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Wrist Injuries in the Immature Athlete
Wrist Injuries in the Immature Athlete Scott H. Kozin, MD,*,† and Joshua M. Abzug, MD‡ The pediatric skeleton has abundant cartilage and thick periosteum shield that protect the immature athlete. Injuries can still result from excessive overuse or overt high energy trauma. This article will focus on injuries about the pediatric wrist primarily distal radius physeal stress syndrome, ulnar abutment syndrome, scaphoid fractures, and distal radius growth arrest. The diagnosis of these entities along with treatment options will be discussed. Surgical techniques to remedy these difficult problems will be highlighted. Published outcomes after the various surgical procedures will also be reviewed. Oper Tech Sports Med 24:148-154 C 2016 Elsevier Inc. All rights reserved. KEYWORDS wrist injuries, gymnast, growth plate, physeal stress syndrome, fracture, scaphoid, nonunion
Introduction
T
he pediatric skeleton has unique anatomical qualities that protect the immature athlete. The abundant cartilage and thick periosteum shield the underlying bone from everyday stress. However, the increasing demands and activities of the modern day immature athlete test the boundaries of these defensive assets. Injuries result from excessive overuse or overt high-energy trauma or both. Upper extremity injury can affect the shoulder, elbow, forearm, wrist, or digits. Overuse is widespread in sporting activities that require upper extremity weight bearing such as gymnastics and competitive cheerleading. Trauma is prevalent in contact athletics and extreme sports such as mountain bike riding. This article focuses on injuries about the pediatric wrist with an emphasis on diagnosis, treatment, and outcome.
Pertinent Anatomy The pediatric skeleton has many distinctive features compared with adults. Most important is the presence of the physis or growth plate that is divided into 4 distinct zones: germinal, proliferative, hypertrophic, and provisional calcification. *Department of Orthopaedic Surgery, Temple University, Philadelphia, PA. †Shriners Hospitals for Children, Philadelphia, PA. ‡Department of Orthopaedics, University of Maryland Children's Hospital, University of Maryland, Timonium, MD. Address reprint requests to Scott H. Kozin, MD, Department of Orthopaedic Surgery, Shriners Hospitals for Children, 3551 North Broad St, Philadelphia, PA 19140. E-mail: [email protected]
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Approximately 75%-80% of forearm growth and 40% of the entire upper extremity growth occurs at the distal radius and distal ulna physes.1 The distal radial physis closes at approximately 16 years of age in girls and 17 years of age in boys.2 As the hypertrophic and provisional calcification zones are relatively weaker when compared with the germinal and proliferative layers,3,4 fracture lines tend to pass through these zones. However, high-energy athletic injuries may have fractures that undulate through all 4 zones and cause substantial growth plate damage. The existence of secondary ossification centers is another distinctive feature. The distal radius epiphysis is absent at birth and appears at approximately 1 year of age. Precisely, the appearance is between 0.5 and 2.3 years in boys and between 0.4 and 1.7 in girls.5 The configuration of the epiphysis also changes with age. The initial epiphysis is transverse in shape and becomes more triangular with time. When there is uncertainty about the normal appearance of the radial epiphysis and the presence of a fracture or growth plate abnormality, comparison x-rays, or consulting a skeletal atlas is essential. The anatomy of the immature scaphoid warrants conversation. The scaphoid develops by endochondral ossification with the ossific nucleus first appearing in the distal pole, typically between 4 and 5 years of age. The bone ossifies from distal to proximal along the primary blood supply, which comes from a branch of the radial artery at the dorsal ridge. Ossification is usually complete between 13 and 15 years of age.6 As the ossification front travels in a proximal direction, there is a relative weakness at the interface between the ossified and nonossified scaphoid.
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Growth Plate Damage Distal Radial Physeal Stress Syndrome Persistent upper extremity weight bearing activities can directly damage the growth plate. The unrelenting stress across the physis produces destructive forces that damage the immature growth plate. The Heuter-Volkmann principle states that the rate of epiphyseal growth is affected by pressures applied to its axes.7 Increased pressure inhibits growth, whereas a decreased pressure accelerates growth. Regarding the gymnast, the former predominates with supraphysiological loads inhibiting growth of the distal radial physis. Early symptoms and signs are pain during exercise and localized tenderness, which are often ignored given the stoic nature of these athletes. Persistent pain and inability to compete would ultimately lead to medical attention being pursued. In addition to the standard history of present illness questions, specifics regarding the number of practice hours performed during a typical week, which specific upper extremity weight bearing activities are being performed, the competition level, and upcoming competitions are important questions that should be asked. In the higher level competitors, the intensity and dedication are often astounding, with 20-30 hours of practice being common. The examination includes assessment of the entire upper extremity from the neck to the finger tips. Specifics regarding the wrist examination include palpation, assessing the range of motion when compared with the contralateral side, and provocative tests for instability. Tenderness about the growth plate is the classic finding with slight loss of wrist motion also typically being present. Frequently, the hands are calloused with normal digital range of motion and exceptional strength. Posteroanterior (PA) and lateral radiographs should routinely be obtained. Classic radiographic findings include physeal wideninig with an irregular appearance because of the repetitive stress and overloading(Fig. 1).8 Additionally, there may be Harris Growth arrest lines consistent with previous trauma.
Treatment requires immobilization, and the athlete needs to “shut down” from all upper extremity weight bearing activities to prevent permanent growth plate injury from occurring. Immobilization can be in the form of a short arm cast or removable splint depending on the perceived trustworthiness of the athlete. He or she can maintain his or her aerobic fitness, but must avoid strenuous load going across the wrist. The exact duration of immobilization and abstinence is unknown. Our practice is to treat physeal stress injuries similar to fractures with immobilization periods of 4-6 weeks dependent on the age of the athlete. Subsequently, return to upper extremity weight bearing activities is delayed until full range of motion has been regained. Afterward, graduated weight bearing is instituted with participation excluded following any recurrence of signs or symptoms.
