WRIST PAIN IN A GYMNAST WITH PRIMARY AMENORRHEA

Abstract

285 DIFFERENTIAL DIAGNOSIS: Wrist pain Distal radius physeal stress reaction Triangular fibrocartilage complex tear Ulnar impaction syndrome Carpal impingement Delayed Menarche Hypothalamic cause (Exercise associated amenorrhea (EAA)) Consitutional delay Ovarian failure Thyroid disease Prolactinoma TESTS AND RESULTS: Bilateral wrist x-rays Open growth plates consistent with bone age of 11-12 yo Non-union of left ulnar styloid Positive ulnar variance Cyst on distal ulnar and raidal physes Sclerosis of distal radial physes Suggestion of widening of radial aspect of distal radial physes FSH: 8 mIU/ml Estradiol: 61 pg/ml TSH: 2 mIU/ml Chemistry panel and CBC: WNL DEXA: Borderline osteopenia of femoral neck FINAL WORKING DIAGNOSES: Delayed menarche secondary to EAA and constitutional delay Distal radius physeal stress reaction with positive ulnar variance Ulnar impaction syndrome Possible right TFCC tear TREATMENT: A trial of decrease upper extremity weight bearing. Wear wrist extension blocking brace. Consider surgical options after further evaluation and a trial of conservative treatment. Monitor menstrual cycles. Review diet for adequate intake of calories, calcium and vitamin D HISTORY: A 18 year old elite female gymnast presents for preparticipation physicals without any complaints. Her medical history reveals that she has not yet undergone menarche. She denies a history of disordered eating behaviors and stress fractures. She has been a gymnast for 13 years and trains 20 hrs/wk. Orthopedic history is significant for ankle arthroscopy for loose body removal in 1994 and rotator cuff tear and repair in 1996. Review of systems is unremarkable for temperature intolerance, bowel changes, palpitations, dry hair or skin, nipple discharge, headaches, visual changes, male pattern hair growth or acne. No history of abdominal or pelvic pain. She is not sexually active. PHYSICAL EXAMINATION: Ht: 4 ft 10 in Wt: 98 lbs VS: WNL Thyroid: WNL Breasts: Tanner stage 3 Skin: No male pattern hair growth, acne or striae Wrists: Marked prominence of the distal ulnas; bilateral diffuse tenderness of the distal ulna and radius and ulnocarpal joint; radioulnar joint nontender; pain reproduced with wrist extension and axial loading; limited extension to 50 degrees bilaterally; audible click with right ulnar deviation; no other bony tenderness. Pelvic: Tanner stage 3; WNL (Note: Menarche occurred prior to the pelvic exam which was performed subsequent to PPE.) HISTORY: (Additional history was sought due to abnormal physical findings) Despite not offering a history of wrist pain, she admitted to having wrist pain for many years and felt it was slowly worsening. Pain occurs with vaulting, tumbling and uneven bar skills that require an inverted grip (extreme wrist pronation and ulnar deviation). She was told that "she may have a problem with her growth plates" following x-rays 8 months ago.