STRESS INJURY OF THE DISTAL RADIAL GROWTH PLATE

S. R. CARTER, M. J. ALDRIDGE

From the Royal Orthopaedic Hospital, Birmingham and the Coventry and Warwickshfre Hospital

We report 21 cases of stress injury of the distal radial growth plate occurring in gymnasts before skeletal
maturity. The injury appears to be caused by inabifity of the growth plate to withstand rotational and
compressive forces. Our observations have confirmed that the skeletal age of gymnasts is retarded, which
increases the length of time during which the epiphysis is at risk of damage.

There has been increasing concern recently about the Training Centre, though some were from local gymnastic
effects of strenuous exercise upon the developing clubs. There were 17 boys and four girls with an age
skeleton as anecdotal reports of overuse injuries and range of 9.5 to 17 years (average 1 3.5 years for the boys
impaired growth receive greater publicity. Studies have and 14 years for the girls).
given some credence to this concern. Some authors have The main symptoms were diffuse pain around the
demonstrated slow or interrupted growth (Rowe 1933; wrist, aggravated by forced dorsiflexion, whether active
Schuck 1962; Delmas 1982), whilst others have shown a or passive. The pain was localised to the radial styloid
retardation of skeletal development (Kato and Ishiko process and some patients also complained of diffuse
1966). Rougier (1982), however, could find no evidence swelling. The symptoms were worse immediately after
that intensive training altered normal growth curves. exercises involving weight bearing on the hands.
As a bone grows in length its growth plate advances, Examination revealed tenderness of the distal radius
leaving behind it matrix which becomes ossified. The particularly around the radial styloid, a nearly full range
growth plate is less resistant to shear and tensile forces ofmovements and, in advanced cases, some enlargement
than the adjacent bone, and newly developed bone is of the wrist.
poorly resistant to compressive forces (Wilkins 1980). Radiographs (Figs 1 and 2) showed widening of the
The plate receives its nutrition through capillary loops distal radial growth
plate particularly on its volar aspect
passing through the newly formed and friable matrix if ; and narrowing of the adjacent epiphysis there was also ;

this matrix is damaged the blood supply to the growth haziness of the growth plate due to irregularity of the
plate may be affected. border between the cartilage and the metaphyseal zone
Some 10% ofskeletal injuries in children involve the of ossification, and an increase in the transverse
growth plate (Pollen 1979) and in this paper we present a diameter of the metaphysis. The lateral view showed
series of stress injuries of the distal radial growth plate, scalloping of the growth plate particularly on its volar
discussing the aetiological factors, the radiological aspect. The distal ulnar epiphysis was narrowed. The
features and possible consequences. differential diagnosis of these changes is discussed in
Carter et al. (1988). The radiographs were also assessed
for bone age (Greulich and Pyle 1959) and for ulnar
PATIENTS AND FINDINGS variance (Gelberman et al. 1975).
Twenty-one patients with stress injuries of the distal In most patients the symptoms subsided after
abstaining from gymnastics for six to 26 weeks. One
radial growth plate were seen by the senior author over a
four year period. Most were gymnasts from the National patient required removal of loose bodies from the
affected wrist, two were given non-steroidal anti-
inflammatory drugs and one patient had physiotherapy.
Once the symptoms had settled, gradual resumption of
S. R. Carter, FRCS, Orthopaedic Registrar
Research and Training Centre, Royal Orthopaedic Hospital, North-
gymnastics was allowed. At this stage the radiographs
field, Birmingham B3l 2AP, England. demonstrated a return to normal in both the width and
M. J. Aldridge, FRCS, Orthopaedic Consultant the haziness of the growth plate, though the scalloping
Coventry and Warwickshire Hospital, Stoney Stanton Road, Coventry
CV! 4FH, England.
remained (Figs 3 to 6).
Correspondence should be sent to Mr S. R. Carter.
The skeletal age of the 21 patients was, on average,
© 1988 British Editorial Society of Bone and Joint Surgery
16 months later than the chronological age in boys in ;

0301-620X/88/5l 36 $2.00 girls the delay was only 12 months. Ulnar variance was
J Bone Joint Sung [Br] 1988:70-B:834-6.
slight, averaging only 0.3 mm.

