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.

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.

Description
Dupuytren’s contracture is an abnormal thickening of tough tissue in the palm and fingers that can cause the fingers to curl. It is more common in men than in women and becomes more common as we grow older.

Risk Factors/Prevention
The cause of Dupuytren’s contracture is not known. It is not caused by an injury. It is not a cancer.

Dupuytren’s contracture is most common in people of Northern European or Scandinavian ancestry.
It is associated with smoking and drinking.
It is also associated with certain medical conditions such as diabetes, thyroid problems and seizures.

Symptoms
Dupuytren’s contracture usually occurs very gradually. It may begin as a small tender lump in the palm. Over time the pain usually goes away, but tough bands may form that cause the fingers to bend toward the palm. The ring and small fingers are most commonly affected.

Treatment Options
There is no way to stop or cure the problem. It is not dangerous. Dupuytren’s contracture usually progresses very slowly and may not be troublesome for years. If a painful lump is present, an injection may help diminish the pain. If the fingers become bent, they may interfere with use of your hand. Treatment is recommended when inability to straighten the fingers significantly limits your hand function. The treatment for Dupuytren’s Disease has advanced tremendously in the last few years. Treatments such as Needle Aponeurotomy and Xiaflex® injections have minimized the need for surgery for this condition.

Needle Aponeurotomy
Is a minimally invasive in office procedure that is performed under local anesthesia to disrupt the fascial bands formed by Dupuytren’s Disease and can correct significant deformity without the need for surgery. This procedure requires minimal recovery and no prolonged hand therapy.

XIAFLEX® Injections
Is an in office injection of Collagenase Clostridium Histolyticum which then enzymatically dissolves the Dupuytren’s cord and can also correct significant deformity with minimal recovery and downtime.

Surgical
Surgery for Dupuytren’s contracture divides or removes the thickened bands to help restore finger motion. Sometimes the wound is left open and allowed to heal gradually. Skin grafting may sometimes be needed. Risks of surgery include injury to nerves and blood vessels and infection. Some swelling and soreness are expected but severe problems are rare. Elevating your hand after surgery and gently moving the fingers helps minimize pain, swelling and stiffness. A physical therapist may be helpful during your recovery after surgery. Most people will have improved motion in the fingers after surgery.

Surgery does not cure the disease, which tends to progress gradually and recur over time.

What is deQuervain’s Tendinitis?

deQuervain’s tendinitis is a condition brought on by irritation or swelling of the tendons found along the thumb side of the wrist (Figure 1). The irritation causes the compartment (lining) around the tendon to swell, changing the shape of the compartment; this makes it difficult for the tendons to move as they should.

The swelling can cause pain and tenderness along the thumb side of the wrist, usually noticed when forming a fist, grasping or gripping things, or turning the wrist.

Signs and Symptoms
Pain over the thumb side of the wrist is the main symptom. The pain may appear either gradually or suddenly. It is felt in the wrist and can travel up the forearm. The pain is usually worse with use of the hand and thumb, especially when forcefully grasping things or twisting the wrist.

Swelling over the thumb side of the wrist is noticed and may be accompanied by a fluid-filled cyst in this region. There may be an occasional “catching” or “snapping” when moving the thumb. Because of the pain and swelling, it may be difficult to move the thumb and wrist, such as in pinching.

Irritation of the nerve lying on top of the tendon sheath may cause numbness on the back of the thumb and index finger.

Diagnosis
A Finkelstein test is generally performed. In this test, the patient makes a fist with the fingers over the thumb. The wrist is then bent in the direction of the little finger (Figure 2).

This test can be quite painful for the person with deQuervain’s tendinitis. Tenderness directly over the tendons on the thumb side of the wrist is the most common finding, however.

Treatment
The goal is to relieve the pain caused by the irritation and swelling. In some cases, your doctor may recommend resting the thumb and wrist by wearing a splint. Anti-inflammatory medication taken by mouth or injected into that tendon compartment may help reduce the swelling and relieve the pain.

In some cases, simply not doing the activities that cause pain and swelling may allow the symptoms to go away on their own. When symptoms are severe or do not improve, surgery may be recommended.

The surgery opens the compartment (covering) to make more room for the irritated tendons (Figure 3). Normal use of the hand can usually be resumed once comfort and strength have returned. Your hand surgeon can advise you on the best treatment for your situation.

Arthritis affects millions of people in the United States. Often, arthritis strikes at the weightbearing joints of the body, such as the knees and the shoulders. But a significant number of people suffer from arthritis in their wrists and hands that make it difficult for them to perform the activities of daily living.

Although there are hundreds of kinds of arthritis, most wrist pain is caused by just two types:

• Osteoarthritis (OA) is a progressive condition that destroys the smooth articular cartilage covering the ends of bones. The bare bones rub against each other, resulting in pain, stiffness and weakness. OA can develop due to normal “wear-and-tear” on the wrist or as a result of a traumatic injury to the forearm, wrist or ligaments.
• Rheumatoid arthritis (RA) is a systemic inflammatory disease that affects the joint linings and destroys bones, tissues, and joints. Rheumatoid arthritis often starts in smaller joints, like those found in the hand and wrist, and is symmetrical, meaning that it usually affects the same joint on both sides of the body.

Signs and symptoms

• OA of the wrist joint manifests with swelling, pain, limited motion and weakness. These symptoms are usually limited to the wrist joint itself.
• RA of the wrist joint usually manifests will swelling, tenderness, limited motion and decreased grip strength. In addition, hand function may be impaired and there may be pain in the knuckle joints (metacarpophalangeal or MP joints).
• Joint swelling may also put pressure on the nerves that travel through the wrist. This can cause a lesion to develop (compression neuropathy) or lead to carpal tunnel syndrome.

Diagnosis and treatment
Six bones make up the wrist joint: the two bones of the lower arm (the radius and the ulna) and four wrist bones (the carpals). Your physician will use a combination of physical examination, patient history, and tests to diagnose arthritis of the wrist. X-rays can help distinguish among various forms of arthritis. Some, but not all, forms of RA can be confirmed by a laboratory blood test.

In general, early treatment is nonsurgical and designed to help relieve pain and swelling. Several therapies can be used to treat arthritis, including:

• Modifying your activities.
• Immobilizing the wrist for a short time in a splint.
• Taking anti-inflammatory medications such as aspirin or ibuprofen.
• Following a prescribed exercise program.
• Getting a steroid injection into the joint.

Your physician may prescribe other therapies, depending on the type of arthritis you have. For example, additional therapies for patients with rheumatoid arthritis include antimalarial drugs, antimetabolites, gold, immunosuppresive drugs (both non-steroidal and corticosteroids) and newer genetically-engineered medications.

When such conservative methods are no longer effective, or if hand function decreases, surgery is an option. The goal of surgery is to relieve pain; depending on the type of surgery, joint function may also be affected. Surgical options include removing the arthritic bones, joint fusion (making the joint solid and preventing any movement at the wrist) and joint replacement.

You and your physician should discuss the options and select the one that is best for you.