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Keinbock's Disease M92.299 732.3

 

Keinbock's Disease xray

lunate avn mri

Keinbock's Disease xray

synonyms: avascular necrosis of the lunate.

Keinbock's Disease ICD-10

 

Keinbock's Disease ICD-9

  • 732.3 (Juvenile osteochondrosis of upper extremity: includes carpal lunate-Kienbocks)

Keinbock's Disease Etiology / Epidemiology / Natural History

  • Likely related to overuse and ulnar negative wrist variance.
  • Associated with sickel cell anemia, steriod use, gout, cerebral palsy.
  • Age: 2nd-5th decade.
  • Male > female

Keinbock's Disease Anatomy

  • Lunate blood supply: single nutrient vessel, or poorly organized intraosseous anastamoses.

Keinbock's Disease Clinical Evaluation

  • Dosral wrist pain +/- swelling/warmth
  • Tenderness over the radiolunate joint
  • Decreased ROM.
  • Decreased grip strength

Keinbock's Disease Xray / Diagnositc Tests

  • PA, Lateral, oblique views of the wrist. Generally demonstrate sclerotic lunate. Early films may be normal or minimal sclerosis. Evaluate for ulnocarpal impaction.
  • MRI: demonstrates avascular changes in the lunate.
  • Ct: demonstrates degree of fragmentation and collapse
  • Bone scan diagnostic at 48hrs (100% sensitive, 98%specific)

Keinbock's Disease Classification / Treatment

Lichtman Classification (Lichtman DM, JBJS 59A;899:1977).

  • Stage 1=The lunate appears normal on xray or there may be a nondisplaced fracture; MRI demonstrates loss of signal consistent with osteonecrosis.
    Treatment: spinting, activity modifications, NSAIDs
    Consider ulnar lengthening or radial shortening for patients with negative ulnar variane.
  • Stage 2=Increased lunate radiodensity without loss of contour; lunate not collapsed. Consider Proximal row carpectomy.
    Treatment: 4 + 5 extensor compartmental vascularized bone graft. (Moran CL, J Hand Surg 2005;30A:50).
  • Stage 3A= Increased lunate radiodensity and fragmentation without loss of carpal height.
    Treatment: 4 + 5 extensor compartmental vascularized bone graft. (Moran CL, J Hand Surg 2005;30A:50).
    Consider scaphocapitate arthrodesis, or scaphotrapeziotrapezoid arthrodesis
  • Stage 3B: Lunate fragmentation with proximal migration of the capitate and rotation of the scaphoid.
    Treatment: scaphocapitate arthrodesis, or scaphotrapeziotrapezoid arthrodesis
    Consider Proximal row carpectomy
  • Stage 4=lunate severely collapsed and fragmented, secondary arthritic changes in the wrist.
    Treatment: Proximal row carpectomy.
    Consider: scaphocapitate arthrodesis, and scaphotrapeziotrapezoid arthrodesis.

Keinbock's Disease Associated Injuries / Differential Diagnosis

Keinbock's Disease Complications

  • Degenerative changes in adjacent joints.
  • Stiffness, motion loss.
  • Weakness.
  • CRPS
  • Continued pain.
  • Instability.

Keinbock's Disease Follow-up Care

  • Post-op: Volar splint in neutral, elevation.
  • 7-10 Days: Wound check, short arm cast.
  • 4 Weeks: Cast removed, xray wrist. Start gentle ROM / strengthening exercises. Functional activities. Cock-up wrist splint prn / for light duty work. No heavy manual labor
  • 3 Months:Full activities, may resume manual labor if adequate strength has been achieved.
  • 6 Months:
  • 1Yr: fo,,ow-up xrays, assess outcome

Keinbock's Disease Review References

  • Weiss AP, Weiland AJ, Moore JR, Wilgis EF: Radial shortening for Kienbock's disease. J Bone Joint Surg Am 1991;73:384-391.
  • Morgan WJ, JAAOS 2001;9:389

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