Stress fractures of the distal radius in adolescent gymnasts

The use of inertial measurement units to quantify forearm loading and symmetry during gymnastics vault training sessions

The upper limbs are important in gymnastics vaulting, as the success of the flight phase is dependent on a quick and forceful push-off from the vault. This places the upper limbs under stress, which has been associated with pain and injury. This study aimed to quantify forearm segmental loading and symmetry when performing foundation to advanced-level vaulting skills during training. Twelve advanced-level artistic gymnasts (female, n = 6; male, n = 6) wore bilaterally forearm-mounted inertial measurement units while completing their vaulting sessions. The peak resultant acceleration for the leading and non-leading forearms during contact were calculated. Female gymnasts performed variations of Yurchenko vaults, while male gymnasts performed Handspring and Tsukahara vaults. Descriptive statistics (median and inter-quartile range), symmetry index scores, and total session impact load (measure of cumulative loading) were calculated between the lead and non-lead forearms. High asymmetrical loading was identified for some Yurchenko, Handspring, and Tsukahara vaults, with large variations identified between gymnasts. Some gymnasts experienced greater loading at their lead forearm, while others experienced greater loading at their non-lead forearm. Results indicate that limb loading patterns in advanced gymnastics are highly individualised, indicating that individual analysis is needed to identify gymnasts (or limbs) at an increased risk for overuse injury.

Inconsistencies and Imprecision in the Nomenclature Used to Describe Primary Periphyseal Stress Injuries: Towards a Better Understanding

Stress injuries involving the epiphyseal-physeal-metaphyseal complex affecting the extremities of child and adolescent athletes were first described in the early 1950s. Initially observed in Little League baseball players, these injuries are now known to affect skeletally immature athletes in a variety of sports that involve high-impact repetitive overuse activities. Collectively known as primary periphyseal stress injuries, they may affect the long bones around the shoulder, elbow, wrist, hand, hip, knee, ankle, and foot of young athletes. These injuries respond well to timely treatment and relative rest, while non-compliance with non-operative treatment can produce skeletal growth disruption and resultant limb deformity. A major concern raised from the existing literature on primary periphyseal stress injuries is the long history of inconsistent and imprecise terminology used to describe these injuries. A variety of terms have been used to describe primary periphyseal stress injuries, including those which potentially misinform regarding who may be affected by these injuries and the true nature and pathophysiologic mechanisms involved. These imprecisions and inconsistencies arise, at least in part, from a misunderstanding or incomplete understanding of the nature and mechanism of primary periphyseal stress injuries. In this article, we examine the inconsistent and imprecise nomenclature historically used to describe primary periphyseal stress injuries. We also offer a novel framework for understanding the pathophysiologic mechanisms behind these injuries, and provide suggestions for more standard use of terminology and further research moving forward.

Primary Periphyseal Stress Injuries in Young Athletes: A Systematic Review

BACKGROUND

Overuse injuries are common in sporting children and adolescents. These injuries are a particular concern when they involve the epiphyseal-physeal-metaphyseal (EPM) complex given their potential to disturb skeletal growth. Specifically, the limits of mechanical tolerance of the EPM complex to repetitive stress may be exceeded by the intense and continuous training characteristic of many youth sports today.

OBJECTIVE

This article describes the present status of knowledge on the occurrence and outcome of primary periphyseal stress injuries (PPSIs) affecting the EPM complex in the extremities of children and adolescents involved in youth sports.

METHODS

A comprehensive review of the sports medicine literature was conducted to determine the nature and extent of PPSIs affecting the EPM complex of the extremities among youth sports participants and the potential for consequent skeletal growth disturbance and resultant limb deformity associated with these injuries.

RESULTS

Our initial search uncovered 128 original published scientific articles reporting relevant data on PPSIs. There were 101 case reports/series, 19 cross-sectional, 1 case-control, and 7 cohort studies with relevant data. The case reports/series studies reported 448 patients with PPSIs involving the extremities. Children and adolescents representing a variety of high impact repetitive youth sports activities-including baseball, badminton, climbing, cricket, dance, gymnastics, rugby, soccer, swimming, tennis, and volleyball-may sustain PPSIs involving the shoulder, elbow, hand and wrist, knee, and ankle and foot. Although incidence data from prospective cohort studies are lacking, data arising from cross-sectional studies suggest that PPSIs may be common in select groups of youth athletes-including the shoulder in baseball players (0-36.6%), wrist in gymnasts (10-83%) and platform divers (52.6%), and fingers in rock climbers (5-58%). Notably, not all stress-related skeletal changes detected on imaging were symptomatic in these studies. When diagnosed and treated with an appropriate period of rest and rehabilitation, most patients studied were able to return to their sport activities. However, our data also show that 57/448 PPSIs (12.7%) produced growth disturbance, and that 28/448 patients (6.2%) underwent surgery for their injuries. Absence of treatment, delayed presentation and diagnosis, and non-compliance with a rest regimen were common in cases that produced growth disturbance.

