Your wrist is made up of many smaller bones and joints that allow your hand to move in several directions. It also includes the ends of the arm bones.
The hand includes eight carpals. These small bones comprise the wrist area between the bones of the forearm and the phalanges, or fingers, of the hand. The lunate is one of these eight carpal bones. These carpals are arranged in two rows, and the lunate is located in the row closest to the radius and ulna. The lunate touches four other carpal bones, which are the scaphoid, the capitate, the hamate, and the triquetral bones.
Kienbock’s disease is a rare and debilitating condition that can lead to chronic pain and dysfunction. It occurs when one of the eight small carpal bones in the wrist, the lunate bone, becomes damaged because there isn’t any blood supply. It is also known as avascular necrosis of the lunate or osteonecrosis of the lunate bone. If blood supply is suddenly cut off to body tissue, oxygen and nutrients cannot reach the tissue, and it will die. This is the meaning of necrosis.
Causes & Symptoms
The general cause of Kienbock’s disease remains unknown. Many patients with Kienbock’s disease think they have a sprained wrist in the earliest phases of the condition. They may have experienced some form of trauma to the wrist, such as a fall. This type of trauma can disrupt the blood flow to the lunate. In addition, some things may put you more at risk for Kienbock’s disease. For instance, most people have two vessels that supply blood to the lunate, but in some people, there’s only one source. Therefore, this may slow the blood flow to the bone. Furthermore, if the two bones of the forearm (the radius and ulna) are different lengths, extra pressure can be put on the lunate during some wrist motions. Over time, this extra stress on the bone may lead to Kienbock’s disease.
As already mentioned, the carpal bones consist of eight wrist bones that connect the hand to the forearm. These are the bones that make flexible positioning of the hand possible. The lunate bone is crucial for proper movement and support of the joint. Damage to this bone can lead to stiffness and pain and eventually arthritis of the wrist. In the early stages of Kienbock’s disease, the patient might experience pain and swelling, similar to a wrist sprain, however, unlike a sprain, the symptoms will persist and worsen. The progression of Kienbock’s disease varies between patients, but it tends to develop slowly and subtly over a number of years. In time, the mechanics of the wrist become affected, leading to abnormal stress and wear inside the wrist.
There are a total of four stages of Kienbock’s disease, such as the following below:
- Stage 1 – The lunate loses its blood supply. The bone may appear normal in an X-ray but may show changes on an MRI test. There may be a pain, swelling, and a risk of a fracture.
- Stage 2 – X-rays show that the bone is unusually dense. However, when bone loses its blood supply, it hardens.
- Stage 3 – The bone starts to fragment and collapse.
- Stage 4 – The lunate has completely collapsed, and nearby bones have also become damaged and arthritic.
Other common signs and symptoms associated with Kienbock’s disease include the following below:
- Clicking or clunking inside the affected wrist.
- Weakening of grip strength.
- Having trouble when turning the hand upward, thus causing pain.
- Swelling, pain, and stiffness in the wrist.
Who gets Kienbock’s Disease?
Certain risk factors associated with Kienbock’s disease include:
- Age – Kienbock’s disease is most common in men between the ages of 20 and 40.
- Gender – Females are less prone to developing this disease rather than males.
- One blood vessel supplying blood – Normally, many people have two blood vessels supplying blood to the lunate. However, having only one blood vessel performing that function can increase the risk of developing Kienbock’s disease.
- Differences in the length and shape of your forearm bone – If the ulna is much shorter than the radial bone, it may exert pressure on the lunate which may lead to Kienbock’s disease.
How Does it Affect You? How Serious is it?
In most severe cases, Kienbock’s disease can be associated alongside with many other complications that can worsen your symptoms, such as the following:
- Lupus – Lupus is a long-term autoimmune disease; in this condition, the immune system becomes hyperactive and attacks normal, healthy tissues. Lupus is often associated with Kienbock’s disease.
- Scapholunate dissociation – It is also known as rotary subluxation of the scaphoid. It is an abnormal orientation of the scaphoid, relative to the lunate, and implies severe injury to the scapholunate interosseous ligament and other stabilizing ligaments.
- Sickle cell anemia – Sickle cell anemia is an inherited red blood cell disorder. In this disorder, there are not enough healthy red blood cells in the blood that can carry oxygen throughout the body.
- Cerebral palsy – It is a group of disorders that affect movement and or posture. It’s caused by damage that occurs to the immature brain.
Recommended Treatment & Rehabilitation
Most patients who have Kienbock’s disease live with the condition for months or years until the symptoms become problematic, and they seek help. The doctor will begin by asking about your symptoms, medical history, previous trauma, and how long the person has had the symptoms. They will also examine the hand and wrist. Kienbock’s disease may be difficult to diagnose accurately in the early stages, because the signs and symptoms resemble those of many other conditions, such as wrist sprain and any cause of arthritis.
