How To Be A Better Mountain Medic ... Growth Plates

Posted by Jeremy Windsor on Nov 13, 2018

If you’re an avid reader of Climber Magazine you might remember this quote from an article on finger board training published in the July-August 2018 edition:

“These training protocols were tested on adults, not children. We already know that campus boarding damages the growth plates in young climber’s finger bones as they have not finished growing. That damage can and has led to permanent finger deformity. As such I would not recommend maximal hangs to young children under the age of 18, on the grounds that it may cause untold damage…”

We asked Tim Halsey, a consultant orthopaedic hand surgeon for more information. 

Thanks Tim for talking to us. Can you start by giving us a bit of background on children’s growth plates – what do they do, where are they and what puts them at risk?

In children, “long bones” grow from the growth plates (epiphyses). Whilst the bones in the fingers are small they are still technically “long bones” and therefore have growth plates at their ends. Within each finger there are 3 bones, the proximal, middle and distal phalynx (plural: phalanges) and they each contain a growth plate. In children they are the weakest and softest parts of the skeleton. Growth plates are at their most metabolically active during the teenage growth spurt and most prone to fracture. With the onset of adulthood, this risk subsides as the skeleton matures and the growth plates close.

The x rays of two climbers - a 16 year old (complete fusion of the growth plates) and a 14 year old (visible growth plates)*

The challenge of growth plate injuries is two-fold. First, it can be difficult to make the diagnosis, either because it has not been considered, or because the imaging used to identify the injury is unable to show it. Second, if these injuries are missed they can result in uneven bone growth and distortion of the growing finger. This is often very difficult to treat.

Fracture of the growth plate of the third finger’s middle phalanx**

The forces that produce growth plate injuries are similar to those that produce a number of other injuries, namely deep crimps or deep flexion of the proximal interphalangeal (PIP) joint. The injury may present as a “one off” painful episode, or develop slowly after a period of intense training. The young climber will notice a painful swollen PIP joint which doesn’t settle with rest. If the injury does not improve within a week, advice should be sought from someone with an understanding of children’s hands and climbing injuries. Following examination, investigations such as x ray, ultrasound and MRI will be used to confirm the diagnosis and guide treatment.

Partial necrosis of the growth plate and bony deformity seen in a climber who continued to climb with a growth plate fracture**

What other conditions may present in this way?

Other potential sites of injuries include:

Tendon – More than twenty flexor and extensor tendons connect the muscles to the bones of each hand. These can become inflamed (tendonitis) or ruptured following traumatic injury.     

Tendon Sheath – The tendon is covered in a lubricating sheath which can become inflamed (tenosynovitis) following periods of overtraining.

Pulley – A series of five pulleys hold the flexor tendons to the phalanges. When the muscles in the forearm contract, the pulleys hold the tendons in place and allow the fingers to curl in. The A2 pulley is most commonly injured during climbing.

Collateral Ligament – Found on either side of the IP joints, these ligaments are damaged when they’re deviated towards the thumb or little finger.

Volar Plate – These are ligaments that provide stability at the metacarpophalangeal (MCP) and IP joints. Injury occurs when the finger is bent backwards (hyperextended) or when a force is applied to the end of the finger.

The Crimp - The cause of so many injuries!

How should a child with a damaged growth plate be managed?

Once the diagnosis has been confirmed the young climber should rest, avoid climbing and wear a splint until the fracture has healed. This is likely to take 4-6 weeks and should be followed by a carefully supervised rehabilitation plan.

Should under 18s use fingerboards?

Ideally, fingerboard training should be avoided until the growth plates are closed. As Volker Schoffl, co-author of “One Move Too Many” says,

“There is really no place for the campus board, the double dynamo or the use of additional weights, in anyone under the age of roughly 18 to 20 years”

This is because the potential for an under-appreciated injury, which could have long term consequences for finger growth, is relatively high.

Are there any other activities which carry a high risk of growth plate injury?

There are all sorts of hazards whether that’s riding a bike to the crag, jumping off a high boulder problem or falling onto the evening barbeque! The main thing with a growth plate injury is the risk of causing long term damage to the anatomical development of the teenage skeleton. Moderation in all things, but probably don’t use campus boards until your fingers have stopped growing!

Thanks Tim!

A fascinating article by Eric Horst on growth plate injury prevention can be found here.

*The image is taken from this article.

An excellent observational study by Thomas Hochholzer and Volker Schoffl can be found here.

**Images are taken from this article.

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