Distal Radial Epiphysitis

Other Names

• Gymnast's Wrist
• Distal Radial Physeal Stress Syndrome
• Radial Epiphysitis

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Background

• This page refers to distal radius epiphysitis, often termed 'Gymnast's Wrist'

Epidemiology

• Affects up to 25% of gymnasts (need citation)

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Pathophysiology

• General
  • Can be considered a chronic type 1 Salter Harris Fracture

Pathophysiology

• Wrist experiences excessive loads due using wrist as a weight bearing joint
• The repetitive stress leads to inflammation of the physis
• Microtrauma can lead to premature fusion of physis and excessive overgrowth of Ulna
• Traction vs stress injury

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Risk Factors

• Sports
  • Gymnastics
    • Especially in uneven parallel bars, vault, balance beam and floor exercises
  • Weight-Lifting
  • Rock Climbing

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Differential Diagnosis

• Fractures
  • Distal Radius Fracture
    • Barton's Fracture
    • Chauffer's Fracture
    • Colles' Fracture
    • Die-Punch Fracture
    • Radial Styloid Fracture
    • Smith's Fracture
  • Distal Ulna Fracture
  • Carpal Fractures
    • Scaphoid Fracture
    • Lunate Fracture
    • Triquetrum Fracture
    • Pisiform Fracture
    • Trapezium Fracture
    • Trapezoid Fracture
    • Capitate Fracture
    • Hamate Fracture
  • Essex Lopresti Fracture
• Dislocations
  • Carpometacarpal Joint Dislocation
  • Distal Radioulnar Joint Dislocation
  • Lunate Dislocation
  • Perilunate Dislocation
• Instability & Degenerative
  • Scapholunate Instability
  • Lunotriquetral Instability
  • Scaphoid Nonunion Advanced Collapse
  • Distal Radial Ulnar Joint Instability
  • Kienbocks Disease
• Tendinopathies & Ligaments
  • De Quervain's Tenosynovitis
  • Intersection Syndrome
  • TFCC Injury
  • Wrist Tendinopathies
  • Extensor Carpi Ulnaris Instability
• Neuropathies
  • Carpal Tunnel Syndrome
  • Pronator Teres Syndrome
  • Anterior Interosseus Nerve Syndrome
  • Posterior Interosseus Nerve Syndrome
  • Guyon Canal Syndrome
• Pediatric Considerations
  • Distal Radial Epiphysitis (Gymnast's Wrist)
  • Torus Fracture
• Arthropathies
  • Wrist Osteoarthritis
  • Rheumatoid Arthritis
• Cartilage
  • Osteochondral Defect
• Vascular
  • Hypothenar Hammer Syndrome
• Other
  • Ganglion Cyst of Wrist
  • Ulnar Impingement Syndrome
  • Infectious Tenosynovitis

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Clinical Features

• History
  • Age 10 to 14
  • Gradual onset
  • Dorsal radial sided wrist pain, worse in extension
  • Worse with axial stress loading (vaulting, hand-walking)
• Physical Exam: Physical Exam Wrist
  • Tenderness, swelling to distal radius
  • Loss of range of motion may be present
  • Pain with hyperextension and axial loading

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Evaluation

Radiographs

• Standard Radiographs Wrist
  • 3 view radiographs initial imaging modality of choice
• Findings
  • May see widened, irregular growth plate
  • Metaphyseal and epiphjyseal sclerosis, irregularity
  • In more chronic patients, positive ulnar variance

MRI

• Indicated in refractory or chronic patients
  • Findings
  • Paraphyseal edema
  • Bridging
  • Bone edema

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Classification

• N/A

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Management

Nonoperative

• Indications
  • Most athletes
• Rest from offending activity
  • While in cast
  • Gradual RTP
• Immobilization for at least 6-8 weeks, sometimes 3-6 months
  • Consider Short Arm Cast, Radial Gutter Cast
• Prevention
  • Manage load and volume
  • Strength and flexibility exercises
  • Proper technique

Operative

• Indications
  • Refractory conservative management
  • Late presentation
• Procedures
  • Resection of physeal bridge
  • Ulnar epiphysiodesis, shortening with radial osteotomy

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Rehab and Return to Play

Rehabilitation

• Needs to be updated

Return to Play

• Depends on rate of recovery, some athletes can be immobilized for 6 months

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Complications & Prognosis

Prognosis

• Prognosis is favorable if treated early
• Can take up to 4-5 months if late to care

Complications

• Microtrauma can lead to premature fusion of physis and excessive overgrowth of Ulna
• Positive ulnar variance
• Radial Shortening
• TFCC Injury

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See Also

• Pediatric Fractures (Main)
• Apophyseal And Epiphyseal Injuries (Main)
• Hand and Wrist Anatomy (Main)
• Wrist Pain (Main)
• Physical Exam Wrist

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