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Figures A through E depict various conditions affecting the pediatric hand and wrist. For which of the depicted conditions is temporary scaphotrapeziotrapezoidal pinning most indicated?
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Temporary scaphotrapeziotrapezoidal (STT) pinning is indicated for treatment of Kienbocks disease in adolescents as shown in Figure D. The radiograph shows increased density and slight lunate collapse. The result is a decrease in radiolunate contact stress while increasing the load on the radioscaphoid articulation. STT pinning is not indicated in any of the conditions explained below.
Ando et al retrospectively reviewed the results of six adolescents treated with temporary scaphotrapezoidal (ST) pinning. All patients had an increase in wrist flexion/extension arc, strength, and lunate intensity on MRI from their preoperative baseline.
Shigematsu et al published a case study on a single 11-year-old patient with wrist pain at rest and with use who was treated with temporary scaphotrapeziotrapedoidal (STT) pinning and cast immobilization for 8 weeks. Both wrist ROM and grip strength improved. Lunate revascularization was also seen on subsequent MRI.
Answer 1,2,3: Radial clubhand, scaphoid fracture, and hypoplastic thumb are not treated with temporary scaphotrapeziotrapezoidal pinning.
Answer 5: Gymnast’s wrist is a distal radius physeal injury due to repetitive axial loading. Plain films will show physeal widening and hazy irregularity. The condition is not treated with temporary scaphotrapeziotrapezoidal pinning.
Ando Y, Yasuda M, Kazuki K, Hidaka N, Yoshinaka Y
J Hand Surg Am. 2009 Jan;34(1):14-9. PMID: 19121725 (Link to Abstract)
Shigematsu K, Yajima H, Kobata Y, Kawamura K, Nakanishi Y, Takakura Y.
Scand J Plast Reconstr Surg Hand Surg. 2005;39(1):60-3. PMID: 15848968 (Link to Abstract)
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Average 3.0 of 35 Ratings
A 39-year-old male presents with longstanding right wrist pain. He has failed conservative measures including prolonged immobilization. His radiographs and MRI are seen in figures A and B. Which of the following options is an accepted treatment option?
Ulnar shortening osteotomy
Radius core decompression
Arthroscopic lunate chondroplasty and debridement
Scapholunate ligament reconstruction
The patient in the clinical scenario has Kienbock's disease. Treatment options include a joint leveling procedure, or radius core decompression, which is thought to incite a local vascular healing response in the lunate.
Sherman et al did a biomechanical study reviewing distal radius core decompression for Kienbock's disease. Although the procedure has good clinical outcomes for this disease process, their findings did not show any biomechanical explanation for these good outcomes.
Illarramendi et al reviewed results of curettage of the distal radius and ulna metaphyseal bone through small cortical windows for the treatment of Kienbock's disease. They concluded that the decompression procedure had good results without any complications. Most patients had improvement in pain and were able to return to work.
Answer 1: Kienbock's disease is commonly associated with ulnar negative variance which is thought to lead to increased forces on the lunate leading to this disease. Therefore a ulnar shortening osteotomy would not be appropriate.
Answer 2,4,5: Are not treatment options for this disease process.
Sherman GM, Spath C, Harley BJ, Weiner MM, Werner FW, Palmer AK.
J Hand Surg Am. 2008 Nov;33(9):1478-81. PMID: 18984326 (Link to Abstract)
Illarramendi AA, Schulz C, De Carli P.
J Hand Surg Am. 2001 Mar;26(2):252-60. PMID: 11279571 (Link to Abstract)
Average 3.0 of 21 Ratings
A 32-year-old carpenter complains of progressively worsening wrist pain for the last 2 months. He denies any recent history of trauma to the wrist or hand. An MRI is obtained and a representative image is provided in Figure A. Which of the following surgical interventions is thought to be effective for this condition by inciting a local vascular healing response?
Distal radius core decompression
Proximal row carpectomy
This clinical scenario and imaging studies are consistent with Kienbock's disease, avascular necrosis of the lunate, in the pre-collapse stage. Core decompression of the distal radius is an accepted treatment for Kienbock's disease. The procedure creates a local vascular healing response facilitating vascular recovery prior to collapse and degeneration of the lunate. Other acceptable interventions include revascularization with a pedicled graft and joint leveling procedures such as a radial shortening osteotomy. The radial shortening osteotomy is ideal for patients with negative ulnar variance who experience greater loads through the radiolunate fossa.