Ulnar Abutment Syndrome Chronic overloading of the distal radius can result is persistent inhibition of distal radial growth, thus leading to ulnar positive variance, and ultimately ulnar abutment syndrome. The pain about the distal ulna is exacerbated by ulnar deviation or shucking of the distal radioulnar joint or both. A concomitant triangular fibrocartilage complex (TFCC) tear can also be present. Plain PA x-rays of the wrist in neutral forearm rotation allow for assessment of the ulnar variance. Typically, apart from positive ulnar variance, Harris Growth arrest lines may be seen in the metaphysis of the radius. Initial management is nonoperative with rest and immobilization. A corticosteroid injection may be provided in case of persistent pain. Recalcitrant symptoms warrant a candid discussion regarding future sports participation and surgical options. Surgical treatment should address any intra-articular pathology such as a TFCC tear. In child with some skeletal growth remaining, ulnar abutment can be addressed by performing a distal ulnar epiphysiodesis, allowing radial growth to result in an ulnar neutral or ulnar negative wrist. Although, the operation is straightforward, symptomatic relief is delayed until equalizing
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Figure 1 A 13-year-old female gymnast with increasing left wrist pain preventing competition. (A) Anteroposterior x-ray with widening and irregularity of the physis. (B) Lateral x-ray with widening more on the volar aspect. (Courtesy: Shriners Hospitals for Children, PA)
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Figure 2 Epiphysiodesis of the distal ulna for Madelung deformity. (A) Kirschner guide wire placed into growth plate. (B) Cannulated drill placed over guide wire. (C) Guide wire removed after drill driven across physis. (D) Drill reapplied to bit. (E) Drill driven back and forth and translated distal and proximal to ablate the physis. Cartilage seen extruding from the stab incision. (F) Additional curettage to ensure epiphysiodesis. (Courtesy: Shriners Hospitals for Children, PA.)
radial growth has occurred. Alternatively, ulnar shortening can be performed as a more definitive procedure that allows immediate unloading of the ulnar aspect of the wrist. The goal is to obtain an ulnar neutral or slight ulnar minus variance. Ulnar Epiphysiodesis Epiphysiodesis can be performed with the aid of minifluoroscopy and a small 1.7-mm cannulated drill. The guide wire for the cannulated drill is percutaneously placed into the distal ulnar physis (Fig. 2A). A small stab incision is made about the guide wire. The drill is placed over the wire and advanced into the growth plate (Fig. 2B). The wire must be removed at this time to avoid breakage during the remainder of the procedure (Fig. 2C). The drill is then passed back and forth and translated distal and proximal to ablate the physis (Fig. 2D). Cartilage would extrude from the stab incision and the physis would widen on the fluoroscopic images (Fig. 2E). The drill is then removed. Additional ablation can be accomplished with a curette or small bur to ensue complete epiphysiodesis (Fig. 2 F). Ulnar Shortening Osteotomy Following wrist arthroscopy and debridement of any central TFCC tear, the limb is placed on a hand table with the shoulder at 901 of abduction. The limb is exsanguinated and an arm tourniquet is used. An incision is made along the ulnar border of the forearm. The internervous interval between the flexor carpi ulnaris and flexor carpi radialis muscles is used to expose the ulna in an extraperiosteal fashion. We prefer to place the plate along the volar aspect of the ulna to minimize the chances of prominent hardware (Fig. 3). An ulnar shortening osteotomy system is used to remove the necessary amount of ulna to achieve ulnar neutral to slight minus variance. Multiple commercially available systems maximize bony coaptation and compression, thereby promoting primary union.9 The plate-and-screw construct and ulnar length are checked with minifluoroscopy before closure. The subcutaneous tissue and
skin are closed with absorbable suture. A long arm splint is applied for 2 weeks and then changed to a well-molded short arm cast that is removed at 6 weeks from surgery. At this point, a short arm thermoplast splint is fabricated and active range of motion started. Formal therapy is often not necessary. Routine activities are resumed following confirmation of union of the osteotomy site. Weight bearing is avoided until 3 months from surgery.
Figure 3 Ulnar osteotomy between the flexor carpi ulnaris and flexor carpi radialis with placement of the plate along the volar aspect of the ulna to minimize the chances of prominent hardware. (Courtesy: Shriners Hospitals for Children, PA.)
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Figure 4 A 11-year-old athlete who presents with left wrist pain and vague football injury 2 years ago. (A) Anteroposterior x-ray reveals shortening of the radius, loss of radial inclination, and ulnar positive variance. (B) Lateral x-ray shows sagittal plane deformity with increased volar tilt. (C) MRI confirms central bar and surrounding unhealthy physis. (D) Following ulnar epiphysiodesis, transflexor carpi radialis approach to radius. (E) Pronator quadratus elevated from radial margin. (F) Radial osteotomy. (G) Osteotomy completed. (H) Osteotomy distracted with laminar spreader. (I) Plate-and-screw fixation using a distal radius plate. (J) Iliac crest autograft placed within the defect. (K) Postoperative AP x-ray after healing. (L) Lateral x-ray with crossing trabeculae. (M) Follow-up wrist extension. (N) Follow-up wrist flexion. MRI, magnetic resonance imaging. (Courtesy: Shriners Hospitals for Children, PA.)
