Kienböck's disease: an unusual cause of wrist pain in a 13-year-old girl.

A 13-year-old girl presented with a 5-month history of right (dominant) wrist pain that resulted from a forced dorsiflexion-type injury. She experienced progressive discomfort in the wrist that subsequently was associated with stiffness and weakness. The pain persisted even though she curtailed her sporting activities, and it became progressive and disabling. She had no history of a fracture or dislocation and no risk factors for avascular osteonecrosis. Physical examination of the right wrist revealed swelling and tenderness over the proximal row of carpal bones. She had decreased range of motion with 30o of palmar flexion and 60o of dorsiflexion, compared with the uninvolved wrist. Neurologic and vascular status findings were satisfactory. Hand grip strength was 10 kg, compared with 21 kg on the uninvolved side. Radiographs demonstrated a collapsed, sclerotic lunate bone with a negative ulnar variance deformity of the wrist measuring 3 mm (Fig. 1). The lunate was graded according to the classification of Lichtman and associates as stage IIIA Kienböck’s disease (lunate collapse without change in intercarpal relation). Further, the carpal height was measured at 2.1 cm, producing a carpal height ratio of 0.44 (normal range 0.45–0.60). CT confirmed fragmentation and collapse of the lunate bone with marked sclerosis but no intercarpal changes. The girl underwent right distal radial shortening osteotomy 6 months after presentation. A dorsal approach was used, and 4 mm of radius was removed, resulting in neutral ulnar variance at the wrist. The osteotomy was fixed with a one-third tubular plate, and a neurectomy of the terminal branch of the posterior interosseous nerve was performed. Postoperatively, she wore a cast for 6 weeks. At that time, radiographs showed progressive consolidation at the osteotomy site and an improved appearance of the lunate bone in both height and density. The carpal height had increased to 2.4 cm, producing a carpal height ratio of 0.58 (Fig. 2). The patient underwent physical therapy to improve strength and range of motion of the wrist. Clinically, her symptoms resolved gradually, and 8 months postoperatively she was pain free and had resumed her normal sports and activities.