In gymnastics, the wrists bear a tremendous amount of weight and are exposed to forces that well exceed normal daily activities. A gymnast's wrist is inclined to injuries because many routines (1) place the body's weight on the wrist while bending it backwards, and (2) often require fast, jolting movements to the wrists and hands. This results in injuries that are both acute, such as fractures, dislocations and sprains, and chronic (long-term). Most acute gymnastic injuries are treated like any other sport injuries, however, two chronic injuries, dorsal wrist impingement and distal radial stress fractures, require specific treatment.

Dorsal wrist impingement
Dorsal wrist impingement is the most common injury to a gymnast's wrist. The injury results from the repetitive combination of hyperextension (extending or straightening the joint beyond its normal range of motion) and axial loading, (placing force on the joint or bone) (Fig. 1). The injury occurs when the dorsal (back) edge of the radius impinges on (strikes) the wrist bones (Fig. 2). This injury often occurs during routines that include walkovers and handsprings. On a vault or balance beam, the injury can intensify when the stance is held with the full weight of the body on the wrist, such as during a handstand. When injury occurs, the gymnast feels pain and tenderness on the backside of the wrist. The pain usually subsides after the routine has ended.

Treatment consists of complete rest from hyperextension and axial loading. A dorsal-wrist-block support or splint can be used to limit hyperextension, while icing plus anti-inflammatory medications, such as ibuprofen or aspirin, can help reduce swelling and pain. A stretching and strengthening program for the wrist and finger flexors should begin after the initial rest and rehabilitation phase has been completed. Gradual return to activity is allowed while continuing a stretching and strengthening program. If pain persists after rest and strengthening exercises, cortisone injections, and, occasionally, surgery may be required to correct the injury.

Distal radial stress fracture
Distal radial stress fractures (Fig. 3) are commonly associated with floor exercises and vaulting. High impact forces, incurred from a double backward somersault, for example, can cause compression on the wrist, causing small fractures (breaks) in the radius (the bone on the thumb side of the forearm). Pain and tenderness are often felt around the entire circum-ference of the radius just above the wrist. The pain is experienced at the onset of participation and progresses as activity continues.

X-rays play an important role in diagnosis of the injury. Because fractures can be seen on a x-ray, a physician can determine the severity of the injury and begin treatment immediately. The injury is often caused by repeated microtrauma (minor trauma) due to axial loading and dorsiflexion (bending) of the wrist. This trauma can affect the growth plate of the radius and can result in decreased growth or length. This could, in affect, cause the radius and ulnar to grow to different lengths. Therefore, it is important to have the injury evaluated when the pain is first felt. Postponing a visit to a physician can lead to a more serious injury and a longer recovery time.

Treatment depends on the severity of the symptoms and the fracture. Resting and avoiding compressive loading routines is the mainstay of treatment. A splint or cast for immobilization may help. A gymnast may return to participation after full range of motion has returned and the pain and tenderness have subsided.

After returning to sport, it is important to monitor the wrists for recurring symptoms. Any recurrence of symptoms will require additional treatment, particularly, a rest period from participation. Surgery is not always necessary; however, severe injury and failure to see a physician right away often result in longer treatments, longer rest periods, and surgery.

David C. Rehak, MD
Columbus, Georgia