Youngsters: Epiphyseal Plate Injuries

Getting children involved in climbing is fantastic, especially as climbing can be viewed as a life-long sport. However, we'd like to keep it that way, and the process to do this is prevent any injuries that will impact the kids in the future.
The main problem with injuries in children is any damage to the growth plates of any kind, and the most likely growth plate to injure is those that are sustaining high stress forces through them, such as the fingers. This post will aim to explain what growth plates are, the incidence of these injuries, and how best to avoid them.

Remember, children are children, not just “mini adults”!!!

What are growth plates?

As a child grows, all their bones start of as cartilage, and develop into bone as they get older. This is why a child's rib cage is much bouncier than an adults (please don't test this out!). This is why children are more likely to get greenstick fractures than pure fractures (this is where the bone bends and splinters, rather than a pure breakage – try this out with a freshly cut tree branch and try and snap it). As these bones develop, there are areas where the bone needs to grow.

The epiphyseal plate (or growth plate) is where new bone is formed to make the bone grow in a longitudinal direction, and on the otherside of the plate, the new bone growth becomes calcified. There is one of these growth plates at either end of the growing bone.

When this growth plate is damaged, the growth of the bone can be changed, from direction, to rate of growth or even stop growth altogether.

Whilst growth plates are still growing, they are the weakest area of the growing skeleton, 2 to 5 times weaker than adjacent ligaments. This is due to the connective tissues needing to allow for the growth of the bones.
Once growth has stopped, the epiphyseal plate is replaced with solid bone through calcification, and ceases to be an area of weakness.

Obviously, weight bearing is key for bone development and growth, however, it is the overuse and over-stressing of these structures that we are concerned about.

Time line of growth plates

If I remember correctly, during the closure of growth plates, the larger bones will fuse first, then the smaller joints. Also, the dorsal aspect of the growth plate closes last. 

This means that the fingers are susceptible to injury longer than larger bones such as the femur or humerus, and the dorsal aspect of the epiphyseal plate is usually where an overuse injury will occur in a child’s finger.

The picture above demonstrates this area of weakness, with a grade 3 Salter-Harris fracture.

Fingers stop growing at a biological age of 17 years old, but key timings to note is that of growth spurts, occurring from around age 12-13 for girls, and 13-15 for boys.

Especially for boys, this is key to note, as growth spurt plus testosterone = temptation to train harder due to the ease in which muscle bulk is put on in this period.

Incidence of growth plate injuries

Amongst junior competition climbers studied within the German National Junior Team by Volker Schoffl and friends found two-thirds who trained regularly on the campus board got fractured growth plates in a finger.
Shigeo Omori and Hajime found over 3 years, 182 junior competition climbers aged 7 to 19 had their fingers medically examined and 77.6% of these climbers had abnormalities, mostly deformation and light flexion contracture (can’t place hand flat on table).


In general, non-climbing public:
Growth-plate injuries comprise 15 percent of all childhood fractures. They occur twice as often in boys as in girls, with the greatest incidence among 14- to 16-year-old boys and 11- to 13-year-old girls. Older girls experience these fractures less often because their bodies mature at an earlier age than boys. As a result, their bones finish growing sooner, and their growth plates are replaced by stronger, solid bone.
Approximately half of all growth plate injuries occur in the lower end of the outer bone of the forearm (radius) at the wrist. These injuries also occur frequently in the lower bones of the leg (tibia and fibula). They can also occur in the upper leg bone (femur) or in the ankle, foot, or hip bone.

Mechanism of injury

Can be acute injury such as a fall, or can be a chronic onset caused by intense training, campus boarding or over-use of the crimp hold grip which causes compression or shearing of the growth plate.
It has been found that these injuries normally occur in climbers within the training scenarios rather than competitions.
Crimping or campus boarding has been found to be a cause of growth plate injuries due to the high loads put through the fingers, therefore causing an overload of growth plate (repetitive stress).

Signs and symptoms

Lack of mobility in fingers
Constant pain
Chronic swelling
Lack of crimping ability due to pain/swelling

The old mandate of “No pain, no gain” is crazy! If it hurts, get it checked out!

Diagnosis of injuries

The diagnosis and classification of a growth plate injury is normally via x-ray, and is classified as 1 to 5 Salter-Harris fracture.

Treatment

As with all fractures, this depends on the severity of the fracture, but will probably comprise of:
Immobilization
Manipulation or surgery
Strengthening/Range of movement exercises

Implication of these injuries

Rotation/shortening of finger
Incomplete growth
Deformity
Some papers suggest there is a link between climbing from an early age and early degenerative changes later on in life such as arthritis.
These will all obviously affect the child later on in life.

