Well-founded practice or personal preference: a comparison of established techniques for measuring ulnar variance in healthy children and adolescents.

OBJECTIVES: Ulnar variance is a clinical measure used to determine the relative difference in length between the radius and ulna. We aimed to examine consistency in ulnar variance measurements and normative data in children and adolescents using the perpendicular and the Hafner methods. METHODS: Two raters measured ulnar variance on hand radiographs of 350 healthy children. Participants' mean calendar and skeletal ages were 12.3 ± 3.6 and 12.0 ± 3.7 years, 52% were female. Raters used the perpendicular method, an adapted version of the perpendicular method (in which the distal radial articular surface is defined as a sclerotic rim) and the Hafner method, being the distance between the most proximal points of the ulnar and radial metaphyses (PRPR) and the distance between the most distal points of both (DIDI). Intraclass correlation coefficients (ICCs) for intermethod consistency and inter- and intrarater agreement were calculated using a two-way ANOVA model. Variability and limits of agreement were determined using the Bland-Altman method. RESULTS: The interrater ICC was 0.75 (95% CI, 0.61-0.84) for the adapted perpendicular method, 0.88 (95% CI, 0.80-0.93) for PRPR, and 0.94 (95% CI, 0.90-0.97) for DIDI. The intermethod consistency ICC was 0.60 (95% CI, 0.48-0.70) for perpendicular versus PRPR and 0.60 (95% CI, 0.49-0.70) for perpendicular versus DIDI. The intrarater ICC was 0.88 (95% CI, 0.70-0.95) for perpendicular, 0.90 (95% CI, 0.83-0.94) for PRPR, and 0.81 (95% CI, 0.69-0.89) for DIDI. The perpendicular method was not useable in 38 cases (skeletal age ≤ 9 years) and the Hafner method in 79 cases (skeletal age ≥ 12 years). CONCLUSIONS: The perpendicular and Hafner methods show moderate intermethod consistency. The Hafner method is preferred for children with skeletal ages < 14 years, with good to excellent inter- and intrarater agreement. The adapted perpendicular method is recommended for patients with skeletal ages ≥ 14 years. KEY POINTS: • The perpendicular method for measuring ulnar variance requires extended instructions to ensure good interrater agreement in pediatric and adolescent patients. • The Hafner method is recommended for ulnar variance measurement in children with unfused growth plates and up to a skeletal age of 13 years, and the perpendicular method is recommended for children with fused growth plates and from skeletal age 14 and older. • The mean ulnar variance measured in this study for each skeletal age group (range, 5-18 years) is provided, to serve as a reference for future ulnar variance measurements using both methods in clinical practice.

A hidden mismatch between experiences of young athletes with overuse injuries of the wrist and sports physicians' perceptions: a focus group study.

BACKGROUND: Although overuse wrist injuries can have serious consequences, young athletes often do not immediately report their injury to a physician. This qualitative study aimed to identify symptoms and limitations related to overuse wrist injuries that young athletes consider important and to compare those with sports physicians' opinions, in order to improve the diagnostic process for early identification of overuse wrist injuries. METHODS: Twenty-one athletes aged 13-25 years in wrist-loading sports (gymnastics, tennis, judo, field hockey, volleyball and rowing) with a (previous) overuse wrist injury were included. In five focus groups, participants discussed important signals and limitations of their injury, as well as a list of relevant items previously composed by sports physicians. Data were grouped into themes and (sub)categories and subsequently coded. RESULTS: Of the resulting 224 signals and 80 limitations, respectively 81 and 20 were labelled important. Athletes considered both pain and limitations during daily life activities important indicators of overuse wrist injury, as well as long pain duration, acute onset of pain, and accompanying symptoms like swelling, cracking and discoloration. All of the sports physicians' items were also considered important by the athletes, but sport-related pain and limitations were regarded by many athletes as a natural part of their sport. CONCLUSIONS: Discrepancies exist between the opinions of young athletes and sports physicians on sport-related pain reporting and competing regardless of pain or limitations. Although clinicians may be inclined to focus on these aspects, they are advised to also inquire specifically about limitations and pain during daily life activities in young athletes with overuse wrist injuries.

Damage of the distal radial physis in young gymnasts: can three-dimensional assessment of physeal volume on MRI serve as a biomarker?

