A CASE

1. KEINBOCK’S DISEASE
DR.SUKESH A N
POST GRADUATE TDMC ALAPPUZHA

2. • Mr. RAJESH 30yr manual labourer
• c/o R wrist pain 3 months
• h/o trauma to R wrist
• Pain gradually progressive
• No aggravating/relieving factors
• No diurnal variation

3. • o/e
• Diffuse swelling R wrist c/to L
• Tenderness at base of 3rd MC dorsal aspect
• No DNVD
• No movement restriction

4. XRAY……

5. • MRI - features suggestive of AVN R LUNATE
Stage II

6. RSO

8. POST OP…..

9. • Lunatomalacia /Avn lunate
1st described by PESTE 1848
• Characteristic finding on a
xray by KEINBOCK 1910
• Term ‘keinbock’s disease’
by SPEED 1916
Austrian
radiologist

10. KEINBOCK’S DISEASE
 A painful disorder of unknown cause in which
radiograph evaluation show osteonecrosis of
Lunate {CAMPELL 12TH ED ,CH 69}
 Men between 15 – 40 years of age

11. ANATOMY
• Semilunar shape
• Center bone of proximal row
• Blood supply
• Dorsal - Dorsal radiocarpal arch and Dorsal intercarpal
arch
• Volar – Braches from Radial, Ulnar and Anterior
interosseous artery
Least vascular area- subchondral bone adjacent to radius

12. ETIOLOGY
•Multifactorial
1. Trauma
2. Anatomic
-Vascular cause
-Lunate morphology
3. Biomechanical factors
-Negative ulnar variance
-Decreased radial inclination

13. VASCULAR
20% of Lunate bones were supplied by a single volar vessel
 Lunate with a single vessel and minimal branching is
at increased risk of AVN
CAMPELL 12TH ED, CHP 69, PG 3422
GELBERMAN et al 3 pattern

14. LUNATE
 Type 1 - weakest trabecular pattern

15. ULNAR VARIANCE • Relationship of distal
articular surface of radius
with convex head of ulna
Neutral – same level in
coronal plane
Positive- ulna >2mm distal to
radius
Negative- ulna > 2mm
proximal to radius
Neg ulnar variance –
keinbocks disease
Hulten described ulnar- minus variant (CAMPELL 12TH ED CH 69 PG 3424)

17. CLINICAL FEATURES
• Dorsal wrist pain
• Wrist swelling
• Tenderness over the dorsal lunate and radiolunate
facet
• Movements -dorsiflexion is limited
• In extreme case clenching of hand fails to show the
normal prominence of 3rd metacarpal
• Percussion over head of 3rd mc –tenderness
FINSTERERS’S SIGN
 symptoms present 18 months before xray evidence
( CAMPELL 12TH ED,CH 69 PAGE 3423)

18. FINSTERERS’S SIGN
Percussion on 3rd mc head produce tenderness

19. INVESTIGATIONS
• •X ray
• •MRI
• •CT scan

20. CLASSIFICATION
• Lichtman X ray
• Schmitt and Lanz MRI
• Bain & begg Arthroscopic

21. LICHTMAN
•Stage 1: Normal radiographs, diffuse changes on
MRI
•Stage 2: Lunate sclerosis
•Stage 3: Lunate collapse
-3A: Normal scaphoid alignment
-3B: Fixed scaphoid rotation (Ring sign)
•Stage 4: severe lunate collapse with Radio-carpal
and Mid-carpal joint degenerative changes

22. Stage 1 Stage 2 Stage 3 Stage 4
CAMPBELL 12TH ED,CH 69

23. SCHMITT AND LANZ
Based on MRI pattern
N- Normal signal
A- Marrow edema with viable and intact bony
trabeculae
B- Early marrow necrosis
C- Necrotic bone marrow with collapse

25. TREATMENT
• Divided into 3 broad category
– Mechanical {lunate unloading}
– Biological {lunate revascularisation}
– Salvage therapy
• Depend on the stage of disease

26. Stage I
• Conservative treatment with CAST
immobilisation for 3 months

27. Stage II or III with negative ulnar
varience
• Goal - to reduce intracarpal stress and allow
revascularisation
• Joint leveling procedures –
Radial shortening osteotomy
Ulnar lengthening procedures

28. RADIAL SHORTENING
• Transverse osteotomy 3”(7.6cm) prox. to
distal articular surface
• Radius shortened by 2mm & fixed with
compression plate
• Preferred over ulnar lengthening;
– Nonunion
– Bone graft
– Hardware removal
CAMPBELL 12TH ED, CH 69, PG 3424

29. Contd…….
• Preop xray (measure amount of shortening required)
• Diaphyseal osteotomy ( to place 3 screws in distal
fragment) [ALMQUIST & BURNS]
• Fix two distal screws before osteotomy
• Remove plate & perform osteotoomy
• Before proximal screw compress osteotomy
CAMPBELL 12TH ED, CH 69, PG 3427

30. Stage II and IIIA Ulnar neutral or
positive Variance
• Revascularisation + stabilization
• Osteotomy
– capitate shortening
– radial wedge osteotomy
• Core decompression

31. CORE DECOMPRESSION
• Concept by Illarramendi et al in 2001
• Curretage of distal radius & ulna through cortical
window
• Cortical window 2 x 0.5 cm ,2 cm prox .to radial
styloid
• Removed cortex fragmented into 5 mm* ,impacted
into metaphysis
• Illarramendi et al resolution of keinbock d/to local vascular
response
• Sherman et al d/to incresed vascularity than biomehanical
unloading Simple
Less invasive
No internal
fixation
CAMPBELL 12 TH ED, CH 69

32. REVASCULARISATION
• Principle – Transplantation
of an arterio-venous
pedicle into normal and
avascular bone results in
new bone formation
• reversal of destruction of
lunate through
neoangiogenesis

33. • Sources
1. Distal radius pedicle graft with Pronater teres
2. Vascularised pisiform graft
3. 4th & 5th extensor compartment artery graft
4. I,II or III dorsal metacarpal artery transfer

34. Stage IIIB
• Goal in this stage
Stabilisation of carpus
Prevent further collapse
Decrease the load across radiolunate joint
• Proximal row carpectomy PRC
• Scapho-trapezio-trapezoid arthrodesis
• Scapho-capitate arthrodesis
• Grafting ,arthroplasty and interposition

35. PRC • Excision of the scaphoid
,lunate and triquetrium
• Transfering load from the
capitate directly to the
lunate facet of the distal
radius

36. Stage IV
• Salvage procedures
• PRC If mild degeneration
• Wrist arthrodesis
• Wrist arthroplasty
• Wrist denervation

37. Experimental treatments

38. We recommend a radial shortening procedure for patients
with severe pain and radiological signs of progressive
carpal collapse.
JBJS

39. • collapse of the carpal bones developed in
elderly patients who had received nonsurgical
treatment. No problems in occupation or
quality of life.
• nonsurgical treatment can be chosen first for
treatment of Kienbock’s disease in elderly
patients

40. < 12 years
-Conservative
13 – 15 years
-Conservative, immobilisation for longer period
> 15 years
-Surgical Rx has good prognosis

41. THANK YOU