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The exact cause of Kienböck's is not known, though there are thought to be a number of factors predisposing a person to Kienböck's.
Recent studies have made a correlation between Kienböck's sufferers and Western European ancestry, but no definitive link can be positively confirmed.
The necrosis of the lunate bone can frequently be traced to a trauma to the wrist, like a compound fracture, which could cause the lunate's blood supply to be interrupted. Blood flows to the lunate through several arteries, each supplying a percentage. When one of these pathways is severed, the likelihood the patient will develop necrosis increases.
Despite a preponderance of evidence, no particular cause has been conclusively verified.
Data exists on the internet that most people suffering from Kienböck's are affected in their dominant hand, though about one-third of sufferers report the condition in their non-dominant hand. In very few cases have there been people that have acquired it in both wrists.
Kienböck's disease is classified as a "rare disorder," meaning that it affects fewer than 200,000 people in the U.S. population.
Many Kienböck's patients are frustrated by the lack of consensus among hand surgeons about optimal treatments for Kienböck's. No matter what the disease's stage of progression, there is no one best treatment, and the decision is often based partially, or even mostly, on incidental factors such as the patient's pain tolerance, the patient's desire to return to active use of the hand (such as in manual occupations), and the surgeon's level of expertise with different treatments.
Though, since each case of Kienböck's is different, the makeup of the wrist and arm bones are important factors which are individualized to each patient. Therefore, one surgery will never be able to solve all the problems associated with the disease. Thus, no consensus can be reached among surgeons.
Being an extremely rare disease, it is unknown as to what exactly causes Panner Disease. It is believed that the disease may be brought on by continuous overuse of the elbow and that puts pressure on the elbow and also strains the elbow in children during the period of rapid bone growth. The overuse of the elbow can be due to the involvement in sports such as baseball, handball, and gymnastics where these sports involve throwing or putting a lot of pressure on the joints. These repeated activities cause microtraumas and results in the affected elbow being swollen, irritated, and in pain. Panner Disease results when the blood supply to the capitellum is disrupted and therefore the cells within the growth plate of the capitellum die and it becomes flat due to the softening and collapsing of the surrounding bone. To prevent future instances of Panner Disease the child is instructed to cease all physical and sports activities that involve the use of the affected elbow until the symptoms are relieved.
Children younger than 6 have the best prognosis, since they have time for the dead bone to revascularize and remodel, with a good chance that the femoral head will recover and remain spherical after resolution of the disease. Children who have been diagnosed with Perthes' disease after the age of 10 are at a very high risk of developing osteoarthritis and coxa magna. When an LCP disease diagnosis occurs after age 8, a better outcome results with surgery rather than nonoperative treatments. Shape of femoral head at the time when Legg-Calve Perthes disease heals is the most important determinant of risk for degenerative arthritis; hence, the shape of femoral head and congruence of hip are most useful outcome measures.
Perthes' disease is one of the most common hip disorders in young children, occurring in roughly 5.5 of 100,000 children per year. The lifetime risk of a child developing the disease is about one per 1,200 individuals. Boys are affected about three to five times more often than girls. New cases of Perthes' disease rarely occur after age 14 years (if diagnosed after 14 years of age, then it is usually old disease from early in childhood or avascular necrosis from an alternative cause).
White northern Europeans appear to be affected more frequently than other races, though a paucity of reliable epidemiology exists in the Southern Hemisphere. Children of sufferers of the disease themselves may have a very slightly increased risk, though it is unclear if this is because of a genetic predisposition, or a shared environmental factor. It is most commonly seen in persons aged three to 12 years, with a median of six years of age. The UK incidence rates show an intriguing pattern with low incidence rates in London, and a progressive increase in disease in more northerly areas (maximal in Scotland). Some evidence suggests, at least in developed countries, more socioeconomically deprived communities have a greater risk of disease (a similar trend to diseases such as adult heart disease), though the reason for this remains unknown. One possible explanation that has been considered is tobacco smoke exposure, though this is significantly confounded by the strong socioeconomic gradient common to both smoking and Perthes' disease. Dietary factors of the child, and of the mother during pregnancy, are of interest to the research groups.
Kienböck's disease is a disorder of the wrist. It is named for Dr. Robert Kienböck, a radiologist in Vienna, Austria who described osteomalacia of the lunate in 1910.
