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

2. 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

3. 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.

4. 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.

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

6. Questions?

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

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

10. 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

11. 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.

12. 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.

14. 3 months later

15. 2 months later

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

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

22. 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.

23. 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.

24. Questions?