kienbock disease
TRANSCRIPT
KIENBOCK DISEASE
DR. MANOJ BHAMASENIOR RESIDENT,
DEPT. OF ORTHOPAEDICS,S.P. MEDICAL COLLEGE,
BIKANER, [email protected]
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
PATHOLOGYPathological 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 isProgressive Sclerosis
Fragmentation
Arthrosis
CLINICAL FEATURE• There may be history of trauma with wrist in
severe dorsiflexionThe lesion presents with1. Dorsal wrist pain:- Pain may be produced in
lunate region by axial strike/injury at distal end of middle finger
2. Swelling3. Decreased Grip strength4. 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 ConservativeCasting of wrist for several wks ; for
early stages of disease ( St I or II, before sclerosis, fragmentation or collapse)
But- Unacceptable & IneffectiveB 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 ShorteningIndication
– Negative ulnar variance– Lunate compression fracture without fragmentation or
flatteningProcedure
Transverse osteotomy 3” proximal to distal articulating surface
shortening of radius by 2 cm
fixing the bone with compression plate
In stage III1. Ulnar lengthening2. Silicon prosthesis
- silicon synovitis- foreign body cyst
3. Interacarpal fusion4. Lunate excision5. Arthrodesis Tri scaphe
Scaphocapitate
In stage IV
• Proximal carpal row resection• Wrist arthrodesis