OBJECTIVE: To explore the use of quantitative volume assessment to identify the presence and extent of stress-related changes of the distal radial physis in gymnasts with suspected physeal injury, asymptomatic gymnasts, and non-gymnasts. METHODS: Symptomatic gymnasts with clinically suspected distal radial physeal injury, asymptomatic gymnasts, and non-gymnasts (n = 69) were included and matched on skeletal age and sex. Volume measurements were performed on coronal water selective cartilage MRI images by creating three-dimensional physeal reconstructions semi-automatically using active-contour segmentation based on image-intensity thresholding. Inter- and intra-rater reliability of the measurements were assessed using intra-class correlation coefficients (ICC) for absolute agreement. RESULTS: Twenty-seven symptomatic-, 18 asymptomatic-, and 24 non-gymnasts were included with a median age of 13.9 years (interquartile range (IQR) 13.0-15.0 years). Median physeal volume was significantly increased (p < 0.05) in symptomatic- (971 mm3, IQR 787-1237 mm3) and asymptomatic gymnasts (951 mm3, IQR 871-1004 mm3) compared with non-gymnasts (646 mm3, IQR 538-795 mm3). Inter-rater (ICC 0.96, 95% CI 0.92-0.98) and intra-rater (ICC 0.93, 95% CI 0.85-0.97) reliability of volume measurements were excellent. Of the 10 participants with the highest physeal volumes, nine were symptomatic gymnasts. CONCLUSION: Increased volume of the distal radial physis can reliably be assessed and is a sign of physeal stress that can be present in both symptomatic- and asymptomatic gymnasts, but gymnasts with suspected physeal injury showed larger volume increases. Future studies should explore if volume assessment can be used to (early) identify athletes with or at risk for physeal stress injuries of the wrist. KEY POINTS: • The volume of the distal radial physis can be reliably assessed by creating three-dimensional physeal reconstructions. • Stress-related volume increase of the distal radial physis is present in symptomatic and asymptomatic gymnasts. • Gymnasts with clinically suspected physeal injury showed larger volume increases compared with asymptomatic gymnasts and may therefore be a valuable addition in the (early) diagnostic workup of physeal stress injuries.

Health Effects of Wrist-Loading Sports During Youth: A Systematic Literature Review.

BACKGROUND: The benefits and risks of performing popular wrist-loading sports at a young age have not been investigated systematically. We aimed to evaluate positive and negative long-term wrist-related health effects of sports performance requiring repetitive wrist loading during youth. METHODS: Six databases were searched for cohort and cross-sectional studies. Three investigators selected studies evaluating quantitatively measured health effects of upper extremities in athletes practicing wrist-loading sports (gymnastics, tennis, volleyball, field hockey, rowing, and judo) for minimally 4 months before the age of 18. RESULTS: A total of 23 studies with 5 outcome measures, nearly all of moderate to good quality, were eligible for inclusion. Bone mineral density and bone mineral content were higher in athletes compared with controls and in tennis players' dominant arm. Mixed results were found for ulnar variance in gymnasts. Handgrip strength was greater in tennis players' dominant arm and in experienced gymnasts. CONCLUSIONS: Wrist-loading sports performance during youth can promote bone strength in wrists and dominant handgrip strength, but evidence on the lasting of these effects and on prevalence of wrist joint degeneration in former young athletes is limited. For better counseling of young athletes and their parents, future studies with increased comparability are essential, for which recommendations are provided.

Systematic assessment of the growth plates of the wrist in young gymnasts: development and validation of the Amsterdam MRI assessment of the Physis (AMPHYS) protocol.

OBJECTIVES: To develop and validate a protocol for MRI assessment of the distal radial and ulnar periphyseal area in gymnasts and non-gymnasts. METHODS: Twenty-four gymnasts with wrist pain, 18 asymptomatic gymnasts and 24 non-gymnastic controls (33 girls) underwent MRI of the wrist on a 3T scanner. Sequences included coronal proton density-weighted images with and without fat saturation, and three-dimensional water-selective cartilage scan and T2 Dixon series. Skeletal age was determined using hand radiographs. Three experienced musculoskeletal radiologists established a checklist of possible (peri)physeal abnormalities based on literature and clinical experience. Five other musculoskeletal radiologists and residents evaluated 30 MRI scans (10 from each group) using this checklist and reliability was determined using the intraclass correlation coefficient (ICC) and Fleiss' kappa. A final evaluation protocol was established containing only items with fair to excellent reliability. RESULTS: Twenty-seven items were assessed for reliability. Intra-rater and inter-rater agreement was good to excellent (respective ICCs 0.60-0.91 and 0.60-0.78) for four epiphyseal bone marrow oedema-related items, physeal signal intensity, metaphyseal junction and depth of metaphyseal intrusions. For physeal thickness, thickness compared with proximal physis of first metacarpal, metaphyseal intrusions, physeal connection of intrusions and metaphyseal bone marrow signal intensity, intra-rater agreement was fair to excellent (ICC/kappa 0.55-0.85) and inter-rater agreement was fair (ICC/kappa 0.41-0.59). Twelve items were included in the final protocol. CONCLUSION: The Amsterdam MRI assessment of the Physis protocol facilitates patient-friendly and reliable assessment of the (peri)physeal area in the radius and ulna.

