KIENBOCK DISEASE :KIENBOCK DISEASE DR. MANOJ BHAMA SENIOR RESIDENT, DEPT. OF ORTHOPAEDICS, S.P. MEDICAL COLLEGE, BIKANER, INDIA mbhama@gmail.com


KIENBOCK DISEASE :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 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 :EPIDIMIOLOGY Age= 15-40 (young individuals) Sex= Men Location= Unilateral, Dominant wrist


PATHOLOGY :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


PATHOLOGY :PATHOLOGY The natural history of Kienbock’s disease is Progressive Sclerosis  Fragmentation  Arthrosis


CLINICAL FEATURE :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


IMAGING :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 :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 :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


Early Disease Stage I & II :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 :Early Disease Stage I & II 2. Radial Shortening Indication Negative ulnar variance Lunate compression fracture without fragmentation or flattening Procedure Transverse osteotomy 3” proximal to distal articulating surface shortening of radius by 2 cm fixing the bone with compression plate


In stage III :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


In stage IV :In stage IV Proximal carpal row resection Wrist arthrodesis