How to avoid these injuries?

• Avoid campus boarding under 18 years of age. Many famous climbers never touch a campus board – Steve Mclure, Tyler Landman so why does the kid?!
• Excessive Crimping – try and promote versatile grip strengths
• Long / intense training sessions
• No need to train strength pre-pubescent – due to motor skills still need to catching up with growth spurt.
• Avoid additional weight when climbing
• Dynamic moves – limit
• When training, try to discourage competition, as it will inevitably lead to someone getting an injury
• Train other areas, such as core, antagonists, balance, movement technique
• Respect growth spurts.
• Maintain good nutrition

No campus boarding (feet-off or dynamically) for under 18's! (to allow margin of error for late developers) UIAA approved advice!


References


Swiss medical weekly


Hochholzer T, Schoffl VR. Epiphyseal fractures of the finger middle joints in young sport climbers. Wilderness Environ Med. 2005;16:139–42.


One Move too many


http://www.medicinenet.com/growth_plate_fractures_and_injuries/article.htm



http://www.thebmc.co.uk/should-u18s-use-campus-boards?s=1



http://www.dpmclimbing.com/articles/view/kid-crushers-training-youth-climbers

Injures in Indoor Rock Climbing: New Research

Now the winter is fast approaching, all but the most tenacious of climbers will scurry indoors. But just how "safe" is indoor climbing?

Well, a new paper has been published this year by Schoffl, Hoffmann and Kupper in Wilderness and Environmental Mecicine has reported on the rate of injuries reported in an indoor climbing wall in Germany.


This study was performed over a 5 year period and was performed prospectively, rather than retrospectively as previous studies have. This meant that less bias could be introduced to the study, due to the events not having already occurred and the results unknown.


This study also had the advantage that climbing time could be monitored exactly due to an electronic entry and exit system at the climbing wall used.


There was a large number of participants registered in the study (515, 337), but this could of been higher due to those involved in group sessions not being counted separately.


Demographic data of the study found 63.6% of climbers were male, the remaining female, with ages between 8 and 80 years old (median being 34 years old). Average climbing time was 2 hours 47 minutes.
The authors reported 30 injuries in total over the 5 year period; 6 cases whilst bouldering, 16 lead climbing, 7 toproping, and in 1 case as a third person (not climbing or belaying) while watching another climber. Bouldering injuries were mostly the result of falls onto the mat, whereas in lead and toprope climbing various scenarios happened, but mostly resulting from belaying mistakes. Fifteen (50%) injuries were UIAA MedCom grade 2, 13 (43%) were grade 3, and 2 (7%) were grade 4, with no fatalities.

Injuries happened in beginner climbers in 5 (16.7%), in intermediate climbers in 16 (53.3%), in experts in 6 (20%), and in professionals in 3 (10%) cases.


In studies such as this, the safety aspect of a sport is given as a number of injuries per 1000 participation hours. The authors concluded that this study had 0.02 injuries per 1000 hours of climbing time, (similar to previous studies) and also much lower than other sports, such as surfing (13 per 1000 hours of competitive surfing (Nathason et al 2007)) and rugby (91 injuries per 1000 player hours (Brooks et al 2005)).

Of the injuries that occurred, the authors report that many of them were preventable, such as belaying or knot tying mistakes.


However, this study did have some flaws, of which are discussed below:

1. This study was only performed in one climbing gym, which may have been a particularly well run gym, and therefore have a better safety record, which the study recognises
   
2. Climbing time less than 30 mins and over 5 hours was omitted (due to probability of less than 30 mins not going to have been a climbing visit, or over 5 hours someone forgetting to log out). However, how many of us pop in to our local wall for a lunch time session, or spend the whole day there and stop for lunch etc?!
   
3. Only injuries that occurred while at the wall that required medical attention then and there were recorded. No overuse/chronic injuries, or those that may have been discovered after the climbing session were recorded.

But there you are, relative to other sports, indoor rock climbing has a much lower risk of injury. 

This article is also available on the BMC website, along with information on preventing becoming an indoor wall injury statistic yourself!

References


Brooks JHM, Fuller CW, Kemp SPT, Reddin DB 2005 Epidemiology of injuries in English professional rugby union: part 1 match injuries. Br J Sports Med 39:757–766


Nathanson A, Bird S, Dao L, Tam-Sing K 2006 Competitive surfing injuries: a prospective study of surfing-related injuries among contest surfers.A m J Sports Med. 35(1):113-7.


Schöffl VR, Hoffmann G, Küpper T 2013 Acute injury risk and severity in indoor climbing-a prospective analysis of 515,337 indoor climbing wall visits in 5 years. Wilderness Environ Med. 24(3):187-94