CONCLUSIONS

PPSIs may affect the extremities of children and adolescents engaged in a variety of youth sports, especially at advanced levels of training and competition. Most skeletally immature patients with PPSIs respond well to timely treatment; however, in extreme cases, PPSIs can progress to produce skeletal growth disruption which may necessitate surgical intervention. Clearly, establishing the early diagnosis of PPSIs and providing timely treatment of these injuries are needed to ensure the skeletal health of youth sports participants. Rigorous prospective longitudinal epidemiological and imaging studies designed to provide incidence rates of PPSIs and to determine the effect of PPSIs on long-term skeletal health are also necessary.

The distal radial physis: Exploring normal anatomy on MRI enables interpretation of stress related changes in young gymnasts

Rationale: Explore the MRI-appearance of the healthy distal radial physis and the distribution of stress-related changes in physeal thickness in young gymnasts to aid in the understanding of the pathophysiological process of stress-related physeal injury. Methods: Symptomatic gymnasts with clinically suspected overuse injury of the distal radial physis and age and gender-matched asymptomatic gymnasts and healthy non-gymnasts underwent an MRI-scan of the wrist. A cartilage-specific sequence was used to obtain three-dimensional reconstructions of the distal radial physis. Heat maps and line charts of these reconstructions visualised distribution of physeal thickness per study group and were used to explore differences between study groups. Symptomatic gymnasts displaying the most profound physeal widening (n = 10) were analysed separately. Results: Twenty-seven symptomatic - (skeletal age 12.9 ± 1.5 years), 16 asymptomatic - (skeletal age 12.8 ± 1.9 years) and 23 non-gymnasts (skeletal age 13.6 ± 1.9 years) were included for analysis. Physes of healthy non-gymnasts had a thin centre and increased in thickness towards the borders. Gymnasts demonstrated an increase in thickness of the entire physeal surface. In symptomatic gymnasts increase in physeal thickness was most prominent at the volar side when compared to asymptomatic gymnasts and non-gymnasts. Conclusion: The healthy distal radial physis is characterised by a thin centre surrounded by thicker borders. Stress applied to the wrist during gymnastics causes an overall increase in physeal thickness. Profound thickness increase is present at the volar side of the physis mainly in symptomatic gymnasts. These results can help unravel the pathophysiological mechanism of stress-related physeal injury in gymnasts and aid early injury identification.

It's a thin line: development and validation of Dixon MRI-based semi-quantitative assessment of stress-related bone marrow edema in the wrists of young gymnasts and non-gymnasts

Purpose

To assess reliability and clinical utility of evaluating stress-related metaphyseal water distribution using a semi-quantitative Dixon MRI-based method for early diagnosis of physeal stress injuries in adolescent gymnasts.

Methods

Twenty-four gymnasts with clinically suspected overuse injury of the distal radial physis, 18 asymptomatic gymnasts, and 24 non-gymnast controls aged 12 ± 1.5 years prospectively underwent hand radiographs and 3T MRI of the wrist including coronal T1-weighted and T2-weighted Dixon sequences. Two raters measured metaphyseal water signal fraction in 13 radial and ulnar regions of interest (ROI). Inter- and intrarater reliability, interslice (between 3 middle radial slices), and inter-ROI (between 3 ROIs on same level) reliability were assessed using intraclass correlation coefficients (ICC). Water signal fractions and their within-person ratios in distal versus most proximal ROIs were compared between groups using one-way analysis of variance.

Results

Inter- and intrarater ICCs were 0.79–0.99 and 0.94–1.0 for T1-weighted, and 0.88–1.0 and 0.88–1.0 for T2-weighted Dixon. Interslice and inter-ROI ICCs were 0.55–0.94 and 0.95–0.97 for T1-weighted, and 0.70–0.96 and 0.96–0.97 for T2-weighted Dixon. Metaphyseal water signal fraction in symptomatic gymnasts was higher in six distal ROIs compared with asymptomatic gymnasts and in nine ROIs compared with non-gymnasts (p < 0.05). Metaphyseal water score (ratio of distal versus most proximal ROIs) was 1.61 in symptomatic gymnasts and 1.35 in asymptomatic gymnasts on T2-weighted Dixon (p < 0.05).

