What is the initial treatment for Kienbock's disease of the hand?

Initial Treatment for Kienbock's Disease of the Hand

The initial treatment for Kienbock's disease of the hand should be conservative management with wrist immobilization, rest, ice, elevation, and anti-inflammatory medications, particularly for early-stage disease (Stage I). 1

Diagnosis and Staging

Before initiating treatment, proper diagnosis and staging are essential:

1. Initial Imaging:

   • Plain radiographs are the first-line imaging modality 2, 1
   • May be normal in early stages (Stage I)

2. Confirmatory Imaging:

   • MRI without contrast is the gold standard when lunate necrosis is suspected 2, 1
   • CT without contrast may be appropriate to assess carpal collapse and bone fragments 1

3. Staging (Modified Lichtman classification):

   • Stage I: Normal radiographs but MRI shows changes
   • Stage II: Sclerosis of lunate visible on radiographs
   • Stage III: Lunate collapse (IIIA: without carpal instability; IIIB: with carpal instability)
   • Stage IV: Degenerative changes in radiocarpal or midcarpal joints 3

Treatment Algorithm

Stage I (Early Disease)

• First-line treatment:
  • Wrist immobilization with splint or cast for 6-12 weeks 1, 4
  • Rest, ice, elevation
  • Anti-inflammatory medications (NSAIDs) 4, 5
  • Consider vitamin C supplementation 1

Stage II

• If conservative treatment fails:
  • For negative ulnar variance: Radial shortening osteotomy or ulnar lengthening 4, 6
  • For neutral/positive ulnar variance: Capitate shortening or radial wedge osteotomy 6
  • Consider revascularization procedures 4, 3

Stage III

• IIIA (without carpal instability):

  • Joint-preserving procedures similar to Stage II 1, 3
  • Vascularized bone grafting 6, 3

• IIIB (with carpal instability):

  • Limited intercarpal arthrodesis (scaphotrapeziotrapezoid or scaphocapitate) 3
  • Replacement arthroplasty 4

Stage IV

• Salvage procedures:
  • Proximal row carpectomy 3
  • Wrist arthrodesis (fusion) 4, 3
  • Consider total wrist arthroplasty in select cases 6

Important Considerations

• Age factors: Patients under 20 years may respond better to conservative management with prolonged immobilization 1
• Ulnar variance is a key factor in selecting the appropriate surgical procedure if conservative treatment fails 1, 6
• Regular monitoring for disease progression is crucial, including worsening pain or decreased range of motion 1
• Early diagnosis and treatment are essential to prevent progression to advanced stages with irreversible collapse 1

Pitfalls to Avoid

• Delayed diagnosis can lead to irreversible lunate collapse and advanced arthritis 1
• Premature return to activities can worsen collapse and necrosis 1
• Inadequate pain management may lead to chronic pain syndromes 1
• Relying solely on radiographs for early diagnosis, as they may appear normal in Stage I 2, 1

The most recent evidence emphasizes that while the etiology of Kienbock's disease remains unclear, the goal of treatment is to decompress the lunate and shield it from shear and compression loads, allowing time for biological healing to occur 5.