Keinböck's disease: Difference between revisions

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Etiology / Epidemiology / Natural History
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{{SI}}


Likely related to overuse and ulnar negative wrist variance.
Associated with sickel cell anemia, steriod use, gout, cerebral palsy.
Age: 2nd-5th decade.
Male > female


Anatomy
 
==Etiology==
 
* Likely related to overuse and ulnar negative wrist variance.
* Associated with sickel cell anemia, steriod use, gout, cerebral palsy.
* Age: 2nd-5th decade.
* Male > female
 
==Anatomy==


Lunate blood supply: single nutrient vessel, or poorly organized intraosseous anastamoses.
Lunate blood supply: single nutrient vessel, or poorly organized intraosseous anastamoses.


Clinical Evaluation
==Clinical Findings==


Dosral wrist pain +/- swelling/warmth
* A painful and sometimes swollen wrist  
Tenderness over the radiolunate joint
* Limited range of motion in the affected wrist (stiffness)
Decreased ROM.
* Decreased grip strength in the hand
Decreased grip strength
* Tenderness directly over the lunate (on the top of the hand at about the middle of the wrist)
* Pain or difficulty in turning the hand upward


Diagnositc Tests
==Diagnostic Tests==


PA, Lateral, oblique views of the wrist. Generally demonstrate sclerotic lunate. Early films may be normal or minimal sclerosis. Evaluate for ulnocarpal impaction.
* PA, Lateral, oblique views of the wrist. Generally demonstrate sclerotic lunate. Early films may be normal or minimal sclerosis. Evaluate for ulnocarpal impaction.
MRI: demonstrates avascular changes in the lunate.
* MRI: demonstrates avascular changes in the lunate.
Ct: demonstrates degree of fragmentation and collapse
* Ct: demonstrates degree of fragmentation and collapse
Bone scan diagnostic at 48hrs (100% sensitive, 98%specific)
* Bone scan diagnostic at 48hrs (100% sensitive, 98%specific)


Classification / Treatment
==Classification and Treatment==


Lichtman Classification (Lichtman DM, JBJS 59A;899:1977).
Lichtman Classification (Lichtman DM, JBJS 59A; 899:1977).


Stage 1=The lunate appears normal on xray or there may be a nondisplaced fracture;
===Stage 1===


MRI demonstrates loss of signal consistent with osteonecrosis.
* The lunate appears normal on xray or there may be a nondisplaced fracture;
* MRI demonstrates loss of signal consistent with osteonecrosis.
Treatment: spinting, activity modifications, NSAIDs
* Treatment: spinting, activity modifications, NSAIDs
* Consider ulnar lengthening or radial shortening for patients with negative ulnar variane.
Consider ulnar lengthening or radial shortening for patients with negative ulnar variane.


Stage 2=Increased lunate radiodensity without loss of contour;
===Stage 2===


lunate not collapsed.  
* Increased lunate radiodensity without loss of contour;
Consider Proximal row carpectomy.
* Lunate not collapsed.  
* Consider Proximal row carpectomy.
Treatment: 4 + 5 extensor compartmental vascularized bone graft. (Moran CL, J Hand Surg 2005;30A:50).
Treatment: 4 + 5 extensor compartmental vascularized bone graft. (Moran CL, J Hand Surg 2005;30A:50).


Stage 3A= Increased lunate radiodensity and fragmentation without loss of carpal height.
===Stage 3A===
 
* Increased lunate radiodensity and fragmentation without loss of carpal height.
Treatment: 4 + 5 extensor compartmental vascularized bone graft. (Moran CL, J Hand Surg 2005;30A:50).
* Treatment: 4 + 5 extensor compartmental vascularized bone graft. (Moran CL, J Hand Surg 2005;30A:50).
Consider scaphocapitate arthrodesis, or scaphotrapeziotrapezoid arthrodesis
* Consider scaphocapitate arthrodesis, or scaphotrapeziotrapezoid arthrodesis
 
===Stage 3B===


Stage 3B: Lunate fragmentation with proximal migration of the capitate and rotation of the scaphoid.
Lunate fragmentation with proximal migration of the capitate and rotation of the scaphoid.
Treatment: scaphocapitate arthrodesis, or scaphotrapeziotrapezoid arthrodesis
* Treatment: scaphocapitate arthrodesis, or scaphotrapeziotrapezoid arthrodesis
Consider Proximal row carpectomy
* Consider Proximal row carpectomy
 
===Stage 4===


Stage 4=lunate severely collapsed and fragmented, secondary arthritic changes in the wrist.
* Lunate severely collapsed and fragmented, secondary arthritic changes in the wrist.
Treatment: Proximal row carpectomy.
* Treatment: Proximal row carpectomy.
Consider: scaphocapitate arthrodesis, and scaphotrapeziotrapezoid arthrodesis.
* Consider: scaphocapitate arthrodesis and scaphotrapeziotrapezoid arthrodesis.
 
==Differential Diagnosis==
 
* Ulnocarpal impaction syndrome
* Preiser's Disease
 
==Complications==
 
* Degenerative changes in adjacent joints.
* Stiffness, motion loss.
* Weakness.
* CRPS
* Continued pain.
* Instability.
 
