Working Diagnosis:
Capitate stress injury + radial/ulnar epiphysitis or "Gymnast's wrist"

Treatment:
The patient was instructed to avoid painful activity and wear a brace to avoid hyperextension of the wrist. After a few weeks of rest, she was back in the gym, and unfortunately, back in pain. MRI was obtained and revealed both stress injury to the capitate and more subtle chronic signs of radial/ulnar epiphysitis or gymnasts wrist. Following the MRI results, this gymnast was held out of all weight-bearing activities for 8 weeks and referred to occupational therapy for formal bracing. Given the dorsal angulation of the capitate amidst its stress injury, she was also referred to a pediatric orthopedic hand specialist, who supported these interventions and period of prolonged rest.

Outcome:
After 8 weeks of complete rest, she returned to gymnastics. Fortunately, she has been completely pain-free for the past 4 months. She will plan to slowly increase the intensity of her training and return to care if her discomfort returns.

Author's Comments:
It is well known that gymnastic activities expose the hand and wrist to frequent overuse and acute stresses. These included repetitive motion, high impact loading, axial compression, torsional forces, and distraction in varying degrees of ulnar or radial deviation and hyperextension.
Most documented cases of carpal stress injury in gymnasts are to the scaphoid. The capitate is responsible for only 1-3% of carpal fractures overall. In this case, the patients capitate was noted to be dorsally angulated, likely predisposing it to impaction. Although rare, it is important that athletes, coaches, parents, and healthcare providers do not dismiss signs of chronic or progressive wrist pain. This is true even in the setting of normal plan radiographs. If discomfort persists, suspicion should remain and possibly warrant use of MRI. Standard treatment for stress fractures and other overuse injuries is a period of relative rest, often between 6-12 weeks. If untreated, injury may result in career-altering or ending outcomes for athletes.

Editor's Comments:
This is a nice case highlighting a less common cause of wrist pain in gymnasts. In a recently published study that looked at wrist bracing to help prevent wrist pain and injuries in skeletally immature gymnasts. The outcomes suggested that volar gel wrist bracing could be helpful in reducing pain in skeletally immature gymnasts, however it was done in male gymnasts.

Trevithick B, Mellifont R, Sayers M. Wrist pain in gymnasts: Efficacy of a wrist brace to decrease wrist pain while performing gymnastics. J Hand Ther. 2020 Jul-Sep;33(3):354-360. doi: 10.1016/j.jht.2019.03.002. Epub 2019 Apr 5. PMID: 30956069.

References:
1. Webb BG, Rettig LA. Gymnastic wrist injuries. Curr Sports Med Rep 2008;7(5):289-95. doi: 10.1249/ JSR.0b013e3181870471.
2. Wolf MR, Avery D, Wolf JM. Upper extremity injuries in gymnasts. Hand Clin 2017;33(1):187-197. doi: 10.1016/j.hcl.2016.08.010.
3. Caine D, Cochrane B, Caine C, Zemper E. An epidemiologic investigation of injuries affecting young competitive female gymnasts. American Journal of Sports Med 2016;17(6):811-20. doi: 10.1177/036354658901700616.
4. Vizkelety T, Wouters HW. Stress fracture of the capitate. Arch Chir Neerl 1972;24(1):47-57.
5. 4. Poletto ED, Pollock AN. Radial epiphysitis (aka gymnast wrist). Pediatr Emerg Care 2012;28(5):484-5. doi: 10.1097/PEC.0b013e318259a5cc.

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