12.11.

2 WRIST - KIENBCKS DISEASE AND ULNAR VARIANCE

= Lunatomalacia 1910 (& Peste 1843)
=AVASCULAR NECROSIS OF THE MAJOR SEGMENT (DORSAL POLE) OF THE
LUNATE
Presentation
Painful stiff swollen wrist
Young active adult
M:F 3:1
Unilateral Dominant
May be due to a stress fracture that leads to devascularization of the
major segment of the lunate if the lunate is supplied by one volar vessel
Assoc ulnar minus variance get more shear on volar blood supply
23% normal and 78% Kienbocks have ulnar negative variance
Diagnosis
X-ray (late)
CT
MRI
Bone Scan early (NB- normal activity around radial and ulnar growth
plates)
STAHL, 1947 Radiological Staging
0 MRI +ve, X-ray ve.
I Radiolucent Line = compression #
II Demineralisation around # (<3/12)
IIIa Sclerosis of dorsal pole carpal height normal
IIIb Fragmentation and flattening carpal height reduced
IV wrist arthrosis, fragmented lunate and proximal migration of the
capitate.
Treatment Options
Clinical stage v Rx (Lichtman)
I +ve bone scan normal x-ray = immobilise
II sclerotic x-ray = radial shortening to get neutral variance
III lunate collapse x-ray = short radius + resect lunate tendon
interposition
IV carpal arthritis = proximal row carpectomy or wrist fusion
Operations
Stage 1 - Foucher, 1988, says try conservative management first always
Stage 2/3a
o
Equalisation - Radial shortening (easier than ulnar lengthening), do
not interfere with ROM or decompression or carpal stabilisation
o Four Corner fusion, Triscaphe (STT) fusion, Lunate revascularisation
(vascularised pisiform/radius/vascular bundle dorsal MC artery
with or without bone graft)
Stage 3b
o Excision Arthroplasty simple lunate excision/anchovy (coiled
tendon)/STT fusion/ Graner operation (SLC fusion)
Stage 4
o Proximal Row carpectomy
o Wrist fusion

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Natural history
Most will get worse x-rays, but not necessarily worse symptoms
If had bad symptoms to start with wont get better with non operative
treatment.
ULNAR VARIANCE (HULTENS variance )

Horizontal line drawn from the junction of the distal articular surface and
sigmoid notch of the radius (the curve that articulates with the ulna)

+ve variance = ulnar head above this line ulnar impingement syndrome
-ve variance = ulnar head above this line Kienbocks disease, SL
dislocation
Neutral = normal ulnar head level

Ulna zero = same length

Ulna plus ulna 1-5 mm longer
Ulna minus ulna 1 to 6 mm shorter

Independent of the styloid length

Measurement affected by forearm rotation, wrist position, grip loading.

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/var/www/apps/conversion/tmp/scratch_5/190993170.doc

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