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Pain in the right wrist

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Q1: Describe the radiographic features in figs 1, 2, and 3 (see p 433)

The radiographs of the right wrist show progressive sclerosis and fragmentation of the lunate bone.

Q2: What is the clinical diagnosis? What investigation would have helped clinch the diagnosis at the first presentation

The radiographic progression is classical of idiopathic avascular necrosis of the lunate: Kienböck's disease. A bone scan or magnetic resonance imaging at the first presentation would have been valuable in clinching the diagnosis.

Q3: What would be your line of management for this patient? Rationalise your answer

As collapse of the lunate has occurred, surgical procedures are ineffective in realigning the ulna. Management at this stage usually involves replacement of the lunate with a titanium implant1 or arthrodesis of the wrist.

Discussion

Kienböck's disease occurs typically in young adults. Recognised predisposing factors include local trauma and a relatively shortened ulna (negative ulnar variance). The latter predisposes the lunate compression to against the distal radius.2 The patient classically complains of pain and weakness of the affected wrist. Examination usually reveals a localised area of tenderness corresponding to the lunate and a significant reduction in grip strength. In later stages of the disease, wrist movements are markedly reduced. Based on the clinical and radiographic features four stages of the disease have been identified (see table1).

Table 1

Four stages of Kienböck's disease

Final diagnosis

Advanced Kienböck's disease of the right lunate.

References

Figure 1

Radiograph showing titanium implant.

View Abstract

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