Overuse wrist injuries in young athletes: What do sports physicians consider important signals and functional limitations?

This study's objective was to collect items from experienced sports physicians, relating to the presence and severity of overuse wrist injuries in young athletes, for developing a measurement instrument for signals of overuse wrist injury. Seven Dutch elite sports physicians involved in guidance and treatment of young athletes in wrist-loading sports (gymnastics, tennis, judo, field hockey, volleyball and rowing) participated in a focus group. They discussed signals and limitations related to overuse wrist injuries in young athletes. Data were coded and categorised into signals and limitations with subcategories, using an inductive approach. Of the resulting 61 signals and limitations in nineteen (sub)categories, 20 were considered important, forming a comprehensive item set for identifying overuse wrist injury in young athletes. Signals such as pain, "click", crepitations, swelling and limited range of motion were marked useful for early identification of overuse wrist injury. Limitations in movement and performance were considered indicative of severe overuse injury but less relevant for initial injury identification. The focus group provided 17 important signals and 3 important limitations indicative of overuse wrist injury. These provide the basis for a valid measurement instrument for identifying overuse wrist injury in young athletes, with equal emphasis on pain and on other symptoms.

Prevalence, incidence and risk factors for overuse injuries of the wrist in young athletes: a systematic review.

BACKGROUND: Overuse wrist injuries can cause long-term symptoms in young athletes performing wrist-loading sports. Information on the prevalence, incidence and associated risk factors is required. PURPOSE: We aimed to review the prevalence and incidence of overuse wrist injuries in young athletes and to identify associated risk factors. We focused on popular wrist-loading youth sports-gymnastics, tennis, field hockey, volleyball, judo and rowing. STUDY DESIGN: Systematic review. METHODS: We conducted a literature search on athletes aged <18 years performing wrist-loading focus sports. Prevalence, incidence and/or risk factor ORs for overuse wrist injuries were extracted directly or calculated from reported data. RESULTS: The search identified six studies on prevalence, five on incidence, and one on risk factors. Prevalence rates were 32-73% for wrist pain and 10-28% for overuse wrist injury. Incidence rates were 7-9% for wrist pain and 0.02-26% for overuse wrist injury. The three criteria associated with wrist pain were (with OR): age of 10-14 years (11.5), training intensity (1.2), and earlier onset of gymnastics training (1.97). CONCLUSIONS: Prevalence and incidence of overuse wrist injuries was high in multiple studies of gymnasts, and largely unknown in other wrist-loading focus sports. Three key risk factors for wrist pain in gymnasts were age between 10 and 14 years, earlier training commencement, and training intensity. Using 'wrist pain' in defining overuse, and further investigating risk factors can aid in identifying overuse wrist injuries in young athletes.

Arthroscopic treatment of osteochondral defects of the talus: outcomes at eight to twenty years of follow-up.

BACKGROUND: The primary aim of this study was to assess the long-term clinical and radiographic outcomes of arthroscopic debridement and bone marrow stimulation for talar osteochondral defects. The secondary aim was to identify prognostic factors that affect the long-term results. METHODS: Fifty (88%) of fifty-seven eligible patients with a primary osteochondral defect treated with arthroscopic debridement and bone marrow stimulation were evaluated after a mean follow-up of twelve years (range, eight to twenty years). Clinical assessment included the Ogilvie-Harris score, Berndt and Harty outcome question, American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, and Short Form-36 (SF-36) as well as resumption of work and sports. Weight-bearing radiographs were compared with preoperative radiographs with use of an ankle osteoarthritis classification system. The size, location, and classification of the defect, patient age and body mass index, traumatic etiology, and duration of symptoms were recorded and analyzed with use of univariate logistic regression. RESULTS: The Ogilvie-Harris score was excellent in 20% of patients, good in 58%, fair in 22%, and poor in 0%. According to the Berndt and Harty outcome question, 74% of patients rated the ankle as good, 20% as fair, and 6% as poor. The median AOFAS score was 88 (range, 64 to 100). Of the eight subscales of the SF-36, six were comparable with population norms and two were superior in the study group. Ninety-four percent of patients had resumed work and 88% had resumed sports. The radiographs indicated an osteoarthritis grade of 0 in 33% of the patients, I in 63%, II in 4%, and III in 0%. Compared with the preoperative osteoarthritis classification, 67% of radiographs showed no progression and 33% showed progression by one grade. None of the prognostic factors was significantly associated with the Ogilvie-Harris score or progression of osteoarthritis. CONCLUSIONS: This study suggests that initial success of arthroscopic debridement and bone marrow stimulation for osteochondral defects of the talus are maintained over time. No factors that were predictive of the outcome could be identified.