Kienbock disease
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This document describes a case of Kienböck's disease in a 37-year-old male bricklayer with 25 years of experience. Clinical examination revealed pain and limited mobility in his right wrist. X-rays showed changes in bone density of the lunate bone. He was diagnosed with stage IIIB Kienböck's disease based on MRI findings and placed on a waiting list for total wrist arthrodesis surgery. The document discusses Kienböck's disease, risk factors like vibration exposure, stages of the disease, treatments, and impact on occupational disability.
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Kienbock disease
- 1. Benedetto Gesmundo M.D.Benedetto Gesmundo M.D. Resident of Occupational Medicine CPRL Huelva Huelva, 26 September 2014 Teaching Unit Occupational Health Multiprofessional of Andalucia Centre for prevention of occupational hazards of HuelvaCentre for prevention of occupational hazards of Huelva Kienböck DiseaseKienböck Disease A clinical case of cumulative trauma disorder
- 2. Case • Male, 37 years old • Bricklayer with 25 years of experience • No refers pathological history • He consulted for the same reason (3 times in a year) • Present condiction: – Pain dominant wrist (right) – Limitation of articular balance – Loss of strength (hand clench) Dr. Benedetto Gesmundo Emergency H.J.R.J.: Medical consultation Date: June 2013
- 3. Clinical examination • Slight edema in dorsal carpal • No bruiding or deformity • No Vascular-nervous disorders • Painful acupressure snuffbox • A.B. very limited – Furthest flexo-estension +/- 10º – Painful ulnar inclination Dr. Benedetto Gesmundo
- 4. Additional tests AP and lateral wrist’s radiograph Dr. Benedetto Gesmundo Subchondral sclerosis with changes in radiographic density of lunate. No crashes or dislocations.
- 5. Plan and Treatment • Relative repose • Immobilization with bottony bandage for a week • Diclofenac retard 75 mg / 12 hours • Contact surgeon guard: citing to unit handContact surgeon guard: citing to unit hand Dr. Benedetto Gesmundo - R3 Medicina del trabajo
- 6. Definitions Cumulative Trauma Disorder Group of disorders that share etiology in which physical demand exceeding capacity biomechanical of extructura used, leading to lasion of the musculo-sjeletal system Dr. Benedetto Gesmundo Kienböck disease Avasculare necrosis of the lunate carpal caused by lack of blood supply to lunate bone, poducing progressive morphological alterations
- 7. Cumulative trauma disorder Dr. Benedetto Gesmundo Phase 1 Phase 2 Phase 3 • Affectation capacity • No recovery pain • Reversible to rest • Fatigue • Good capacity • Pain during the rest (weekend) • Production injury • Didability and personal limitation time paincapacity
- 8. Robert Kienböck Dr. Benedetto Gesmund Robert Kienböck (1871-1953)Robert Kienböck (1871-1953) Austrian RadiologistAustrian Radiologist Lunatomalacia (1910)Lunatomalacia (1910)
- 9. Epidemiology Dr. Benedetto Gesmundo - R3 Medicina del trabajo Rare disease • Young patient: between 20 – 40 years old • Ratio Man : Woman = 7 : 1 • Prevalence < 1/200000 • Incidence < 1/2000 • Bilaeral incidence = 25 cases from 1937 to date • Manuals Background: 97% of cases
- 10. Anatomia del carpo Dr. Benedetto Gesmundo - R3 Medicina del trabajo Distal row:Distal row: •Trapezium •Trapezoid •Capitate •Hamate Proximal row:Proximal row: •Scaphoid •LunateLunate •Triquetrum •Pisiform Ulna Radio
- 11. Lunate’s anatomy Dr. Benedetto Gesmundo - R3 Medicina del trabajo • Crescent-shaped • 6 veneers: 4 articular + 2 roughened • Superior (convex): Radio • Inferior (concave): Capitate y hamate • External (flat): Scaphoid • Internal (flat): Triquetrum • Previus: no articular • Rear: no articular Vascularización Extraósea: •Arcopalmar profundo •Arco Radiocarpiano Intraósea: (3 patrones) •2 A.Dorsales + 1 A.Ventral •1 A.Dorsal + 1 A.Ventral •2 A.Dorsales + 2 A.Ventrales 59%59% 31%31% 10%10%
