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