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Had vehicle accident. X-ray showed osteoarthritis but no fractures. MRI showed broken lunate. What should I be aware of?

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Orthopaedic Surgeon
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I am a 59 year old male, healthy and active, working in an active occupation. At the end of July I was involved in a work related vehicle accident. At the ER, the Xray showed osteoarthritis, but, no fractures, they applied a wrist brace, gave me some pain meds and told me to see the PA in a week. The PA perscribed "tincture of time" and continued use of the wrist brace. About a month later, with only minimal improvement, a bone scan was done, confirming osteoarthritis in the injured left wrist, the right wrist (I'm right handed) showed only a small spot of osteoarthritis at the base of the thumb. Five months later, I requested and was granted an MRI . At my next visit, the PA said you have a brolen lunate.
I now have an appointment with an orthopaedic surgeon in two weeks. What should I be aware of and what questions should I ask?
Posted Sat, 5 May 2012 in Bones, Muscles and Joints
Answered by Dr. Atul Wankhede 11 hours later
Dear sir,
Thanks for posting your query.

I can understand your plight. I fail to understand if Xray was inconclusive initially, why did they not take a CT scan immediately. Bone scan was absolutely not required. And rubbishing it as an osteoarthritic pain post trauma is an unforgivable mistake.

Nevertheless, the course of action here onwards needs to be decided. I think if the pain has subsided and range of motion of wrist is normal, then you have nothing to worry. Just continue using the splint and some physiotherapy will work wonders. The most common complication of lunate fracture (I'm sure you must be aware by now) is Kienbock's disease. The bone, if devoid of blood supply (in your case due to fracture), gets slowly dissolved and over a time disappears. The line of management in such case is vast and beyond the scope of this answer.

In short the questions that one needs to ask the orthopaedician now are-

1. Is the lunate fracture now united?
2. If united, is it in good position or is it malunited?
3. If it is not united, then is it nonunited or could it be a delayed union?
4. Are there any signs of avascular necrosis of lunate (kienbock's disease)?
5. If yes, then what stage it is, the protocol of treatment here onwards and the possible outcomes.

Do a little home work on the conservative and surgical modalities of treating kienbock's disease. I hope this helps you prepare yourself. Please get back to us if you need more assistance.
Good day.
Above answer was peer-reviewed by
Follow-up: Had vehicle accident. X-ray showed osteoarthritis but no fractures. MRI showed broken lunate. What should I be aware of? 10 days later
I have just seen the orthopaedist. He said avascular necrosis of the lunate, Kienbacks disease. He said this was likely brought on by the injury. he further said that there were "changes" occurring in the wrist. He also confirmed that the lunate was fractured. I have done some research into treatment options.

1. Revascularisation of a graft on the lunate.
I am 59 years old, are the chances poor for success?
Will the "changes" be arrested or slowed by the new plumbing?

2. prosthetic lunate
years old technology 70% success rate
has technology improved, is this even done anymore?

3. Surgical "cleanup" of the wrist.
Surgeon is not highly confident of the outcome

4. Wrist fusion
Not my idea of the way back to work
The limited mobility will force me into a new career.

My philosophy has always been to do the minimum to achieve the maximum.
I do not look forward to several surgries with less than favorable outcomes.

What am I missing?
Are there other treatments?
What else do I need to think about?

Answered by Dr. Atul Wankhede 11 hours later
Hello once again.
Thanks for getting back to us.

Glad you did that homework. To be honest, I have limited knowledge of lunate prosthesis. But to achieve revascularisation is a age old technique. At your age it is unpredictable and possibly unfavourable too. But if it does work out then the progress of Kienbock's will be arrested and even reverse. This would depend on its stage.

Surgical clean up needs to be done only if no other modality is available due to advanced stage. This will give you a functional but painful (occasional)hand. Wrist fusion on the other hand gives a painless and limited functioning wrist.

In my opinion, with due respect to your philosophy, you should go for clean up. Atleast before thinking of fusion. Also take a second opinion for prosthesis. We have not missed anything yet. So dont worry, these are the best possible treatment options and I'm sure it will work for you.

Wish you good luck and please get back to me if you have more queries.
Good day.
Above answer was peer-reviewed by
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