Treatment of Avascular Necrosis of the Carpal Bones Continues to Evolve

Avascular necrosis or osteonecrosis (bone death) of the carpal bones (wrist) causes pain, limited motion of the wrist, and weakness. Frequently, patients with this problem end up with arthritis in the affected wrist. The author of this article examined different treatment methods of avascular necrosis.

The most common type of avascular necrosis is called Kienbock disease, a disorder where the blood supply fails to reach a small bone, called the lunate in the wrist, causing bone cell death. Patients often report that it feels at first like a sprained wrist. There are various types of treatment for Keinbock disease and there isn’t big agreement as to which is best. The treatments include leveling off the joint, removing part of the bone (osteotomy), bone grafts, or fusing the bones (arthrodesis), among others.

One of the procedures, joint leveling involves lengthening of the ulnar bone (one of the forearm bones) and shortening the radial bone (the other forearm bone). It has been found to be effective in helping the wrist. Patients who have this type of surgery have reported less pain, and better strength and range of motion of the wrist. But, there have also been many reports of non-union, where the bones don’t join and heal together.

Surgeons also partially fuse the wrists of some patients with Kienbock disease. Although this procedure can reduce pain and prevent further damage, it also reduces the range of motion of the wrist, which can be difficult for some patients. Bone grafting is also done with some success, resulting in less pain and increased strength. Some patients did develop signs of arthritis later on, however.

Another form of avascular necrosis is osteonecrosis of the scaphoid or Preiser disease. In this disease, the osteonecrosis happens in the scaphoid bone in the wrist, the first bone nearest the thumb. It is a rare disease so there aren’t any tried and true treatments. Treatments can include debriding the damaged and dead tissue from the area, grafting, or removing part of the bone.

Avascular necrosis of proximal scaphoid associated with fracture and non-union is another problem that doctors encounter. The scaphoid bone is easily broken so it’s a common injury. Sometimes, when the bone is broken, the blood supply is cut off and this can cause cell death, or osteonecrosis. As well, the bone doesn’t always heal. Non-union occurs in between 5 percent to 15 percent of wrist fractures. To treat this problem, surgeons often choose bone grafting but this may also result in non-union.

The author wrote that this condition can be difficult to treat with surgery and although the different procedures are available, further study is needed to find the best types of treatment for the each form of osteonecrosis.