Conclusion

Semi-quantitative Dixon MRI-based water signal fraction assessment has good to excellent reproducibility and shows increased metaphyseal water scores in symptomatic gymnasts compared with asymptomatic gymnastic peers.

Key Points

• The proposed Dixon MRI-based semi-quantitative method for assessment of metaphyseal bone marrow water content is reliable, with off-the-shelf availability and short scan times.

• The metaphyseal water score allows comparisons between gymnasts using a within-person reference area for unaffected metaphyseal bone.

• As metaphyseal water score was increased in symptomatic gymnasts compared with asymptomatic gymnasts, this semi-quantitative method can potentially be used as an indicator of bone marrow edema in the early diagnosis of gymnastic physeal stress injury.

Electronic supplementary material

The online version of this article (10.1007/s00330-019-06446-8) contains supplementary material, which is available to authorized users.

Effect of Long-Term Diving on the Morphology and Growth of the Distal Radial Epiphyseal Plate of Young Divers: A Magnetic Resonance Imaging Study

OBJECTIVE

To investigate the effects of long-term diving on the morphology and growth of the distal radial epiphyseal plate in young divers.

STUDY DESIGN

Cohort study.

SETTING

Guangzhou Sport University.

PARTICIPANTS

Thirty-eight professional divers, aged 10 to 17 years, and 25 age-matched volunteers.

INTERVENTIONS

Each subject received a physical examination at the beginning of the study and underwent bilateral magnetic resonance imaging of the wrist. The divers were divided into 2 groups depending on the status of the epiphyseal plate: group A (positive distal radial epiphyseal plate injury) and group B (no positive distal radial epiphyseal plate injury). A third group, group C, consisted of the 25 volunteers.

MAIN OUTCOME MEASURES

The frequency of distal radial epiphyseal plate injury and the thickness of the distal radial epiphyseal plate were analyzed across the 3 groups.

RESULTS

Twenty-nine cases (29/76, 38.15%) of distal radial epiphyseal plate injury were observed in 20 divers (20/38, 52.63%). The incidence of injury to the right hand was higher than that for the left (P = 0.009). There were statistically significant differences (P = 0.000) among the 3 groups in terms of epiphyseal plate thickness; group A > group B > group C.

CONCLUSIONS

Distal radial epiphyseal plate injury is common in divers, and more injuries are seen in the right hand. Moreover, growth of the radius was impaired in divers relative to controls. We consider that loading during diving may influence growth of the epiphyseal plate in either a transient or permanent manner.

Physeal fracture in the wrist and hand due to stress injury in a child climber: A case report

RATIONALE

In competitive athletes, the upper extremity is subject to tremendous torsional forces with axial loading due to repetitive weight bearing. Approximately 25% of injuries in sports are related to the hand or wrist. Skeletal deformity on the wrist physis is common in athletes due to repetitive loading and presents at early ages between 6 and 13 years. Additionally, it is more common in female than in male athletes.

PATIENT CONCERNS

An 11-year-old girl who was a climber complained of pain on her left wrist without direct trauma. She had participated in climbing exercise for several years and had no medical history. Thorough radiological evaluation, we diagnosed physeal injury of the left radius. After healing of the physeal injury of the radius, she complained of pain on fourth finger of right hand and radiographs revealed physeal injury of the right fourth finger.

DIAGNOSIS

Radiographs revealed physeal injury of the left radius. Magnetic resonance imaging revealed epiphyseal widening of the radial aspect of the wrist and bone marrow signal increase on T2-weighted imaging. Likewise, radiographs showed physeal injury of the right fourth finger INTERVENTIONS:: No surgery was performed and we applied wrist brace and finger splint for conservative treatment.

OUTCOMES

The patient's pain was immediately relieved. The patient had no complications or recurrence of symptoms and was undergoing regular check-ups every 6 months.

LESSONS

During climbing exercise, repeated high pressure causes damage of the hand and wrist joints in young patients. Chronic pain in this group must be carefully evaluated, and radiographs should be obtained for diagnosis and early treatment. Conservative treatment of these injuries has good results, and avoiding intensive power training avoids the risk of this injury.

Upper Extremity Injuries in Gymnasts

Gymnastics is a unique sport, which loads the wrist and arms as weight-bearing extremities. Because of the load demands on the wrist in particular, stress fractures, physeal injury, and overuse syndromes may be observed. This spectrum of injury has been termed "gymnast's wrist," and incorporates such disorders as wrist capsulitis, ligamentous tears, triangular fibrocartilage complex tears, chondromalacia of the carpus, stress fractures, distal radius physeal arrest, and grip lock injury.

