Bad Breaks
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I saw two patients last week, both 15-year-old boys training for climbing competitions, with finger fractures caused by overtraining.
When you think of finger injuries, broken bones probably don’t come to mind, but with climbers getting younger and younger, and the modern gymnastic approach to training, today’s crop of youth is at risk. Many could even be climbing with broken fingers and not know it. Climbing-team coaches and parents in particular should be on the alert for this relatively new type of injury that, unchecked, can adversely affect the shape and length of the bone.
While climbers have an acute appreciation of how training produces muscle fatigue and in turn stronger muscles, they know less about bone fatigue and recovery. Bones, like muscles, adapt to stress. When loaded progressively, bones strengthen. In an adult this process produces finger bones with thicker-than-normal walls. Although the muscles and tendons in young people recover more quickly than in their adult counterparts, young bones actually need more rest. Immature bones have a growth plate that does not abide chronic stress with the same resilience as adult bones.
A growing long bone (the fingers, although small, are long bones) contains various parts. The long section in the middle of the bone is the diaphysis. On each end of the bone is a bulbous bit called the metaphysis, and a sliver known as the epiphysis. Sandwiched between the epiphysis and the metaphysis is a thin plate of cartilage, the epiphyseal plate or growth plate. This is where the bone grows in length, layer on layer.
The growth plate is about the width of a small coin and is particularly susceptible to stress-related fractures, known as Salter-Harris fractures. The most common fracture in a young climber runs from the growth plate directly through the epiphysis, thereby dividing the epiphysis in two. This is called a Type Three Salter-Harris fracture. Given enough chronic load, the fragment can pull away from the metaphysis.
Typical symptoms of a Salter-Harris fracture are a progressively aggravated and swollen proximal interphalangeal (PIP) joint: the one in the middle of the finger. The pain can be sharp, but usually this is after the knuckle is already sore. Most pain occurs around the joint line, usually on the back of the knuckle, and tenderness depends on just how much the child is pissing off the fracture.
There are nine different types of Salter-Harris fractures. Type-three fractures, those that run from the growth plate through the epithysis (see x-ray), are the most common in the fingers of climbers. Within this category is a severity spectrum dictated by the size and position of the fragment, and how long it has been broken. In severe cases, surgery can be necessary to stabilize and relocate the fragment.
Unfortunately, the insidious and low- grade onset of pain that accompanies a Salter-Harris fracture can cause it to be written off as “growing pains” or a tweak that will fix itself over time. A sore finger that causes a child to avoid climbing should raise a red flag.
Knowing the symptoms of ligament damage and pulley tears is critical for differentiating and diagnosing Salter- Harris fractures. Ligament damage typically comes on suddenly and is caused by an obvious injury such as over torquing your hand in a crack. Pulley injury can be either acute or chronic. An acute tear will have an obvious starting point and create swelling and pain. Chronic pulley stress will produce pain of slow onset in the meat of the finger on the anterior or anterolateral aspect, not on the back or around the joint line (the widest part of the knuckle), as is the case for fracture.
Closure of the growth plate—the point where bones stop growing— varies by gender and bone, but generally occurs in girls by the mid-teens and in boys by late teens. Up to this point the growth plate is susceptible to fracturing, and Salter-Harris fractures are twice as likely among boys as girls.
There are precious few doctors interested in climbing injuries. Combine this void with the one between current knowledge and its application to young climbers, and our kids are in the eye of a perfect storm. Any young person with a chronically sore finger has a growth-plate fracture until proven otherwise. If there is a history of chronic pain, an x-ray is the bare minimum for a medical check-up.
Given the propensity for Salter-Harris fractures to fly under the radar until detonation, coaches and parents must pay attention. There are early signs of pathological bone fatigue, such as pain that aggravates with each climbing session, a little thickening through the middle of the finger with acute tenderness if you squeeze it and, most notably, that there was no particular injury event.
Children with Salter-Harris fractures must put their feet up for a while, perhaps even do some homework. Typically, when immobilized for four to six weeks, Salter-Harris fractures heal well with no long-term issues. If you suspect a Salter-Harris fracture, take your child to a suitable specialist, usually a pediatric orthopedist, to assess the injury and direct you to an appropriate treatment.
Prevention
A sore joint presages a fat finger, and a fat finger is a portent of osseous calamity. How do you avoid the carnage? Simple—start early! Dodging bullets is easier if there is no loaded gun in the first place.
A young climber’s training schedule is apt to push the fragile growth plate beyond its capacity. Perhaps it’s the four bouldering sessions each week. Perhaps it’s that toothy crocodile the campus board. Whatever the catalyst, it is easy to do too much volume and break those finger bones.
For the sake of simplicity, we will call 100 moves at one pound of load (endurance) the same as one move at 100 pounds of load (power). If endurance conditioning is death by a thousand cuts, power training is death by 10 cuts! Translation: Young climbers will arrive at a fracture inordinately more quickly by over emphasizing power, since power training is a far stronger catalyst of bone fatigue. The obvious question is how much and what type of training is safe?
Limiting apparatuses such as hangboards and campus boards is clearly warranted. For kids, anything outside of random-novelty use is a no-no. For adolescents, a fingerboard or campus-board session once every seven to 10 days is a good place to start. After six or eight consecutive sessions, the youth should take at least a month off from high-intensity finger training. Projecting boulder problems for a long time is no less problematic because it produces highly repetitive strain.
Bear in mind that, even at the same age, one child’s tolerance is another child’s broken finger.
This article appeared in Rock and Ice 230