==Follow-up Care==


Differential Diagnosis
* Post-op: Volar splint in neutral, elevation.
* 7-10 Days: Wound check, short arm cast.
* 4 Weeks: Cast removed, xray wrist. Start gentle ROM, strengthening exercises. Functional activities.
* 3 Months: Full activities, may resume manual labor if adequate strength has been achieved.
* 6 Months and 1 year follow-up: x-rays, assess outcome


Ulnocarpal impaction syndrome
==References==
Preiser's Disease


Complications
* Weiss AP, Weiland AJ, Moore JR, Wilgis EF: Radial shortening for Kienbock's disease. J Bone Joint Surg Am 1991;73:384-391.
* Morgan WJ, JAAOS 2001;9:389


Degenerative changes in adjacent joints.
Stiffness, motion loss.
Weakness.
CRPS
Continued pain.
Instability.


Follow-up Care


Post-op: Volar splint in neutral, elevation.
[[Category:Orthopedics]]
7-10 Days: Wound check, short arm cast.
4 Weeks: Cast removed, xray wrist. Start gentle ROM / strengthening exercises. Functional activities. Cock-up wrist splint prn / for light duty work. No heavy manual labor
3 Months:Full activities, may resume manual labor if adequate strength has been achieved.
6 Months:
1Yr: fo,,ow-up xrays, assess outcome


References


Weiss AP, Weiland AJ, Moore JR, Wilgis EF: Radial shortening for Kienbock's disease. J Bone Joint Surg Am 1991;73:384-391.
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Morgan WJ, JAAOS 2001;9:389
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Etiology

  • Likely related to overuse and ulnar negative wrist variance.
  • Associated with sickel cell anemia, steriod use, gout, cerebral palsy.
  • Age: 2nd-5th decade.
  • Male > female

Anatomy

Lunate blood supply: single nutrient vessel, or poorly organized intraosseous anastamoses.

Clinical Findings

  • A painful and sometimes swollen wrist
  • Limited range of motion in the affected wrist (stiffness)
  • Decreased grip strength in the hand
  • Tenderness directly over the lunate (on the top of the hand at about the middle of the wrist)
  • Pain or difficulty in turning the hand upward

Diagnostic Tests

  • PA, Lateral, oblique views of the wrist. Generally demonstrate sclerotic lunate. Early films may be normal or minimal sclerosis. Evaluate for ulnocarpal impaction.
  • MRI: demonstrates avascular changes in the lunate.
  • Ct: demonstrates degree of fragmentation and collapse
  • Bone scan diagnostic at 48hrs (100% sensitive, 98%specific)

Classification and Treatment

Lichtman Classification (Lichtman DM, JBJS 59A; 899:1977).

Stage 1

  • The lunate appears normal on xray or there may be a nondisplaced fracture;
  • MRI demonstrates loss of signal consistent with osteonecrosis.
  • Treatment: spinting, activity modifications, NSAIDs
  • Consider ulnar lengthening or radial shortening for patients with negative ulnar variane.

Stage 2

  • Increased lunate radiodensity without loss of contour;
  • Lunate not collapsed.
  • Consider Proximal row carpectomy.

Treatment: 4 + 5 extensor compartmental vascularized bone graft. (Moran CL, J Hand Surg 2005;30A:50).

Stage 3A

  • Increased lunate radiodensity and fragmentation without loss of carpal height.
  • Treatment: 4 + 5 extensor compartmental vascularized bone graft. (Moran CL, J Hand Surg 2005;30A:50).
  • Consider scaphocapitate arthrodesis, or scaphotrapeziotrapezoid arthrodesis

Stage 3B

Lunate fragmentation with proximal migration of the capitate and rotation of the scaphoid.

  • Treatment: scaphocapitate arthrodesis, or scaphotrapeziotrapezoid arthrodesis
  • Consider Proximal row carpectomy

Stage 4

  • Lunate severely collapsed and fragmented, secondary arthritic changes in the wrist.
  • Treatment: Proximal row carpectomy.
  • Consider: scaphocapitate arthrodesis and scaphotrapeziotrapezoid arthrodesis.

Differential Diagnosis

  • Ulnocarpal impaction syndrome
  • Preiser's Disease

Complications

  • Degenerative changes in adjacent joints.
  • Stiffness, motion loss.
  • Weakness.
  • CRPS
  • Continued pain.
  • Instability.

Follow-up Care

  • Post-op: Volar splint in neutral, elevation.
  • 7-10 Days: Wound check, short arm cast.
  • 4 Weeks: Cast removed, xray wrist. Start gentle ROM, strengthening exercises. Functional activities.
  • 3 Months: Full activities, may resume manual labor if adequate strength has been achieved.
  • 6 Months and 1 year follow-up: x-rays, assess outcome

References

  • Weiss AP, Weiland AJ, Moore JR, Wilgis EF: Radial shortening for Kienbock's disease. J Bone Joint Surg Am 1991;73:384-391.
  • Morgan WJ, JAAOS 2001;9:389


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