Overview: Causes of chronic wrist pain in children and adolescents

INTRODUCTION — Injuries to the wrist are common in children, adolescents, and young adults. A thorough understanding of the anatomy of the growing wrist, common wrist injuries, and other causes of wrist pain are essential to accurate diagnosis and appropriate treatment.

Causes of chronic wrist pain in children and adolescents include acute injuries that have failed to heal, overuse syndromes, and pain unrelated to trauma. Traumatic and nontraumatic causes of chronic wrist pain in children and adolescents will be presented here. Acute wrist injuries, wrist anatomy, and the evaluation of wrist pain in children and adolescents are discussed separately. (See "Overview of acute wrist injuries in children and adolescents" and "Evaluation of wrist pain and injury in children and adolescents".)

OVERUSE INJURIES — Overuse injuries, which include tendonitis, distal radius physeal stress reaction, Kienböck disease, chronic distal radioulnar joint (DRUJ) and triangular fibrocartilage complex (TFCC) injury, neuropathy, and impaction syndromes, are more common among adolescents than younger children (table 1).

Overuse injuries have insidious symptoms; they frequently are identified when an acute injury is superimposed at the site of previous microtrauma [1]. The etiology of most overuse injuries in the wrist can be categorized by the amount of gripping, repetitive trauma, and weightbearing load involved in each sport (table 2):

●Gripping sports (those that use a racquet, oar, bat, etc) require the wrist to perform specific motions repetitively, which can result in tendinitis and impingement.

●Repetitive trauma such as a volleyball hitting the radial styloid or a football lineman blocking, forcing their wrist into extension, can accumulate damage and anti-inflammatory changes over time without macro-injury.

●Weightbearing loaded sports, such as competitive youth gymnastics, have been associated with a high prevalence of overuse injury (eg, 28 percent in one study [2]). Risk factors include younger age (10 to 14 years of age) and later initiation of competitive training (7 versus 5 years of age) [3].

Other risk factors for overuse injuries in children and adolescents include rapid intensification of training, muscle-tendon imbalance, poor conditioning before training, deficient nutrition, associated chronic disease, and periods of rapid growth [1,4].

Tendon injuries — Tendonitis involves inflammation of the tendon or its synovial sheath. Tendonitis is caused by repetitive motion or impact stress (eg, in gymnastics, racquet sports). Clinical features include pain that is exacerbated by activity and can be reproduced by passive stretching of the affected tendon or active contraction of the associated muscle [5]. Radiographs are not usually necessary in the evaluation of patients with tendonitis but may be helpful in excluding other injuries or conditions.

Treatment strategies for tendonitis include rest, bracing, antiinflammatory agents, glucocorticoid injections, and correcting the training error or biomechanical etiology. Sports activity can be gradually resumed once symptoms have resolved.

●De Quervain – De Quervain tenosynovitis involves the sheath of the abductor pollicis longus and the extensor pollicis brevis at the level of the radial styloid. De Quervain's tenosynovitis occurs in individuals who are in gripping activities like golf, fly fish, or play racquet sports. The clinical manifestations, diagnosis, and treatment are discussed separately. (See "de Quervain tendinopathy".)

●ECU tendonitis – Extensor carpi ulnaris (ECU) tendonitis is seen in participants of sports that require forceful wrist extension (eg, racquet sports, golf, rowing) [6,7]. Inflammation occurs in the sixth dorsal extensor compartment as the ECU tendons pass in a groove along the ulna [8].

Clinical features of ECU tendonitis include tenderness and swelling over the ECU tendon in the ulnar groove and pain that is exacerbated by wrist extension against resistance [9,10]. Relief of pain with lidocaine injection into the ECU sheath can confirm the diagnosis if confirmation is necessary [7].

Initial treatment involves rest, immobilization with a neutral wrist brace, modification of activities, and oral antiinflammatory agents [7]. Glucocorticoid injection into the sheath is a reasonable second-line option. Failure to improve with these treatments may indicate additional pathology and further evaluation is warranted [7]. Surgical decompression with division of the subsheath housing the ECU tendon is the final treatment option.

●ECU subluxation – ECU subluxation results from rupture or attenuation of the ECU subsheath, usually due to sudden wrist flexion under ulnar deviation [7]. It may occur in golfers, weight lifters, rodeo riders, tennis players, and baseball players [7,10].