FREQUENCY OF WRIST GROWTH PLATE INJURY IN YOUNG GYMNASTS AT A TRAINING CENTER

Objective:

To assess the frequency of physeal injuries and wrist pain in young competitive gymnasts according to their training characteristics.

Methods:

This is a cross-sectional study (January-June 2015) of a male gymnastics team in São Paulo, SP, Brazil. Nineteen gymnasts, mean age 13.3 years, were evaluated in three ways: a questionnaire, physical examination and radiographs.

Results:

On average, they trained since 6 years-old and during hours per week. Eighty-two percent had wrist pain and 65% had wrist physeal injury. The pain was worse in practitioners of (82%) and soil (17%) exercises. A greater frequency of physeal injury was found in those with more years of training and higher weekly working hours, wrist pain was more frequent in those with higher weekly working hours, and a decreased range of motion was observed in those with physeal injury, results statistically significant.

Conclusions:

We found that 65% of gymnasts had wrist physeal injury and 82% had wrist pain. There were statistically significant relationships between physeal injury and years of training, physeal injury and weekly working hours, pain and weekly working hours, and physeal injury and range of motion. Level of Evidence IV, Case Series.

Physeal arrest of the distal radius

Fractures of the distal radius are among the most common pediatric fractures. Although most of these fractures heal without complication, some result in partial or complete physeal arrest. The risk of physeal arrest can be reduced by avoiding known risk factors during fracture management, including multiple attempts at fracture reduction. Athletes may place substantial compressive and shear forces across the distal radial physes, making them prone to growth arrest. Timely recognition of physeal arrest can allow for more predictable procedures to be performed, such as distal ulnar epiphysiodesis. In cases of partial arrest, physeal bar excision with interposition grafting can be performed. Once ulnar abutment is present, more invasive procedures may be required, including ulnar shortening osteotomy or radial lengthening.

Taking the stress out of evaluating stress injuries in children

Pediatric stress injuries result from a mismatch between (a) the burden of activity on growing bone and cartilage and (b) their intrinsic biomechanical properties. Although the presentation of stress injuries varies with the specific physical activity and the site of injury, in children it varies primarily with the degree of skeletal maturation. During the past several years, there has been a substantial increase in the incidence of pediatric stress injuries. The differential diagnosis of a stress injury in a child or adolescent can be challenging because the injury sometimes can appear aggressive at imaging assessment. Awareness of the spectrum of imaging features of stress injuries can help the radiologist to reach the correct diagnosis and prevent unnecessary anxiety. This review depicts the range of stress injuries in children and adolescents in various anatomic locations, with emphasis on their appearances at magnetic resonance imaging.

Physeal injuries in children's and youth sports: reasons for concern?

A systematic review of the literature on the frequency and characteristics of sports related growth plate injuries affecting children and youth in organised sport was carried out. Both acute and chronic physeal injuries related to participation in sports have been reported to occur, although injury incidence data are somewhat limited. Of particular concern is the growing number of stress related physeal injuries, including those affecting the lower extremities. Although most physeal injuries appeared to resolve with treatment and rest, there is also evidence of growth disturbance and deformity. Possible injury risk factors and countermeasures are discussed, and suggestions for directing future research provided.

Imaging of upper extremity stress fractures in the athlete

Although it is much less common than injuries in the lower extremities, an upper extremity stress injury can have a significant impact on an athlete. If an accurate and timely diagnosis is to be made, the clinician must have a high index of suspicion of a stress fracture in any athlete who is involved in a throwing, weightlifting, or upper extremity weight-bearing sport and presents with chronic pain in the upper extremity. Imaging should play an integral role in the work-up of these patients; if initial radiographs are unrevealing, further cross-sectional imaging should be strongly considered. Although a three-phase bone scan is highly sensitive in this regard, MRI has become the study of choice at most centers.

Wrist pain, distal radial physeal injury, and ulnar variance in the young gymnast

In gymnastics, the wrist joint is subjected to repetitive loading in a weightbearing fashion. In this setting, chronic wrist pain is quite common. Because gymnasts ordinarily enter the sport at very young ages and train for several years before skeletal maturity is attained, the growth plates of the wrist are at risk for injury. In addition, imaging studies have identified evidence of injury to the distal radial physis and the development of positive ulnar variance. Recent studies provide more information on the relationships between these findings, as well as factors that may predispose some gymnasts to wrist pain. This article provides a comprehensive review of these issues and offers suggestions for management, preventive measures, and future research.