Growth Arrest of the Distal Radius In the adolescent athlete, unrelenting loading can lead to frank arrest of the distal radius growth plate similar to arrest following a fracture. A central bar is most common and would result in a shortened radius with maintenance of sagittal (volar tilt) and coronal (radial inclination) alignment. A peripheral bar is less common and would lead to angular deformity over time. Operative intervention is indicated to prevent further deformity. The surgical tactic is dependent upon multiple variables including the age of the patient, the amount of growth
remaining, and the degree of deformity. A small central bar can be resected and the defect filled with fat with the hope of growth plate recovery. Unfortunately, this technique does not uniformly result in growth plate recovery. The length inequality can be addressed by shortening the ulna or lengthening the radius. There are advantages and disadvantages to each technique. Alignment of the distal radius articular surface is a key factor. Unacceptable sagittal (volar tilt) or coronal (radial inclination) alignment or both require correction via radial osteotomy. Acceptable distal radius articular parameters allow
152 either ulnar or radial osteotomy. When performing either of these procedures, concomitant distal ulna epiphysiodesis is recommended. Radial Osteotomy High quality–centered PA and lateral x-rays of both wrists would permit assessment of the deformity (Fig. 4 A and B). Additionally, magnetic resonance imaging can provide higher resolution of the physeal bar and the status of the surrounding growth plate (Fig. 4C). The patient is placed supine on the operating room table. The entire extremity is prepped and draped in the usual sterile fashion. Subsequently, the limb is exsanguinated and the tourniquet is inflated. A transflexor carpi radialis approach is performed with exposure of the underlying pronator quadratus muscle (Fig. 4D). The pronator quadratus muscle is elevated in a radial to ulnar direction to expose the metaphysis of the radius (Fig. 4E). If possible, an anatomical distal radius plate is applied just proximal to the articular surface before performing the osteotomy. In some cases, however, plate application is impossible (eg, excessive volar tilt), and the osteotomy is completed first (Fig. 4F). The osteotomy site is manipulated using bone reduction clamps and laminar spreaders to gradually gain length and sagittal or coronal alignment (Fig. 4 G and H). Once correction has been achieved, a distal radius plate is applied using a combination of locking and nonlocking screws and pegs to achieve rigid fixation (Fig. 4I). Autograft is placed within the intervening gap to promote union (Fig. 4J). Any remaining ulnar growth is stopped via epiphysiodesis as described earlier. Following closure and application of sterile dressings, a sugar-tong splint is applied. The patient is admitted overnight for strict elevation and neurovascular monitoring. Median nerve paresthesias are common, especially with large corrections. The development of the As (increasing analgesia requirements, anxiety, and agitation) signal compartment syndrome and require prompt return to the operating room for the performance of fasciotomies.10 Even with these large corrections, we have not had a patient develop a compartment syndrome. Following 3 weeks surgery, the dressings are removed and a short arm cast is applied for an additional 3 weeks. Subsequently, a short arm thermoplast splint is fabricated and range of motion is started. x-rays are followed until union (Fig. 4 K and L). Formal therapy is usually not required (Fig. 4 M and N).
Scaphoid Fractures Scaphoid stress fractures have been reported secondary to overuse in the elite athlete.11 More commonly, contact sports such as football, lacrosse, skateboarding, and snowboarding result in scaphoid fractures. The typical mechanism of injury is a fall onto an outstretched hand that generates tension across the scaphoid. However, there are atypical mechanisms that cause scaphoid fractures, including punching and crush injuries.12 Historical reports of this injury have typically described nondisplaced fractures in the distal third of the scaphoid.
S.H. Kozin, J.M. Abzug Vahvanen and Westerlund13 reported on 108 pediatric scaphoid fractures. Further, 87% occurred at the distal pole, 12% at the waist, and 1% at the proximal pole. The predominance of distal pole injuries has been correlated to scaphoid ossification as discussed earlier. However, as Bob Dylan said, “The Times they are a Changin” and recent studies have shown a changing trend in the patterns of pediatric scaphoid fractures.14,15. Waters and colleagues reported on 312 pediatric scaphoid fractures, with the most common fracture location being the waist (71% of patients). In total, 23% and 6% of fractures occurred at the distal and proximal poles, respectively.15 The authors attributed this changing epidemiology in the pediatric population to a variety of factors including the emergence of extreme sports, increased body mass indicies, and more intense participation in sports at a younger age. Hence, the fracture pattern of pediatric or adolescent scaphoid fractures has shifted to parallel that of adult injuries. High-level athletes may seek operative intervention for acute scaphoid fractures. Potential advantages of surgical fixation include a shorter time to fracture union, a limited period of immobilization, and an accelerated rehabilitation program. In adults, reports have shown a decreased time to fracture union and an earlier return to work or sports with surgical fixation of nondisplaced scaphoid fractures in comparison to cast immobilization.16,17 In the pediatric and adolescent populations, there are currently limited data addressing this issue. We speculate that the advantages observed in the adult population may translate to the pediatric population, especially as children approach skeletal maturity. Pediatric and adolescent scaphoid fractures are often encountered with a delayed presentation or late diagnosis. There are numerous reasons for this late presentation, including a reluctance for children to tell their parents or coaches about their mechanism of injury, moderate symptoms that were not severe enough to seek medical attention, and a fear of losing their position on a sporting team. In the report by Waters et al,15 almost one-third of fractures were evaluated more than 6 weeks after the initial injury. The most appropriate management of these injuries is poorly defined. An attempt should be made to distinguish the late-presenting fracture from a chronic scaphoid nonunion, but differentiating between the 2 may be difficult. For an established nonunion, the principles of operative scaphoid nonunion treatment in children are similar to those in adults. The goal is to obtain union to prevent long-term arthrosis. Most reported pediatric scaphoid nonunions involve the waist (Fig. 5 A and B). Multiple techniques have been described to manage this condition. Successful treatment has been reported with nonoperative treatment. Surgical treatment options include open reduction with bone grafting alone, bone grafting and Kirshner wire fixation, and open reduction using a compression screw with or without bone grafting.18-21 Our preference is open reduction, bone grafting, and rigid internal fixation. This technique maximizes the chances of healing and restores wrist kinematics. Vascularized bone grafting is reserved for frank avascular necrosis seen in skeletally mature adolescents, as the presence of an active
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Figure 5 A 10-year-old child with persistent left wrist pain after falling 6 months ago. (A) Anteroposterior x-ray reveals a frank scaphoid nonunion. (B) Lateral x-ray shows minimal sagittal plane deformity. (C) Distraction via finger-trap attachment and weighted pulley. (D) The superficial volar branch of the radial artery is isolated as it crosses the surgical field for implantation into the nonunion site. (E) The nonunion site is opened and debrided of fibrous tissue and necrotic bone. (F) Cancellous bone graft is harvested from the distal radius proximal to the growth plate. (G) A 14-gauge angiocatheter is used as a drill guide and the guide wire passed from distal to proximal across the nonunion site. (H) The guide wire is seen traversing the nonunion site into the proximal pole. (I) The superficial volar branch of the radial artery is placed into the nonunion site. (J) Cancellous bone is packed around the vascular pedicle and guide wire to fill the void. (K) The position and length of the screw is confirmed via minifluoroscopy. (L) Final x-rays show good screw position and length. Screw appears long, but covered by abundant scaphoid cartilage. (Courtesy: Shriners Hospitals for Children, PA.)
physis in the immature skeleton negates many of the vascular pedicles used for scaphoid nonunions.
