GRANDROUNDS 2/1/93
J. McCARTHY , J CULVER.
In 1910, Dr. Robert Kienbock, a professor of radiology in Vienna, wrote his classic article describing "Traumatic Malacia of the Lunate and its Consequences", (only 15 years after x-rays were discovered). In his article he describes many of the radiographic features of Kienbock's disease as well as providing a rather complete clinical review. He felt that it was caused by a "disturbance of nutrition" secondary to tears of the interosseous ligaments and blood vessels.
Hulten, in 1928, noticed that patients with Kienbock's disease have a greater tendency for their ulna to be shorter than the radius, when measured at the wrist. This later came to be known as the ulna-minus variant and fornded the basis for early treatment aimed at "leveling" the wrist by either shortening the radius or lengthening the ulna.
Recent work has involved newer lmaging techniques and treatment
for all staqes of Kienbock's disease
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Kienbock's disease is a painful disorder of the wrist, which
usually affects the young adult population, ages 15-40 years old. In
this population, it more often affects males, although Yoshida (1990),
demonstrated in the older population it more often affects females.
It will more likely affect the dominant hand, and is preceded by trauma
in 72% (Beckenbaugh, 1980). According to Rooker (1977), it occurs more
frequently in adults with cerebral palsy (9%), and can infrequently
occur bilaterally (Morgan, 1983). It is felt to be more common in
laborers, as described by Kienbock in his original article, "all the
women were housemaids" and all but one of the men were laborers of
various types including; "quarry workers, coachmen, bricklayers and
soldiers". Recently Nakamura (1991) demonstrated a similar clinical
history with sports related Kienbock's disease
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Kienbock's disease is a condition in which the vascular supply to the lunate is compromised, and the lunate, especially the proximal pole, undergoes AVN. This may occur as a result of trauma which allows the compressive forces exerted by the capitate to increase the stress applied to the articular surface and lead to vascular compromise (Linscheid 1992).
Although there is a high incidence of previous trauma, Linscheid (1992) believes 40% of patients show no evidence of prior fracture. He feels that interference with the rather tenuous vascular supply of the lunate by the foraminal areas impinging on the radial rims accounts for the vascular compromise. Gelberman (1980) described the vascular supply to the lunate, with three general patterns, Y, X, I (see figure 1). The vessels can enter the bone only at the dorsal and palmer poles, due to the articular cartilage surrounding the rest of the surface.
figure 1. schematic representation of Y, X, I vascular patterns in the lunate ( after Gelberman 1980).
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A number of good review articles and textbooks describe the signs and symptoms which vary little from Kienbock's original description. Patients often present with an insidious history of wrist pain. 72% of patients give a history of trauma, usually a fall on the extended hand, although it is often elicited in retrospect and may be treated as a "sprain" acutely.
Patients present months, even years later with limitation of motion in the wrist, especially palmar flexion, weakness (grip can be decreased by 50% as compared to the oppisite hand), and tenderness over the dorsal central aspect of the wrist. The differential diagnosis is listed in table 1.
TABLE 1. DIFFERENTIAL DIAGNOSIS OF WRIST PAIN (CHRONIC) ==========================================================
Physical findings may precede radiographic changes by as much as 18 months or both may precede rather rapidly. The earliest evidence is small fracture lines, and rarification. Increased density or sclerosis of the lunate follows, as compared with the adjacent bones. Flattening of the articular surface, especially the proximal portion leading to a decrease in lunate height and carpal height ratio (see figure 2), follows. Fragmentation and finally degenerative changes of The carpal bones are signs of the late stages of Kienbock's disease. The classification of Kienbock's disease is often based on these changes as listed in table 2, and pictured in figure 3.
figure 2. The carpal height ratio is L2/L1 ( after McMurtry et al, JBJS 60-A:955, 1978)
TABLE 2. RADIOGRAPHIC CHANGES IN KIENBOCK'S DISEASE (Lichtman 1982)
figure 3. Radiographic classification of Kienbock's disease (after Lichtman 1982).
The association between ulnar variance (the distance between a line drawn perpendicular to the longitudinal axis of the forearm through the proximal cortical line of the lunate and the ulnar pole) and Kienbock's disease was first described (as state above) by Hulten. Recently the significance of this finding has been debated, and it is felt by some authors (Kristensen 1987, Chen 1987, Nakamura 1991) to be of little importance and may occur as a result of the disease.
CT and tomography are occasionally used to further define structural
changes in the lunate (Friedmand, 1991) and have demonstrated that
fracture of the lunate may be more common than previously thought.
Technetium 99 bone scans is helpful for early diagnosis of Kienbock's
disease, but is difficult to localize anatomically. Several recent
reports demonstrate the effectiveness of MRI to demonstrate AVN
in the lunate, often before other techniques.
(Trumble 1990, Dresser 1990, Imaeda 1992).
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Conservative treatment for Kienbock's disease is probably ineffective. Mikkelsen (1987) found that only 6 of 25 patients has no pain after an average of 8 years, and 7 were forced to change occupations.
Person (1945) classically described ulnar lengthening in Kienbock's disease, after Hulten's observation of the ulna-minus variant. Radial shortening is also performed, and has the advantage of not requiring a bone graft. Both procedures (often referred to as joint leveling procedures) unload the lunate by distributing the force to the ulnar head and triangular fibrocartilage. Success of these procedures is widely documented (Weiss 1991, Sundberg 1984, Kinnard 1983, Rock 1991, Armistead 1982), and relief of pain routinely occurs in approximately 90%, with improvement in range of motion and strength. The primary complication of ulnar lengthening is non-union (15% in Armistead's study). Excessive radial shortening is the primary complication in the radial shortening procedure, according to Nakamura (1990), this occurs if the radius is shortened > 4mm, and results in ulnar wrist pain. All authors warn that in late stages of Kienbock's disease, especially with carpal arthritis, joint leveling procedures may not be effective at relieving pain and a salvage procedure may be more appropriate
Other methods of decompressing the lunate include scaphotrapeziotrapezoidal (STT) fusion, capitohamate fusion, scaphocapitate fusion and capitate recession. Biomechanical studies indicate that decompression is greatest with a joint leveling procedure, and that STT and SC fusions are more effective that capitohammate fusion (Trumble 1986, Horii, 1990). Short (1992) demonstrated that STT fusion is more effective in unloading the lunate if the scaphoid is fused in neutral or slight extension. Watson (1985) and Voche (1992) have both demonstrated good symptomatic relief with STT fusion.
Proximal row carpectomy has been used with limited success in Kienbock's disease (Inoue 1990, Ferlic 1991). Lunate excision is the oldest treatment for Kienbock's disease, and although carpal collapse occurs, the patients have good relief from pain and reasonably good function (Kawai 1988). More recently this void is being filled with a coiled tendon (anchovi) or silicone implant. Results of this procedure are not well established (Kato 1986, Ishiguro 1984).
Radial wedge osteotomy (Nakamura 1991) demonstrated satisfactory results, with good relief of pain and increase in range of motion and strenqth.
Although early success was demonstrated with silicone
replacement arthroplasty (SRA) (Lichtman 1977), silicone synovitis
and carpal collapse in a high percentage of long term follow-up patients
make this choice less appealing (Alexander 1990, Evans 1986,
O'Flanagan 1992).
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