Sherman et al performed a cadaveric study demonstrating minimal change in the distribution of force between the radiocarpal fossa and ulnocarpal fossa following core decompression of the distal radius.
Illarramendi et al reviewed 22 cases of Kienbock's treated with radial and ulnar metaphyseal core decompression. No surgical complications occurred, and 20 of 22 reported satisfactory clinical outcomes while one patient developed intercarpal arthritis.
1. Proximal row carpectomy and wrist fusion would be options for the collapsed and degenerative lunate.
2. Ulnar shortening osteotomy and scapholunate ligament reconstruction are incorrect as they do not address the pathology of Kienbock's.
4. Proximal row carpectomy and wrist fusion would be options for the collapsed and degenerative lunate.
5. Ulnar shortening osteotomy and scapholunate ligament reconstruction are incorrect as they do not address the pathology of Kienbock's.
Average 2.0 of 56 Ratings
A 30-year-old female undergoes arthroscopy for a chronically painful right wrist that failed to improve with 4 months of immobilization and NSAIDS. Her clinical examination revealed point tenderness dorsally over the lunate but no tenderness elsewhere in the wrist. A picture from the procedure is shown in Figure A where 'R' identifies the distal radius, 'L' the lunate, and '*' represents a chondral flap. The articular surface of the lunate is stable to probing. A radiograph and MRI image of the patients wrist are shown in Figures B and C respectively. What is the most appropriate next step in treatment?
Continue Immobilization and NSAIDS
Radial shortening osteotomy
The patients clinical presentation and radiographs are consistent with Stage 2 Kienbock's disease in the setting of negative ulnar variance. Radial shortening osteotomy is the most appropriate treatment option listed for Stage 2 disease which is defined as lunate sclerosis without significant collapse. Shortening osteotomy can alter DRUJ contact pressures leading to remodeling, especially in the presence of a Tolat Type II DRUJ, such as that shown in the radiographs. However, this remodeling has been shown to occur without the development of arthritis, and therefore is not a contraindication to this procedure.
This patients radiographs shows some slight sclerosis of the lunate and negative ulnar variance, and the MRI shows diffuse edema and early osteonecrosis of the lunate. The arthroscopic image shows a cartilage flap with a stable base left on the lunate. Based on these images, the patient has Stage 2 disease and should be treated with a joint leveling procedure; or radial shortening osteotomy in this case.
Sltusky et al provide a review article which focuses on the methodology behind a normal arthroscopic wrist examination and discusses some of the more standard arthroscopic procedures along with the expected outcomes.
Bain et al review the arthroscopic staging of Kienbock's disease, and state that this techinique is a valuable assessment tool which allows for not only classification of Kienbock's disease, but also may guide treatment.
Schuind et al. provide a review of the pathogenesis of Kienbock's. They conclude that the natural history of the condition is not well known, and the symptoms do not correlate well with the changes in shape of the lunate and the degree of carpal collapse. They also state that there is no strong evidence to support any particular form of treatment.
Illustration A shows a table which outlines the Stages of Kienbock's Disease.
Illustration B shows a table which outlines the general treatment options for each stage of Kienbock's Disease.
Answer 1: Immobilization and NSAIDS is indicated in Stage I disease or as a first line of treatment for Stage 2, which this patient has failed.
Answer 3: Proximal row carpectomy is indicated in Stage 3B.
Answer 4: STT Fusion is indicated in Stage 3B.
Answer 5: Wrist fusion is indicated in Stage 4.
Slutsky DJ, Nagle DJ.
J Hand Surg Am. 2008 Sep;33(7):1228-44. PMID: 18762125 (Link to Abstract)
Bain GI, Begg M
Tech Hand Up Extrem Surg. 2006 Mar;10(1):8-13. PMID: 16628114 (Link to Abstract)
Schuind F, Eslami S, Ledoux P.