Surgical Technique Under general anesthesia, a nonsterile pneumatic tourniquet is applied to the extremity followed by prepping and draping in the usual sterile fashion. Additionally, the ipsilateral iliac crest is prepped and draped in the event that autologous bone graft is needed. A Carter hand table (Instrument Specialists, Inc., Boerne, TX) is used to allow for traction during the procedure. The hand table attaches to a standard operating room table and has a pulley attachment at the end that accepts a braided wire with a weight attachment loop on one end and a finger-trap attachment on the other end that is placed around the thumb (Fig. 5C). This table allows for hands-free, continuous distraction across the nonunion. The arm is abducted 901 on the hand table and 10 pounds of finger-trap traction is applied. A rolled towel is placed under the wrist to produce wrist extension. A modified Wagner approach is performed for exposure of the volar scaphoid. To augment vascularity, we often perform a vascular pedicle transfer. The superficial volar
branch of the radial artery is isolated as it crosses the surgical field (Fig. 5D). The artery is ligated distally as it enters the thenar muscles and preserved for later implantation into the nonunion site. A small portion of the radioscaphocapitate ligament is divided to allow adequate visualization of the fracture site. The nonunion site is debrided of fibrous tissue and necrotic bone (Fig. 5E). Cancellous bone graft is harvested from the distal radius (proximal to the growth plate) or the iliac crest depending upon the size of the defect (Fig. 5F). A 14-gauge angiocatheter is used as a drill guide for the guide wire that is drilled from distal to proximal across the nonunion site (Fig. 5G). The guide wire is seen traversing the nonunion site into the proximal pole (Fig. 5H). Fluoroscopy is used to verify guide wire position. The superficial volar branch of the radial artery is placed into the nonunion site (Fig. 5I). Cancellous bone is packed around the vascular pedicle and guide wire to fill the void (Fig. 5J). Once the graft is in position, a cannulated headless compression screw is placed across the nonunion site. Before removing the guide wire, the position and length of the screw is confirmed via fluoroscopy (Fig. 5K). The guide wire is then removed and additional bone graft can be packed into the nonunion site (Fig. 5L). The wrist is moved
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154 in flexion or extension and radial or ulnar deviation to ensure firm fixation is present across the nonunion. Following irrigation and closure of the wound, the patient is placed in a long- or short-arm thumb spica cast depending upon the age, compliance, and fixation. The cast is worn for 4-6 weeks followed by fabrication of a short arm thumb spica thermoplast splint. Active range of motion is started with serial x-rays until bony union is noted by crossing trabeculae. Contact sports are resumed at 3 months after surgery, assuming union is present without tenderness in the snuffbox.
Outcomes Results following surgical treatment of a pediatric scaphoid nonunion uniformly yield good-to-excellent range of motion and resolution of pain.22-25 Mintzer and Waters24 reported a series of 13 scaphoid nonunions in children (age group 9-15 years), all of which involved the waist. The mechanism of injury was a fall on the outstretched arm in all cases and 9 of the 12 fractures occurred during a sporting event. Preferred treatment was surgical intervention. The average time between fracture and surgery was 16.7 months. All nonunions united following surgical stabilization. The average time for follow-up was 6.9 years. In total, 4 nonunions were treated using the Matti-Russe procedure and 9 were treated with Herbert screw fixation combined with iliac crest bone grafting. All cases resulted in clinical and radiographic union with range of motion and strength similar to the contralateral wrist. Toh et al25 reported their experience managing 64 pediatric scaphoid fractures, including 46 fracture nonunions. The age of the patients ranged from 11-15 years. The average duration from injury to surgery was 74 days (range: 42-210 days) and the average time of follow-up was 27 months. The authors' surgical indications included acute unstable fractures, fractures with fibrous union, and fractures with an established pseudoarthrosis. Surgery consisted of cannulated screw fixation in 52 cases, including 35 cases of bone graft. All, but 2 cases, achieved solid bony union. The functional outcome was not statistically significantly different between the acute cohort and the nonacute group. In the 2 cases of persistent nonunion, 1 patient was an ice hockey player that was noncompliant with immobilization. He required a secondary bone grafting procedure to achieve bony union. The other patient developed a persistent nonunion that necessitated repeat Herbert screw fixation and bone grafting to achieve bony union.
Conclusion The immature athlete can place undue stress across the wrist causing injury. The stress can be chronic and repetitive with resultant damage to the growing physis. Prompt treatment is necessary to prevent physeal closure and permanent damage. The stress can also be acute and overwhelming resulting in fracture of the distal radius or carpal scaphoid. Accurate diagnosis and appropriate management is required to prevent
long-term problems. High-level immature athletes may ignore wrist injury and present with established sequelae requiring secondary treatment.
