Kienbock’s Disease

Kienbock’s Disease
January 28, 2016

Having been passionately dedicated to his profession for past 25 years, Dr. Gupta a renowned name in the field of shoulder and upper extremity region stresses, “Kienbocks disease is a rare disease that happens usually in your working hand. It is an occurrence due to clinical failure of lunate bone in your wrist.”

Kienbock_Fig1Explaining about the disease in simple terms he says, “There are eight bones in your hand called carpal bones. One of them is lunate which contributes to the movement of the wrist. When blood supply starts to reach this bone insufficiently it becomes damaged or dead making the wrist lose its motion and become painful.”

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Successfully having operated on more than 6000 patients with complex cases Dr. Vikas speaks about this complicated disease with an ease and points out, “Unlike other diseases, in Kienbock’s the condition of your wrist slowly deteriorates and becomes intense so consulting a doctor at an early stage of the disease is advisory to stop further damage to the lunate. The symptoms of Kienbock’s disease can be co-related to pain, tenderness and difficulty in movement of the wrist. As the damage to the lunate increases so does a clunking sound in your wrist as the lunate has broken into fragments inside which make noise when trying to move.”

Dr. Vikas performing surgical treatment on wrists affected by Kienbock’s disease since 1999 as one of the most skillful and efficient surgeons in India while talking about the underlying causes of the disease eminently says, “It is difficult to determine the exact causes of the disease but invariably lack of blood supply to the lunate by arteries or pressure on it by length difference in ulna and radius bone, leads to the disease.”

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In terms of Dr. Gupta, Head, Shoulder and Hand Division, MAX Saket & Gurgaon, former Director ‘The Hand & Upper Extremity Surgery’ at The Medanta Institute of Bone & Joint Disease, Gurgaon, “Diagnosing the disease is not easy as damage to lunate is not visible in the initial X-ray. What it portrays is a possibility of sprain or fracture of your wrist. It is only with supported MRI scan and CT scan that the disease is uncovered and with certain physical examinations and questionnaire we decide the treatment option that is best suited for the patient.”

Being one of the first surgeons in India to use 4, 5 ICRSA vascularised bone graft for Kienbock’s disease Dr. Gupta believes that, “Patients with Kienbock’s disease have to take note of the fact that one type of surgical treatment is not sufficient to relieve them of their pain. Kienbock’s disease is complex yet with skill and expertise by the related surgeon it can be efficiently treated. Usually we perform more than one surgical treatment on patients as the disease progresses to relieve them of their pain and bring back movement in their wrists. Revascularization, joint leveling, proximal row carpectomy are some of the few surgical methods that we perform.”

“All I will say regarding complexities in Kienbock’s disease is that it should be handled by an expert surgeon because any carelessness in treatment can leave you impaired as regards wrist motion”, concludes Dr. Gupta.

FAQ – Kienbock’s Disease

Out of the eight small bones in your wrist called carpal bones, there is a small bone lunate. When blood supply to lunate gets interrupted due to any reason, you are said to be having Kienbock’s disease or avascular necrosis.
Lunate is one of the carpal bones that assist in the movement of the wrist. Bone requires continuous blood supply to survive as it is a living tissue. When it does not get regular supply it becomes inactive thus impairing all functions that are done by it. Clinically lunate also becomes dead when blood supply to it is hindered being called as ‘osteonecrosis of the lunate.’ Damaged lunate causes the wrist to become stiff and painful.

Exact causes of Keinbock’s disease are still to be determined by the doctors but there are many indirect factors which trigger it off.

  • An injury to your wrist because of a fall or sprain might disrupt blood supply to lunate thus causing the disease.
  • Sometimes ulna is shorter in length than the radius bone in the forearm and this exerts more pressure uponlunate to do certain wrist motions which could lead to the disease.
  • If there is a problem with either the blood supply source i.e. the arteries or blood drainage source i.e. veins, lunate will not get adequate supply of blood thus resulting in the disease.
Initially you will feel that you have sprained your wrist as there will be mild swelling but as symptoms become severe Keinbock’s disease might be suspected. The most common signs that indicate towards the disease are-
  • Painful, swollen and stiff wrist which makes movement difficult
  • Weakening in grip strength
  • Soreness just above lunate bone
  • Pain while moving hand in the upward direction
  • An unusual clunking sound in the wrist
Keinbock’s disease is a disease with which you can live for several months before you feel the pain and condition to have deteriorated so severely that you consult a doctor. This disease passes through four stages of progression-

STAGE1: In this stage the mild pain in the wrist suggests either a wrist sprain or a possibility of fracture as there are no other visible symptoms.

STAGE2: In this stage the lack of blood supply to lunate makes it hard and the wrist becomes painful, swollen and tender on touch.

STAGE3: Stage 3 makes the pain in the wrist severely intense, limits movement and weakens the grip strength of the wrist as the lunate starts to shatter and collapse in this stage.

STAGE4: Stage 4 is the stage where the lunate is clinically completely dead and the bones around it also start deteriorating leading to arthritis.

Initially it is difficult to co relate between your wrist pain and Keinbock’s disease. Your doctor will do a physical examination of your wrist and ask you some related questions. Thereafter he will recommend X-ray, MRI and CT scan of your wrist to determine the exact damage to the lunate.
Treatment of the disease depends upon the stage where the disease is when diagnosed by the doctor.

NON SURGICAL TREATMENTS: under this treatment option your doctor might help relieve your wrist pain by anti inflammatory medicines, injections, putting your wrist in a cast or splint for appropriate weeks to give it rest which will help blood flow back to lunate and physical therapy to assist in learning movements that put less pressure on wrist. In spite of all above medications and therapy if you are not relieved of your pain and do not restore your wrist movement, the doctor will opt for surgical treatment.

SURGICAL TREATMENTS: There are various surgical methods to treat Kienbock’s disease and which option is decided upon by your doctor depends on many factors.

REVASCULARIZATION: This treatment option is adopted by the surgeon during stage 1 or 2 of the disease before the lunate is completely damaged. Under this method, your surgeon performs ‘vascularized graft’ which means that he takes out a portion of bone along with its blood vessels from some other bone of the body and inserts it into your lunate bone to bring back the flow of blood. After that he may fix your bones together by a temporary external fixator ( instrument made of metal which is attached on your wrist from outside end with pins that go down into your lunate bone) to help them heal.

JOINT LEVELING: This method is adopted when the disease occurs because of difference in length of ulna and radius. The surgeon levels the bones to bring them to equal lengths by either using a bone graft to lengthen the bone or shorten it by removing the required section from it. This helps to relieve the excess pressure that the lunate bone had to exert thus putting on hold further deterioration of the bone.

PROXIMAL ROW CARPECTOMY: When the lunate is severely damaged or broken then your surgeon might remove it along with the two bones on either side, under this procedure. It will help you to regain partial wrist movement and relieve you of pain.

FUSION: depending upon the extent of damage your surgeon might go in for partial or complete fusion. In partial fusion some bones of your wrist are fused together to make them one big solid bone to relieve pain and provide wrist motion. In case of arthritis your surgeon might fuse all your wrist bones together. This procedure of complete fusion will help you relieve your pain, help in movement of your forearm but will not be able to restore your wrist movement.

IMPLANT ARTHROPLASTY: Under this relatively new method, a prosthetic replica of lunate is made from pyrolytic carbon material and is implanted in place of the original one. It helps other bones to preserve their normal functioning and helps in wrist movement.

If this disease is left untreated it will slowly result in complete loss of wrist functioning as well as lifetime pain. After treatment the wrist will never regain complete motion but partial wrist movement will be restored and it will not get damaged further.
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