Wrist Pain- Baseball Pitcher

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HISTORY: A 16 year old high school baseball pitcher presented in July with persistent right wrist pain for 2 months after slipping at the beach. Initial exam revealed only ulnar sided wrist tenderness. A radiograph showed no fractures, with a small lucency in the capitate resembling a bone cyst. He was managed as a sprain with splinting, rest, ice and NSAIDs. He returned to daily activities, but noted worsening pain in September, specifically with weightlifting and deadlifts. His course was complicated by acute severe hand swelling, prompting an urgent clinic visit. PHYSICAL EXAM: BP: 122/80; HR: 78; Temp: 36.6 Severe swelling noted on the dorsal right wrist without erythema, bruising, lacerations, nail infection or skin breakdown, and no extension proximally. He had 5/5 strength in all directions, but with pain on flexion and extension of the wrist without a humpback deformity. Dorsal and volar aspects of the wrist were painful over the capitate and lunate, without anatomic snuffbox tenderness or scaphoid shift. Distal radioulnar joint tenderness was not as severe as his previous visit. Radial pulses and sensation to light touch bilaterally were normal. Concern over the acuity and severity of his wrist swelling prompted repeat imaging with an x-ray and MRI, as well as blood work. DIFFERENTIALS: 1.Wrist sprain 2.Carpal stress fracture 3.Synovitis 4.Infection 5.Tumor 6.Rheumatoid Arthritis TESTS/RESULTS: WBC- 7 Hemoglobin/Hematocrit- 15/45 Platelet- 257 Rheumatoid Factor- 6.7 Vitamin D25- 40 ANA- negative CRP- 3 ESR- 2 Right Wrist X-Ray: _ No acute fracture or dislocation _ Persistent stable lucency in proximal capitate. Right Wrist MRI _ diffuse signal abnormality in lunate with negative ulnar variance in keeping with Kienbock’s Disease _ Soft tissue edema on dorsal wrist adjacent to lunate and capitate and deep to extensor tendons _Thickening and heterogenous signal involving dorsal extrinsic ligaments predominantly at capitate and lunate compatible with sprain FINAL/WORKING DIAGNOSIS: Kienbock’s Disease Stage 1 TREATMENT/OUTCOME: 1.Intermittent immobilisation during the day when symptomatic and continuously at night 2.Counseled on disease progression and future need for surgery 3.Referred to an Orthopedic Hand Specialist for surgical options, with a re-evaluation in 6 months by MRI