Gymnast Wrist Dr. Kris Buedts, Dr Yo Baeten Europa Ziekenhuis Site Sint Michiel, Brussel Dr. Briffoz, Marc Walraeven lic. Medical Staff Topsportschool Gent Dr Nick Baelde MRI Unit AZ Jan Palfijn Gent

Wrist pain Introduction General considerations Case Reports Outline of a prospective study protocol in elite gymnasts

General considerations More gymnasts Immature skeleton Higher training levels in elite and non-elite gymnasts

Wrist pain Is common among both sexes The wrist is converted into a weight bearing structure Loading in dorsiflexion As much as 16X body weight Prevalence : 46% to 79%, Difiori et al, Clinical sports medicine update 2006

Wrist pain Floor Exercises

Wrist pain Balance Beam

Wrist pain Pommel Horse

Wrist pain Vaulting

Wrist pain Wrist pain for several months is common up to 45%, Mandelbaum Br et al, Am J Sportsmedecine, 1996 In direct correlation with 1) Training intensity (= level of competition X training hours 2) Age 3) Age of initiation

Wrist pain Distribution in function of training intensity

Wrist pain Side of pain, DiFiori et all, Am J of Sportsmedicine, 1996 Dorsal : 61,5 % Ulnar : 12,3 % Palmar : 7,7 % Radial : 6,2 % Non localized : 14 %

Wrist pain Distribution, Garron et all, Clinics in sportsmedicine, 1992 More ulnar sided pain in female More dorsal sided pain in male Age More ulnar sided pain in mature wrist More dorsal sided pain in immature wrist

Wrist Pain Distal Radius Physeal stress reaction

Wrist pain Stress fracture of the scaphoid

Wrist pain Scaphoid impaction syndrome and scapholunate area injury

Wrist pain Ulnar Impaction syndrome

Wrist pain Avascular necrosis of the capitate

Wrist pain Distal Radius Physeal arrest

Wrist pain Triquetrolunate impingement

Wrist pain Chronic Soft tissue capsulitis Wrist Impingement Wrists splint Ganglia TFCC complex tears

Point of interest The Immature wrist : Distal Radius Physeal stress reaction Why ? Protection for future Prevention for wrist degeneration Repetitive injury and compression of the wrist leads to a premature closure of the distal radials growth plate resulting in secondary ulnar overgrowth, L De Smet et al, Am J of Sports medicine, 1994

Difference between boys and girls Short Statue Leanness More proprioceptif training More ulnar sided wrist pain Boys Power training More repetition Less proprioceptif training More dorsal sided wrist pain

Wrist degeneration Ulnar wrist pain Madelung like deformity Ulna + with Ulnar impingement syndrome And/or TFCC problems, L. De Smet et al, Act Orthop Belg, 1993,

Prevention Prevention measures : cut down of wrist pain Training equipment Cleaning of bars Bracing Nutritional advice Coaching

One Exception Puberal Boys and girls Age Group 12- 15 years Initiation to training : <5.6Y> High training intensity Fysionomy Small stature Delayed puberty Out of Control

Case Report HT, 15y, Dorsal sided wrist pain, elite Started training at 5Y

Case Report

Distal Radial Physeal Injury Biomechanics - 80% of load is borne by the radius in the extended wrist, Palmer et al, J Hand Surg 1982 - Shortening of the ulna increases the load borne by the radius - open physis : <mean ulnar variance> - 2 mm Hafner et al, Skeletal rad, 1989

Distal Radial Physeal Injury Histology Dynamic compression can stimulate bone growth Loading can exceed adaptive capacity of the growth plate Growth plate more vulnerable during puberal growth spurt Flachsmann et al, Clin Orthop rel res, 2000

Distal Radial Physeal Injury Compromise of blood supply Disrupts mineralization Prolonging the life of the chondrocytes Widening of the growth plate “Logjam” of chondrocytes Jaramillo et al, Radiology 1993

Distal Radial Physeal Injury Radiology Widening of the distal radial physis Beaking of the epiphysis Cystic changes and irregularity of the methaphyseal margin

Distal Radial Physeal Injury

Distal Radial Physeal Injury

Introduction to a prospective study protocol in elite gymnast Purpose To determinate mean velocity age of onset To determinate wrist side involvement To determinate <Ulna -> in open physis To determinate correlation between ulna + and Distal Radial Physeal Injury To protect our young athletes for chronic injury

Introduction to a prospective study protocol in elite gymnast Questionnaire Physical examination Training volume, Training intensity Rate of growth, endocrinal follow up Standard RX Screening with MRI Control group

Distal Radial Physeal Injury Thank you