Kienbock Disease

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Kienbock Disease

  1. 1. KIENBOCK DISEASE DR. MANOJ BHAMA SENIOR RESIDENT, DEPT. OF ORTHOPAEDICS, S.P. MEDICAL COLLEGE, BIKANER, INDIA [email_address]
  2. 2. KIENBOCK DISEASE <ul><li>Synonyms: Avascular Necrosis of Lunate </li></ul><ul><li>First Described by Robert Kienbock in 1910; as “traumatic softening” of Lunate bone </li></ul><ul><li>It is a painful disorder of wrist, due to avascular necrosis of carpal lunate, due to unknown cause </li></ul>
  3. 3. AETIOLOGY <ul><li>Aetiology = unknown, but several cause have been proposed </li></ul><ul><li>vascular compromise from repetitive trauma causes microfracture & excessive stress on microscopic architecture (sports injury) </li></ul><ul><li>Ulnar minus variant:- Individual having ulnar minus variance are at increased risk. Short Ulna  increases shear force across the lunate  Causes vascular insufficiency </li></ul>
  4. 4. EPIDIMIOLOGY <ul><li>Age= 15-40 (young individuals) </li></ul><ul><li>Sex= Men </li></ul><ul><li>Location= Unilateral, Dominant wrist </li></ul>
  5. 5. PATHOLOGY <ul><li>Pathological changes proceed in 4 stages:- </li></ul><ul><li>Stage 1: Ischemia with naked eye or radiological examination </li></ul><ul><li>Stage 2: Trabeculae Necrosis with reactive new bone formation & increased radiographic density, but little or no distortion of shape. </li></ul><ul><li>Stage 3: Collapse of Bone </li></ul><ul><li>Stage 4: Disruption of Radio-carpal congruence & secondary OA </li></ul>
  6. 6. PATHOLOGY <ul><li>The natural history of Kienbock’s disease is </li></ul><ul><li>Progressive Sclerosis </li></ul><ul><li>  Fragmentation </li></ul><ul><li>  Arthrosis </li></ul>
  7. 7. CLINICAL FEATURE <ul><li>There may be history of trauma with wrist in severe dorsiflexion </li></ul><ul><li>The lesion presents with </li></ul><ul><li>1. Dorsal wrist pain:- Pain may be produced in lunate region by axial strike/injury at distal end of middle finger </li></ul><ul><li>2. Swelling </li></ul><ul><li>3. Decreased Grip strength </li></ul><ul><li>4. Decreased range of motion; particularly in extension. In later stage movement may be painful </li></ul>
  8. 8. IMAGING <ul><li>X-ray at first show no abnormality but bone scan may reveals increased activity </li></ul><ul><li>Later x-ray may show either mottled or diffuse density of bone – to – osteoarthritic changes in wrist </li></ul><ul><li>MRI Most reliable way of detecting the early change </li></ul>
  9. 9. CLASSIFICATION <ul><li>Kienbock disease advances through 4 radiological stages </li></ul><ul><li>Stage I : Normal architecture; consistent with Microfracture </li></ul><ul><li>(Lunate abnormal on bone scan) </li></ul><ul><li>Stage II : Lunate sclerosis without collapse </li></ul><ul><li>Stage III : Lunate collapse or Fragmentation & proximal migration of capitate </li></ul><ul><li>Stage IV : Perilunate arthritis changes </li></ul>
  10. 10. TREATMENT <ul><li>A Conservative </li></ul><ul><li>Casting of wrist for several wks ; for early stages of disease ( St I or II, before sclerosis, fragmentation or collapse) </li></ul><ul><li>But- Unacceptable & Ineffective </li></ul><ul><li>B Operative </li></ul><ul><li>Surgery is only definitive treatment </li></ul>
  11. 11. Early Disease Stage I & II <ul><li>Unloading the Lunate* </li></ul><ul><li>1. Ulnar lengthening </li></ul><ul><li>Transverse osteotomy at distal ulna  Distraction  Cortical iliac graft  Tightening of plate screw </li></ul>
  12. 12. Early Disease Stage I & II <ul><li>2. Radial Shortening </li></ul><ul><li>Indication </li></ul><ul><ul><li>Negative ulnar variance </li></ul></ul><ul><ul><li>Lunate compression fracture without fragmentation or flattening </li></ul></ul><ul><li>Procedure </li></ul>Transverse osteotomy 3” proximal to distal articulating surface shortening of radius by 2 cm fixing the bone with compression plate
  13. 13. In stage III <ul><li>1. Ulnar lengthening </li></ul><ul><li>2. Silicon prosthesis </li></ul><ul><li>- silicon synovitis </li></ul><ul><li>- foreign body cyst </li></ul><ul><li>3. Interacarpal fusion </li></ul><ul><li>4. Lunate excision </li></ul><ul><li>5. Arthrodesis Tri scaphe </li></ul><ul><li> Scaphocapitate </li></ul>
  14. 14. In stage IV <ul><li>Proximal carpal row resection </li></ul><ul><li>Wrist arthrodesis </li></ul>

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