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Kienbock Disease


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Kienbock Disease

  2. 2. 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
  3. 3. 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
  4. 4. EPIDIMIOLOGY • Age= 15-40 (young individuals) • Sex= Men • Location= Unilateral, Dominant wrist
  5. 5. 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
  6. 6. PATHOLOGY • The natural history of Kienbock’s disease is Progressive Sclerosis  Fragmentation  Arthrosis
  7. 7. 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
  8. 8. 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
  9. 9. 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
  10. 10. 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
  11. 11. Early Disease Stage I & II • Unloading the Lunate* • 1. Ulnar lengthening • Transverse osteotomy at distal ulna  Distraction  Cortical iliac graft  Tightening of plate screw
  12. 12. Early Disease Stage I & II 2. Radial Shortening Indication – Negative ulnar variance – Lunate compression fracture without fragmentation or flattening Procedure Transverse osteotomy shortening of radius 3” proximal to distal by 2 cm articulating surface fixing the bone with compression plate
  13. 13. 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
  14. 14. In stage IV • Proximal carpal row resection • Wrist arthrodesis