A 17-year-old right-hand-dominant male, Mr. B, presented to our pediatric fracture clinic with a complaint of left wrist pain. He had a history of an undocumented scaphoid fracture three years earlier with an increase in pain levels in the three weeks prior to presentation. 

Mr. B was an athletic young man with a history of boxing as a sport and had been increasing his training prior to the onset of his current symptoms.

1. History

On presentation, Mr. B was a well-developed male who appeared his stated age. His medical history was significant for mild, controlled asthma and an atypical depressive disorder, which was in remission. Examination of his extremities — with particular attention to the affected left wrist — showed a symmetric range of motion bilaterally with no obvious skin lesions. The patient’s left wrist demonstrated no effusion or edema; tenderness was noted in the anatomic snuffbox, at the scapholunate junction, and in the lunate fossa. Results of a neurovascular exam were normal.

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2. Examination and Initial Treatment

Standard films of the left wrist to include a scaphoid series were obtained and showed no acute osseous abnormality (Figure 1). There was no evidence of ligamentous instability and no scapholunate widening. 

Additionally, no evidence of any osseous necrotic process was appreciated. At this time, we elected to treat the patient conservatively in a short-arm thumb spica cast with the interphalangeal joint of the thumb free. 

Mr. B was referred for an MRI of the affected wrist to evaluate for a possible occult fracture or ligament disruption. 

3. Diagnosis

This represents an unusual case seldom reported and instructive in its uniqueness. Plain films on presentation were unremarkable and an MRI was needed to establish the diagnosis. The MRI demonstrated avascular necrosis (AVN) of the capitate with complete involvement. 

The patient underwent conservative management in a short-arm cast for several weeks and eventually had complete resolution of symptoms. 

4. Extended Treatment

At 14 days post-presentation, MRI demonstrated changes in the patient’s capitate consistent with osteonecrosis. Images demonstrated complete involvement with uniform consistency (Figures 2 and 3). Mr. B was pain-free in his cast.

At six weeks after presentation, the cast was removed and Mr. B was placed in a thumb spica brace with activity restrictions consisting of no sports and limited lifting. He reported no pain while in the cast, and was appropriately stiff when the cast was removed. Plain films of the capitate demonstrated no interval change on this visit.

At three months post-presentation, a follow-up MRI was obtained. Mr. B still reported that he was symptom-free with no limitations on his activities, which he had resumed three weeks prior to this visit. His physical exam was normal in comparison to his unaffected side, with no obvious deformity, weakness, or loss of motion. The MRI showed changes consistent with early resolution of his osteonecrosis, and plain films at this visit continued to show no change in the capitate or carpal alignment (Figures 4 and 5). The scaphoid and scapholunate distance remained appropriate for the patient’s age. Mr. B was released to normal activity with a six-month return visit anticipated.

Nearly 10 months post-presentation, Mr. B continued to report no symptoms. His physical exam showed a symmetric range of motion with the unaffected wrist, no tenderness, and symmetric grip strength. His plain films were interpreted as normal (Figures 6A and 6B).

This article originally appeared on Clinical Advisor