Physical exam manœuvres

Physical exam manœuvres

Physical exam manœuvres

Physical exam manœuvres

Physical exam manœuvres

Investigations It’s usually reasonable to start with plain film X-rays *if it’s radial-sided pain, please don’t forget scaphoid views!!!

Pediatric wrist X-rays http://pubs.rsna.org/doi/full/10.1148/rg.342135073

Imaging

Imaging

Imaging

Imaging

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

Epidemiology of gymnasts’ wrist The incidence of sport-related hand and wrist injuries: between 3 and 9%(Rettig 1998) Gymnastics requires early specialization (often identified for elite levels by age 6 or 7)(Caine and Nassar 2005; Sands 2000) A unique aspect of gymnastics is the regular use of the upper extremities to support body weight The radial side of the wrist carries 80% of the axial load and the ulnar side the remaining 20% (Palmer and Werner 1984).

Gymnast injuries Gymnastics has higher rate of wrist injuries versus other sports 46–87% of gymnasts develop significant wrist pain at least once in their career The majority of injuries are to the radial physis (Caine et al. 1992; Difiori et al. 1997). The highest incidence of upper extremity injury occurs in the wrist in females and the shoulder in males(Caine and Nassar 2005). Elite gymnasts are more likely to have chronic rather than acute injuries (Caine and Nassar 2005)

Diagnosing growth plate injury Xray: early stages: often no visible abnormality advanced stages: widened growth plate cystic changes in metaphysis of growth plate beaked appearance of distal epiphysis haziness in growth plate (usually radiolucent) (DiFiori et al. 2006; Roy et al.1985) MRI: horizontal fractures vertical fractures transphyseal linear striations metaphyseal bone bruise physeal cartilage extension into metaphysis (sign of healing) (Koh et al. 2007; Shih et al. 1995). A.H. Karantanas (ed.), Sports Injuries in Children and Adolescents, Med Radiol Diagn Imaging, DOI: 10.1007/174_2010_6, © Springer-Verlag Berlin Heidelberg 2011

Diagnosing growth plate injury A.H. Karantanas (ed.), Sports Injuries in Children and Adolescents, Med Radiol Diagn Imaging, DOI: 10.1007/174_2010_6, © Springer-Verlag Berlin Heidelberg 2011

Imaging for suspected scaphoid fracture Views: AP, lateral, scaphoid views Scaphoid fractures are not always apparent on X-ray immediately after injury There is risk of non-union, avascular necrosis and arthritis Splint the wrist if clinically suspicious and re-xray 2 weeks post injury stress fracture may be seen with sclerosis or a discrete fracture line MRI and CT are equally effective in diagnosis of scaphoid fractures (Ring and Lozano-Calderon 2008)

Basic principles of treatment Immobilize!!! No weight bearing Refer to plastics/ortho

Questions?

References Caine D, Roy S, Singer KM, Broekhoff J (1992) Stress changes of the distal radial growth plate. A radiographic survey and review of the literature. Am J Sports Med 20:290–298 Caine DJ, Nassar L (2005) Gymnastics injuries. Med Sport Sci 48:18–58 Court-Brown CM, Wood AM, Aitken S (2008) The epidemiology of acute sports-related fractures in adults. Injury 39: 1365–1372 Davis KW. Imaging pediatric sports injuries: upper extremity. Radiol Clin North Am 2010;48(6): 1199–1211. CrossRef, Medline DiFiori JP, Puffer JC, Mandelbaum BR, Dorey F (1997) Distal radial growth plate injury and positive ulnar variance in nonelite gymnasts. Am J Sports Med 25:763–768 DiFiori JP, Caine DJ, Malina RM (2006) Wrist pain, distal radial physeal injury, and ulnar variance in the young gymnast. Am J Sports Med 34(5):840–849 Dwek JR. The periosteum: what is it, where is it, and what mimics it in its absence? Skeletal Radiol 2010;39(4):319–323. CrossRef, Medline Frost HM, Schönau E. The “muscle-bone unit” in children and adolescents: a 2000 overview. J Pediatr Endocrinol Metab 2000;13(6):571–590. CrossRef, Medline Karantanas AH (ed.), Sports Injuries in Children and Adolescents, Med Radiol Diagn Imaging, DOI: 10.1007/174_2010_6, © Springer-Verlag Berlin Heidelberg 2011 Koh ES, Lee JC, Healy JC (2007) MRI of overuse injury in elite athletes. Clin Radiol 62(11):1036–1043 Palmer AK, Werner FW (1984) Biomechanics of the distal radioulnar joint. Clin Orthop Relat Res 187:26–35 Rettig AC (1998) Epidemiology of hand and wrist injuries in sports. Clin Sports Med 17:401–406 Ring D, Lozano-Calderon S (2008) Imaging for suspected scaphoid fracture. J Hand Surg [Am] 33(6):954–957 Roy S, Caine D, Singer KM (1985) Stress changes of the distal radial epiphysis in young gymnasts. A report of twenty-one cases and a review of the literature. Am J Sports Med 13(5): 301–308 Shih C, Chang CY, Penn IW, Tiu CM, Chang T, Wu JJ (1995) Chronically stressed wrists in adolescent gymnasts: MR imaging appearance. Radiology 195(3):855–859