|3475 Torrance Blvd., Ste F
Torrance, CA 90503
Office hours: M-F, 9am
– 5 pm
Worker’s compensation, Medicare
and most insurance plans accepted.
In September 2008, we will be moving to a beautiful new 4,400 sq ft,
state of the art dedicated hand center located at 2808 Columbia Ave
in Torrance, CA., which will feature onsite nerve conduction studies,
occupational hand therapy and digital x-ray.
KIENBOCKS AND PREISERS DISEASE
A loss of the blood supply or avascular necrosis of a wrist or carpal
bone can result in gradual collapse of the bone followed by progressive
wrist arthritis. The lunate is the most commonly affected bone. This condition
is termed Kienböck’s disease. The scaphoid may also be involved,
which is termed Preiser’s disease, but this is much less common.
Kienböck was a radiologist who in 1910, directed attention to a condition
that resulted in softening of and collapse of the lunate. The etiology
of this condition has been debated ever since, despite the wealth of knowledge
that has accumulated. There is a consensus that the changes in the lunate
are due to loss of it’s blood supply, or avascular necrosis. Various
authors are divided as to whether the inciting event consists of a single
transverse fracture of the lunate v.s. numerous compression fractures
from repeated compressive strains. Due to the tenuous blood supply of
the lunate it becomes avascular, setting up a sequence of events that
are marked by collapse of and fragmentation of the lunate. As this occurs,
the smooth articular surfaces of the lunate become irregular. The capitate,
which articulates with the distal surface of the lunate, settles down
into the newly created space. This ultimately leads to the development
of scapholunate dissociation and progressive radiocarpal and midcarpal
Most patients present with the gradual onset of wrist pain with no obvious
history of trauma. The pain is mechanical in nature in that it is precipitated
by activity and is temporarily relieved by rest in the early phases. It
is more common in men between the 2nd and 4th decades, but can occur in
women and the elderly. Many patients are engaged in heavy manual labor.
The wrist examination may show thickening of the capsule over the lunate,
along with diminished wrist motion, localized carpal tenderness and reduced
grip strengths. Occasionally the symptoms of carpal tunnel syndrome may
be present. Patients who develop Kienböck’s often have an increased
incidence of a relatively longer radius as compared to the ulna on an
AP wrist x-ray, i.e. a negative ulnar variance, when compared to the general
The diagnosis is established by various imaging techniques. The disease
has been classified into four stages. Stage I, is the acute stage, and
is indistinguishable from a wrist sprain. X-rays are normal except for
the possibility of a linear or compression fracture that may show up on
tomography. An MRI may be diagnostic and can show a loss of bone marrow
fat. This finding is not necessarily specific to avascular necrosis, but
is significant if it involves more than _ of the lunate. Bone scans may
show an increased uptake in the lunate. Stage II is present when there
is increased density of the lunate which causes it to appear whiter than
the surrounding carpal bones, but without collapse. Stage III shows lunate
collapse with proximal migration of the capitate. There may be fragmentation
of the lunate. Advanced stage III is present when there is associated
scapholunate dissociation (link to kienbocks 1-3). Stage IV is present
when there are generalized arthritic changes in the radiocarpal and midcarpal
rows. Arthroscopically one may see a marked loss of joint cartilage with
cartilage fragments hanging down into the joint (link to kienbocks 4).
Wrist immobilization has been attempted by many authors but reports of
unsatisfactory results and progressive collapse of the lunate are common.
Stage I, II and early stage III may be treated with joint leveling procedures
or revascularization procedures. If the patient has an ulnar minus variance,
the forces across the lunate can be diminished by shortening the radius
or lengthening the ulna, so that the ulna bears more of the load across
the wrist. If the patient has an ulna neutral or positive variance, a
capitate shortening osteotomy or a capitohamate fusion without shortening
have been shown to have the same effects biomechanically and clinically.
An alternative approach has been to revascularize the lunate directly.
This can be done by inserting a vascularized bone graft pedicled on the
pronator quadratus muscle, or by transplanting a vascularized bundle into
the lunate. Results in a number of series are encouraging with either
approach. These procedures cannot restore a lunate that has already collapsed,
and they should not be used when carpal instability has occurred. In these
cases, some type of partial wrist fusion is indicated, along with excision
of the lunate and/or replacement with a soft tissue spacer, usually a
rolled up tendon graft. Stage IV is generally managed by either resecting
the 3 carpal bones of the proximal carpal row (i.e. a proximal row carpectomy)
or a partial wrist fusion (link to Kienbocks 5). Both of these procedures
preserve wrist motion to a variable degree. Occasionally, a total wrist
fusion is indicated, especially for manual laborers who may need strength
more than motion. Total wrist arthroplasty is generally not indicated
for young vigorous patients.
No single treatment course has been universally successful. The treatment
must be individualized to the patient’s specific anatomy and needs.
In the early stages, efforts are directed towards salvaging the lunate
and preventing the loss of the normal wrist architecture by altering the
natural course of the disease. In the later stages treatment is directed
towards restoring wrist architecture, and in the end stages the architecture
is sacrificed to restore function.
This is much less common than Kienbocks. It involves partial or complete
involvement of the scaphoid bone (link to Preisers 1,2). There are no
large studies on the treatment of this condition hence a standardized
approach is still lacking. With partial scaphoid bone involvement, resection
of the avascular portion and replacement with a soft tissue spacer such
as freeze dried fascia lata, can provide short term relief (link to Preisers
3-5). Inevitably, radiocarpal arthritis ensues which may require a more
extensive procedure (link to Preisers 6).