References 1. Ogden JA, Beall JK, Conlogue GJ, et al: Radiology of postnatal skeletal development IV. Distal radius and ulna. J Skeletal Radiol 6:255-266, 1981 2. Greulich W, Pyle SI: Radiographic Atlas of Skeletal Development of the Hand and Wrist. Stanford: Stanford University Press, 1959 3. Bright RW, Bursein AH, Elmore SM: Epiphyseal-plate cartilage: A biomechanical and histological analysis of failure modes. J Bone Joint Surg Am 56:688-703, 1974 4. Moen CT, Pelker RR: Biomechanical and histological correlations in growth plate failure. J Pediatr Orthop 4:180-1184, 1984 5. Garn SM, Rohmann CG, Silverman FN: Radiographic standards for postnatal ossification and tooth calcification. Med Radiogr Photogr 43:45-66, 1967 6. Stuart HC, Pyle SI, Cornoni J, et al: Completions and spans of ossification in the 29 bone growth centers of the hand and wrist. Pediatrics 29:237-249, 1962 7. Mehlman CT, Araghi A, Roy DR: Hyphenated history: The HueterVolkmann law. Am J Orthop 26:798-800, 1997 8. DiFiori JP, Puffer JC, Aish B, et al: Wrist pain, distal radial physeal injury, and ulnar variance in young gymnasts: Does a relationship exist? Am J Sports Med 30:879-885, 2002 9. Martin DE, Zlotolow DA, Russo SA, et al: Comparison of compression screw and perpendicular clamp in ulnar shortening osteotomy. J Hand Surg 39:1558-1564, 2014 10. Bae DS, Kadiyala RK, Waters PM: Acute compartment syndrome in children: Contemporary diagnosis, treatment, and outcome. J Pediatr Orthop 5:680-688, 2001 11. Hanks GA, Kalenak A, Bowman LS, et al: Stress fracture of the carpal scaphoid. A report of four cases. J Bone Joint Surg Am 71:938-941, 1989 12. Horii E, Nakamura R, Watanabe K: Scaphoid fracture as a“puncher's fracture”. J Orthop Trauma 8:107-110, 1994 13. Vahvanen V, Westerlund M: Fracture of the carpal scaphoid in children. A clinical and roentgenological study of 108 cases. Acta Orthop Scand 51:909-913, 1980 14. Stanciu C, Dumont A: Changing patterns of scaphoid fractures in adolescents. Can J Surg 37:214-216, 1994 15. Gholson JJ, Bae DS, Zurakowski D, et al: Scaphoid fractures in children and adolescents: Contemporary injury patterns and factors influencing time to union. J Bone Joint Surg Am 93:1210-1219, 2011 16. Bond CD, Shin AY, McBride MT, et al: Percutaneous screw fixation or cast immobilization for nondisplaced scaphoid fractures. J Bone Joint Surg Am 83:483-488, 2001 17. Arora R, Gschwentner M, Krappinger D, et al: Fixation of nondisplaced scaphoid fractures: Making treatment cost effective. Prospective controlled trial. Arch Orthop Trauma Surg 127:39-46, 2007 18. De Boeck H, Van Wellen P, Haentjens P: Nonunion of a carpal scaphoid fracture in a child. J Orthop Trauma 5:370-372, 1991 19. Russe O: Fracture of the carpal navicular: Diagnosis, nonoperative, and operative treatment. J Bone Joint Surg Am 42:759-768, 1960 20. Southcott R, Rosman MA: Nonunion of carpal scaphoid fractures in children. J Bone Joint Surg Br 59:20-23, 1977 21. Maxted MJ, Owen R: Two cases of non-union of carpal scaphoid fractures in children. Injury 12:441-443, 1982 22. Southcott R, Rosman MA: Non-union of carpal scaphoid fractures in children. J Bone Joint Surg Br 59:20-23, 1977 23. Waters PM, Stewart SL: Surgical treatment of nonunion and avascular necrosis of the proximal part of the scaphoid in adolescents. J Bone Joint Surg Am 84:915-920, 2002 24. Mintzer CM, Waters PM: Surgical treatment of pediatric scaphoid fracture nonunions. J Pediatr Orthop 19:236-239, 1999 25. Toh S, Miura H, Arai K, et al: Scaphoid fractures in children: Problems and treatment. J Pediatr Orthop 23(2):216-221, 2003
Introduction
T
he pediatric skeleton has unique anatomical qualities that protect the immature athlete. The abundant cartilage and thick periosteum shield the underlying bone from everyday stress. However, the increasing demands and activities of the modern day immature athlete test the boundaries of these defensive assets. Injuries result from excessive overuse or overt high-energy trauma or both. Upper extremity injury can affect the shoulder, elbow, forearm, wrist, or digits. Overuse is widespread in sporting activities that require upper extremity weight bearing such as gymnastics and competitive cheerleading. Trauma is prevalent in contact athletics and extreme sports such as mountain bike riding. This article focuses on injuries about the pediatric wrist with an emphasis on diagnosis, treatment, and outcome.
Pertinent Anatomy The pediatric skeleton has many distinctive features compared with adults. Most important is the presence of the physis or growth plate that is divided into 4 distinct zones: germinal, proliferative, hypertrophic, and provisional calcification. *Department of Orthopaedic Surgery, Temple University, Philadelphia, PA. †Shriners Hospitals for Children, Philadelphia, PA. ‡Department of Orthopaedics, University of Maryland Children's Hospital, University of Maryland, Timonium, MD. Address reprint requests to Scott H. Kozin, MD, Department of Orthopaedic Surgery, Shriners Hospitals for Children, 3551 North Broad St, Philadelphia, PA 19140. E-mail: [email protected]
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Approximately 75%-80% of forearm growth and 40% of the entire upper extremity growth occurs at the distal radius and distal ulna physes.1 The distal radial physis closes at approximately 16 years of age in girls and 17 years of age in boys.2 As the hypertrophic and provisional calcification zones are relatively weaker when compared with the germinal and proliferative layers,3,4 fracture lines tend to pass through these zones. However, high-energy athletic injuries may have fractures that undulate through all 4 zones and cause substantial growth plate damage. The existence of secondary ossification centers is another distinctive feature. The distal radius epiphysis is absent at birth and appears at approximately 1 year of age. Precisely, the appearance is between 0.5 and 2.3 years in boys and between 0.4 and 1.7 in girls.5 The configuration of the epiphysis also changes with age. The initial epiphysis is transverse in shape and becomes more triangular with time. When there is uncertainty about the normal appearance of the radial epiphysis and the presence of a fracture or growth plate abnormality, comparison x-rays, or consulting a skeletal atlas is essential. The anatomy of the immature scaphoid warrants conversation. The scaphoid develops by endochondral ossification with the ossific nucleus first appearing in the distal pole, typically between 4 and 5 years of age. The bone ossifies from distal to proximal along the primary blood supply, which comes from a branch of the radial artery at the dorsal ridge. Ossification is usually complete between 13 and 15 years of age.6 As the ossification front travels in a proximal direction, there is a relative weakness at the interface between the ossified and nonossified scaphoid.
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Growth Plate Damage Distal Radial Physeal Stress Syndrome Persistent upper extremity weight bearing activities can directly damage the growth plate. The unrelenting stress across the physis produces destructive forces that damage the immature growth plate. The Heuter-Volkmann principle states that the rate of epiphyseal growth is affected by pressures applied to its axes.7 Increased pressure inhibits growth, whereas a decreased pressure accelerates growth. Regarding the gymnast, the former predominates with supraphysiological loads inhibiting growth of the distal radial physis. Early symptoms and signs are pain during exercise and localized tenderness, which are often ignored given the stoic nature of these athletes. Persistent pain and inability to compete would ultimately lead to medical attention being pursued. In addition to the standard history of present illness questions, specifics regarding the number of practice hours performed during a typical week, which specific upper extremity weight bearing activities are being performed, the competition level, and upcoming competitions are important questions that should be asked. In the higher level competitors, the intensity and dedication are often astounding, with 20-30 hours of practice being common. The examination includes assessment of the entire upper extremity from the neck to the finger tips. Specifics regarding the wrist examination include palpation, assessing the range of motion when compared with the contralateral side, and provocative tests for instability. Tenderness about the growth plate is the classic finding with slight loss of wrist motion also typically being present. Frequently, the hands are calloused with normal digital range of motion and exceptional strength. Posteroanterior (PA) and lateral radiographs should routinely be obtained. Classic radiographic findings include physeal wideninig with an irregular appearance because of the repetitive stress and overloading(Fig. 1).8 Additionally, there may be Harris Growth arrest lines consistent with previous trauma.