834 THE JOURNAL OF BONE AND JOINT SURGERY

 STRESS INJURY OF THE DISTAL RADIAL GROWTH PLATE 835

Fig. I Fig. 2

Fig. 3 Fig. 4
‘ -‘
. *..v.. .

Fig. 5 Fig. 6

Radiographs of the right wrist of a male gymnast. Figures 3 and 4 - At presentation. Figures 5 and 6 - The
same wrist after a three month rest from gymnastics ; the haziness and widening of the growth plate have
resolved, though some scalloping persists.

DISCUSSION growth plate is at risk. Comparing the skeletal age with

the chronological should give this information. In our
More and more children are participating in active patients the skeletal age was considerably delayed and
sport ; those who hope to achieve representative status this is a general tendency among gymnasts (Malina et al.
need to start intensive training before puberty and 1982). Consequently the at-risk period is prolonged.
skeletal maturation. This has resulted in increasing In many of our patients the pain came on gradually
numbers of children presenting for treatment, presum- with no history of acute trauma. It was worse with
ably because the immature skeleton is more vulnerable exercises in which the body was supported by the arms,
than that of the adult (Rowley, personal communication but was less severe when the patient was hanging by the
1985). arms. Boys said that their symptoms were aggravated by
Concern has been expressed that injuries to growing pommel horse exercises, while with girls vaulting and
bone might lead to permanent skeletal damage and it is floor exercises caused most problems. In all these
important to know the length of time for which the activities both compressive and torsional forces are

VOL. 70-B, No. 5, NOVEMBER 1988

836 S. R. CARTER, M. J. ALDRIDGE

being applied to the distal radius. Read (1982) suggested until skeletal maturity is reached. Possible changes
that tumbling and the Tsukahara vault (in which impact include positive ulnar variance (Chan and Huang 1971)
on the wrist at 60#{176}
of wrist dorsiflexion is combined with or an altered inclination of the distal radial articular
twisting) produced ulnar deviation, since in his patients surface. The radiographs of our gymnasts showed an
the “pivotal” wrist was much more often affected. The average ulnar variance of only 0.3 mm and there was no
preponderance of boys in our series may be because their discernable alteration of the carpal angle, but to exclude
gymnastic exercises differ from those of girls, or because any possible growth disturbances these patients should
they are heavier, or because the at-risk period of the be followed up to skeletal maturity.
growth plate was four months longer than in girls.
No benefits in any form have been received or will be received from a
The weakest portion of the growth plate is the commercial party related directly or indirectly to the subject of this
hypertrophic layer just above the zone of calcification article.
(Salter and Harris 1963; Peltonen et al. 1984) and this is
particularly vulnerable when at its thickest during the REFERENCES

growth spurt, or when widened as a result of repetitive

CarterSR, Aldridge MJ, Fitzgerald R, Davies AM. Stress changes of the
trauma. Repeated forces applied to the distal radial wrist in adolescent gymnasts. Br J Radio! l988;6l :109-12.
growth plate may ultimately result in changes which Chan KP, Huang P. Anatomical variations in radial and ulnar lengths
resemble a stress fracture, and the metaphyseal changes in the wrists of Chinese. C/in Orthop 1971 ;80 :17-20.