Upper Extremity Stress Fractures

Although less common than lower-extremity stress fractures, upper-extremity stress fractures are becoming recognized much more frequently. A majority of these fractures are caused by overuse and fatigue of the surrounding musculature and, as a result, may be prevented by appropriate training and conditioning. Diagnosis is made by history and physical examination with the aid of plain radiographs, bone scans, and MRI. Most of these fractures heal with a period of relative rest followed by a structured rehabilitation program. A small percentage of these fractures, however, may require surgical fixation. The present article reviews the different types of upper extremity and torso stress fractures seen in athletes, starting with the sternum and extending outward to the fingers. The presentation, diagnosis, mechanism of injury, treatment, prevention, and prognosis for each of these injuries will be discussed.

A Comparison of Upper-Extremity Reaction Forces between the Yurchenko Vault and Floor Exercise

The purpose of this study was to examine reaction forces transmitted to the upper extremities of high-level gymnasts during the round-off phase of the Yurchenko vault. A secondary purpose of this study was to compare reaction forces during the Yurchenko vault to reaction forces observed in a tumbling pass during the floor exercise. Ten high-level, female gymnasts volunteered to participate. Conditions of the independent variable were the Yurchenko vault and floor exercise; dependent variables were peak vertical and peak anterior-posterior reaction forces. Each participant performed three trials of both conditions with the trail hand contacting a force platform. Vertical and anterior-posterior reaction forces, normalized to body weight, were greater (p < 0.05) during the round-off phase of the Yurchenko vault (2.38) than during the floor exercise round-off (2.15). Vertical reaction forces during the round-off phase of the Yurchenko vault and floor exercise round-off are similar to reaction forces transmitted to upper extremities during other gymnastic skills and ground reaction forces transmitted to lower extremities while running and walking at various speeds. Results of this study reveal a need for further research considering methods aimed at reducing reaction forces transmitted to the upper extremities during the Yurchenko vault and floor exercise. Key PointsDespite high difficulty and increased risk, a dearth of information exists concerning reaction forces transmitted to upper-extremities of high-level gymnasts performing the Yurchenko vault.Reaction forces experienced by high-level gymnasts performing the Yurchenko vault are relatively high; aforementioned forces are comparable to forces transmitted to lower-extremities during various activities and may be responsible for upper-extremity injury.Reaction forces observed during this study will serve as a baseline in the evaluation of methods purporting to reduce forces transmitted to upper-extremities during the Yurchenko vault.

Wrist pain, distal radial physeal injury, and ulnar variance in young gymnasts: does a relationship exist?

BACKGROUND

Chronic wrist pain affects up to 79% of young gymnasts. Distal radial growth plate injury and positive ulnar variance have also been reported in this population.

HYPOTHESIS

There is a relationship between wrist pain, radiographic findings of distal radial growth plate injury, and ulnar variance in skeletally immature young gymnasts.

STUDY DESIGN

Cross-sectional study.

METHODS

Fifty-nine gymnasts (28 girls and 31 boys; average age, 9.3 years) completed a questionnaire detailing training and wrist pain symptoms. Each received a wrist examination, grip strength measurement, and bilateral wrist radiographs.

RESULTS

Wrist pain was reported by 56% of the gymnasts (33 of 59), with 45% (15 of 33) describing pain of at least 6 months' duration. Factors significantly associated with wrist pain included higher skill level, older age, and more years of training. For those between 10 and 14 years of age, 83% had wrist pain, compared with 44% for those outside of that age range. Fifty-one percent of the gymnasts (30 of 59) had findings of stress injury to the distal radial physis of at least a grade 2; 7% (4) had frank widening of the growth plate. Wrist pain prevalence was significantly related to the grade of radiographic injury. Mean ulnar variance was significantly more positive than established norms. Ulnar variance was not associated with wrist pain or radiographic injury of the distal radial physis.

CONCLUSIONS

Radiographic findings of distal radial physeal injury are associated with wrist pain among young nonelite gymnasts.

Stress fracture of the ulna associated with crutch use

Stress fractures of the ulna are extremely rare. The purpose of this article is to report one more case of this occurrence in an eleven-year-old girl, who was using adjustable metal crutches, and to discuss the possible cause.

Salter-Harris III stress fracture of the proximal first metatarsal: a case report

An intraarticular, dorsal, proximal epiphyseal stress fracture (Salter-Harris III) of the first metatarsal was identified in a 14-year-old boy. Successful fracture healing was achieved with a rocker sole shoe modification and activity limitation.

