Rationale

There are a number of treatment options well described in adults with Kienböck’s disease. The disease is known to occur in younger patients as well. The best treatment option in this group is highly controversial.

Clinical comment

The condition can be highly disabling at a time of life when the patient is highly active. The natural history in this age group is unclear. The ideal treatment would allow the patient to rapidly return to functional activity.

Available literature and quality of the evidence

• Level IV: 2 case series, 3 case reports.

Findings

Irisarri’s series reports his experience in 13 cases.¹ Four patients had infantile lunatomalacia (up to and including 12 years of age). All patients resolved with nonoperative management, with immobilization alone. All patients resolved symptomatically, although one patient had only partial remodeling of the lunate. Nine patients were treated with juvenile lunatomalacia (age 13 until skeletal maturity). After periods of immobilization, three patients remained symptomatic and were treated with radial shortening osteotomy. At a mean follow‐up of five years, clinical and radiological outcome was good in this subgroup.

Iwasaki reported his experience with radial osteotomies in 11 patients between the ages of 11 and 19 who had failed nonoperative treatment for Kienböck’s disease.² There were three patients with Lichtman stage II disease, two with stage IIIA disease, and six with stage IIIB disease. Nine patients with negative ulnar variance had radial shortening osteotomies, and two with zero or positive ulnar variance had lateral closing wedge osteotomies. Ten out of 11 patients had excellent clinical outcomes. Eight patients had radiographic improvement showing lunate revascularization. One patient had persistent wrist pain following surgery.

In other case reports, radial shortening or temporary scaphotrapeziotrapezoidal (STT) joint pinning for four weeks has been shown to lead to improvement in pain, function, and lunate revascularization.³,⁴ In two cases of patients with cerebral palsy and Kienböck’s disease, temporary immobilization resulted in functional and radiographic resolution.⁵

Resolution of clinical scenario

The vast majority of patients with pediatric Kienböck’s disease will resolve with a variable period of immobilization in a splint or cast. This usually leads to improvement both radiologically and clinically. In the older child or teenager with juvenile osteomalacia, recalcitrant cases do occur. Ulnar‐negative patients may benefit from a radial shortening osteotomy. Ulnar‐neutral or ulnar‐negative patients may benefit from radial closing wedge osteotomy or temporary STT joint pinning.