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

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

3. 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

4. pediatric considerations

5. 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

6. Pediatric considerations

7. Normal pediatric bone development in the wrist
Radiopaedia

8. 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

9. differential diagnosis

10. Pediatric wrist differential diagnosis
TRAUMA
Buckle, greenstick, complete, and physeal injuries
Galeazzi-equivalent Fractures

11. Salter-Harris Classification
Buckle fractures

12. 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

13. 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

14. 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

15. 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

16. 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

17. Dorsal anatomy

18. Volar anatomy

19. Volar anatomy

20. Soft tissue anatomy

21. Key wrist landmarks

22. Sensation of the hand/wrist

23. 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)

24. Physical exam inspection

25. Physical exam inspection

26. Physical exam inspection

27. Physical exam inspection

28. 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)

29. Physical exam manœuvres