efficient history both hands on pillow exposed above the elbows always compare to the contralateral side

Dorsal anatomy

Volar anatomy

Volar anatomy

Soft tissue anatomy

Key wrist landmarks

Sensation of the hand/wrist

Physical exam inspection Skin changes (psoriatic plaques, lacerations) Muscle wasting (thenar wasting, interosseous wasting) joint deformity (heberden’s nodes, bouchard’s nodes, CMC squaring, subluxation/ulnar deviation, gouty tophi) Swelling (dactylitis, individual joints), warmth Masses (ganglion)

Physical exam inspection

Physical exam inspection

Physical exam inspection

Physical exam inspection

Physical exam manœuvres ROM Power Neuro Palpation of anatomic snuff box, axial loading of thumb (scaphoid pathology) Piano key sign (DRUJ) Finkelstein’s, resisted thumb extension (De Quervain’s) Phalen’s, Tinel’s (carpal tunnel) TFCC grind, fovea test (TFCC tear) Watson’s test, palpation of SL ligament (SL ligament instability) UCL stress testing (Gamekeeper’s thumb)

Physical exam manœuvres