Kienbock's Disease
Original Editor - Jessica Worrell
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Clinically Relevant Anatomy[edit | edit source]
There are eight carpal bones arranged into two rows of four. The carpus is convex posteriorly and concave anteriorly. The lunate is one of four carpal bones in the proximal row, resting between the scaphoid and triquetrum. It articulates with the distal radius which transmits 80% of the axial loading through the wrist.
Mechanism of Injury / Pathological Process[edit | edit source]
Kienböck disease is osteonecrosis of the lunate. It typically is seen in the dominant wrist of men aged 20-40. Potential factors leading to Kienböck disease are poor vascularization to the lunate, bone geometry of the lunate (Type I) and radius (decreased inclination), repetitive microtrauma, and negative ulnar variance. It is thought that an increased load through the lunate helps to accelerate the process of fracture and ultimately collapse.[1]
Clinical Presentation[edit | edit source]
Reports of activity-related dorsal wrist pain, limited wrist flexion and extension, and decreased grip strength. Swelling and tenderness may also be noted dorsally. More commonly, symptoms are in the dominant wrist and a history of trauma may be present.[1]
Diagnostic Procedures[edit | edit source]
Plain radiographs are the primary modality for staging and treatment of Kienböck disease. There are 5 stages based on Lichtman's modification of Stahl's classification: Stage I-Normal; Stage II-Increased radiodensity of lunate with decrease of lunate height on radial side; Stage IIIa-Lunate collapse; Stage IIIb-Lunate collapse, fixed scaphoid rotation; Stage IV-Degenerative change of the lunate
Tomograms are used to determine the extent of the disease.
Bone scan helps to exclude the presence of Kienböck disease, but it is not specific enough to exclude the many other causes of increased uptake in the area of the lunate.
MRI is used early in the disease when plain films are not diagnostic. It is extremely sensitive and specific to detect osteonecrosis.[2]
Outcome Measures[edit | edit source]
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Management / Interventions[edit | edit source]
The primary methods of nonoperative treatment are immobilization and anti-inflammatory medications. Treatment is directed by the level of symptoms.
Operative treatment is classified into 6 categories, as follows: Lunate excision with or without replacement such as lunate excision, excision with soft-tissue replacement, or silicone replacement arthroplasty. Joint-leveling procedures such as radial shortening and ulnar lengthening. Intercarpal fusions: Primarily a scaphotrapeziotrapezoid (STT) or triscaphe fusion. Revascularization: The use of a vascular bone (radius, pisiform, or pronator quadratus) pedicle directly implanted into the lunate. Salvage procedures: Proximal row carpectomy.[3]
Differential Diagnosis
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Key Evidence[edit | edit source]
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Resources
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Case Studies[edit | edit source]
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References[edit | edit source]
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- ↑ 1.0 1.1 Watson HK, Guidera PM. Aetiology of Kienbock's disease. J Hand Surg [Br]. Feb 1997;22(1):5-7.
- ↑ Watanabe K, Nakamura R, Imaeda T. Arthroscopic assessment of Kienbock's disease. Arthroscopy. Jun 1995;11(3):257-62.
- ↑ Watanabe T, Takahara M, Tsuchida H, Yamahara S, Kikuchi N, Ogino T. Long-term follow-up of radial shortening osteotomy for Kienbock disease.J Bone Joint Surg Am. 2008 Aug;90(8):1705-11.
