What is the treatment for Keinbock's disease?

Treatment of Kienbock's Disease

Conservative management with wrist immobilization, rest, ice, elevation, and anti-inflammatory medications is the first-line treatment for early-stage Kienbock's disease. 1

Diagnosis

Before discussing treatment options, proper diagnosis is essential:

• Plain radiographs are the first-line imaging modality, but may appear normal in early Stage I disease 1
• MRI without contrast is the gold standard for diagnosing lunate necrosis and can detect changes even when radiographs are normal 1
• The Modified Lichtman classification is used for staging:
  • Stage I: Normal radiographs but MRI shows changes
  • Stage II: Sclerosis of lunate, early compression fracture
  • Stage III: Lunate collapse (IIIA: without carpal instability; IIIB: with carpal instability)
  • Stage IV: Degenerative changes in radiocarpal or midcarpal joints 1, 2

Treatment Algorithm Based on Disease Stage

Stage I

• Conservative management is the treatment of choice 1, 3
  • Wrist immobilization (splint or cast)
  • Rest, ice, elevation
  • Anti-inflammatory medications
  • Duration: 3-6 months

Stage II

• For negative ulnar variance:

  • Radial shortening osteotomy or ulnar lengthening 1, 3, 2
  • May be combined with revascularization procedures 3

• For neutral/positive ulnar variance:

  • Capitate shortening or radial wedge osteotomy 1, 2
  • Direct revascularization with vascularized bone grafting may be attempted 2

Stage IIIA

• Similar options as Stage II, but with greater emphasis on surgical intervention:
  • Radial shortening (negative ulnar variance)
  • Capitate shortening (neutral/positive ulnar variance)
  • Vascularized bone grafting 2, 4

Stage IIIB

• Procedures to address carpal collapse:
  • Scaphotrapeziotrapezoid or scaphocapitate arthrodesis to correct scaphoid hyperflexion 2
  • Vascularized pedicled scaphoid graft combined with partial radioscaphoid arthrodesis 4

Stage IV

• Salvage procedures:
  • Proximal row carpectomy 3, 2
  • Wrist arthrodesis (fusion) 3, 2, 4
  • Total wrist arthroplasty 4
  • Pyrocarbon lunate arthroplasty (for younger patients) 5

Age Considerations

• Patients under 20 years: Conservative management with prolonged immobilization is often sufficient 1
• Adult patients: More likely to require surgical intervention based on stage 1

Monitoring and Follow-up

• Regular assessment for signs of progression (worsening pain, decreased range of motion)
• Evaluate for development of carpal instability or wrist arthritis
• Follow-up imaging to monitor lunate status and carpal alignment 1

Important Considerations

• Delayed diagnosis can lead to irreversible collapse and advanced arthritis
• The underlying cause of Kienbock's disease remains unclear, but likely involves vascular compromise to the lunate 6
• Decompression osteotomies don't heal the necrosis but protect the lunate from collapse, providing time for biological healing 6
• Currently, there are no effective biological treatments 6

The treatment approach should be guided by disease stage, ulnar variance, patient age, and functional demands, with early intervention being critical to prevent progression to advanced stages with irreversible changes.