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Kienbock's Disease

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Topic updated on 10/21/14 7:36pm
Introduction
  • Avascular necrosis of the luntate leading to abnormal carpal motion
  • Epidemiology
    • incidence
      • most common in males between 20-40 years old
    • risk factors
      • history of trauma
  • Pathophysiology
    • thought to be caused by multiple factors
      • biomechanical factors
        • ulnar negative variance
          • leads to increased radial-lunate contact stress
        • repetitive trauma
      • anatomic factors
        • geometry of lunate
        • vascular supply to lunate
          • patterns of arterial blood supply have differential incidences of AVN
          • disruption of venous outflow
  • Prognosis
    • potentially debilitating condition if unrecognized and untreated
Anatomy
  • Blood supply to lunate
    • 3 variations
      • Y-pattern
      • X-pattern
      • I-pattern
        • 31% of patients
        • postulated to be at the highest risk for avascular necrosis
Classification
 
Lichtman Classification
Stage Description Treatment Image
Stage I No visible changes on xray, changes seen on MRI Immobilization and NSAIDS
Stage II Sclerosis of lunate Joint leveling procedure (ulnar negative patients) 
Radial wedge osteotomy or STT fusion (ulnar neutral patients)
Distal radius core decompression
Revascularization procedures
Stage IIIA Lunate collapse, no scaphoid rotation Same as Stage II above
Stage IIIB Lunate collapse, fixed scaphoid rotation
Proximal row carpectomy or STT fusion
Stage IV Degenerated adjacent intercarpal joints Wrist fusion, proximal row carpectomy, or limited intercarpal fusion
 
Presentation
  •  Symptoms
    • dorsal wrist pain
      • usually activity related
      • more often in dominant hand
  • Physical exam
    • inspection and palpation
      • +/- wrist swelling
      • often tender over radiocarpal joint
    • range of motion
      • decreased flexion/extension arc
      • decreased grip strength
Imaging
  •  Radiographs
    • recommended views
      • AP, lateral, oblique views of wrist
    • findings (see table above)
  • CT
    • most useful once lunate collapse has already occurred
    • best for showing
      • extent of necrosis
      • trabecular destruction
      • lunate geometry
  • MRI
    • best for diagnosing early disease 
    • findings
      • decreased T1 signal intensity
      • reduced vascularity of lunate
Treatment
  • Nonoperative
    • immobilization, NSAIDS
      • indications
        • initial management for Stage 1 disease
      • outcomes
        • a majority of these patients will undergo further degeneration and require operative management
  • Operative
    • temporary scaphotrapeziotrapezoidal pinning
      • indications
        • adolescent with radiographic evidence of Kienbock's and progressive wrist pain
    • joint leveling procedure
      • indications
        • Stage I, II, IIIA disease with ulnar negative variance
      • technique
        • can be radial shortening osteotomy or ulnar lengthening
    • radial wedge osteotomy
      • indications
        • Stage I, II, IIIA disease with ulnar positive or neutral variance
    • vascularized bone grafts
      • indications
        • Stage I, II, IIIA disease
      • outcomes
        • early results promising, but long-term data lacking
        • greatest success in Stage II patients
    • distal radius core decompression
      • indications
        • Stage I, II, IIIA disease
      • technique
        • creates a local vascular healing response
    • STT fusion
      • indications
        • Stage II disease with ulnar neutral or positive variance
        • Stage IIIA or IIIB disease
      • must address internal collapse pattern (DISI)
    • proximal row carpectomy (PRC)
      • indications
        • stage IIIB disease
        • stage IV disease
      • outcomes
        • some studies have shown superior results of STT fusion over PRC for stage IIIB disease
    • wrist fusion
      • indications
        • stage IV disease
      • technique
        • must remove arthritic part of joint
    • total wrist arthroplasty
      • indications
        • Stage IV disease
      • outcomes
        • long-term results not available
Techniques
  • Vascularized bone grafts
    • technique
      • many options have been described including
        • transfer of pisiform
        • transfer of distal radius on a vascularized pedicle of pronator quadratus
        • transfers of braches of the first, second, or third dorsal metacarpal arteries
        • 4 + 5 extensor compartment artery (ECA) 
      • temporary pinning of the STT joint, SC joint or external fixation may be used to unload lunate after revascularization
  • Impact of surgical procedure on radiolunate contact stress 
Operative Procedure
% decrease on radiolunate contact stress
STT fusion   3%
Scaphocapitate fusion 12%
Capitohamate fusion 0%
Ulnar lengthening of 4mm 45%
Radial shortening of 4mm 45%
Capitate shortening and capitohamate fusion 66%, but 26% increase in radioscaphoid load


 

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Qbank (5 Questions)

TAG
(OBQ11.112) 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? Topic Review Topic
FIGURES: A   B   C   D   E  

1. A
2. B
3. C
4. D
5. E

PREFERRED RESPONSE ▶
TAG
(OBQ11.144) 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? Topic Review Topic
FIGURES: A   B        

1. Ulnar shortening osteotomy
2. TFCC repair
3. Radius core decompression
4. Arthroscopic lunate chondroplasty and debridement
5. Scapholunate ligament reconstruction

PREFERRED RESPONSE ▶
TAG
(OBQ10.61) A 32-year-old carpenter complains of progressively worsening wrist pain for 2 months duration. He denies any recent history of trauma to the wrist or hand. A MRI 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. Topic Review Topic
FIGURES: A          

1. Wrist fusion
2. Ulnar shortening osteotomy
3. Distal radius core decompression
4. Proximal row carpectomy
5. Scapholunate ligament reconstruction

PREFERRED RESPONSE ▶
TAG
(OBQ10.74) 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? Topic Review Topic
FIGURES: A   B   C      

1. Continue Immobilization and NSAIDS
2. Radial shortening osteotomy
3. Proximal row carpectomy
4. Scaphotrapeziotrapezoid fusion
5. Wrist fusion

PREFERRED RESPONSE ▶
TAG
(OBQ07.244) 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? Topic Review Topic
FIGURES: A          

1. Ultrasound
2. Angiography
3. CT scan of the wrist
4. Clenched fist AP radiograph of wrist
5. Bone scan of the wrist

PREFERRED RESPONSE ▶



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