Patients complain of dorsal ulnar wrist pain and "snapping" that are increased with rotation of the forearm [10]. Triangular fibrocartilage complex injuries can present with similar signs and symptoms. On examination, the ECU tendon can be observed subluxing over the ulnar styloid when the patient deviates the wrist ulnarly in full supination [7]. ECU subluxation responds well to immobilization; surgical reconstruction is rarely needed.

●FCR tendonitis – Flexor carpi radialis (FCR) tendonitis presents with pain at the area of the FCR with resisted/active flexion (follow-through on volleyball spike or basketball shot) or passive wrist extension (figure 1).

Initial treatment involves rest, immobilization in a neutral wrist brace, antiinflammatory agents, and stretching exercises. Glucocorticoid injection is slightly more difficult because the FCR is in close proximity to the radial artery. In prolonged cases, surgery may be indicated [11].

●FCU tendonitis – The flexor carpi ulnaris (FCU) tendon partially fans out in its distal insertion on to the pisiform before attaching to the base of the fifth metacarpal (figure 1). Flexor carpi ulnaris (FCU) tendonitis can result from repetitive motion or pisotriquetral compression. Compression occurs from loading, hitting with an open fist (eg, in karate or volleyball), or trauma (eg, from the end of a racquet, stick, or club at the end of the swing) [7,8].

The characteristic feature of FCU tendonitis is pain in the region of the FCU tendon with resisted wrist flexion [8]. Pain with compression of the pisotriquetral complex is more suggestive of pisotriquetral arthritis or contusion. Point tenderness over the hamate is more suggestive of hamate fracture. (See "Overview of acute wrist injuries in children and adolescents", section on 'Hamate fractures'.)

Plain radiographs are normal in patients with FCU tendonitis. They may show degenerative changes at the pisotriquetral joint in patients with pisotriquetral arthritis or fractures of the hook of the hamate. (See "Overview of acute wrist injuries in children and adolescents", section on 'Hamate fractures'.)

Conservative management with rest, a neutral wrist brace, and stretching is usually successful for FCU tendonitis secondary to repetitive motion or pisotriquetral compression. Subperiosteal excision of the pisiform can be curative for recalcitrant cases of pisotriquetral arthritis [11].

●Intersection syndrome – Intersection syndrome results from repetitive wrist extension against resistance (eg, rowing, weight lifting) [6-9]. Pain and tenderness are localized at the point of intersection of the abductor pollicis longus, extensor pollicis brevis, and the extensor carpi radialis. Active extension of the wrist and thumb against resistance triggers pain 4 to 6 cm proximal to the wrist joint dorsally [8]. This maneuver may be accompanied by palpable or audible crepitus [7,8].

Symptoms usually respond to rest, a neutral wrist brace with thumb spica extension, and antiinflammatory agents, with or without glucocorticoid injection [7]. Surgical decompression may be necessary in refractory cases. Sports activity can be gradually resumed once symptoms have resolved.

Distal radius physeal stress reaction — Repetitive loading of the extended wrist can lead to stress and eventual osteolysis of the distal radial growth plate. The typical patient is female, 12 to 14 years of age, and doing gymnastics about 35 hours per week [12]. Distal radius physeal stress reaction also occurs in rock climbers and weight lifters [6]. It should be suspected in patients with dorsal pain made worse by stress loading, such as vaulting or hand-walking and no history of acute trauma [5].

Distal radius stress reaction may result in growth inhibition or premature growth arrest of the radius. If this occurs, there is relative overgrowth of the ulna ("positive ulnar variance"). Radial shortening may be accompanied by ulnocarpal impaction and tears of the TFCC [12]. (See 'Ulnar impaction' below and "Overview of acute wrist injuries in children and adolescents", section on 'TFCC injuries'.)

Early in the course, before radiographic changes, wrist pain with extension and axial loading may be the only manifestation [12]. At this stage, restriction of activity for at least two to four weeks facilitates the return of full strength and pain-free range of motion. Full strength and pain-free range of motion are necessary before progressive return to grip and tumbling exercises.

Radiographic findings, which include widening and irregularity (cystic and sclerotic changes) of the growth plate and palmar spurring of the metaphysis, indicate more severe disease. Elite gymnasts and other high-risk athletes may develop radiographic changes without symptoms; regular radiographic examination may be appropriate [9].