It is breakdown of the lunate bone, a carpal bone in the wrist that articulates with the radius in the forearm. Specifically, Kienböck's disease is another name for avascular necrosis (death and fracture of bone tissue due to interruption of blood supply) with fragmentation and collapse of the lunate. This has classically been attributed to arterial disruption, but may also occur after events that produce venous congestion with elevated interosseous pressure.
In general, SCFE is caused by increased force applied across the epiphysis, or a decrease in the resistance within the physis to shearing. No single cause accounts for SCFEs, as several factors play a role in the development of a SCFE, particularly mechanical and endocrine (hormone-related) factors. Mechanical risk factors include obesity, coxa profunda, femoral or acetabular retroversion. Obesity is the most significant risk factor. In 65 percent of cases of SCFE, the person is over the 95th percentile for weight. Common misconception is heredity. Majority of cause is due to being overweight. Endocrine diseases also contribute, such as hypothyroidism, hypopituitarism, and renal osteodystrophy.
Dysbaric osteonecrosis is a significant occupational hazard, occurring in 50% of commercial Japanese divers, 65% of Hawaiian fishermen and 16% of commercial and caisson divers in the UK.
Its relationship to compressed air is strong in that it may follow a single exposure to compressed air, may occur with no history of DCS but is usually associated with significant compressed air exposure. The distribution of lesions differs with the type of exposure - the juxta-articular lesions being more common in caisson workers than in divers.
There is a definite relationship between length of time exposed to extreme depths and the percentage of divers with bone lesions. Evidence does not suggest that dysbaric osteonecrosis is a significant risk in recreational scuba diving.
The ultimate cause for these conditions is unknown, but the most commonly cited cause factors are rapid growth, heredity, trauma (or overuse), anatomic conformation, and dietary imbalances; however, only anatomic conformation and heredity are well supported by scientific literature. The way that the disease is initiated has been debated. Although failure of chondrocyte differentiation, formation of a fragile cartilage, failure of blood supply to the growth cartilage, and bone necrosis all have been proposed as the starting point in the pathogenesis, recent literature strongly supports failure of blood supply to growth cartilage as most likely.
Although the exact cause of Panner Disease is unknown, in recent research, it has been concluded that it may be associated with frequent throwing or other athletic activity. In the same article that talks about varying osteochondrosis diseases, it is pointed out that Panner Disease always involves alteration of the capitellum, which can be visualized by radiography. In another research article, the research team aimed to summarize the best available evidence for diagnosis and treatment for Panner Disease. In the article it was found that the most common symptoms that patients with Panner Disease present with are elbow stiffness and swelling, limited range of motion, and limited elbow extension. In alignment with the previously mentioned article, the team of researchers also concluded that Panner Disease involves irregularity of the capitellum, specifically that it appears flattened. Panner Disease often gets misdiagnosed as osteochondritis dissecans (OCD), and in this article they distinguish the difference between the two diseases are age difference and radiographic findings. In alignment with the two previously discussed articles, another article that reports on three case studies of Panner Disease, states that the primary treatment that is used for Panner Disease is rest and restriction from all physical and athletic activity that involves the use of the upper extremities; the activity is suggested to be ceased until the symptoms are relieved.
Metallosis is the putative medical condition involving deposition and build-up of metal debris in the soft tissues of the body.
Metallosis has been hypothesized to occur when metallic components in medical implants, specifically joint replacements, abrade against one another.
Metallosis has also been observed in some patients either sensitive to the implant or for unknown reasons even in the absence of malpositioned prosthesis. Though rare, metallosis has been observed at an estimated incidence of 5% of metal joint implant patients over the last 40 years. Women may be at slightly higher risk than men. If metallosis occurs, it may involve the hip and knee joints, the shoulder, wrist, or elbow joints.
The abrasion of metal components may cause metal ions to be solubilized. The hypothesis that the immune system identifies the metal ions as foreign bodies and inflames the area around the debris may be incorrect because of the small size of metal ions may prevent them from becoming haptens. Poisoning from metallosis is rare, but cobaltism is an established health concern. The involvement of the immune system in this putative condition has also been theorized but has never been proven.
Purported symptoms of metallosis generally include pain around the site of the implant, pseudotumors (a mass of inflamed cells that resembles a tumor but is actually collected fluids), and a noticeable rash that indicates necrosis. The damaged and inflamed tissue can also contribute to loosening the implant or medical device. Metallosis can cause dislocation of non-cemented implants as the healthy tissue that would normally hold the implant in place is weakened or destroyed. Metallosis has been demonstrated to cause osteolysis.