J Bone Joint Surg Br. 2008 Feb;90(2):133-9. PMID: 18256076 (Link to Abstract)
Average 3.0 of 32 Ratings
A 37-year-old man has a 2-year history of increasing right wrist pain that is worse at night and aggravated by activity. He denies systemic symptoms, history of trauma, or recent weight loss. On physical exam he has tenderness over the dorsal radiocarpal joint. Radiographs of the right wrist are shown in Figure A. Which of the following imaging studies would be most sensitive for determining the stage of this patient's underlying condition?
CT scan of the wrist
Clenched fist AP radiograph of wrist
Bone scan of the wrist
The clinical presentation of dorsal radiocarpal wrist pain is suggestive of Kienbock’s disease. Figure A shows an AP radiograph of the right wrist with evidence of lunate sclerosis with no obvious collapse. The imaging study most sensitive for identifying early lunate collapse in Kienbock's disease is CT scanning of the wrist.
Kienbock’s disease is defined by avascular necrosis of the lunate. It is classified into 4 stages under the Lichtman Classification. In stage 1, plain radiographs appear normal and magnetic resonance imaging is required for diagnosis. MRI is useful for detecting early disease when sclerosis is not evident on plain film radiographs. In stage 2, plain radiographs and/or CT scan images will show sclerosis of the lunate but no evidence of collapse. In stage 3, radiographs and/or CT scan images will show lunate collapse. For stage 4, radiographs show degenerative changes to the adjacent carpus and intercarpal joints.
Imaeda et al. examined the use of MRI for the diagnosis and staging of Kienbock's disease. They found that MRI was most sensitive in detecting early focal loss of signal intensity in the lunate on T1-weighted images. This was a key diagnostic feature in early stages of Kienböck's disease when plain radiographs appear normal.
Cross et al. reviewed the latest concepts for diagnosis, staging, and management of Keinbock's disease. They suggest that computed tomography (CT) or tomography will better characterize lunate necrosis and trabecular destruction once collapse or sclerosis has occurred in late stage disease.
Illustration A is a collection of CT scanning images that show osteonecrosis of the lunate. The blue arrow shows lunate flattening and sclerosis. The red double arrow shows a loss of lunate height and the yellow shows fragmentation of the bone.
Answer 1: Ultrasound is not used in the staging of Kienbock's disease.
Answer 3: Angiography would not be warranted in this scenario.
Answer 4: A clenched fist AP radiograph of the wrist is used to evaluate widening of the scapholunate interval.
Answer 5: A bone scan of the wrist is a non-specific test, which would likely be positive in almost all patients with chronic wrist pain.
Imaeda T, Nakamura R, Miura T, Makino N.
J Hand Surg Br. 1992 Feb;17(1):12-9. PMID: 1640138 (Link to Abstract)
Cross D, Matullo KS
Orthop. Clin. North Am.. 2014 Jan;45(1):141-52. PMID: 24267215 (Link to Abstract)
Average 3.0 of 20 Ratings
HPI - Condition started 6 months ago with minor trauma to right hand after falling. After one month of medical treatment there was no improvement and a cast was placed for another 2 months. Cast immobilization did not lead to any improvement so surgery was performed. Excision of the lunate was performed with postoperative immobilization for one month. Physiotherapy until now. Despite this, the patient continues to complain of weakness, stiffness, and pain with exertion of right hand.
What Lichtman Classification of Kienbock's Disease would you call this patient in the preoperative images?
HPI - 29 yo female, martial arts enthusiast, dorsal wrist pain left non-dominant side, obvious palpable dorsal ganglion
during routine check mri reveals lunate cysts/AVN?
DD Kienbock's disease that needs treatment (radial shortening) or asymptomatic lunate cysts (no further treatment)?
DD Kienbock's disease that needs treatment (radial shortening) or asymptomatic lunate cysts (no further treatment)?
HPI - Patient is a 22 year old healthy LHD male college student with more than 6 months of pain and stiffness in his right wrist. He denies any history of trauma. He reports 8/10 pain with weight-bearing and range of motion of his wrist. He has tried splinting, NSAIDs and corticosteroid injections without significant relief. He has plans to work as a police officer.
How would you treat this patient's Kienbocks's disease?
Proximal Row Carpectomy for Keinbock's Disease