WRIST PAIN - GYMNASTICS 860

Abstract

HISTORY - 15-1/2 year old female club gymnast complained of increasing right wrist pain over 2-3 months, without recalling a specific episode of trauma. About 1 month after onset of the pain she discontinued gymnastics practice for 4 weeks, with partial improvement, and then pursued a modified practice, limiting the floor exercise and vaults that caused most pain, until seeking medical evaluation. One brief episode of right wrist pain had occurred approximately 6 months prior to our examination and had resolved in two weeks without practice modification or treatment. The gymnast was right-handed, started cartwheels on right hand and spent approximately 20 hours per week in practice. In the year leading up to her symptoms she accumulated 816 hours of training in 197 practice sessions, plus 10 competitions at Level 9-10. Menarche had occurred at age 14 years 11 months, and there had been significant increases in weight and changes in body configuration during the six months preceding the oneset of symptoms. PHYSICAL EXAMINATION - Healthy-appearing with significant findings limited to the right upper extremity. The ulnar styloid was prominent and very tender, with tenderness extending distal to it into the dorsal ulnar aspect of the wrist, and over the distal radioulnar joint. Compared to the left wrist, supination and extension was markedly limited on the right. There was no demonstrable instability of the distal radioulnar joint, no“snuff-box” tenderness. negative lunatotriquetral shear and negative scaphoid ballottement. No other joints showed evidence of abnormality. DIFFERENTIAL DIAGNOSIS: Stress fracture ulnar styloid Stress/avulsion fracture triquetrum Premature closure radial physis Injury to ulnar triangular fibrocartilage complex Distal radial or ulnar “epiphysitis” Distal ulnar subluxation TESTS AND RESULTS: Wrist radiographs that had been performed by another provider two months previously were reviewed; they showed subtle signs of early radial physis closure, a possible fracture through the radial epiphysis, and slight positive ulnar variance. A bone scan showed decreased uptake in the right radius distal growth plate. Repeat wrist radiographs showed essentially complete closure of the right distal radial physis, open distal growth plates in the right ulna and left radius and ulna; ulnar variance was 4 mm positive right, 1 mm negative left. FINAL/WORKING DIAGNOSIS: Premature closure right distal radial physis. TREATMENT: Surgery to shorten right ulna with plate fixation, providing correction to 1-2 mm negative ulnar variance. Short-arm cast immobilization for 6 weeks, then splint for comfort with weaning as tolerated. Gradual resumption of conditioning, avoiding repetitive and/or impact loading of wrist to 6 months post-op. Hardware removal at one year, with limited activity 1-2 months following until healed. Inability to bear weight on the right wrist without pain despite excellent healing precluded return to competitive gymnastics.