seen on the radiographs are similar to those of Salter Cumming GR, Garand T, Borysyk L. Correlation of performance in
track and field events with bone age. J Pediatr 1972:80:970-3.
Type I epiphyseal injuries when healing has been
Delmas A. Intense physical training among children and adolescents.
prevented (Fliegel 1986). FIEP Bulletin 1982:52:29-33.
Narrowing ofthe epiphysis is mainly confined to the Fliegel CP. Stress related widening of the radial growth plate in
volar aspect of the distal radius and produces a type of adolescents. Ann Radio! (Paris) l986;29 :374-6.
Madelung deformity. The explanation for this may be as Gelberman RH, Salamon PB, Jurist JM, Poach JL. Ulnar variance in
Kienb#{246}ck’s disease. J Bone Joint Sung [Am] 1975;57-A:674-6.
follows : in support exercises the wrist is fully dorsiflexed,
Greulich WW, Pyle SI. Radiographic at/as ofske!eta!deve!opment of the
in which position the lunate dorsiflexes and moves hand and wrist. 2nd ed. Stanford, California : Stanford University
palmarwards; in addition the wrist is deviated ulnar- Press. London Oxford University Press, 1959.

wards causing the lunate to dorsiflex also (resulting in an Kato S, Ishiko T. Obstructive growth of children’s bones due to
excessive labor in remote corners. Proceedings of Internationa!
increased force being applied to the distal ulna). These Congress of Sports Sciences, Tokyo, 1964:479.
two mechanisms result in a concentration of forces on the Malina RM, Bouchard C, Shoup RF, Demirjian A, Larivi#{232}re G. Growth
volar aspect of the distal radius. and maturity status of Montreal Olympic athletes less than I8
years of age. Medicine Sport 1982;16 :1 17-27.
Eleven of our 21 patients had symptoms of other
Oseid S, Bjenth G, Evjenth 0, Gunnari H, Meen D. Lower back trouble
osteochondritides, including those of Osgood and Schlat- in young female gymnasts : frequency, symptoms and possible
ter, Scheuermann, Sever, and Sinding-Larsen; this may causes. FIEP Bulletin 1974:44:11-14.

simply indicate that the skeletal development of these Peltonen J, Aalto K, Karahanju E, Alitalo I, Gr#{246}nblad M. Experimental
epiphyseal separation by torsional force. J Pediatr Onthop
gymnasts had not yet reached sufficient maturity to 1984:4:546-9.
withstand the forces applied during gymnastic competi- Pollen AG. Fracture involving the epiphyseal plate. Reconstr Sung
tion. There appears to be a specific relationship between Tnaumato/ 1979; 17:25-39.
skeletal maturity, training and success in youth sport Read MT. Stress fractures of the distal radius in adolescent gymnasts.
(Rowley, personal communication) which is largely a Br J Sports Med 1981:15:272-6.
Rochelle RH, Keffiher MS, Thornton R. Relationship of maturation age
consequence of selection, rather than a result of training
to incidence of injury in tackle football. Research Quanter!yfon the
(Shephard I 984). Rochelle, Kelliher and Thornton American Association of Hea!th and Physica! Education
1961:32:78-82.
(1961) and Cumming, Garand and Borysyk (1972) have
Rougier G. Competitive sport and young children. FIEP Bulletin
suggested that the best predictor of success in youth sport 1982,52:39.
is the skeletal age of the child. Thus the delay in skeletal
Rowe FA. Growth comparison ofathletes and non-athletes. R Quarter!;
maturation in the gymnasts reported here may be an 1933:3:108-16.
important factor in their success. However, this very Shephard RJ. Physical activity and child health. Sports Med
1984:1 :205-33.
factor may predispose them to an increased period of risk
Salter RB, Harris WR. Injuries involving the epiphyseal plate. J Bone
of skeletal damage, thus offering an explanation for the Joint Sung [Am] 1963 :45-A :587-622.
high incidence of osteochondritides noted here and in
Snook GA. Injuries in women’s gynastics : a 5-year study. Am J Sports
other studies (Osied et al. 1974; Snook 1979). There was Med 1979;7:242-4.
no evidence of skeletal age stand-still during the recovery Shuck GR. Effects of athletic competition on the growth and
period.
development of junior high school boys. Research Q
1962 ;33 :288-98.
Whether the changes we have described result in
Wilkins KE. The uniqueness of the young athlete : musculoskeletal
any permanent growth disturbance may not be known injuries. Am J Sports Med 1980:8:377-82.

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