(Kiefhaber and Stern, 1992). Athletes will typically
complain of pain and swelling distal to the ulnar head,
worsened by resisted wrist extension. A painful snap
may be elicited as subluxation of the ECU occurs with
supination and ulnar deviation of the wrist. Initial
treatment includes rest, splinting, anti-inflammatory
medication, corticosteroid injection, and activity mod-
ification. Patients who fail to respond to nonoperative
treatment require surgical decompression of the sixth
dorsal compartment with radial release of the fibro-
osseous tunnel and repair of the extensor retinaculum
(to prevent postoperative subluxation) (Hajj and Wood,
1986). After surgery, the wrist is immobilized in 20°of
extension for 3 weeks prior to starting activity (Rettig,
2001). Patients with acute ECU subluxation may be
treated with long-arm casting with the wrist in full
pronation and slight dorsiflexion (Wood and Dobyns,
1986). This frequently fails to respond to conservative
treatment and often requires stabilization of the ECU
with return to sport after a minimum of 8 to 10 weeks.FLEXOR COMPARTMENT TENDINOPATHIES
- Inflammation of the flexor tendons most commonly
occurs in the flexor carpi radialis(FCR) and flexor
carpi ulnaris(FCU) as a result of repetitive wrist
motions such as golf and racquet sports (Plancher,
Peterson, and Steichen, 1996). FCR tendonitis usually
presents with pain over the volar aspect of the wrist,
proximal to the wrist crease over the FCR tendon.
Pain may be elicited with abrupt wrist extension or
resisted wrist flexion and radial deviation. Athletes
with FCU tendonitis may complain of pain and
swelling just distal to the pisiform. Pain may be exac-
erbated with passive wrist extension, or resisted wrist
flexion and ulnar deviation. Initial treatment of both
of these conditions includes rest, anti-inflammatory
medication, splinting, corticosteroid injection, and
activity modification. If symptoms persist, surgical
decompression of the fibro-osseous tunnel containing
the FCR is performed in the case of FCR tendonitis
(Gabel, Bishop, and Wood, 1994). Surgical treatment
of FCU tendonitis includes FCU lengthening with or
without pisiform excision (Palmieri, 1982).
PEDIATRIC INJURY
GYMNAST’S WRIST
- The number of athletes competing in competitive
gymnastics has been steadily increasing. As a result
there has been a rise in the frequency of wrist pain in
skeletally immature athletes. Mandelbaum et al found
that 75% of all male and 50% of all female competi-
tive gymnasts complained of some wrist pain
(Mandelbaum et al, 1989). This is most likely due to
repetitive axial loading across a hyperextended wrist
(Le and Hentz, 2000). Injuries can result from either
acute, high-energy trauma or chronic and repetitive
stress. Physical examination of young gymnasts with
wrist pain can be challenging due to difficulty in pin-
pointing the location of pain and fear of injury which
would preclude competition. Female gymnasts more
commonly complain of ulnar sided wrist pain,
whereas males had similar frequency of radial and
ulnar sided wrist pain (Mandelbaum et al, 1989).- Initial radiographic evaluation includes plain X-rays
that may reveal stress related changes of the distal
radial epiphysis including widening of the growth
plate, epiphyseal cystic changes with beaking of the
distal epiphysis, and metaphyseal irregularity (Roy,
Caine, and Singer, 1985). These changes may lead to
premature physeal closure and ultimately a higher
incidence of ulnar positive variance. As a result, fol-
lowing skeletal maturity, gymnasts may present with
ulnar abutment syndrome, or Madelung-like defor-
mity. MRI and technetium bone scanning may be
useful in determining the presence or extent of phy-
seal injury and assist determining return to sports par-
ticipation, especially in the face of normal plain
radiographs (Morgan and Slowman, 2001). - It is rare that the treatment of wrist pain in a skeletally
immature athlete is other than rest and withdrawal
from the offending activity. Prevention may be the
best form of treatment by using protective gear, spot-
ters, proper warm up, and preclusion of sudden
changes in activity intensity. If a physeal injury is sus-
pected or found, the athlete generally is withdrawn
from activity, treated symptomatically, and allowed to
return to sport when symptoms have resolved. It may
also be possible to remove the gymnast from the spe-
cific event causing symptoms and allow continued
competition in other events that do not exacerbate
symptoms.
REFERENCES
Angelides AC, Wallace PF: The dorsal ganglion of the wrist: Its
pathogenesis, gross and microscopic anatomy, and surgical
treatment. J Hand Surg 1:228–235, 1976.
Bergfeld JA, Weiker GG, Andrish JT, et al: Soft playing splint for
protection of significant hand and wrist injuries in sports. Am
J Sports Med 10:293–296, 1982.304 SECTION 4 • MUSCULOSKELETAL PROBLEMS IN THE ATHLETE