Keinböck's disease: Difference between revisions

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Etiology / Epidemiology / Natural History
==Etiology==


Likely related to overuse and ulnar negative wrist variance.
Likely related to overuse and ulnar negative wrist variance.
Line 6: Line 6:
Male > female
Male > female


Anatomy
==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 Evaluation==


Dosral wrist pain +/- swelling/warmth
Dosral wrist pain +/- swelling/warmth
Line 17: Line 17:
Decreased grip strength
Decreased grip strength


Diagnositc Tests
==Diagnositc 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.
Line 24: Line 24:
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: Lunate fragmentation with proximal migration of the capitate and rotation of the scaphoid.
===Stage 3B===
 
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
==Differential Diagnosis==


Ulnocarpal impaction syndrome
* Ulnocarpal impaction syndrome
Preiser's Disease
* Preiser's Disease


Complications
==Complications==


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


Follow-up Care
==Follow-up Care==


Post-op: Volar splint in neutral, elevation.
* Post-op: Volar splint in neutral, elevation.
7-10 Days: Wound check, short arm cast.
* 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
* 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.
* 3 Months:Full activities, may resume manual labor if adequate strength has been achieved.
6 Months:
* 6 Months:
1Yr: fo,,ow-up xrays, assess outcome
* 1 Yr: fo,,ow-up xrays, assess outcome


References
==References==


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

Revision as of 08:04, 9 January 2009

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 Evaluation

Dosral wrist pain +/- swelling/warmth Tenderness over the radiolunate joint Decreased ROM. Decreased grip strength

Diagnositc 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. 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:
  • 1 Yr: 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.
  • Morgan WJ, JAAOS 2001;9:389
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