Kienbock Disease
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Kienbock Disease

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Kienbock Disease Kienbock Disease Presentation Transcript

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