Working Diagnosis:
Keinbock's disease (avascular necrosis of the lunate)

Treatment:
Treatment was initially conservative with cockup wrist splint, limited repetitive wrist hyperextension and loading, home stretching and strengthening program and Voltaren gel while completing Lovenox course. After discovery of MRI findings suggestive of Keinbock's disease, Lichtman stage IIIA, patient was immobilized for six weeks in a short arm cast, given a bone stimulator and referred to hand surgeon for possible surgical intervention.

Outcome:
At the time of referral, the patient was felt to be clinically in stage IIIB (by CT correlation as well) and thus offered a proximal row carpectomy or scaphotrapeziotrapezoid fusion. Patient declined and will delay surgical intervention for now as she is currently only symptomatic with loaded wrist extension. Functional bracing allows her to remain active in triathlons, Spinning, swimming and playing piano.

Author's Comments:
The uniqueness of this lunate avascular necrosis case lies in the potential predisposing factor of a hypercoagulable state in the typical setting of an ulnar variant wrist within the context of repetitive trauma.

Editor's Comments:
- A hypercoagulable state should broaden the clinician's differential diagnoses to include avascular necrosis and infarction of boney structures.
- The main distinguishing difference in staging Kienbock's disease is when the lunate goes from a stable sclerotic state (stage II) to early collapse (stage III).
- While plain radiographs may be very helpful in assessing the progression of the lesion, CT scan and MRI can provide more specific information.

References:
Beredjiklian PK. Kienböck’s disease. J Hand Surg. 2009;34(1):167-75. Accessed on February 24, 2014 from PubMed.
Canale ST and Beaty JH. Fractures of the lunate and Kienböck Disease. Canale and Beaty: Campbell’s Operative Orthopedics [book online]. 12th ed. Philadelphia, PA: Elsevier; 2012. Accessed from http://www.mdconsult.com on February 21, 2014.
DeLee JC, Drez Jr D, Miller MD. Kienböck's disease. DeLee: DeLee and Drez's orthopaedic sports medicine. 3rd ed. Philadelphia, PA: Elsevier; 2009. Accessed from http://www.mdconsult.com on January 12, 2014.
Kouwabunpat D. Varicella complicated by Group A Streptococcal sepsis and osteonecrosis. Pediatrics. 1999 Oct;104(4):967-969. Accessed from EBSCO on March 6, 2014.
Lutsky K, Beredjiklian PK (2012). Kienböck disease. J Hand Surg. 2012; 37(9):1942–1952. Accessed from http://www.sciencedirect.com.proxy.library.vcu.edu on December 20, 2013
Meena DS, Saini N, Kundanani V, Chaudhary L, Meedna D. Distraction histiogenesis for treatment of Kienbock's disease: A 2- to 8-year follow-up. Indian J Orthop. 2009; 43(2): 189–193. Accessed on February 21, 2014 from PubMed.
Raifer R, et al (2013). A novel arthroscopic technique utilizing bone morphogenetic protein in the treatment of Kienböck disease. Tech Hand Up Extrem Surg. 2013 Mar;17(1):2-6. Accessed from http://ovidsp.tx.ovid.com.proxy.library.vcu.edu on January 12, 2014
Stahl S et al. A systematic review of the etiopathogenesis of Kienböck's disease and a critical appraisal of its recognition as an occupational disease related to hand-arm vibration. BMC Musculoskeletal Disorders. 2012; 13(225):2-12. Accessed on March 1 from http://www.biomedcentral.com/1471-2474/13/225

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