G.O. Irowa
Journal of Manipulative Physiol-Therap Dec 1987
INTRODUCTION
Existence of avascular necrosis of various growth centers within the body has long been recognized (1). In children or adolescents, such changes are frequently referred to as ischernic necrosis and usually are associated with temporary interruption of blood supply. Such conditions are, as a result, self-limiting.
In the case of avascular necrosis of the carpal lunate, the condition frequently occurs during adult life. Secondary to an injury, and as a result of the injury, the blood supply is often permanently lost. This condition has been referred to in the literature as "Kienbock's disease".
Robert Kienbock (1871-1953) qualified as a radiologist in 1895 (same year Roentgen discovered x rays and, interestingly, D. D. Palmer introduced chiropractic manipulation to the Health Care System) and published his classic description of a "Malazie" of the lunate in 1910 ... "Concerning traumatic malacia of the lunate and its consequences.. . ".
X-ray cases studied showed isolated disease of the lunate, and associated changes in other carpal bones were slight and for the most part, secondary. The lunate alone was severely affected and showed changes in the bone itself. The disease was seen in the vast majority of cases to begin in the proximal portion of the lunate with internal destruction and with eventual changes in the shape and/or structure of this bone .
In addition to illustrations and the primary historical and physical findings, this case study provides an insight into appropriate treatment by allied health care professionals.
CASE REPORT
A 20-yr-old Hispanic male presented to National College of Chiropractic Clinic with a Primary complaint of right wrist pain with some radiation to the right forearm and elbow as well as into the third and fourth digits. There was also a complaint of swelling of the right wrist, and the patient indicated that the pain and swelling had been present for approximately 3 months.
History by interview revealed that this patient had related his right wrist problem to his job where he lifts heavy objects all day. He works as a cook in a restaurant.
Prior history of the patient revealed the usual childhood diseases He recounted a baseball injury to his right wrist and fingers 7 months previously. The family history was unremarkable.
Physical examination revealed a fairly well-developed male. He stood 67 inches tall and weighed 155 pounds. He was afebrile, with respiration range of 20/min and normal cardiac rate and rhythm. Blood pressure on the left arm was 120 over 80 mm Hg with the patient sitting.
Neurological evaluation of the patient revealed no abnormalities nor deficits.
Urinalysis and complete blood count with deferentials were within normal limits.
Orthopedic examination, relevant to the area of the patient's complaints was nonconclusive at this time because of the patient's continuous complaint of pain. Any forced increase ranges of the right wrist motion aggravated the patient's complaint of pain. Severe pain was noted at 20* flexion (normal 80-90* range), 10* extension (normal 60-70* range), radial deviation 0*
(normal 20-30* range) and 10* ulnar deviation (normal 30-60* range). Swelling was apparent over dorsal Surface of the right wrist. Right-hand grip, measured with Jamar adjustable Dynamometer, showed marked weak ness., The patient is right-handed and 6 kg of force was noted compared with 280 kg of force on the left hand Pain was aggravated in the right wrist during measurements.
Radiographic examination of the right wrist revealed no fracture or dislocation. Increased density of the right carpal lunate was noted, which is believed to be due to avascular necrosis. A diagnosis of traumatic avascular necrosis of the right carpal lunate (Kienock's disease) was made.
Treatment in this clinic consisted of pain control using high-volt galvanism current combined with ultrasound under water. Cold packs were applied at intervals of 15 min at a time. Immobilization of the wrist was obtained using an orthodotic device. Home instructions for the patient included wearing of a brace all day and applications of ice for 10-15 min during each hour. The patient was referred to an orthopedic surgeon who specializes in reconstruction of the hand.
Treatment in this clinic was palliative, with reduction of swelling and pain. The medical orthopedist performed a scaphoid triangular trapezoid (STT) arthrodesis.
Postsurgical re-evaluation of this patient revealed the following: minimal swelling was noted over dorsal surface of the right wrist. There was no redness or tenderness upon palpation. Goniometric evaluation showed some improvement to 35* flexion, 20* extension and 25* ulnar deviation. No improvement was noted with radial deviation, which remained at 0*. There was mild improvement in right-hand grip to 8 kg of force.
Visualization of the postsurgical right wrist (Fig. 3) reveals general disuse osteoporosis. The lunate has remained free and appears more cystic with more internal rarefaction sites.
Postsurgical treatment included moderate wrist exercises (both active and passive) and correction of cervical and upper thoracic subluxations. C5, C6, C7, C8, TI and T2 are dermatomal segments to arm/wrist/ hand. Two weeks of this therapeutic procedure produced increase in radial wrist deviation movement from 0* to 8* and hand grip to 10 kg of force. Prognosis is for continued improvement with minimal or no chronic disability.
DISCUSSION
This case emphasizes the importance of making a proper diagnosis of a condition which, if undiagnosed, will lead to chronic disability of the wrist. The patient in question has been experiencing pain and swelling for 3 months. Unfortunately, by this time frame, the condition had advanced significantly.
The changes in the lunate in this case were due to trauma. A congenital anomaly or disturbance in development, an arthritis or osteitis of a tuberculosis or syphilitic variety, the initial finding in an early rheumatic arthritis, an osteoarthritis unrelated to trauma, a traumatic osteomalacia due to ischemia and a result of a compression fracture can also result in changes in lunate bone. Disturbance in the nutrition of the lunate caused by the rupture of the ligaments and blood vessels during contusions, sprains and subluxations has become another explanation for the changes in this condition.
Several surgical approaches for the correction of this condition are available and have been described. The surgeon's choice of procedure in this case was based on the fact that the scaphoid was volar fle xed and reduction of the scaphotrapezial angle was needed in order to take pressure (the axial loading) off the lunate bone.
Of particular interest in this case management is the good referral relationship with an allied health care physician. Developing such a relationship is very important for adequate care and consideration of our patient population. As a result of this relationship, further complications were avoided, and the condition was readily corrected.
CONCLUSION
Avascular necrosis of the navicular lunate is not an unusual finding following trauma to the wrist. Early diagnosis and treatment may lead to resolution of the condition. However, in many cases, surgical intervention becomes necessary and it almost always becomes necessary if early diagnosis and treatment are not accomplished. Failure to recognize the condition and to have proper surgical intervention almost always results in chronic disability of the wrist with degenerative joint disease. Particular importance in a case such as this is the need to have a well-established relationship with an allied health care professional who specializes in such conditions.