Treatment requires immobilization, and the athlete needs to “shut down” from all upper extremity weight bearing activities to prevent permanent growth plate injury from occurring. Immobilization can be in the form of a short arm cast or removable splint depending on the perceived trustworthiness of the athlete. He or she can maintain his or her aerobic fitness, but must avoid strenuous load going across the wrist. The exact duration of immobilization and abstinence is unknown. Our practice is to treat physeal stress injuries similar to fractures with immobilization periods of 4-6 weeks dependent on the age of the athlete. Subsequently, return to upper extremity weight bearing activities is delayed until full range of motion has been regained. Afterward, graduated weight bearing is instituted with participation excluded following any recurrence of signs or symptoms.
Ulnar Abutment Syndrome Chronic overloading of the distal radius can result is persistent inhibition of distal radial growth, thus leading to ulnar positive variance, and ultimately ulnar abutment syndrome. The pain about the distal ulna is exacerbated by ulnar deviation or shucking of the distal radioulnar joint or both. A concomitant triangular fibrocartilage complex (TFCC) tear can also be present. Plain PA x-rays of the wrist in neutral forearm rotation allow for assessment of the ulnar variance. Typically, apart from positive ulnar variance, Harris Growth arrest lines may be seen in the metaphysis of the radius. Initial management is nonoperative with rest and immobilization. A corticosteroid injection may be provided in case of persistent pain. Recalcitrant symptoms warrant a candid discussion regarding future sports participation and surgical options. Surgical treatment should address any intra-articular pathology such as a TFCC tear. In child with some skeletal growth remaining, ulnar abutment can be addressed by performing a distal ulnar epiphysiodesis, allowing radial growth to result in an ulnar neutral or ulnar negative wrist. Although, the operation is straightforward, symptomatic relief is delayed until equalizing
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Figure 1 A 13-year-old female gymnast with increasing left wrist pain preventing competition. (A) Anteroposterior x-ray with widening and irregularity of the physis. (B) Lateral x-ray with widening more on the volar aspect. (Courtesy: Shriners Hospitals for Children, PA)
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Figure 2 Epiphysiodesis of the distal ulna for Madelung deformity. (A) Kirschner guide wire placed into growth plate. (B) Cannulated drill placed over guide wire. (C) Guide wire removed after drill driven across physis. (D) Drill reapplied to bit. (E) Drill driven back and forth and translated distal and proximal to ablate the physis. Cartilage seen extruding from the stab incision. (F) Additional curettage to ensure epiphysiodesis. (Courtesy: Shriners Hospitals for Children, PA.)
radial growth has occurred. Alternatively, ulnar shortening can be performed as a more definitive procedure that allows immediate unloading of the ulnar aspect of the wrist. The goal is to obtain an ulnar neutral or slight ulnar minus variance. Ulnar Epiphysiodesis Epiphysiodesis can be performed with the aid of minifluoroscopy and a small 1.7-mm cannulated drill. The guide wire for the cannulated drill is percutaneously placed into the distal ulnar physis (Fig. 2A). A small stab incision is made about the guide wire. The drill is placed over the wire and advanced into the growth plate (Fig. 2B). The wire must be removed at this time to avoid breakage during the remainder of the procedure (Fig. 2C). The drill is then passed back and forth and translated distal and proximal to ablate the physis (Fig. 2D). Cartilage would extrude from the stab incision and the physis would widen on the fluoroscopic images (Fig. 2E). The drill is then removed. Additional ablation can be accomplished with a curette or small bur to ensue complete epiphysiodesis (Fig. 2 F). Ulnar Shortening Osteotomy Following wrist arthroscopy and debridement of any central TFCC tear, the limb is placed on a hand table with the shoulder at 901 of abduction. The limb is exsanguinated and an arm tourniquet is used. An incision is made along the ulnar border of the forearm. The internervous interval between the flexor carpi ulnaris and flexor carpi radialis muscles is used to expose the ulna in an extraperiosteal fashion. We prefer to place the plate along the volar aspect of the ulna to minimize the chances of prominent hardware (Fig. 3). An ulnar shortening osteotomy system is used to remove the necessary amount of ulna to achieve ulnar neutral to slight minus variance. Multiple commercially available systems maximize bony coaptation and compression, thereby promoting primary union.9 The plate-and-screw construct and ulnar length are checked with minifluoroscopy before closure. The subcutaneous tissue and
skin are closed with absorbable suture. A long arm splint is applied for 2 weeks and then changed to a well-molded short arm cast that is removed at 6 weeks from surgery. At this point, a short arm thermoplast splint is fabricated and active range of motion started. Formal therapy is often not necessary. Routine activities are resumed following confirmation of union of the osteotomy site. Weight bearing is avoided until 3 months from surgery.
Figure 3 Ulnar osteotomy between the flexor carpi ulnaris and flexor carpi radialis with placement of the plate along the volar aspect of the ulna to minimize the chances of prominent hardware. (Courtesy: Shriners Hospitals for Children, PA.)
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Figure 4 A 11-year-old athlete who presents with left wrist pain and vague football injury 2 years ago. (A) Anteroposterior x-ray reveals shortening of the radius, loss of radial inclination, and ulnar positive variance. (B) Lateral x-ray shows sagittal plane deformity with increased volar tilt. (C) MRI confirms central bar and surrounding unhealthy physis. (D) Following ulnar epiphysiodesis, transflexor carpi radialis approach to radius. (E) Pronator quadratus elevated from radial margin. (F) Radial osteotomy. (G) Osteotomy completed. (H) Osteotomy distracted with laminar spreader. (I) Plate-and-screw fixation using a distal radius plate. (J) Iliac crest autograft placed within the defect. (K) Postoperative AP x-ray after healing. (L) Lateral x-ray with crossing trabeculae. (M) Follow-up wrist extension. (N) Follow-up wrist flexion. MRI, magnetic resonance imaging. (Courtesy: Shriners Hospitals for Children, PA.)
