1. Physical exam manœuvres

2. Physical exam manœuvres

3. Physical exam manœuvres

4. Physical exam manœuvres

5. Physical exam manœuvres

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

7. Pediatric wrist X-rays

8. Imaging

9. Imaging

10. Imaging

11. Imaging

12. 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

13. 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).

14. 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 ; 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)

15. 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: /174_2010_6, © Springer-Verlag Berlin Heidelberg 2011

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

17. 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)

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

19. Questions?

20. 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: /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