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Distal Radial Epiphysitis

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Other Names

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

Background

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

History

Epidemiology

  • Affects between 46% to 79% of gymnasts[1]

Pathophysiology

Magnetic resonance arthrogram demonstrating bony bridging across the distal radial physis as is seen in growth arrest[2]
AP wrist radiograph demonstrating positive ulnar variance in a young gymnast.[2]
  • General
    • Seen in skeletally immature athletes with repetitive axial loads to the wrist
    • Can be considered a chronic type 1 Salter Harris Fracture
    • Occurs with repetitive microtrauma from load bearing the wrist joint
    • Overall, poorly described in the literature and mostly limited to case reports

Pathophysiology

  • General
    • Wrist experiences excessive loads due using wrist as a weight bearing joint
    • This creates repetitive compressive loading, shearing forces on the dorsiflexed wrist
    • The repetitive stress leads to inflammation of the physis
    • In the skeletally immature, physis is weaker than the joint capsule and ligamentous structures
    • Microtrauma can lead to premature fusion of physis and excessive overgrowth of Ulna
    • Due to either physeal microfractures or temporary ischemia

Risk Factors

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

Differential Diagnosis

Clinical Features

  • History
    • Age 10 to 14
    • Gradual onset over months
    • No history of trauma
    • 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 (dorsal and volar)
    • Range of motion may be normal or diminished
    • Pain with hyperextension and axial loading
    • Grip strength, neurovascular exam should be normal

Evaluation

AP and lateral views of both wrists of a gymnast with bilateral disease. There is widening over the lateral and volar aspects of the distal radial physis (arrows) right greater than left.[3]
MRI demonstrating widening of the lateral aspect of the radial physis (arrow). The linear hyperintense signal inferior to the physis (arrowhead) may represent cartilaginous rests within the metaphysis[3]

Radiographs

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

MRI

  • Indicated in refractory or chronic patients
  • Findings
    • Paraphyseal edema
    • Bridging
    • Bone edema
    • Widening of the physis

Ultrasound

  • Ultrasound use is not described in the literature
  • Likely useful to augment other imaging modalities

Classification

  • N/A

Management

Nonoperative

Example of a brace (wrist guards) that can be used to limit wrist dorsiflexion.[2]
  • Indications
    • Most athletes
  • Rest from offending activity
    • Cessation of all weight bearing activities while immobilized
    • Duration can range from 2-4 weeks for mild cases
    • More symptomatic cases may require 3 months or longer
    • Gradual RTP
  • Immobilization for at least 6-8 weeks, sometimes 3-6 months
  • Serial radiographs
    • Should be obtained at set intervals if initial radiographs are abnormal
    • Normal radiographs are not required to prevent RTP
  • Prevention
    • Manage load and volume
    • Strength and flexibility exercises
    • Proper technique
    • Wrist guards may blunt or prevent extreme dorsiflexion

Operative

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

Rehab and Return to Play

Rehabilitation

  • During immobilization
    • Can perform alternative conditioning and strengthening exercises
    • Wrist rehabilitation aimed at full ROM, strength
    • Under supervision of physiccal therapist

Return to Play

  • General
    • Depends on rate of recovery, some athletes can be immobilized for 6 months
    • Once symptoms have resolved, gradual increase in training loads can begin
    • Athlete must demonstrate full range of motion, normal strength
    • Emphasis on sport specific biomechanics and proper form

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

See Also

External

References

  1. ↑ DiFiori, John P. "Overuse injury and the young athlete: the case of chronic wrist pain in gymnasts." Current sports medicine reports 5.4 (2006): 165-167.
  2. ↑ 2.0 2.1 2.2 Benjamin, Holly J., Sean C. Engel, and Debra Chudzik. "Wrist pain in gymnasts: a review of common overuse wrist pathology in the gymnastics athlete." Current Sports Medicine Reports 16.5 (2017): 322-329.
  3. ↑ 3.0 3.1 Poletto, Erica D., and Avrum N. Pollock. "Radial epiphysitis (aka gymnast wrist)." Pediatric emergency care 28.5 (2012): 484-485.
Created by:
John Kiel on 30 June 2019 20:30:31
Authors:
Last edited:
16 October 2022 15:20:24

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