Stress fractures of the upper limb

Stress fractures are commonly found in the lower limb, but also occur in the upper limb, and are particularly associated with upper limb-dominated sports such as tennis and swimming and those involving throwing activities. Stress fractures of the clavicle and scapula are rare but have been reported, whereas those of the humerus are more frequent and have been described mainly in adolescent baseball pitchers. Olecranon stress fractures occur in throwers and gymnasts. Stress fractures of the ulna and radius have also been reported in a number of different upper limb-dominated sports. In all cases, these fractures heal with conservative management. The physician should consider stress fracture as a possible diagnosis in cases of upper limb pain of bony origin where the pain is associated with overuse.

Gymnastic wrist injuries

Wrist injuries in the gymnast are due to the transformation of the upper extremity into a weight bearing entity. Both acute and chronic disorders occur and are difficult to manage in these athletes because of the intensity of training and competition. Treatment is dependent on the injury as well as the expectations of the patient, coach, and family--a situation that at times may alter the usual management program.

Distal radial growth plate injury and positive ulnar variance in nonelite gymnasts

To assess the prevalence of stress injury to the distal radial growth plate and of positive ulnar variance in a nonelite gymnast population, we administered a radiographic survey and questionnaire to 44 skeletally immature nonelite gymnasts (27 girls and 17 boys). The subjects trained an average of 11.9 hours per week. Radiographic findings consistent with stress injury of the distal radial physis were found in 25% (11 of 44) of participants. Ulnar variance was found to be more positive in the gymnasts when compared with age-predicted norms. An average side-to-side difference in ulnar variance of 0.9 mm was observed. Radiographic findings of stress injury to the growth plate and the amount of ulnar variance were not associated with age, sex, training intensity, wrist pain, height, or weight. There was also no significant relationship between ulnar variance and radiographic findings. The mean ulnar variance in nonelite gymnasts was between that measured for elite gymnasts and nongymnasts. These results indicate that stress injury of the distal radial growth plate occurs in a significant percentage of nonelite gymnasts. It also appears that ulnar variance is more positive than would otherwise be predicted, suggesting growth inhibition of the distal radius, a growth stimulation of the ulna, or a combination of both.

Wrist pain in a young gymnast: unusual radiographic findings and MRI evidence of growth plate injury

A 10-yr-old gymnast, training well below the elite level, reported a 3-wk history of bilateral dorsal wrist pain. Physical examination and radiographic findings were consistent with stress injury to the distal radial growth plates. The patient's radiographs also displayed rare findings including cleft radial and ulnar epiphyses, as well as epiphyseal spur formation. Magnetic resonance imaging (MRI) demonstrated evidence of metaphyseal and epiphyseal ischemia of the growth plate. The patient responded well to conservative treatment, including ice, splinting, and activity modification. This case illustrates several potentially confusing radiographic abnormalities and the emerging role of MRI in evaluating wrist pain in young gymnasts.

Stress fractures in skeletally immature patients

Stress fractures are a common injury in an active population. As children become increasingly involved in organized sports, the recognition of stress fractures and differentiation from infections or neoplasms requires a knowledge of their most common sites, presentation, and clinical course. We retrospectively reviewed 34 stress fractures in 32 skeletally immature patients from June 1977 to May 1993. Age, fracture location, treatment, time to union or healing, associated conditions, complications, radiographs, and clinical outcome were recorded. Fifty percent of patients were involved in sports; the most common complaint was pain with activity. The most common site was the tibia (47%) followed by the fibula (21%) and femur (12%). All had resolution of symptoms and returned to normal activity. All but two healed with either activity modification or cast immobilization. The radiographic findings included early periosteal callus formation that rapidly consolidated to new bone on serial studies. A careful history, physical examination, and radiographs can help diagnose most common stress fractures in the skeletally immature individual and can differentiate stress fractures from infection or neoplasm with appropriate conservative treatment.

Factors associated with wrist pain in the young gymnast

We conducted a cross-sectional survey of 52 nonelite gymnasts (32 girls, 20 boys; average age, 11.8 years) to assess their history of training and wrist pain within the last 6 months. An intensity index was created using the number of training hours per week and the athletes' skill levels. Wrist pain was prevalent in 38 (73%) of the gymnasts. Gymnasts with wrist pain were older (12.6 years versus 9.7 years; P = 0.0002), trained more hours per week (13.5 versus 7.7; P = 0.0002), trained at a higher skill level (P = 0.01), and began training at an older age (7.0 years versus 5.1 years; P = 0.006). Analysis of intensity versus age suggested that a threshold of training intensity may be important in the development of wrist pain. Logistical regression found these factors to be independently associated with wrist pain: intensity (P = 0.036), age > 10 years (P = 0.018), age < 14 years (P = 0.016), and the age of initiation of training (P = 0.020). This study demonstrates that wrist pain is a common problem among nonelite young gymnasts. Training intensity, relative to the age of the participant and the age when training was initiated, appears to be an important determinant of the development of wrist pain in this population.