Women, those who are small in stature, and the obese are at greater risk for metallosis because their body structure causes more tension on the implant, quickening the abrasion of the metal components and the subsequent build-up of metallic debris.
SLAC and SNAC are both caused by injury, for example a fall on an extended hand. SLAC is caused by rupture of the scapholunate ligament, SNAC is caused by a scaphoid fracture which does not heal and because of that will develop in a non-union fracture. SLAC is more common than SNAC; 55% of the patients with wrist osteoarthritis has a SLAC wrist. Although they have a different underlying pathology, they both lead to abnormal wrist kinematics which will eventually lead to osteoarthritis of the wrist.
First described by Preiser in 1910 in 5 patients, all with previous history of wrist trauma, and scaphoid fractures in 3 of them.
SCFE affects approximately 1-10 per 100,000 children. The incidence varies by geographic location, season of the year, and ethnicity. In eastern Japan, the incidence is 0.2 per 100,000 and in the northeastern U.S. it is about 10 per 100,000. Africans and Polynesians have higher rates of SCFE.
SCFEs are most common in adolescents 11–15 years of age, and affects boys more frequently than girls (male 2:1 female). It is strongly linked to obesity, and weight loss may decrease the risk. Other risk factors include: family history, endocrine disorders, radiation / chemotherapy, and mild trauma.
The left hip is more often affected than the right. Over half of cases may have involvement on both sides (bilateral).
Leri-Weill dyschondrosteosis is a pseudoautosomal dominant disorder which occurs more frequently in females and is due to a mutation, deletion or duplication of the SHOX gene. The SHOX gene plays a particularly important role in the growth and maturation of bones in the arms and legs. The SHOX gene is located within band Xp22.3 of the pseudoautosomal region of the X chromosome, which escapes X-inactivation. Homozygous SHOX gene mutations result in Langer mesomelic dysplasia.
Schmorl's nodes are fairly common, especially with minor degeneration of the aging spine, but they are also seen in younger spines. Schmorl's nodes often cause no symptoms, but may simply reflect that "wear and tear" of the spine has occurred over time; they may also reflect that bone strength was at one time somewhat compromised, perhaps due to a vitamin D deficiency although this has yet to be confirmed with studies, or if heavy lifting is done at a young age before the vertebral bodies are completely ossified such as in young farm workers. There is also a strong heritability of Schmorl's Nodes (>70%). While often non-complicating, Schmorl's nodes also tend to occur more often in cases of spinal deformity, specifically Scheuermann's disease. These defects are caused when the vertebra loses its normal function and is not moving/hypomobile/subluxated. During this time the forces normally distributed by the nucleus pulposus (the incompressible gelatinous center of the intervertebral disc) are concentrated in a certain area causing endplates to deform in a concave manner.
OCD is a relatively rare disorder, with an estimated incidence of 15 to 30 cases per 100,000 persons per year. Widuchowski W "et al." found OCD to be the cause of articular cartilage defects in 2% of cases in a study of 25,124 knee arthroscopies. Although rare, OCD is noted as an important cause of joint pain in active adolescents. The juvenile form of the disease occurs in children with open growth plates, usually between the ages 5 and 15 years and occurs more commonly in males than females, with a ratio between 2:1 and 3:1. However, OCD has become more common among adolescent females as they become more active in sports. The adult form, which occurs in those who have reached skeletal maturity, is most commonly found in people 16 to 50 years old.
While OCD may affect any joint, the knee—specifically the medial femoral condyle in 75–85% of knee cases—tends to be the most commonly affected, and constitutes 75% of all cases. The elbow (specifically the capitulum of the humerus) is the second most affected joint with 6% of cases; the talar dome of the ankle represents 4% of cases. Less frequent locations include the patella, vertebrae, the femoral head, and the glenoid of the scapula.
Preiser disease, or (idiopathic) avascular necrosis of the scaphoid, is a rare condition where ischemia and necrosis of the scaphoid bone occurs without previous fracture. It is thought to be caused by repetitive microtrauma or side effects of drugs (e.g., steroids or chemotherapy) in conjunction with existing defective vascular supply to the proximal pole of the scaphoid. MRI coupled with CT and X-ray are the methods of choice for diagnosis.
