[Kienböck's disease in paediatric and juvenile patients]

Kienböck's disease is a rare condition in children or juvenile patients with unique features. This article presents a review of the literature on this topic and an evaluation of our own patients to help to establish therapeutic guidelines.

From 1994-2005 we treated 23 patients. The 2 paediatric patients could be followed - one for 102 months after vascularised transposition of the pisiform and the other one for 24 months after conservative treatment. 15 out of the 21 juvenile patients could be followed: 9 patients on average for 47 months after radial shortening osteotomy, 5 patients on average for 94 months after partial wrist fusion and one for 24 months after arthroscopic debridement. Beginning in 2006 our therapeutic strategy has been changed. Since then one paediatric and one juvenile patient could be followed after temporary transfixation of the scaphotrapezoidal joint as well as one juvenile patient after spontaneous healing of the lunate bone. We measured motion, grip strength and pain level in rest and under load using the visual analogue scale, as well as the DASH score. Furthermore, standard X-rays of the wrist were performed.

The 3 paediatric patients demonstrated good clinical and radiological results with healing of the lunate bone. The juvenile patients with radial shortening osteotomy had a better motion than those with partial wrist fusion. Reduction of pain level was similar in both groups. Radiologically we found no progression of lunate disease in these patients. In spite of a temporary ST transfixation the 17-year-old boy with advanced Kienböck's disease developed symptomatic progression of the disease.

In paediatric and juvenile patients with Kienböck's disease we find an age-related potential for spontaneous remodelling and revascularisation. Therefore in paediatric and in juvenile patients not older than 14 years our method of choice is an immobilisation with regular gadolinium-enhanced MRI studies. In those who do not improve and in older juvenile patients we prefer temporary transfixation of the scaphotrapezoidal joint. Alternatively, in cases of the ulnar minus variant, radial shortening osteotomy or a combination of these 2 methods is indicated as the primary approach. In our opinion there is no longer an indication for partial wrist fusions as a primary procedure in these patients.