a day ago
48-Year-Old's Wrist Pain Reveals Bone Necrosis
A 48-year-old man presented with a 2-year history of oedema and pain in his right hand. Initially diagnosed with tendonitis, he underwent physical therapy which provided limited relief. MRI demonstrated avascular necrosis of the lunate.
The patient underwent surgery and follow-up treatment with home exercises and a structured physiotherapy program; he regained minimal wrist flexion restriction and normal grip strength.
The Patient and His History
In 2018, the patient had a vertebral fracture that resolved without complications. He received physical therapy and anaesthetic injections which provided limited relief. Due to the persistent symptoms, further evaluation was conducted.
Findings and Diagnosis
Physical examination revealed palm ecchymosis, reduced range of motion in both flexion and extension of the right wrist, and diminished grip strength. Imaging studies, including X-rays and MRI, indicated osteosynthesis of the carpal bones and fractures of the scaphoid and lunate bones. Coronal MRI showed diffuse hypointensity and collapse of the lunate.
The patient was diagnosed with avascular necrosis of the semilunar bone of the carpus, Kienböck disease stage IV (according to the Lichtman classification), and carpal arthrofibrosis.
The patient underwent surgical intervention, including scaphoid-lunate fusion with bone grafting, semilunar tendon arthroplasty, and radiocarpal capsulectomy.
Postoperatively, the patient experienced significant improvement, although the chronic pain initially persisted. He underwent a 12-session physical therapy program. No medications for pain were prescribed. After 1-year of home exercises, he achieved almost full range of motion, with minimal wrist flexion restriction and normal grip strength.
Discussion
Kienböck disease, or lunate osteonecrosis, is a debilitating condition that primarily affects the lunate bone in the wrist. It is characterised by avascular necrosis due to an interrupted blood supply, leading to bone death. This rare condition affects approximately 0.0066% of the population, predominantly men aged 20-40 years.
The aetiology of Kienböck disease is largely unknown; however, several contributing factors have been identified. These include repetitive microtrauma, acute wrist injuries, and anatomical variations in the lunate blood supply, which are limited to a few vessels, making it susceptible to ischaemic damage. Systemic conditions, such as lupus or sickle cell disease, that impair blood flow may also play a role.
The pathophysiology begins with an ischaemic event leading to lunate necrosis, followed by changes such as bone fragmentation, collapse, and carpal instability.
Management varies by stage, focusing on pain relief, preservation of wrist function, and prevention of disease progression. Early stages may respond to conservative treatments such as immobilisation, nonsteroidal anti-inflammatory drugs, and physical therapy, but these are often ineffective in advanced stages.
Management requires a tailored approach based on disease stage and individual factors. Early diagnosis is crucial for effective treatment to preserve wrist function and slow disease progression. The authors noted that continued research and advances in imaging are expected to improve both the understanding and management of this condition.
