26 year old female presenting with pain and weakness in the left wrist.
This 26 year old female presented with pain and weakness affecting the left wrist. On questioning she recalled injuring her wrist aged 17 which had swelled at the time and left her with ongoing symptoms of pain and progressive loss of strength. On examination there was tenderness localised to the area of the lunate dorsally and marked weakness of grip. Plain radiographs of the wrist were performed.
First described by Robert Kienbock in his classic description of lunatomalacia in 1910, Kienbock's disease is a radiographical diagnosis based on characteristic radiograph density changes in the lunate. Increased density is later followed by fracture lines, fragmentation and collapse. The exact cause is unknown, although it is thought to be due to repeated stress or an acute fracture that leads to interruption of blood supply in a susceptible or "at-risk" lunate. A history of trauma is often described by the patient, although this is frequently absent. The condition may be suspected in cases of pain and stiffness of the wrist with tenderness localised to the lunate dorsally. As well as tenderness, there is limitation of movement and often striking weakness of grip. The diagnosis is usually made by plain x-rays, although an MRI or bone scan may pick up earlier disease, and these should be considered in patients presenting with wrist pain localised to the region of the lunate but with negative X-rays. Kienbock's disease can be staged as follows: Stage I: Linear or compression fracture, otherwise normal architecture and density. Bone scan shows increased uptake around the lunate, MRI shows loss of signal on T1-weighted images. Stage II: Density is abnormal (definite increase relative to other carpal bones), without lunate or carpal collapse. Stage IIIA: Lunate collapse, without carpal collapse/ fixed scaphoid rotation. Stage IIIB: Lunate collapse accompanied by carpal collapse/ fixed scaphoid rotation. Stage IV: As per stage III, plus generalised carpal degenerative arthritis. The precise pathogenesis and natural history of Kienbock's disease are still undetermined, and there are many treatment options ranging from observation to complex surgical reconstruction. Whilst it is possible for progression of the disease to arrest at any stage and for revascularisation to occur spontaneously, most cases continue to progress over time and result in carpal instability and arthritis. The treatment of choice for Stage I disease is immobilisation, either in plaster or with the application of an external fixator. Currently the most popular surgical treatment for stage II Kienbock's disease with ulnar-minus variance remains one of the joint leveling procedures, either radial shortening or ulnar lengthening, which have the effect of unloading the lunate, allowing possible revascularisation. With an ulnar positive or neutral variance, a lunate revascularisation procedure is indicated. With Stage III disease limited intercarpal fusion is indicated to restore stability and to prevent further degeneration, whilst with Stage IV disease salvage operations may be indicated, such as proximal row carpectomy and wrist arthrodesis, although the choice of procedure depends on the needs of the patient and the integrity of the articular surfaces of the lunate fossa and the capitate.
Kienbock's disease
From the provided posteroanterior (PA) wrist X-ray, the following can be observed:
Considering the patient’s age, clinical symptoms (left wrist pain and decreased grip strength), the X-ray findings of increased lunate density, and mild contour alterations, the most likely diagnosis is:
Kienböck’s Disease (Avascular Necrosis of the Lunate), likely in an early to intermediate stage (between Stage II and IIIA)
For more precise staging, further evaluations such as MRI or bone scanning are advised to assess lunate vascular supply, fracture lines, and soft tissue changes.
Given that the patient is young and appears to be in an early stage of Kienböck’s disease, the following approaches can be considered:
For patients who fail conservative treatment or show progression of disease:
After immobilization is discontinued or when pain subsides, a gradual exercise regimen is essential to maintain or restore wrist joint flexibility and muscle strength:
Closely monitor pain levels and any swelling during rehabilitation. If symptoms worsen, seek medical evaluation promptly, and adjust the rehabilitation plan as necessary.
This report provides a reference analysis based on the current radiological and clinical history. It does not replace an in-person medical consultation or professional medical opinion. Specific treatment plans should be determined by a specialist after comprehensive evaluation, including any further necessary investigations.
Kienbock's disease
