Presentation
Right wrist pain of 4 months duration. The patient denies numbness or tingling and does not have any recent history of trauma. Physical exam reveals diffuse swelling of the right wrist with reduced range of motion in flexion and extension.
Patient Data
Radiographs of the wrist show no definite scapholunate interval widening. There is slightly negative ulnar variance. The lateral view shows a thin linear density projecting across the mid lunate with sclerosis in the dorsal half of the lunate. There is dorsal soft tissue edema/effusion.
MRI shows thin linear PD/T2 hyperintensity through the central portion of the lunate consistent with a coronally oriented nondisplaced fracture, as seen on sagittal and axial images. T1 hypointensity with T2 hyperintensity in the lunate, particularly in the dorsal half of the lunate, may indicate edema and/or ischemia. There is a tear of the scapholunate ligament with widening of the scapholunate interval on coronal images. A wrist joint effusion is seen.
Case Discussion
Taking into consideration the subacute to chronic nature of the patient’s symptoms and the findings on radiographs and MRI, particularly an isolated coronal split fracture of the lunate and marrow signal abnormality, this likely represents the sequela of Kienböck’s disease.
This condition occurs due to disrupted blood flow to the lunate. Negative ulnar variance is a risk factor. The lunate fracture/fragmentation may be a consequence of Kienböck’s disease, rather than a cause of it. In particular, this fracture is observed in Lichtman stage IIIC Kienböck's disease.
MRI is considered to have the highest sensitivity and specificity for detecting early Kienböck’s disease. Changes typically expected include low T1 and low T2 signal representing sclerosis, often seen diffusely throughout the lunate. Decreased T1 and increased T2 signal representing edema may be seen in the early stages of the disease.
Case courtesy of Dr. Emad Allam - Assistant Professor of Radiology, Loyola University Medical Center
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