kienbock's disease

Kienböck’s Disease:

Kienböck’s Disease 6/15/11 By: Megan Dempsey Dwayne King Emily Lucci

Description of Kienböck’s Disease:

Description of Kienböck’s Disease “ Osteochondrosis or slow degeneration of the lunate bone of the wrist; usually resulting from trauma.” 1 Pathogenesis is similar to other osteochondroses with only two exceptions: The lunate heals much slower in adults than in children, and may never fully heal. 2 The articular cartilage is more likely to be affected in adults as lunate collapse occurs. 2

Signs and Symptoms2:

Signs and Symptoms 2 Initially mild aching in the wrist that will progressively become worse. Local tenderness over lunate Minimal swelling Restricted wrist motion Decreased grip strength on affected side

Incidence:

Incidence More prevalent in young adults specifically, 20-40 yr old working class men. 2 Most common in carpenters, pneumatic jackhammer operators, and riveters. 2 M ore common in the right hand. 2 Ulnar -plus variance is more common in black and Asians and rare in Caucasians. 3

Diagnosis and Prognosis:

Diagnosis and Prognosis Diagnosis most likely made by MRI 4 The classification system by Lichtman et al, has been shown to have good reliability and reproducibility. 4 Prognosis is poor as the pathological process is irreversible. 2 In most cases surgical intervention is required. 2 Adults have poorer outcomes than children. 2

Biomechanical/Physical Impairments4:

Biomechanical/Physical Impairments 4 Decreased wrist flexion and extension in Ulnar and radial deviation. Collapse of the lunate may cause shortening at the Ulno -carpal joint, further restricting active and passive range of motion. Chronic pain may develop and surgical interventions will be indicated. Functional limitations can include gripping, coordinated movements, and fine motor activties

Treatment2:

Treatment 2 The aim of the treatment is pain relief. The earliest phases consist of wrist immobilization. Before degenerative changes develop excision of the lunate is recommended. If and only if there is osteoarthritis that is advanced then the only way to provide relief is to perform a wrist arthrodesis .

Prevention4:

Prevention 4 Ergonomic intervention may be the most cost effective preventative measure. Studies have shown that ergonomic intervention increases productivity, improves safety and health, increases job satisfaction, work quality, lowers worker turnover, lowers lost time at work, lowers workers compensation claims and decreases the risk of OSHA fines.

Role of Imaging4,5:

Role of Imaging 4,5 Because Kienbock’s disease may mimic other musculoskeletal conditions such as wrist sprains, etc. i t is imperative that imaging plays the major role in diagnosis of Kienbock’s . Diagnosis may be made by plain radiographs while MRI may also be necessary.

Examples:

Examples http://www.learningradiology.com/caseofweek/caseoftheweekpix2/cow175.jpg Questions: If you were looking at this image would you suggest further imaging? Why or Why not? What type of therapeutic exercise would you recommend in a 28 year old construction worker that has just been diagnosed with Stage I Kienböck’s Disease?

Radiographic ABC’s:

Radiographic ABC’s Alignment: -There are no breaks in the cortex -Ulna shorter than radius -The carpals are in alignment with metacarpals and carpals in alignment with carpals with the exception of the lunate which demonstrates a classic " lunate collapse" as seen in Keinbock's disease. -There are no visible subluxations or dislocations Bone Density: - Sclerosing of the lunate -Increased bone density distal radius Cartilage: -Increased joint space at the ulnocarpal joint Soft tissue: -No abnormal findings of the soft tissue.

References:

References Venes D. Taber’s Cyclopedic Medical Dictionary. 21 st ed. Philidelphia , PA: F.A. Davis Company; 2009:1269. Salter RB. Textbook of Disorders and Injuries of the Musculoskeletal System, 3 rd ed.1999:353-354. Scuind F, Eslami S, Ledoux P. Aspects of Current Management: Keinbock’s Disease. JBJS. 2008; 90(2): 133-139. Fredricks TK, Fernandez JE, Pirela -Cruz. Keinbock Disease II. Risk Factors. Diagnosis, and Ergonomic Interventions. Int J Occup Med Environ Health. 1997; 10(2): 147-157. Takase K, Imakire A. Lunate Excision, Capitate Osteotomy , and Intercarpal Arthrodesis for Advanced Keinbock’s Disease. JBJS . 2001; 83(2): 177-183.