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Kienbocks Disease
From WikiSM
Other Names
- Avascular Necrosis of the Lunate
- Osteonecrosis of the lunate
- Kienbock's Disease
- Kienbock Disease
- Lunatomalacia
Background
- This page refers to Kienbock's disease, or avascular necrosis of the Lunate
History
- Named after Viennese radiologist Robert Kienbock, who termed it lunatomalacia[1]
Epidemiology
- Poorly described in the literature
- Affects dominant hand of men between age 20 - 40 (need citation)
Pathophysiology
General
- Disease of unclear etiology resulting in avascular necrosis or osteonecrosis of the carpal Lunate
- Ulnar variance leads to scaphoid exhibiting excessive loads across the lunate
- Can lead to progressive wrist pain, abnormal carpal motion
Risk Factors
- Negative ulnar variance
- History of trauma
- Occupational Risk factors
- Manual laborer
- Repetitive loading occupations
Differential Diagnosis
- Fractures
- Dislocations
- Wrist Dislocation (Radiocarpal and/or Ulnocarpal)
- Carpometacarpal Joint Dislocation
- Distal Radioulnar Joint Dislocation
- Lunate Dislocation
- Perilunate Dislocation
- Instability & Degenerative
- Tendinopathies & Ligaments
- Neuropathies
- Pediatric Considerations
- Distal Radial Epiphysitis (Gymnast's Wrist)
- Torus Fracture
- Arthropathies
- Cartilage
- Vascular
- Other
Clinical Features
History
- Patients report dorsal wrist pain
- Decreased wrist motion and grip strength
- Patients may endorse a history of or have clinically swelling and tenderness at the radiocarpal joint
- Worse with activity
- Dominant hand more commonly affected
Physical Exam: Physical Exam Wrist
- Tenderness along the lunate, radiocarpal joint
- Swelling may or may not be present
- Decreased range of motion in flexion/extension of wrist
- Decreased grip strength
Evaluation
Patient number 3, left wrist, Stage IIIa Kienböck's disease in 1992. B) the same wrist in 2012, 20 years later, still at Stage IIIa.[2]
Radiographs
- Standard Radiographs Wrist
- Findings (see staging lichtman classification)
CT
- Useful for staging
- Especially once Lunate collapse has occurred
- Useful for describing
- Extent of necrosis
- Trabecular destruction
- Lunate geometry
MRI
- Valuable in early disease staging
- Findings
- Decreased T1 signal intensity
- Reduced lunate vascularity
Classification
Lichtman Classification
- Based upon radiographs
- Stage I - Normal radiograph (however changes seen on MRI)
- Stage II - Increased radiodensity or sclerosis of lunate
- Stage IIIa - Lunate collapse, no scaphoid rotation
- Stage IIIb - Lunate collapse, fixed scaphoid rotation
- Stage IV - Degenerative changes around the lunate
Management
Nonoperative
- Indicated in stage 1
- Immobilization with Short Arm Cast
- NSAIDS
Operative
- Indications
- Surgery indicated for Stage II - IV
- Technique[3]
- Temporary scaphotrapeziotrapezoidal pinning
- Joint leveling procedure
- Radial wedge osteotomy
- Vascularized bone grafts
- Distal radius core decompression
- Partial wrist fusions
- Proximal row carpectomy (PRC)
- Wrist fusion
- Total wrist arthroplasty
Rehab and Return to Play
Rehabilitation
- Needs to be updated
Return to Play/ Work
- Unknown, no clear guidelines
Complications and Prognosis
Prognosis
- Progressive, debilitating if not recognized and treated appropriately (need citation)
- Better in the pediatric and elderly patients, than the typical 20- to 40-year-old patient[4]
- Irisarri et al study divided pediatric patients into infantile (12 years and younger) and juvenile (13 years to skeletal maturity)[5]
- Infantile group: treated nonoperatively, excellent outcomes, including lunate revascularization on magnetic resonance imaging (MRI)
- Juvenile group: treated with immobilization,, 30% had progression and required a joint leveling procedure
Complications
- Radiocarpal arthritis
See Also
Internal
- Avascular Necrosis (Main)
- Forearm Pain (Main)
- Wrist Pain (Main)
- Hand and Wrist Anatomy (Main)
- Physical Exam Wrist
External
- Sports Medicine Review Wrist Pain: https://www.sportsmedreview.com/by-joint/wrist/
References
- ↑ Kienböck R. Über traumatische Malazie des Mondbeins und ihre Folgezustände: Entartungsformen und Kompressionsfrakturen. Fortschr Geb Rontgenstr. 1910;XVI(2):77–103.
- ↑ Viljakka, T., K. Tallroth, and M. Vastamäki. "Long-Term Natural Outcome (7–26 Years) of Lichtman Stage III Kienböck’s Lunatomalacia." Scandinavian Journal of Surgery 105.2 (2016): 125-132.
- ↑ https://www.orthobullets.com/hand/6050/kienbocks-disease
- ↑ Lichtman D M, Degnan G G. Staging and its use in the determination of treatment modalities for Kienböck's disease. Hand Clin. 1993;9(3):409–416.
- ↑ Irisarri C, Kalb K, Ribak S. Infantile and juvenile lunatomalacia. J Hand Surg Eur Vol. 2010;35(7):544–548.