Once radiographic changes are present, cast or forearm-based volar splint immobilization for four to eight weeks is typically necessary for resolution of symptoms and signs. Radiographic healing lags behind clinical improvement. Restriction of activity is essential in patients with radial shortening; such patients also may require surgical treatment for ulnocarpal impingement [12]. (See "Basic techniques for splinting of musculoskeletal injuries".)

If there is a positive ulnar variance and conservative management does not improve symptoms, surgical debridement and ulnar shortening may be indicated [12].

Kienböck disease — Kienböck disease is a progressive collapse of the lunate (figure 2). The mechanism remains unclear but appears to involve disruption of the blood supply, possibly related to undiagnosed fractures of the lunate, repetitive trauma, or abnormal biomechanical loading patterns at the radiocarpal joint [6,13].

Kienböck disease occurs in adolescents (most commonly males) involved in repetitive impact activities (eg, volleyball, the martial arts) [1,6,14,15]. It affects the dominant wrist and presents insidiously [10]. The most common symptoms are dorsal wrist pain with mild swelling followed by persistent pain, crepitation, stiffness, and decreased range of motion [8,13]. There may be associated weakness or difficulty grasping heavy objects [10,16,17].

The diagnosis is made radiographically (AP views). In the earliest stages, radiographs are normal but bone scan shows increased uptake and MRI shows decreased signal in the lunate on T1 images. With progression, there is increased density in the lunate (Stage 2), followed by bony collapse (Stage 3), and, finally, carpal instability and arthritis (Stage 4). Negative ulnar variance may be associated with more advanced cases due to the radial impaction on the lunate [18].

Early referral to a hand surgeon is essential. Treatment options range from immobilization for Stage 1 disease, to revascularization, radial shortening procedures, and arthrodesis for end-stage disease [13].

Chronic DRUJ and TFCC injuries — Chronic DRUJ injuries are usually related to repetitive pronation as may occur in tennis, gymnastics, or bowling. Chronic DRUJ instability also may follow trauma to the wrist/forearm (ie, Galeazzi fracture), presenting months later with progressive pain with supination and pronation. Initial radiographs may be normal or demonstrate degenerative changes at the sigmoid notch between the radius and ulna. Definitive treatment is usually surgical.

Chronic TFCC injury is caused by repetitive activity involving twisting, compression, and ulnar deviation (eg, tennis, squash, ice hockey, golf, baseball, softball, boxing, water skiing, and pole vaulting) [6,16,19-21].

Chronic TFCC tears are believed to be the result of ulnar impaction. Impaction on the lunate on the ulnar head puts increased axial pressure on the TFCC, eventually wearing it down and creating a central perforation. If impaction continues, lunate and ulnar chondromalacia develop, followed by arthritic changes [22]. (See 'Ulnar impaction' below.)

Treatment of chronic TFCC tears requires arthroscopy with repair or debridement. If ulnar impaction is the cause of the TFCC tear, an ulnar shortening procedure (to correct the underlying cause of impaction) is usually carried out in addition to TFCC debridement.

Neuropathy

Carpal tunnel — Carpal tunnel syndrome (median neuropathy) is the most common compressive neuropathy in sports [23]. It occurs in players of racquet, stick, and club sports; golfers; skiers; and cyclists and is related to the repetitive motion of grasping or extended periods of extension or flexion [6].

Carpal tunnel syndrome is discussed separately. (See "Carpal tunnel syndrome: Pathophysiology and risk factors" and "Carpal tunnel syndrome: Clinical manifestations and diagnosis" and "Carpal tunnel syndrome: Treatment and prognosis".)

Ulnar neuropathy — Compression of the ulnar nerve in Guyon's canal may occur in cyclists (related to prolonged hyperextension), hockey goaltenders, and in players of racquet sports (related to repetitive gripping and the impact of the racquet handle) [6,14,24-26].

Ulnar neuropathy is discussed separately. (See "Overview of upper extremity peripheral nerve syndromes", section on 'Ulnar nerve syndromes'.)

Radial neuropathy — Radial neuropathy (Wartenberg syndrome), compression of the superficial radial nerve at the wrist, occurs in players of sports that involve repeated supination and pronation [27]. It also may occur after direct trauma.

