Case to discuss [Radek Kebrle - Czech Republic - 2019]
Case to discuss
I have a case to discuss. 16yo 3times European young female box champion has 1 year of ulnar sided wrist pain bilateral. Hyperelasticity, pain at the tip of styloid process progressed to pain at ADL. See the x-rays attached. MRI except peristyloid oedema negative, no signs of tfcc or ecu lesion, just increased ulnar inclination. Has anyone seen a case like that. Any sugestions??
Would you mind posting the MRI images, please? Was it an MRI arthrogram? The sensitivity of plain MRI for TFCC tears can be very variable, MRI arthrogram is better (around 80%)
Calcification of ulnocarpal ligaments due to repetitive trauma? Trying with shock waves?
Could it be a case of stylo-carpal impingement?
What an amazing case.
I think we are seeing obvious anatomical abnormality here with that almost Madelung’s like inclination but given the MRI findings described I wonder how much of that is long term change. That inclination, combined with her increased laxity and what I’m guessing would be a rigorous training combination of repetition of striking (bag, focus pad and other work), strength and conditioning and cardiovascular training of probably greater than 20 hours per week, has led to this.
Despite her anatomy, I would still go back to basics and examine all facets of her mechanics and training, breaking down the percentages and times on heavy bag work as well as how hard her trainer strikes back on focus pad work. It may simply be too much heavy striking activity for her at this time and need to be backed off or modified in the short to medium term.
I’d discuss how she wraps for each session and even involve the therapists to see if it could be modified to provide increased coronal support. I’d make sure her glove selection for training was optimised and at least take her to 16 oz in a good glove, involving her trainer’s input into that.
I’d look at her strength and conditioning/cardio training and maybe modify any aggravating activity there, take away loaded extension (pushing with straight wrists), remove dumbbells in favour of bars or machine weights and even reduce load and duration.
I’d still make sure there is not a mental component to this presentation, excluding a burn out element as I think she has been putting up with this for a while on top of training heavily throughout her early teens. I find this age group is where I tend to have gymnasts drop off in that manner.
On top of training modifications I would still try focussed injections, for both treatment and diagnostic value to confirm what is driving the pain. I’d certainly warn her that the first may not provide relief but would try (based on history, examination and her radiology) to find the focus of her pain via diagnostic injection.
Ultimately the changes in training (train smarter) and the injections/simple medication may be enough. Only after all of the above, and with confirmation with the patient and her team that there is a future in boxing and ongoing strong desire, would osteotomy be discussed. In this case, in a striking athlete (sorry had not said skeletally mature but is) with likely incredible shear force being produced across that joint, I would favour radial osteotomy, even with element of closing radially and opening (not a lot, very subtle lengthening only) at ulnar aspect to correct radial inclination as well as variance. I would image with CT, 3D recon and consider printing her radius and ulna to fully understand the deformity and practice any procedure. In this sort of case I don’t tend to use commercially crafted cutting guides but that is an option though more difficult given bilateral problem.
I hope this helps.
As if mail boxing is in ulnar deviation it is looks like stylo-triquetral impingement.
She is right or left handed? Is there some reaction of triquetrum on MRI?