Wrist Pain in a Mechanic Timothy Dekker, MD George G.A. Pujalte, MD, FACSM Stephen D. Trigg, MD Mayo Clinic, Jacksonville, Florida

History 38-year-old, right-hand dominant male presented due to right wrist pain Focused on the radial-dorsal wrist Pain was sharp, worsened with activities Swelling over the dorsal wrist Decreased range of motion No trauma or previous injury No paresthesia Minimal relief with pain medications or a wrist splint

History Past Medical: Hyperlipidemia Medications: Tramadol, meloxicam Allergies: None Social: Worked as a mechanic Competitive volleyball player and softball pitcher Tobacco smoker Occasional alcohol use.

Physical Examination Mild dorsal wrist swelling Tender to palpation over the dorsal aspect of the proximal carpal row, worse centrally Range of motion: Volar flexion 20/80 (70-90) Dorsiflexion 50/70 (65-85) Pain with radial deviation Decreased grip strength on the right > left No decreased sensation.

Differential Diagnosis Early degenerative joint disease (DJD) and/or carpal bossing Ganglion cyst Intersection syndrome Kienbock’s disease

Questions?

Labs H/H - 14.2/41.0 WBC – 7.0 A1c - 5.7 Total cholesterol - 158, HDL - 28, LDL - 92, TG -191

Imaging Right Wrist X-ray - evidence of mottled, increased osteodensity within the lunate; on the lateral view, a depression-type fracture.

Additional imaging Computed tomography (CT) - confirmed avascular necrosis of the lunate, with a coronal, nondisplaced fracture of the lunate. No degenerative changes. Mild negative ulnar variance

Final Working Diagnosis Kienbock’s disease Lichtman stage 2 Avascular necrosis or osteomalacia of the lunate Progressing to fragmentation and collapse of the lunate and ultimately degenerative changes Possibly related to repetitive microtrauma, abnormal biomechanical loading patterns at the radiocarpal joint or undiagnosed fractures of the lunate.

Treatment and Outcomes Right wrist denervation Continued to have pain at work, especially with torqueing motions Repeat x-rays showed further sclerosis, with no evidence of revascularization. Offered further surgical intervention, but declined due to financial burdens.

3 months later

2 months later

Treatment and Outcomes CT scan showed advanced sclerosis and fragmentation of the lunate, mild-moderate degenerative changes, consistent with sequela of Kienbock malacia.

Surgery Lunate excision and scaphocapitate (SC) fusion Custom static wrist orthotic

Treatment and Outcomes Five months post operation, pain no better CT showed successful scaphocapitate arthrodesis, but increased degenerative changes Several more steroid injections provided relief for a few months at a time. Small movements continued to be painful A fourth extensor compartment injection was done and provided significant relief.

Final Outcome Patient was seen for follow up in the Sports Medicine clinic Reported the wrist continued to bother him Still working as a mechanic with only mild pain and limitations.

Questions?