Kienböck’s Disease

Bone is living tissue that requires a regular supply of blood for nourishment. If the blood supply to a bone stops, the bone can die, a condition known as osteonecrosis. That’s what happens in Kienböck’s disease, which affects the lunate, one of the small bones of the hand near the wrist.

Kienböck’s Disease: Signs and Symptoms

The cause of Kienböck’s disease is unknown. Many people with Kienböck’s disease think they have a sprained wrist at first. 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 most people, two vessels supply blood to the lunate, but in some people there is only one source. This puts them at greater risk for developing the disease.

As the disease progresses, other signs and symptoms are noted, including:

  • A painful and sometimes swollen wrist
  • Limited range of motion in the affected wrist (stiffness)
  • Decreased grip strength in the hand
  • Tenderness directly over the bone (on the top of the hand at about the middle of the wrist)
  • Pain or difficulty in turning the hand upward

Progression

Kienböck’s disease follows a specific progressive pattern through four stages.

  • Stage 1: Symptoms are similar to those of a wrist sprain. X-rays may be normal or show a line indicating a possible fracture. Magnetic resonance imaging (MRI) may also be helpful in making the diagnosis in this early stage.
  • Stage 2: The lunate bone begins to harden. On an X-ray, it may appear brighter or whiter than the surrounding bones. These changes indicate that the bone is dying. Either an MRI or a computed tomography (CT) scan may be used to assess the condition of the bone. Recurrent pain, swelling and wrist tenderness are common.
  • Stage 3: The dead bone begins to collapse and break into pieces. The surrounding bones may begin to shift position. Patients experience increasing pain, weakness in gripping, and limited motion.
  • Stage 4: The surfaces of adjoining bones are affected, resulting in arthritis of the wrist.

Diagnosis and treatment
In its early stages, Kienböck’s disease may be difficult to diagnose because the symptoms are so similar to those of a sprained wrist. Even X-rays of the wrist may appear normal. At this point, the goal of treatment is to relieve the pressure on the lunate and help restore blood flow within the bone. Your physician may splint or cast your wrist for two to three weeks.

Anti-inflammatory medications such as aspirin or ibuprofen will help relieve any pain and reduce swelling. If the pain continues, your physician may refer you to an orthopaedic or hand surgeon for further evaluation.

Surgical options
Although there is no cure, there are several surgical options for treating the more advanced stages of Kienböck’s disease. The right procedure for you will depend on several factors, including disease progression, your personal activity levels and goals and your surgeon’s experience with various procedures.

Do not hesitate to discuss these options with your orthopaedic or hand surgeon and to ask why he or she is recommending a particular procedure.

In some cases, returning the blood supply to the bone (revascularization) may be possible. This procedure uses a bone graft from the inner bone of the lower arm. It may be combined with an external fixator, a metal device that helps relieve pressure on the lunate and preserve the spacing between bones.

If the bones of the lower arm are uneven in length, a joint leveling procedure may be recommended. Bones can be made longer with bone grafts, or shortened by removing a section of the bone.

This reduces the compressive forces on the lunate and seems to halt progression of the disease. If the lunate is severely collapsed or fragmented, it can be removed. The two bones on either side of it are also removed. This procedure is called a proximal row carpectomy and will relieve pain while maintaining partial wrist motion.

Another way to ease pressure on the bone is to fuse several of the small bones of the hand together. However, this will not improve range of motion. If the disease has progressed to severe arthritis of the wrist, fusing the bones will reduce pain and help maintain function, although motion is limited.

Human Bites

Human bite wounds may not sound very dangerous, but they are. Human bite wounds contain very high concentrations of bacteria, so the risk of infection is high. Even though the wound may appear insignificant, an infection can lead to a severe joint infection. About one third of all hand infections result from human bite wounds. These infections can progress quickly and result in significant complications, so early treatment is necessary.

Bites can transmit the human immunodeficiency virus (HIV), as well as the hepatitis B virus and syphillis. Joint infections can lead to septic arthritis. Someone who has a human bite wound should get prompt first aid and see a doctor within 24 hours of the injury if the skin is broken.

Sometimes the wound is incurred directly (an actual bite). Other times, it is indirect (a clenched fist strikes a tooth, which breaks the skin on the hand). In a fight, a punch to the mouth can result in an indirect bite injury at the knuckle joint (MP or metacarpophalangeal joint), which can lead to a severe infection and possible destruction of the joint if it is not promptly treated.

Signs and Symptoms
In some cases, the bite will not break the skin but may cause damage to underlying tendons and joints. If the skin is broken, there is the additional possibility of infection as well as injury to joints, tendons and nerves. An injury to the top of the hand can result in significant swelling within hours.

Signs of an infection include:

  • Warmth around the bite wound
  • Swelling
  • Pain
  • A pus discharge

Signs of damage to tendons or nerves include:

  • An inability to bend or straighten the finger
  • A loss of sensation over the tip of the finger

First aid
Don’t put the bitten area in your mouth!

If there is no bleeding, wash the wound thoroughly. Use soap and water or an antiseptic such as hydrogen peroxide or alcohol. Apply an antibiotic ointment and cover with a non-stick bandage. Watch the area carefully to see if there are signs of damaged nerves or tendons. If you see any, seek medical help immediately.

