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Distal Radial Epiphysitis
From WikiSM
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
- Gymnastics
Differential Diagnosis
- Fractures
- Dislocations
- Wrist Dislocation (Radiocarpal and/or Ulnocarpal)
- Carpometacarpal Joint Dislocation
- Distal Radioulnar Joint Dislocation
- Lunate Dislocation
- Perilunate Dislocation
- Instability & Degenerative
- Tendinopathies & Ligaments
- Neuropathies
- Pediatric Considerations
- Distal Radial Epiphysitis (Gymnast's Wrist)
- Torus Fracture
- Arthropathies
- Cartilage
- Vascular
- Other
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
- Consider Short Arm Cast, Radial Gutter Cast, Cock Up Wrist Splint
- 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
- Pediatric Fractures (Main)
- Apophyseal And Epiphyseal Injuries (Main)
- Hand and Wrist Anatomy (Main)
- Wrist Pain (Main)
- Physical Exam Wrist
External
- Sports Medicine Review Wrist Pain: https://www.sportsmedreview.com/by-joint/wrist/
References
- ↑ 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.
- ↑ 2.0 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.
- ↑ 3.0 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
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Last edited:
16 October 2022 15:20:24
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