Growth Arrest of the Distal Radius In the adolescent athlete, unrelenting loading can lead to frank arrest of the distal radius growth plate similar to arrest following a fracture. A central bar is most common and would result in a shortened radius with maintenance of sagittal (volar tilt) and coronal (radial inclination) alignment. A peripheral bar is less common and would lead to angular deformity over time. Operative intervention is indicated to prevent further deformity. The surgical tactic is dependent upon multiple variables including the age of the patient, the amount of growth
remaining, and the degree of deformity. A small central bar can be resected and the defect filled with fat with the hope of growth plate recovery. Unfortunately, this technique does not uniformly result in growth plate recovery. The length inequality can be addressed by shortening the ulna or lengthening the radius. There are advantages and disadvantages to each technique. Alignment of the distal radius articular surface is a key factor. Unacceptable sagittal (volar tilt) or coronal (radial inclination) alignment or both require correction via radial osteotomy. Acceptable distal radius articular parameters allow
152 either ulnar or radial osteotomy. When performing either of these procedures, concomitant distal ulna epiphysiodesis is recommended. Radial Osteotomy High quality–centered PA and lateral x-rays of both wrists would permit assessment of the deformity (Fig. 4 A and B). Additionally, magnetic resonance imaging can provide higher resolution of the physeal bar and the status of the surrounding growth plate (Fig. 4C). The patient is placed supine on the operating room table. The entire extremity is prepped and draped in the usual sterile fashion. Subsequently, the limb is exsanguinated and the tourniquet is inflated. A transflexor carpi radialis approach is performed with exposure of the underlying pronator quadratus muscle (Fig. 4D). The pronator quadratus muscle is elevated in a radial to ulnar direction to expose the metaphysis of the radius (Fig. 4E). If possible, an anatomical distal radius plate is applied just proximal to the articular surface before performing the osteotomy. In some cases, however, plate application is impossible (eg, excessive volar tilt), and the osteotomy is completed first (Fig. 4F). The osteotomy site is manipulated using bone reduction clamps and laminar spreaders to gradually gain length and sagittal or coronal alignment (Fig. 4 G and H). Once correction has been achieved, a distal radius plate is applied using a combination of locking and nonlocking screws and pegs to achieve rigid fixation (Fig. 4I). Autograft is placed within the intervening gap to promote union (Fig. 4J). Any remaining ulnar growth is stopped via epiphysiodesis as described earlier. Following closure and application of sterile dressings, a sugar-tong splint is applied. The patient is admitted overnight for strict elevation and neurovascular monitoring. Median nerve paresthesias are common, especially with large corrections. The development of the As (increasing analgesia requirements, anxiety, and agitation) signal compartment syndrome and require prompt return to the operating room for the performance of fasciotomies.10 Even with these large corrections, we have not had a patient develop a compartment syndrome. Following 3 weeks surgery, the dressings are removed and a short arm cast is applied for an additional 3 weeks. Subsequently, a short arm thermoplast splint is fabricated and range of motion is started. x-rays are followed until union (Fig. 4 K and L). Formal therapy is usually not required (Fig. 4 M and N).
Scaphoid Fractures Scaphoid stress fractures have been reported secondary to overuse in the elite athlete.11 More commonly, contact sports such as football, lacrosse, skateboarding, and snowboarding result in scaphoid fractures. The typical mechanism of injury is a fall onto an outstretched hand that generates tension across the scaphoid. However, there are atypical mechanisms that cause scaphoid fractures, including punching and crush injuries.12 Historical reports of this injury have typically described nondisplaced fractures in the distal third of the scaphoid.
S.H. Kozin, J.M. Abzug Vahvanen and Westerlund13 reported on 108 pediatric scaphoid fractures. Further, 87% occurred at the distal pole, 12% at the waist, and 1% at the proximal pole. The predominance of distal pole injuries has been correlated to scaphoid ossification as discussed earlier. However, as Bob Dylan said, “The Times they are a Changin” and recent studies have shown a changing trend in the patterns of pediatric scaphoid fractures.14,15. Waters and colleagues reported on 312 pediatric scaphoid fractures, with the most common fracture location being the waist (71% of patients). In total, 23% and 6% of fractures occurred at the distal and proximal poles, respectively.15 The authors attributed this changing epidemiology in the pediatric population to a variety of factors including the emergence of extreme sports, increased body mass indicies, and more intense participation in sports at a younger age. Hence, the fracture pattern of pediatric or adolescent scaphoid fractures has shifted to parallel that of adult injuries. High-level athletes may seek operative intervention for acute scaphoid fractures. Potential advantages of surgical fixation include a shorter time to fracture union, a limited period of immobilization, and an accelerated rehabilitation program. In adults, reports have shown a decreased time to fracture union and an earlier return to work or sports with surgical fixation of nondisplaced scaphoid fractures in comparison to cast immobilization.16,17 In the pediatric and adolescent populations, there are currently limited data addressing this issue. We speculate that the advantages observed in the adult population may translate to the pediatric population, especially as children approach skeletal maturity. Pediatric and adolescent scaphoid fractures are often encountered with a delayed presentation or late diagnosis. There are numerous reasons for this late presentation, including a reluctance for children to tell their parents or coaches about their mechanism of injury, moderate symptoms that were not severe enough to seek medical attention, and a fear of losing their position on a sporting team. In the report by Waters et al,15 almost one-third of fractures were evaluated more than 6 weeks after the initial injury. The most appropriate management of these injuries is poorly defined. An attempt should be made to distinguish the late-presenting fracture from a chronic scaphoid nonunion, but differentiating between the 2 may be difficult. For an established nonunion, the principles of operative scaphoid nonunion treatment in children are similar to those in adults. The goal is to obtain union to prevent long-term arthrosis. Most reported pediatric scaphoid nonunions involve the waist (Fig. 5 A and B). Multiple techniques have been described to manage this condition. Successful treatment has been reported with nonoperative treatment. Surgical treatment options include open reduction with bone grafting alone, bone grafting and Kirshner wire fixation, and open reduction using a compression screw with or without bone grafting.18-21 Our preference is open reduction, bone grafting, and rigid internal fixation. This technique maximizes the chances of healing and restores wrist kinematics. Vascularized bone grafting is reserved for frank avascular necrosis seen in skeletally mature adolescents, as the presence of an active
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Figure 5 A 10-year-old child with persistent left wrist pain after falling 6 months ago. (A) Anteroposterior x-ray reveals a frank scaphoid nonunion. (B) Lateral x-ray shows minimal sagittal plane deformity. (C) Distraction via finger-trap attachment and weighted pulley. (D) The superficial volar branch of the radial artery is isolated as it crosses the surgical field for implantation into the nonunion site. (E) The nonunion site is opened and debrided of fibrous tissue and necrotic bone. (F) Cancellous bone graft is harvested from the distal radius proximal to the growth plate. (G) A 14-gauge angiocatheter is used as a drill guide and the guide wire passed from distal to proximal across the nonunion site. (H) The guide wire is seen traversing the nonunion site into the proximal pole. (I) The superficial volar branch of the radial artery is placed into the nonunion site. (J) Cancellous bone is packed around the vascular pedicle and guide wire to fill the void. (K) The position and length of the screw is confirmed via minifluoroscopy. (L) Final x-rays show good screw position and length. Screw appears long, but covered by abundant scaphoid cartilage. (Courtesy: Shriners Hospitals for Children, PA.)
