Keinböck's disease: Difference between revisions
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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 | |||
[[Category:Orthopedics]] | |||
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Latest revision as of 16:41, 9 August 2012
| Keinböck's disease |
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