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
Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Four Corner Wrist Fusion Orthobullets Team Hand - Scaphoid Nonunion Advanced Collapse (SNAC)
QUESTIONS 1 of 11 1 2 3 4 5 6 7 8 9 10 11 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ17SE.27) A 28-year-old jack-hammer operator presents with 4 years of wrist pain. The patient was seen three years ago and had normal wrist radiographs at that time. The PA who saw him diagnosed him with a wrist sprain, and he subsequently returned to work. His symptoms never improved, even after a period of casting, so he was referred to your clinic after an MRI was obtained (Figure A). On physical examination, he has dorsal wrist tenderness and limited wrist extension. What surgical procedure may offer him the most reliable pain relief while best preserving the native anatomy? QID: 211402 FIGURES: A Type & Select Correct Answer 1 Vascularized bone graft 46% (904/1973) 2 Proximal pole excision and tendon interposition 11% (212/1973) 3 Scapho-capitate (SC) fusion 17% (341/1973) 4 Proximal row carpectomy 3% (69/1973) 5 Scaphoidectomy and four corner fusion (4CF) 22% (440/1973) L 4 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (SBQ17SE.2) A 30-year-old right-hand-dominant accountant has progressive wrist pain for the last 18 months. He was initially treated in a cast, however his symptoms have continuously worsened. Figures A and B are radiographs taken in the office today. He reports decreased grip strength, and physical exam is significant for decreased wrist extension and tenderness directly over the radiocarpal joint. Examination of the contralateral wrist is otherwise unremarkable. All of the following are described as etiologies for the above condition EXCEPT: QID: 211127 FIGURES: A B Type & Select Correct Answer 1 Ulnar negative variance 14% (245/1728) 2 High interosseous pressure 9% (153/1728) 3 Underlying medical conditions 17% (295/1728) 4 Decreased radial inclination 20% (340/1728) 5 Increased carpal height 39% (681/1728) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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: A B C D E Type & Select Correct Answer 1 A 5% (218/4398) 2 B 33% (1454/4398) 3 C 5% (214/4398) 4 D 50% (2197/4398) 5 E 6% (283/4398) L 4 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (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: A B Type & Select Correct Answer 1 Ulnar shortening osteotomy 5% (205/4326) 2 TFCC repair 1% (47/4326) 3 Radius core decompression 75% (3261/4326) 4 Arthroscopic lunate chondroplasty and debridement 17% (734/4326) 5 Scapholunate ligament reconstruction 1% (59/4326) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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: A Type & Select Correct Answer 1 Wrist fusion 1% (31/4142) 2 Ulnar shortening osteotomy 8% (343/4142) 3 Distal radius core decompression 83% (3432/4142) 4 Proximal row carpectomy 3% (138/4142) 5 Scapholunate ligament reconstruction 4% (175/4142) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (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: A B C Type & Select Correct Answer 1 Continue Immobilization and NSAIDS 9% (377/4157) 2 Radial shortening osteotomy 68% (2822/4157) 3 Proximal row carpectomy 11% (458/4157) 4 Scaphotrapeziotrapezoid fusion 9% (372/4157) 5 Wrist fusion 2% (95/4157) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (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: A Type & Select Correct Answer 1 Ultrasound 1% (67/6108) 2 Angiography 4% (269/6108) 3 CT scan of the wrist 67% (4088/6108) 4 Clenched fist AP radiograph of wrist 9% (520/6108) 5 Bone scan of the wrist 19% (1131/6108) L 4 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic
All Videos (1) Podcasts (1) Login to View Community Videos Login to View Community Videos Proximal Row Carpectomy for Kienbock's Disease Mark Karadsheh Hand - Kienbock's Disease C 2/19/2013 3270 views 3.2 (16) Hand⎪Kienbock's Disease Hand - Kienbock's Disease Listen Now 17:0 min 9/14/2020 729 plays 3.0 (1)
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