Updated: 5/20/2021

Kienbock's Disease

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https://upload.orthobullets.com/topic/6050/images/keinbocksmri_figure3.jpg
https://upload.orthobullets.com/topic/6050/images/ulnar variance.jpg
https://upload.orthobullets.com/topic/6050/images/stage 1.jpg
https://upload.orthobullets.com/topic/6050/images/stage 2.jpg
https://upload.orthobullets.com/topic/6050/images/stage 3a.jpg
  • Summary
    • Kienbock's Disease is the avascular necrosis of the lunate which can lead to progressive wrist pain and abnormal carpal motion.
    • Diagnosis can be made with wrist radiographs in advanced cases but may require MRI for detection of early disease.
    • Treatment is NSAIDs and observation in minimally symptomatic patients. A variety of operative procedures are available depending on severity of disease and patient's symptoms. 
  • Epidemiology
    • Incidence
      • most common in males between 20-40 years old
    • Risk factors
      • history of trauma
  • Etiology
    • Pathophysiology
      • thought to be caused by multiple factors
        • biomechanical factors
          • ulnar negative variance
            • leads to increased radial-lunate contact stress
          • decreased radial inclination
          • 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 leading to increased intraosseous pressure
            • Blood supply to capitate is also poor and may lead to AVN.
  • 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
      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, STT fusion, or SC 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
      • rule out ulnar impaction
      • findings
        • decreased T1 signal intensity
        • reduced vascularity of lunate
  • Treatment
    • Nonoperative
      • observation, immobilization, NSAIDS
        • indications
          • initial management for Stage I 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
          • initial operative managment
        • technique
          • can be radial shortening osteotomy or ulnar lengthening
          • more evidence on radial shortening
      • radial wedge osteotomy
        • indications
          • Stage I, II, IIIA disease with ulnar positive or neutral variance
      • vascularized bone grafts
        • indications
          • Stage I, II, IIIA, IIIB disease
        • outcomes
          • early results promising, but long-term data lacking
          • best results in Stage III patients
      • distal radius core decompression
        • indications
          • Stage I, II, IIIA disease
        • technique
          • creates a local vascular healing response
      • partial wrist fusions
        • STT
        • capitate shortening osteotomy +/- capitohamate fusion
        • scaphocapitate
        • 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 branches 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
      • 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
  • Prognosis
    • Progressive and potentially debilitating condition if unrecognized and untreated

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(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?

QID: 3535
FIGURES:
1

A

5%

(205/4161)

2

B

33%

(1377/4161)

3

C

5%

(204/4161)

4

D

50%

(2079/4161)

5

E

6%

(267/4161)

L 4 C

Select Answer to see Preferred Response

(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?

QID: 3567
FIGURES:
1

Ulnar shortening osteotomy

5%

(197/4046)

2

TFCC repair

1%

(42/4046)

3

Radius core decompression

76%

(3076/4046)

4

Arthroscopic lunate chondroplasty and debridement

16%

(660/4046)

5

Scapholunate ligament reconstruction

1%

(53/4046)

L 2 B

Select Answer to see Preferred Response

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(OBQ10.61) 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?

QID: 3149
FIGURES:
1

Wrist fusion

1%

(28/3919)

2

Ulnar shortening osteotomy

9%

(335/3919)

3

Distal radius core decompression

83%

(3239/3919)

4

Proximal row carpectomy

3%

(128/3919)

5

Scapholunate ligament reconstruction

4%

(168/3919)

L 2 C

Select Answer to see Preferred Response

(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?

QID: 3162
FIGURES:
1

Continue Immobilization and NSAIDS

9%

(353/3986)

2

Radial shortening osteotomy

68%

(2727/3986)

3

Proximal row carpectomy

11%

(424/3986)

4

Scaphotrapeziotrapezoid fusion

9%

(356/3986)

5

Wrist fusion

2%

(94/3986)

L 2 C

Select Answer to see Preferred Response

(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?

QID: 905
FIGURES:
1

Ultrasound

1%

(67/5784)

2

Angiography

5%

(266/5784)

3

CT scan of the wrist

67%

(3850/5784)

4

Clenched fist AP radiograph of wrist

8%

(480/5784)

5

Bone scan of the wrist

19%

(1089/5784)

L 4 D

Select Answer to see Preferred Response

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