Patients with radial neuropathy complain of pain shooting up the thumb and paresthesias and pain over the dorsal thumb and dorsal radial hand with normal strength [27]. Radial neuropathy is treated conservatively with rest, antiinflammatory medications, and splinting.

Impaction syndromes

Dorsal impaction — Dorsal impaction syndrome, also known as dorsiflexion jam syndrome, is an overuse syndrome that may occur in gymnasts and football offensive lineman. Clinical features include wrist swelling and pain. Radial-sided pain may be related to impaction of the distal radius on the scaphoid and lunate, whereas ulnar-sided pain may represent the ulnar impaction on the TFCC, lunate, or triquetrum. Radiographs are normal.

Treatment involves restriction of wrist extension with extension-limiting braces and limiting stress across the injured wrist. Glucocorticoid injection also may be helpful. If there is a positive ulnar variance and conservative management does not improve symptoms, surgical debridement and ulnar shortening may be indicated [12].

Scaphoid impaction — Scaphoid impaction syndrome, a subset of dorsal impaction syndrome, is related to repetitive wrist extension, particularly with axial loading, which forces the dorsal rim of the scaphoid against the radius [6,7]. It occurs in gymnasts (floor exercises, vaulting, balance beam), weight lifters (when resting the bar in the palms), or from excessive pushups.

Clinical features include pain over the scapholunate ligament when the wrist is extended and axially loaded (figure 3) [8]. Radiographs may be normal or demonstrate ossicle formation at the rim of the radius or dorsal scaphoid [12]. Initial management entails avoidance of extension activities and/or the use of an orthoses [12].

Ulnar impaction — Ulnar impaction syndrome, also known as ulnar abutment syndrome and ulnar impingement syndrome, results from overload of the ulnar aspect of the wrist (eg, from activities requiring ulnar deviation and pronation or abnormal positive ulnar variance) [6,12]. Ulnar overload is particularly common with the vaulting in gymnastics [6,12].

Clinical findings include tenderness of the ulnar snuff box, tenderness with passive ulnar deviation, and tenderness with palmar and dorsal manipulation with the wrist in ulnar deviation [12]. Radiographic features include positive ulnar variance, or cyst formation or sclerosis of the ulnar head or lunotriquetral interface [12].

Initial management includes avoidance of the precipitating activity, antiinflammatory agents, and/or glucocorticoid injection of the DRUJ [12].

Hypothenar hammer syndrome — Hypothenar hammer syndrome occurs when repetitive impact to the palmar aspect of the wrist and hand causes damage to the ulnar artery and superficial palmar arch, resulting in diminished blood flow to the fingers [6,8]. Hypothenar hammer syndrome may occur in the dominant hand of players of racquet, stick, and club sports; volleyball players; and practitioners of the martial arts [28,29]. It also may occur with acute trauma.

Clinical features include complaints of pain in the palm that may radiate to the forearm and coldness of the digits, and an abnormal modified Allen test (figure 4) [27].

Ganglion cyst — Chronic irritation of the wrist causes an overproduction of joint fluid. Because of the limited capacity of the synovial cavity of the radiocarpal joint, excess synovial fluid escapes through a sinus into the subcutaneous tissues where the body confines it by forming a surrounding thick wall (a ganglion cyst). A ganglion cyst may present as an obvious swelling on physical examination, or it may only be manifested by wrist pain. The majority of wrist ganglia are located on the dorsal surface. (See "Ganglion cysts of the wrist and hand".)

NONTRAUMATIC CAUSES

Juvenile idiopathic arthritis — The wrist and hand are frequently involved in juvenile idiopathic arthritis (JIA). Chronic bilateral wrist pain and swelling may be the initial presentation. (See "Systemic juvenile idiopathic arthritis: Clinical manifestations and diagnosis" and "Polyarticular juvenile idiopathic arthritis: Clinical manifestations, diagnosis, and complications" and "Oligoarticular juvenile idiopathic arthritis".)

Rickets — Rickets is the most common metabolic cause of nontraumatic wrist swelling in children. Risk factors include malabsorption, lack of sunlight exposure, malnutrition, kidney disease, and hereditary enzyme deficiencies. Laboratory findings include decreased calcium and increased phosphorus, alkaline phosphorus, and parathyroid hormone. Radiographs reveal widening of the epiphysis and fraying of the distal metaphysis (image 1). Early treatment is associated with improved potential for catch-up growth [30]. (See "Overview of rickets in children".)

