Gymnast’s Wrist Gone Wrong

Abstract

HISTORY: A 13-year-old, level 8 gymnast presented for evaluation of left wrist pain that began two months prior during gymnastics without inciting trauma. Pain was located circumferentially about the wrist with occasional pain in the hand, fingers, and forearm as well. Pain initially occurred only with weight bearing through the wrist but now was present even at rest. There was no numbness, tingling, weakness, or mechanical symptoms. PHYSICAL EXAMINATION: Examination revealed mild tenderness over the distal radius, anatomic snuffbox, and scapholunate interval. Range of motion, strength, and sensation were intact. TFCC compression test was negative. DIFFERENTIAL DIAGNOSIS: 1. Gymnast’s wrist 2. Scaphoid fracture 3. Ganglion cyst TESTS AND RESULTS: Left wrist radiographs (AP, lateral, oblique) 8/21/20: –mild sclerosis about the distal radial physis Left wrist MRI 9/11/20: –lunate subchondral edema. Subsequent Left wrist MRI 2/3/21: –ulnar positive variance with close apposition of the ulna and lunate –bone marrow edema of the lunate and less so triquetrum –TFCC displaced and stretched due to the ulnar positive variance –extensor carpi ulnaris tendon subluxed Bilateral wrist films in pronation and supination 2/22/21: –positive ulnar variance and some fusion of the distal radius growth plate, greater on the left FINAL/WORKING DIAGNOSIS: Lunate stress reaction, ulnar impaction secondary to distal radius growth arrest TREATMENT AND OUTCOMES: 1. Rest and as-needed brace use was followed for 6.5 weeks. 2. Patient returned to gymnastics on own despite unresolved pain. 3. Repeat MRI revealed continued lunate edema and positive ulnar variance. 4. Referred to pediatric orthopedic surgeon to discuss surgical options. 5. Bilateral wrist radiographs revealed more prominent ulnar positive variance and more progressed distal radius physis closure on the affected side. 6. Pursued surgical correction with ulna shortening osteotomy, distal ulna and radius epiphysiodesis. 7. Post-operatively was in a short arm cast for 9 weeks, after which she started hand therapy. 8. At 3.5 months post-operatively, was allowed to do conditioning and range of motion but continue to refrain from high impact activity to the wrist. 9. Was allowed full return to gymnastics 6.5 months post-operatively with further follow up as needed.