Therefore, during stage 1, an X-ray will show an apparently normal lunate bone, but an MRI scan can help to assess the blood supply to the lunate. In the later stages of Kienbock’s disease, an X-ray will reveal the damage, and a CT scan may be able to determine the number and sizes of the bone fragments.
Physiotherapy is a highly effective treatment for Kienbock’s disease. You will work with a physiotherapist to devise a treatment plan that is specific to your condition and goals. Some of these treatments include:
- Pain management – Your physiotherapist will help you identify and avoid painful movements and show you how to correct abnormal postures to reduce stress on the wrist. Your therapist may recommend resting the wrist short-term and applying ice to the area to help alleviate pain. Your physiotherapist may also apply a wrist brace to restrict wrist movement, allowing the tendons to heal.
- Manual therapy – Your physiotherapist may use hand-on techniques, such as gentle joint movements, soft-tissue massage, and wrist stretches to get your wrist moving properly.
- Range-of-motion exercises – You will learn certain exercises and stretches to help reduce stiffness and help your wrist, hand, and forearm begin to move properly.
- Strengthening exercises – Your physiotherapist will determine which strengthening exercises are right for you, depending on your specific areas of weakness. The entire arm, including the shoulder, elbow, and wrist, can potentially be weakened and contribute to the movement dysfunction that causes Kienbock’s disease. Your physiotherapist will design an individualized home-exercise program to meet your specific needs and goals, which you can continue long after you have completed your main physiotherapy session.
- Patient education – Depending on the specific activities you plan on resuming, your physiotherapist will teach you ways to perform actions, while protecting your wrist and hand. For example, keeping the wrist in a neutral position to reduce excessive force while performing repetitive tasks, and taking frequent breaks are ways to decrease your chances of reinjury.
- Functional training – As your symptoms improve, your physiotherapist will teach you how to correctly perform functional movement patterns using proper wrist mechanics, such as typing on a computer or swinging a racquet. This training will help you return to pain-free function on the job, at home, and when playing sports.
There are several surgical options for treating Kienbock’s disease. The choice of procedure will depend on how far advanced the disease is. Additional factors your healthcare provider will consider are; your personal goals, your activity level, and your surgeon’s expertise. The following surgical procedures include:
- Lunate excision – This surgery removes the problem bone. To prevent slipping by the missing lunate bone, the surgeon will set an artificial bone in the place of the removed lunate.
- Joint leveling – If Kienbock’s disease is the result of uneven bones in the forearm, joint leveling might be an option. By shortening or lengthening the forearm, the surgeon helps to put the forearm bones at a healthy ratio to one another. Afterward, there is little pressure on the wrist, and disease progression stops.
- Intercarpal fusion – This surgical procedure is typically done in the late stages of the disease to join the lunate to the carpal bone. The procedure may be combined with a revascularization procedure.
- Revascularization – This procedure, which involves surgically sliding blood vessels from another part of the wrist to over the lunate, is a common procedure done in the early stages of Kienbock’s disease.
- Proximal row carpectomy – In the fourth stage of Kienbock’s disease, the collapsed lunate bone begins causing arthritis throughout the entire wrist. With a proximal row carpectomy, the surgeon will remove four of the eight bones in the wrist joint, making room for the wrist to regain its stability. While this surgery can cause some wrist strength loss, it will still relieve wrist pain and maintain a range of motion.
Generally, wrist exercises increase flexibility and help lower the risk of injury. Stretches are recommended as a preventive measure or to ease slight pain. Therefore, here are some exercise examples that can improve symptoms of stage 1 Kienbock’s disease:
Extend your arm with your palm facing up toward the ceiling. Next, with your free hand, gently press your fingers down toward the floor. Gently pull your fingers back toward your body, then hold for 10-30 seconds. Repeat this method 2-3 times a day.
While seated, place your open hands on your thighs with palms up. Close your hands slowly into fists without clenching too tightly. With your forearms touching your legs, raise your fists off of your legs and back toward your body, bending at the wrist. Hold this position for 10 seconds, then lower fists and slowly open your fingers wide. Repeat this exercise 10 times a day.
While seated, place your palms face up under a desk or table. Press upwards against the bottom of a desk. Hold this position for 5-10 seconds before repeating 10 times a day.
Alternative & Homeopathic Treatment
There are various amounts of homeopathic treatments that can strongly help improve symptoms associated with Kienbock’s disease, such as:
- Rest – Rest the affected hand and wrist for at least 2 weeks to recover rapidly to stage 1 of Kienbock’s disease.
- Non-steroidal anti-inflammatory drugs (NSAIDs) – It is recommended to take over-the-counter pain relievers, such as ibuprofen or naproxen, to help relieve pain and swelling.
- Heat application – Apply heat to the wrist to help reduce pain and increase blood circulation.
- Ice application – Using an ice pack, which can also help decrease swelling.