If there is bleeding, apply direct pressure with a clean dry cloth. Elevate the area. Do not clean a wound that is actively bleeding. Cover the wound with a clean dressing and seek medical help. In these situations, early intervention (within 24 hours) is needed to prevent complications.

Medical assistance
Be sure to tell your doctor how you got the bite. Your physician will measure the wound, note its location, and check for signs of nerve or tendon damage. The doctor may examine your arm to see if there are signs of a spreading infection. You may need to get X-rays and a blood test.

You may also need to get a tetanus shot and a prescription for antibiotics. You may also have to return in a day or two so that the physician can confirm that an infection has not developed. If the tendons or nerves have been injured, you may need to see a specialist for additional treatment.

Hand Surgery

Our hands serve many purposes. Hands help us eat, dress, write, earn a living, create art and do many other activities. To accomplish these tasks and activities, our hands require sensation and movement, such as joint motion, tendon gliding and muscle contraction.

When a problem takes place in the hand, care must be given to all the different types of tissues that make function of the hand possible.

Hand surgeons are specifically trained to give that care:

  • Hand surgery is the field of medicine that deals with problems of the hand, wrist and forearm.
  • Hand surgeons care for these problems without surgery, and they are specially trained to operate when necessary.
  • Many hand surgeons are also experts in diagnosing and caring for shoulder and elbow problems.
  • Hand surgeons are orthopedic, plastic or general surgeons who have additional training in surgery of the hand.
  • To become a member of the American Society for Surgery of the Hand, a hand surgeon must complete a full year of additional training and must pass a rigorous certifying examination.

Hand Fractures

Have you ever been so frustrated that you wanted to slam your fist into a wall? If you do, you could break one of the bones in your hand (metacarpals). Fractures of the hand bones account for about one-third of all hand fractures. In fact, fractures of the fifth bone (the one that leads to your little finger) are commonly known as “boxer’s fractures.”

The hand bones can break near the knuckle, mid-bone, or near the wrist. Signs and symptoms of a broken bone include:

  • Swelling
  • Tenderness
  • Deformity
  • Inability to move the finger
  • Shortened finger
  • Depressed knuckle
  • Finger crosses over its neighbor when you make a partial fist

Diagnosis and Treatment
Your physician will request X-rays to identify the fracture location and type. The physical examination may include some range of motion tests and an assessment of sensation in the fingers to ensure that there is no damage to the nerves.

Most of the time, the physician can realign the bones by manipulating them without surgery. Then, a cast, splint or fracture-brace is applied to immobilize the bones and hold them in place. The cast will probably extend from the fingertips down past the wrist almost to the elbow to ensure that the hand bones remain fixed in place.

Your physician will probably request a second set of X-rays about a week later to ensure that the bones remain in the proper position.

You will usually have to wear the cast for three to four weeks, but you can probably begin gentle hand exercises after three weeks. Afterwards, the finger may be slightly shorter, but this should not affect your ability to use your hand and fingers.

Surgical options
Some hand fractures, such as those that break through the skin or result from a crushing accident, require surgery to stabilize and align the bones. The orthopaedic surgeon implants wires, screws or plates in the hand to hold the fracture in place. If the bone rotates while healing, loss of function could result.

After the bone has healed, the surgeon may remove the implants, or they may be left in the hand. Research to develop implants that are resorbed into the body is ongoing. Your physician may ask you to return frequently for check-ups to ensure that the joint doesn’t tighten (contract) during healing. You may experience some joint stiffness in your hand because of the long immobilization period.

Your physician may prescribe exercises to help restore strength and range of motion or recommend that you see a physical therapist.

Fracture of the Finger

You might think a broken finger is a minor injury, but without proper treatment it can cause major problems. The bones in a normal hand line up precisely, letting you perform many specialized functions like grasping a pen or manipulating small objects in your palm. When you fracture a finger bone, it can put your whole hand out of alignment. Without treatment, your broken finger might stay stiff and painful.

Signs of a fractured finger

  • Swelling
  • Tenderness
  • Inability to move it completely
  • Deformity

Diagnosis

If you think you broke your finger, tell your doctor right away exactly what happened and when. You have three bones (phalanges) in each finger and two in each thumb. Your doctor must determine not only which bone fractured, but also how it broke: straight across, in a spiral, into several pieces, or shattered completely.

Your doctor may want to see how your fingers line up when you extend your hand or make a fist. Does any finger overlap its neighbor? Angle in the wrong direction? Look too short? Your doctor may X-ray both of your hands for comparison.

Treatment and rehabilitation

Your doctor will put your broken bone back into place, usually without surgery. Sometimes you need pins, screws or wire to hold it together, especially if you have a complicated injury. You’ll get a splint or cast to hold your finger straight and protect it from further injury while it heals. Sometimes your doctor may splint the fingers next to the fractured one for support.

Your doctor will tell you how long to wear the splint – usually about three weeks. Sometimes you may need more X-rays as you heal so your doctor can check your progress.

Begin using your hand again as soon as your doctor determines it is okay to move your finger. Doing simple rehabilitation exercises each day will help reduce the finger’s stiffness and swelling. You may be required to see a physical therapist to assist you in these exercises.