Radial Epiphyseal Stress Reaction

Original Editor - Trista Chan
Top Contributors - Trista Chan and Carina Therese Magtibay

Introduction

Radial epiphyseal stress reaction is a common overuse injury affecting skeletally immature athletes engaged in high-impact sports. It is particularly common among gymnasts, thus it is also known as the ‘gymnast’s wrist’. It is found that up to 32-73% of youth athletes are affected by wrist pain from overuse injuries, and 15% of which involves the growth plate.

Clinically Relevant Anatomy

 Radial epiphyseal stress reaction involves the distal radial physes (also called growth plates), which is located at the end of the long bone where secondary ossification centres for growth and development occur . The growth plates are especially susceptible to injuries in children and adolescents, but most commonly in children between 10-14 years old. <be>

Mechanism of Injury / Pathological Process

Activities that put repetitive compressive, shearing, distraction and torsional forces through the distal radial growth plates, such as handstands, cartwheels and handsprings, increase the risk of growth arrest in this population.

Clinical Presentation

Gymnast wrist often presents as pain, swelling, tenderness, limited range of motion and wrist instability during physical examination. Palpation along the distal radius growth plate and over dorsal rim radius often reproduce pain. Patients often report symptoms being aggravated by weight-bearing activities or impact-related activities.

Diagnostic Procedures

Diagnostic procedures for gymnast wrist typically involve a combination of clinical reasoning and imaging findings. Clinical assessment includes comprehensive medial history, patient-reported symptoms and physical examination. The athlete is then often referred for a radiographic or MRI scan if injury to the growth plate is suspected. Diagnostic criteria include:

• widening of the growth plate in the palmar and radial side.
• cystic changes in the metaphysis
• beaked appearance of the distal palmer and radial parts of the growth plate,
• blurry appearance within the growth plate

Outcome Measures

• Patient Specific Functional Scale
• Visual Analogue Scale
• Faces Pain Scale for younger children
• DASH Outcome Measure

Management / Interventions

Management of the gymnast wrist often involves a multidisciplinary team including orthosurgeons, peadiatricians, physiotherapists, and coaches. Patients with epiphyseal injury may be managed conservatively or surgically, depending on severity of the imaging findings, individual factors and goals.

Conservative management

Physiotherapists play an important role in conservative management which includes rest and immobilization with splints or casts.

Advice and education regarding activity modification is also important to maintain function. When pain and symptoms subside, exercise should be implemented in their management plan to help improve strength, range of motion and motor control. This generally takes 4-6 weeks but can also last up to 3-5 months, until the athlete can gradually return to training if their symptoms continue.

Physiotherapist should work closely with the patient, their coaches and other members of the multidisciplinary team to ensure early goal setting and safe return to sports, as well as providing guidance in self-management.

Medical management

The patients should be referred for medical consults if a fracture is suspected. Orthopedic surgeons are responsible in assess the severity of the wrist injury, order appropriate imaging tests such as, X-rays, CT, MRI. Based on the imaging findings, individual factors, and goals, they may recommend whether conservative management or surgical intervention is necessary. If surgery is required, orthopedic surgeons perform procedures such as arthroscopy, osteotomy, or fixation to address the injury. They may also provide guidance on post-operative care and rehabilitation protocols.

Differential Diagnosis

• Salter Harris stress fracture
• Distal radius fracture
• Keinbock's disease
• Joint instability