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OJHAS Vol. 8, Issue 4: (2009
Oct-Dec) |
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| Kienbock Disease |
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Sajad Ahmad Salati, Assistant Consultant,
Sari M Rabah, Consultant,
Department of
Plastic & Reconstructive Surgery, King Fahad Medical City,
Riyadh, Saudi Arabia |
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Address For Correspondence |
Assistant Consultant,
Department
of Plastic &Reconstructive Surgery,
King Fahad Medical City,
Riyadh, Saudi Arabia.
E-mail:
docsajad@yahoo.co.in |
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Salati SA, Rabah SM. Kienbock Disease. Online J Health Allied Scs.
2009;8(4):15 |
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Submitted: Nov 1, 2009;
Accepted:
Apr 1, 2010; Published: Apr 30, 2010 |
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| Abstract: |
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A case of a
27 years old female with history of pain in left wrists is presented.
Investigations revealed necrosis of left lunate (Kienbock disease).
Key Words:
Kienbock disease, Lunate necrosis |
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A 27 years
old female reported with pain in left wrist of about 18 months duration,
mostly felt while typing on the keyboard of computer. There was no
significant
past history. Patient was getting relief by regular use
of analgesics (NSAIDS). Physical examination did not reveal any
significant
abnormality. Plain films of left wrist (Fig.1) revealed features of
necrosis of lunate (Kienbock disease).
Kienbock
disease
is the eponym for avascular necrosis of the lunate.1 It
is named after Robert Kienbock, a Viennese radiologist in the early
1900's. The exact etiology is poorly understood particularly2
as it occurs most often in the absence of obvious trauma. Most patients
are men in their third to fourth decades and are either manual laborers
or actively participating in recreational activities that repetitively
load the wrist. Patients present with complaints of activity-related
dorsal wrist pain, decreased wrist motion in the flexion-extension arc,
and poor grip strength. On examination, dorsal wrist swelling and
tenderness are
frequently present over the radio carpal joint. Kienbock disease has
been found to be associated with ulnar minus variance. It is thought
that these patients are predisposed to abnormally increased stresses
across the lunate resulting in repeated micro trauma leading to
necrosis.
With time, there is resultant abnormal rotation of the scaphoid leading
to increased lunate loading and further necrosis. Plain films and MRI
are the most useful modalities for diagnosis and staging. There are
four stages of this disease based upon the radiological progression
of the disease:3
Stage
I: Radiographic findings are normal, but the bone scan findings
are positive for disease. MRI shows a decreased signal on T1- and
T2-weighted
images.
Stage
II: Sclerotic changes and fractures are visible on radiographs;
however, carpal integrity is intact.
Stage
III (A and B): This stage occurs when the lunate collapses and the
capitate migrates proximally. In stage IIIA, no fixed carpal derangement
is noted. In stage IIIB, decreased carpal height, ulnar migration of
the triquetrum, scapholunate dissociation, and flexion of the
scaphoid
are noted.
Initially
treatment is conservative and includes analgesia and immobilization
with splints.4 When unsuccessful, various surgical options
are available which include lunate excision with or without silicon
replacement arthroplasty, osteotomy of the radius to compensate for
ulna minus variance, intercarpal fusion and revascularization. Radial
shortening (joint levering)5 is most commonly used,
resulting
in decreased pain and improved function in up to 90% of patients. In
spite of surgical correction, collapse and degeneration of the lunate
may continue.
Fig 1: Plain
radiographs of left wrist: Oblique view (A) and Antero-posterior
view (B) showing lunate necrosis (black arrow). |
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 |
- Alexander
AH, Lichtman DM. Kienböck disease. Orthop Clin North Am. Jul 1986;17(3):461-72
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Watson HK, Guidera PM. Aetiology of Kienbock disease. J Hand Surg [Br] 1997;22(1):5-7
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Morhart
M, Tredget EE, Jarman ATA, Ghahary A. Hand, Wrist Fractures and
Dislocations Available at http://emedicine.medscape.com/article/1285825-overview Updated: Oct 6, 2008
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Delaere
O, Dury M, Molderez A. Conservative versus operative treatment for
Kienbock
disease- A retrospective study. J Hand Surg [Br] 1998;23(1):33-6
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Takahara
M, Watanabe T, Tsuchida H, Yamahara S, et al. Long-term follow-up
of radial shortening osteotomy for Kienbock disease. Surgical technique.
J Bone Joint Surg Am 2009;91 Suppl 2:184-90
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