- 12. Etiology (multifactorial) Necrosis avascularNecrosis avascular Dr. Benedetto Gesmundo Traumatic theoryTraumatic theory Atraumatic theoryAtraumatic theory Vascular sorceVascular sorce Bone sorceBone sorce CapsuloligamentousCapsuloligamentous injuryinjury Neurovascular theoryNeurovascular theory Nerve incolvement:Nerve incolvement: 1. Primary vasodilatation1. Primary vasodilatation ->-> Bone decalcificationBone decalcification 2. Vasocostricion2. Vasocostricion -> Bone infarction-> Bone infarction Constitutional factorsConstitutional factors Vascular obliterationVascular obliteration (embolus o thrombus)(embolus o thrombus) Connective tissue diseasesConnective tissue diseases (vasculitis and corticosteroids)(vasculitis and corticosteroids) Lunate’s fractureLunate’s fracture Compression fractureCompression fracture Trabecular fracturesTrabecular fractures in patients within patients with predisposingpredisposing anatomic variantsanatomic variants
- 13. Dr. Benedetto Gesmundo Occupational etiology Necrosis avascularNecrosis avascular Traumatic theoryTraumatic theory Atraumatic theoryAtraumatic theory Vascular sorceVascular sorce Bone sorceBone sorce CapsuloligamentousCapsuloligamentous injuryinjury Neurovascular theoryNeurovascular theory Nerve incolvement:Nerve incolvement: 1. Primary vasodilatation1. Primary vasodilatation ->-> Bone decalcificationBone decalcification 2. Vasocostricion2. Vasocostricion -> Bone infarction-> Bone infarction Constitutional factorsConstitutional factors Vascular obliterationVascular obliteration (embolus o thrombus)(embolus o thrombus) Connective tissue diseasesConnective tissue diseases (vasculitis and corticosteroids)(vasculitis and corticosteroids) Lunate’s fractureLunate’s fracture Compression fractureCompression fracture Trabecular fracturesTrabecular fractures in patients within patients with presidspodingpresidspoding anatomic variantsanatomic variants
- 14. Dr. Benedetto Gesmundo Traumatic theory
- 15. Predisposing anatomic variants Dr. Benedetto Gesmundo Index inferior radioulnar Radial rake angle Angle of the lunate fossa Translation medial index “Cubit short” > Angle , > Radiolunate load Flattened pit > lunate load Medial translation < 1/5 of lunate
- 16. Dr. Benedetto Gesmundo Most frequent occupational cause At work, the most frequet causes of vascular, neurological and skeletal disordes are VIBRATIONSVIBRATIONS Vibreation (frequency between 25-250 Hz) are transmitted to wrist by hand-held machines. 90% of vibration trasmitted to hand is absorbed in the wrist, especially Lunate and scaphoid.
- 17. Risk factors • Age: < 20 y.o. y > 40 y.o. • History of arthritic process wrist • Previous trauma • Mechanical vibration [20, 250] Hz: Hammers, Punches, Percussion drills, Sanders, pulidoras, Saws, sealed guns, grinders, ... • Minimal exposure: 5 years • Maintained repetitive gestures Dr. Benedetto Gesmundo
- 18. Precautions • Application of specific protocols: Load and repeated movements • Limit exposure to vibration: Acceleration: 5m/s2 for 8 hours • USE IPE Vibration Gloves • Damped system Machines • Alterations of tasks Dr. Benedetto Gesmundo
- 19. Symptoms • Wrist pain, synovitis associated • Limited mobility • Decreased grip strenght • Thinkening of wrist edema • Functional limitation Dr. Benedetto Gesmundo A long term disease often leads to osteoarthritits of wrist
- 20. Diagnosis Dr. Benedetto Gesmundo Plain radiography Establishing evolution’s degree (Initial stage) NMR y Scintigraphy Provide date to diagnose the process (Early diagnosis) Radiography
- 21. Diagnosis Dr. Benedetto Gesmundo Nulcear Magnetic Resonance
- 22. Dr. Benedetto Gesmundo Stages Proposed by Lichtman Progresive symptomatology Negative radiology Possible diagnosisi by NMR or Scintigraphy
- 23. Dr. Benedetto Gesmundo Changes in radiographic density of lunate, without collapse Stages Proposed by Lichtman
- 24. Dr. Benedetto Gesmundo - R3 Medicina del trabajo Lunate collapse occurs, Proximal migration of capitate, without alteration of joint scaphoid-lunate Stages Proposed by Lichtman
- 25. Dr. Benedetto Gesmundo Scapholunate instability, Rotatory subluxation of scaphoid (ring sign), Dorsiflexion of lunate (DISI) Stages Proposed by Lichtman
- 26. Dr. Benedetto Gesmundo Radiocarpal arthrosis SLAC wrist (Scapho-Lunate Advanced Collapse) Stages Proposed by Lichtman
- 27. Differential diagnosis • Avascular necrosis of scaphoid (Preiser disease) • Scaphoid fracture • Scapholunate instability • Lunate-triquetral instability • Synovial cysts • Tenosynovitis • Carpal tunnel syndrome • Osteoarthritis • Arthritis Dr. Benedetto Gesmundo