Carpal tarsal osteolysis — Carpal tarsal osteolysis is a rare condition in which the carpal and tarsal bones are progressively resorbed. It usually presents in childhood with progressive pain and stiffness of the wrists, feet, and elbows. The clinical picture is often mistaken for JIA but labs are normal and radiographs show a characteristic appearance of the lack of any carpal bones.

Congenital anomalies — Congenital wrist abnormalities include skeletal dysplasias, hereditary absent radius syndrome, constriction ring syndromes (amniotic band syndromes), and Madelung deformity. If these abnormalities are severe, they can lead to abnormal joint surface contact and the development of arthritis over time. Early swelling, due to venous or lymphatic obstruction, may occur with severe constriction ring syndromes. (See "Amniotic band sequence".)

Madelung deformity — Madelung deformity is a focal dysplasia of the distal radial physis. Premature closure leads to a progressive deformity with dorsal displacement of the ulna and palmar displacement of the carpus (picture 1 and image 2) [31,32]. Madelung deformity occurs in girls and is usually bilateral.

Madelung deformity is usually detected between 8 and 12 years of age [31]. Clinical features include prominence of the distal end of the ulna, limitation of supination, and DRUJ incongruity with forearm rotation [31]. Activity-related wrist pain typically develops in late adolescence. Associated conditions include Leri-Weill dyschondrosteosis, Hurler syndrome, Turner syndrome, achondroplasia, and Ollier disease [32].

The diagnosis of Madelung deformity is made radiographically; radiographs of both wrists, forearms, and elbows should be obtained [31]. Radiographic abnormalities include shortening of the radius and abnormal distal radial articulations. Magnetic resonance imaging (MRI) or computed tomography (CT) show physeal narrowing or closure of the palmar and ulnar aspects of the distal radial physis [31]. Generalized bone dysplasia and postinfectious and posttraumatic deformity should be excluded.

The treatment depends upon severity. Early cases can be treated with serial casting or prophylactic excision of the physeal bar bridging the growth plate.

SUMMARY

●Overuse injuries – Overuse injuries of the wrist (table 1) are more common among adolescents than younger children. The etiology of most overuse injuries in the wrist can be categorized by the amount of gripping, repetitive trauma, and weightbearing load involved in each sport (table 2). Risk factors for overuse injuries include (see 'Overuse injuries' above):

•Rapid intensification of training

•Muscle-tendon imbalance

•Poor conditioning before training

•Deficient nutrition

•Associated chronic disease

•Periods of rapid growth

●Tendon injuries – Clinical features of tendonitis include pain that is exacerbated by activity and can be reproduced by passive stretching of the affected tendon or active contraction of the associated muscle. (See 'Tendon injuries' above.)

●Distal radius physeal stress fracture – Distal radius physeal stress reaction primarily occurs with repetitive loading of the extended wrist (gymnasts, rock climbers, weight lifters). It should be suspected in patients with dorsal pain made worse by stress loading. (See 'Distal radius physeal stress reaction' above.)

●Kienböck disease – Kienböck disease is a progressive collapse of the lunate (figure 2). Clinical features include dorsal wrist pain with mild swelling followed by persistent pain, crepitation, stiffness, and decreased range of motion. (See 'Kienböck disease' above.)

●Chronic distal radioulnar joint (DRUJ) and triangular fibrocartilage complex (TFCC) – Chronic DRUJ and TFCC injuries are related to repetitive twisting of the wrist. Clinical features include progressive pain with supination and pronation. MRI may be necessary for diagnosis. (See 'Chronic DRUJ and TFCC injuries' above.)

●Neuropathy – Wrist neuropathies arise from compression of the radial, ulnar, or median nerves during repetitive motion or after direct trauma. (See 'Neuropathy' above.)

●Impaction syndromes – Impaction syndromes occur from overuse and can affect the dorsal, scaphoid, and ulnar aspects of the wrist. (See 'Impaction syndromes' above.)

●Nontraumatic causes – Nontraumatic causes of chronic wrist pain in children and adolescents include juvenile idiopathic arthritis, rickets, and congenital deformities. (See 'Nontraumatic causes' above.)