physis in the immature skeleton negates many of the vascular pedicles used for scaphoid nonunions.
Surgical Technique Under general anesthesia, a nonsterile pneumatic tourniquet is applied to the extremity followed by prepping and draping in the usual sterile fashion. Additionally, the ipsilateral iliac crest is prepped and draped in the event that autologous bone graft is needed. A Carter hand table (Instrument Specialists, Inc., Boerne, TX) is used to allow for traction during the procedure. The hand table attaches to a standard operating room table and has a pulley attachment at the end that accepts a braided wire with a weight attachment loop on one end and a finger-trap attachment on the other end that is placed around the thumb (Fig. 5C). This table allows for hands-free, continuous distraction across the nonunion. The arm is abducted 901 on the hand table and 10 pounds of finger-trap traction is applied. A rolled towel is placed under the wrist to produce wrist extension. A modified Wagner approach is performed for exposure of the volar scaphoid. To augment vascularity, we often perform a vascular pedicle transfer. The superficial volar
branch of the radial artery is isolated as it crosses the surgical field (Fig. 5D). The artery is ligated distally as it enters the thenar muscles and preserved for later implantation into the nonunion site. A small portion of the radioscaphocapitate ligament is divided to allow adequate visualization of the fracture site. The nonunion site is debrided of fibrous tissue and necrotic bone (Fig. 5E). Cancellous bone graft is harvested from the distal radius (proximal to the growth plate) or the iliac crest depending upon the size of the defect (Fig. 5F). A 14-gauge angiocatheter is used as a drill guide for the guide wire that is drilled from distal to proximal across the nonunion site (Fig. 5G). The guide wire is seen traversing the nonunion site into the proximal pole (Fig. 5H). Fluoroscopy is used to verify guide wire position. The superficial volar branch of the radial artery is placed into the nonunion site (Fig. 5I). Cancellous bone is packed around the vascular pedicle and guide wire to fill the void (Fig. 5J). Once the graft is in position, a cannulated headless compression screw is placed across the nonunion site. Before removing the guide wire, the position and length of the screw is confirmed via fluoroscopy (Fig. 5K). The guide wire is then removed and additional bone graft can be packed into the nonunion site (Fig. 5L). The wrist is moved
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154 in flexion or extension and radial or ulnar deviation to ensure firm fixation is present across the nonunion. Following irrigation and closure of the wound, the patient is placed in a long- or short-arm thumb spica cast depending upon the age, compliance, and fixation. The cast is worn for 4-6 weeks followed by fabrication of a short arm thumb spica thermoplast splint. Active range of motion is started with serial x-rays until bony union is noted by crossing trabeculae. Contact sports are resumed at 3 months after surgery, assuming union is present without tenderness in the snuffbox.
Outcomes Results following surgical treatment of a pediatric scaphoid nonunion uniformly yield good-to-excellent range of motion and resolution of pain.22-25 Mintzer and Waters24 reported a series of 13 scaphoid nonunions in children (age group 9-15 years), all of which involved the waist. The mechanism of injury was a fall on the outstretched arm in all cases and 9 of the 12 fractures occurred during a sporting event. Preferred treatment was surgical intervention. The average time between fracture and surgery was 16.7 months. All nonunions united following surgical stabilization. The average time for follow-up was 6.9 years. In total, 4 nonunions were treated using the Matti-Russe procedure and 9 were treated with Herbert screw fixation combined with iliac crest bone grafting. All cases resulted in clinical and radiographic union with range of motion and strength similar to the contralateral wrist. Toh et al25 reported their experience managing 64 pediatric scaphoid fractures, including 46 fracture nonunions. The age of the patients ranged from 11-15 years. The average duration from injury to surgery was 74 days (range: 42-210 days) and the average time of follow-up was 27 months. The authors' surgical indications included acute unstable fractures, fractures with fibrous union, and fractures with an established pseudoarthrosis. Surgery consisted of cannulated screw fixation in 52 cases, including 35 cases of bone graft. All, but 2 cases, achieved solid bony union. The functional outcome was not statistically significantly different between the acute cohort and the nonacute group. In the 2 cases of persistent nonunion, 1 patient was an ice hockey player that was noncompliant with immobilization. He required a secondary bone grafting procedure to achieve bony union. The other patient developed a persistent nonunion that necessitated repeat Herbert screw fixation and bone grafting to achieve bony union.
Conclusion The immature athlete can place undue stress across the wrist causing injury. The stress can be chronic and repetitive with resultant damage to the growing physis. Prompt treatment is necessary to prevent physeal closure and permanent damage. The stress can also be acute and overwhelming resulting in fracture of the distal radius or carpal scaphoid. Accurate diagnosis and appropriate management is required to prevent
long-term problems. High-level immature athletes may ignore wrist injury and present with established sequelae requiring secondary treatment.
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