- 28. Diagnostico diferencial Dr. Benedetto Gesmundo KienböckKienböck PreiserPreiser Scaphoid fractureScaphoid fracture Scapholunate instabilityScapholunate instability Lunate-TriquetralLunate-Triquetral instabilityinstability
- 29. Treatments Dr. Benedetto Gesmundo Observation, developmental control Immobilization if pain Low symptoms Stage 0, I, II Symptoms present Stage I, II, IIIA Articular selective desnervation Radial shortening osteotomy Symptoms present Stage IIIB, IV Proximal Hemicarpectomy Partial or complete artrodesis Lunate prosthesis
- 30. Surgical treatments Dr. Benedetto Gesmundo Proximal hemicarpectomyProximal hemicarpectomy • Articular consevationArticular consevation • Age and WorkAge and Work • Mobility preservedMobility preserved • Loss of strengthLoss of strength • Load limitedLoad limited • Severe osteoarthritisSevere osteoarthritis • Age and workAge and work • Mobility abolishedMobility abolished • Preserved forcePreserved force • Not limited loadNot limited load Wrist’s ArtrodesisWrist’s Artrodesis
- 31. Experimental treatments Dr. Benedetto Gesmundo Lunate prosthesisLunate prosthesis • Pyrocarbon o SilasticPyrocarbon o Silastic • Conservacion articularConservacion articular • Mobility preservedMobility preserved Total wrist prosthesisTotal wrist prosthesis • Metal y polymerMetal y polymer • Severe osteoarthritisSevere osteoarthritis • Mobility preservedMobility preserved
- 32. Occupational Impact Dr. Benedetto Gesmundo Kienböck’s disease is a debilitating condictiontion that produce a high risk of occupational disability, partial o total. Surgery is almeliorative and their results are conditioner by several factors: • Age of patient • Radiological stage • Evolution time • Manual activity • Limitations secuelae • Type of surgery The results of work disability in patients tratd for a total osteoarthrosis have a lower demand for Total Permamant Disability compared to other occupational pathology of wrist with equal tratment. Enfermedad de Kienböck: TPD 86%, PPD 14% Otras enfermedades: TPD 70%, PPD 30%
- 33. Common or occupational contingency? Dr. Benedetto Gesmundo Common ContingencyCommon Contingency (core cases)(core cases) Etiology not related to workl activity (no traumatic theory) • Anatomical factors • Specific constitutional factors • Vascular disorders of lunate Occupational Contingency: Occupational diseaseOccupational Contingency: Occupational disease Cases, without traumatic history, having a vascular ingury related to work activity • Microtraumatic process • Mechanical activity • Repetitive gesture maintained Occupational Contingency: Occupational accidentOccupational Contingency: Occupational accident Cases which dideas is a result of a traumatic process that producea vascular injury • Inseparable factors trauma • Demonstrate a cause-effect
- 34. Vibration diseases Dr. Benedetto Gesmundo Suspected osteoarticualr involvement by hand-arm vibration transmittedSuspected osteoarticualr involvement by hand-arm vibration transmitted Rate other cause Rate other cause Occupational disease Occupational disease NO NO NO SI SI SI NO SI RMN SI Exposure to vibrations Exposure > 5 years Onset latency > 2 years Findings compatible? Findings compatible? Involvement in early? RX
- 35. Case: 1st visit • Clinical examination unchanged • Ordered tests: NMR • Diagnostic suspicions: – Kienböck disease – Carpal ligament instability – Carpal osteoarthritis – Fractures (lunate or scaphoid) • Tanporary disability (1 month) Dr. Benedetto Gesmundo Vázquez Díaz Hospital Date: june 2013
- 36. Caso clínico: 2ª cita • NMR: Findings compatible with Kienböck disease stage IIIB • Surgical waiting list fot Total wrist arthrodesis • Temporary disability (4 month) Dr. Benedetto Gesmundo Vázquez Díaz Hospital Date: january 2014 Juan Rámon Jiménez Hospital …Waiting… • Surgery: Total wrist arthrodesis • Temporary disability • Partial permanent disability?
- 37. Conclusions • Crippling disease • Boxdifficult qualifying in origin by its multible etiologies • It relates to works ofgreat mechanical stress and vibration • Medicolegal conflictsMedicolegal conflicts (contingency) • Determines PPD and TPD • Fondamental by occupational medical doctor: – Diagnose the disease at early stage – Precautions – Orient to ideal treatment for each patient Dr. Benedetto Gesmundo
- 38. Dr. Benedetto Gesmundo Thank you