Gymnast wrist: an epidemiologic survey of ulnar variance and stress changes of the radial physis in elite female gymnasts

The ulnar variance in female gymnasts attending the World Championship Artistic Gymnastics Rotterdam 1987 was measured. There was a marked increase in the ulnar length in adult as well as immature gymnast compared with nonathletes. The changes in relative ulnar length were correlated to weight, height, and skeletal age of the athletes. In 10% of the gymnasts' wrists we noted so-called "stress-related changes" of the distal physis of the radius. Repetitive injury and compression of the wrist leads to a premature closure of the distal radial growth plate resulting in secondary ulnar overgrowth.

Wrist injuries in sport

The wrist is a complex joint that biomechanically transmits forces generated at the hand through to the forearm. The radial side of the wrist carries 80% of the axial load and the ulnar side the remaining 20% of the load. The incidence of wrist (and hand) injuries in the sporting population is approximately 25%. This tends to be higher in those sports using the hand and wrist, and when the potential for trauma is present. The injuries are divided into 4 categories: overuse, nerve (and vascular), traumatic, and weight-bearing injuries. Overuse injuries are common in sports involving the hand and wrist, such as racquet sports, netball, basketball and volleyball. Nerve injuries are more commonly compressive neuropathies, and are seen with cyclists who may compress the ulnar nerve in Guyon's canal. Vascular injuries are uncommon and usually result from a high velocity impact from balls. Traumatic injuries are the most common and are due to either a fall on to the wrist, a direct blow, or combination of a rotatory and torsional force. The weight-bearing injuries are more specific to gymnastics, and result from repetitive excessive compressive and rotational forces across the wrist. The pommel horse event is associated with a high incidence of wrist pain in male competitors. Arthroscopy of the wrist provides direct inspection of intra-articular structures and diagnosis of conditions that may be unclear with other investigations. As techniques advance, more conditions may be treated arthroscopically and potentially facilitate an earlier return to sport.

Stress changes of the distal radial growth plate. A radiographic survey and review of the literature

We conducted a radiographic survey to determine skeletal age and the nature and prevalence of stress-related changes affecting the distal radial growth plate in 60 young competitive gymnasts (39 females, 21 males). Comparison of results for chronological and skeletal age revealed a significant delay in maturation for girls (P less than 0.001). Radiographic evaluation revealed 5 gymnasts (4 girls and 1 boy) with stress-related changes of the left wrist, and four of these were considered to be minimal. These results, in conjunction with our previous findings and the review of related literature, reveal three important observations. First, the widening and irregularities of the distal radial physis that we described previously appear to be the first in a spectrum of abnormal changes secondary to overuse and probably represent a stress fracture of the distal radial growth plate. The radiographic changes associated with this injury are not the normal adaptive changes seen in young, competitive gymnasts. Secondly, more serious long-term abnormality may result even though the injury may initially resemble a Salter-Harris type I or II stress fracture. Long-term complications may include symmetrical or asymmetrical retardation or halted growth at the affected site, positive ulnar variance, and associated pathoanatomic sequelae. Thirdly, the incidence of distal radial growth plate stress injury remains unclear; we recommend a further, large-scale prospective epidemiologic study involving both male and female gymnasts. We urge that physicians and other health professionals associated with gymnastics clubs educate coaches about the possibility of significant injury to the distal radial physis, risk factors, and suggested preventive measures.

Stress Fracture of the Distal Radius

In brief A 14-year-old female gymnast reported pain at the dorsum of her right wrist. Physical examination and radiographs suggested a stress fracture of the wrist physis-an injury reported most often in highly competitive, advanced gymnasts. Radiographs revealed marked widening of the growth plate and haziness within the epiphyseal plate. Treatment involved immobilization of the patient's wrist for 7 weeks until radiographic abnormalities reversed, and physical therapy for 2 weeks to increase wrist flexibility and strength.

Gymnastic injuries

In the past 15 to 20 years gymnastics has become very popular. The increased participation exposes a greater number of athletes to potential injury. The risk of gymnastic injuries seems to be proportional to the level of the athletes; the higher the level of gymnastics, the more hours are spent in practice, with a greater exposure time. With the increased risk in gymnastics, the incidence of acute injuries will also increase, and as the skill level increases, the load during the workout will also increase, providing more opportunity for chronic injuries. As in many sports, the ankle is the most injured body part. Some injuries, however, seem to be specific to gymnastics. In gymnastics the upper extremities are used as weightbearing limbs, so high impact loads are distributed through the elbow and wrist joint. Back problems appear to result not only from single episodes of macrotrauma, but also from repeated microtrauma caused by specific impact loads during vaults and hyperextension. Early detection is the key to treating elbow, wrist and back pain in the gymnast. Reinjury following an acute injury may be reduced by allowing for complete rehabilitation before returning to full practice. Some studies indicate that maturation rate could play a potential role in injury predisposition. The combination of periods of rapid growth and intense training could provide for conditions where the gymnast is more injury prone.

Stress changes of the wrist in adolescent gymnasts

The radiographic appearances are reported of chronic stress to the wrist joints of eight adolescent males, seven gymnasts and one roller skater. These consist of bilateral, asymmetrical widening and irregularity of the distal radial growth plates with an ill-defined cystic appearance, sclerosis and flaring of the metaphyses in all eight cases. Similar but less marked changes were present in the distal ulnar growth plates in five cases. The aetiology is thought to be that of a Salter Type I stress fracture of the growth plate due to chronic repetitive shear forces applied to the hyperextended wrist joint. Rapid healing of the stress fracture will occur with cessation of the sporting activity but continued strenuous use of the wrists will result in further widening and irregularity of the growth plate. The differential diagnosis of the radiographic appearances and previous literature are discussed.

Stress fracture of the ulnar diaphysis: review of the literature and report of a case

A 22-year-old athlete developed chronic pain in the forearm aggravated by weight lifting. Physical examination revealed localized tenderness at the junction of the middle and distal third of the ulnar diaphysis. X-ray films revealed an osteolytic lesion at the same level. The patient developed an overt fracture at the same site when he failed to stop sports activities against advice. The fracture healed uneventfully with immobilization in a sleeve cast.

Injury prediction in female gymnasts

In order to identify injury-proneness in female competitive gymnasts, 20 measures of flexibility, hypermobility, spinal posture and anthropometry were performed on 40 competitive gymnasts and injury scores were derived from the severity and extent of previous gymnastic injury and inherent hypermobility traits. Results were compared between contrasting groups of "low" and "high" injury gymnasts respectively (both N = 10). Nine variables demonstrated significant differences between the "low" and "high" injury risk status groups namely, weight (p less than 0.001), height (p less than 0.001), age (p less than 0.001), mesomorphy (p less than 0.01), Quetelet Index (p less than 0.01), shoulder flexion (p less than 0.05) and lumbar extension (p less than 0.05), standing lumbar curvature and total peripheral flexibility score (both p less than or equal to 0.05). Multiple regression analysis was applied to determine the relative contribution of these variables to the estimation of injury-proneness as evidenced by previous history of injury and hypermobility traits. Using 9 independent variables, multiple regression yielded a multiple correlation coefficient (R) = 0.840, accounting for over 70% of the observed variance (R2 = 0.706) in injury scores among the total group of gymnasts. However, a subset of five variables, (weight, mesomorphy, standing lumbar curvature, age and height) yielded a multiple correlation coefficient (R) = 0.834 accounting for almost 70% of the observed variance (R2 = 0.696). This was not significantly different from the larger subset. Using injury classification system of "low", "medium", and "high" risk categories, comparisons were made between predicted and observed injury scores in the respective risk categories. In "high" risk and "low" risk gymnasts, injury scores could be classified correctly with 70% and 79% accuracy respectively, so that relative risk status could be determined from simple physical tests which may be employed by practitioners in the field.

Stress changes of the distal radial epiphysis in young gymnasts. A report of twenty-one cases and a review of the literature

Between 1980 and 1983, 21 young, high-performance gymnasts with stress changes related to the distal radial epiphysis, were treated and followed for a mean of 24 months (range, 6 to 42 months). Eleven of the gymnasts presented with roentgenographic changes of the distal radial epiphysis, and in these recovery took at least 3 months. This group was compared to a group of ten gymnasts who had similar symptoms but no roentgenographic changes, and who recovered within an average of 4 weeks. The roentgenographic changes, which are described in detail, are considered to represent stress changes, possibly stress fractures, of the distal radial epiphysis. No residual growth-related problems have been observed. Possible etiologic factors are discussed, and the literature as it pertains to stress-related adaptation and injury in the growing athlete is reviewed.