Preiser's disease is initially treated by immobilising the wrist with a cast. However, in most cases the avascular scaphoid will start to collapse leading to degeneration within the wrist joints. This often requires surgical intervention to prevent the progression of arthris. Two commonly performed procedures are:
1. Proximal row carpectomy (PRC), which involves removing the first row of the carpal bones, i.e. the scaphoid, lunate and triquetrum. The wrist is immobilised in a cast for six weeks after the surgery and then physiotherapy is started.
2. Scaphoid excision and 4-corner fusion, which is a procedure consisting of the removal of the scaphoid and fixation of the remaining wrist bones with a plate (called a "spider plate") or wires in order to provide stability. The plate usually is left inside the patient's wrist, while the wires (usually K-wires) have to be removed in a second surgery. This procedure of partial wrist fusion allows for limited wrist movement, whereas total wrist fusion immobilizes the wrist permanently. Following surgery it can take several months for affected patients to regain strength.
Unfortunately both of these operations are salvage procedures and movements in the wrist will be significantly reduced.
It is more common in females over the age of 50 with possible risk factors of corticosteroid use, Lupus, alcoholism, pancreatitis, sickle cell anemia, and rheumatoid arthritis.
It is a congenital subluxation or dislocation of the ulna's distal end, due to malformation of the bones. Sometimes, minor abnormalities of other bone structures, often caused by disease or injury, such as a fracture of the distal end of the radius with upward displacement of the distal fragment. The deformity varies in degree from a slight protrusion of the lower end of the ulna, to complete dislocation of the inferior radio-ulnar joint with marked radial deviation of the hand. Severe deformities are associated with congenital absence or hypoplasia of the radius.
The male:female rate of this disorder is 1:4. The incidence is unknown, and there is no described racial predominance. Even though Madelung's Deformity is considered a congenital disorder, symptoms sometimes aren't seen until adulthood. In most cases, symptoms find their onset during midchildhood. At this age, the relatively slower growth of the ulnar and palmar part of the radius, leads to an increasingly progressive deformity. Pain and deformity are the main symptoms patients present with. Typical clinical presentation consists of a short forearm, anterior-ulnar bow of the radius and a forward subluxation of the hand on the forearm. As mentioned before, the severity of the disorder varies greatly, which also leads to a spectrum of presentation.
If the diver has not been exposed to excessive depth and decompression and presents as DON, there may be a predisposition for the condition. Diving should be restricted to shallow depths. Divers who have suffered from DON are at increased risk of future fracture of a juxta-articular lesion during a dive, and may face complications with future joint replacements. Because of the young age of the population normally affected, little data is available regarding joint replacement complications.
There is the potential for worsening of DON for any diving where there might be a need for decompression, experimental or helium diving. Physically stressful diving should probably be restricted, both in sport diving and work diving due to the possibility of unnecessary stress to the joint. Any diving should be less than 40 feet/12 meters. These risks are affected by the degree of disability and by the type of lesion (juxta-articular or shaft).
Avascular necrosis usually affects people between 30 and 50 years of age; about 10,000 to 20,000 people develop avascular necrosis of the head of the femur in the US each year. When it occurs in children at the femoral head, it is known as Legg-Calvé-Perthes syndrome.
Despite much research, the causes remain unclear but include repetitive physical trauma, ischemia (restriction of blood flow), hereditary and endocrine factors, avascular necrosis (loss of blood flow), rapid growth, deficiencies and imbalances in the ratio of calcium to phosphorus, and problems of bone formation. Although the name "osteochondritis" implies inflammation, the lack of inflammatory cells in histological examination suggests a non-inflammatory cause. It is thought that repetitive microtrauma, which leads to microfractures and sometimes an interruption of blood supply to the subchondral bone, may cause subsequent localized loss of blood supply or alteration of growth.
Trauma, rather than avascular necrosis, is thought to cause osteochondritis dissecans in juveniles. In adults, trauma is thought to be the main or perhaps the sole cause, and may be endogenous, exogenous or both. The incidence of repetitive strain injury in young athletes is on the rise and accounts for a significant number of visits to primary care; this reinforces the theory that OCD may be associated with increased participation in sports and subsequent trauma. High-impact sports such as gymnastics, soccer, basketball, lacrosse, football, tennis, squash, baseball and weight lifting may put participants at a higher risk of OCD in stressed joints (knees, ankles and elbows).
Recent case reports suggest that some people may be genetically predisposed to OCD. Families with OCD may have mutations in the aggrecan gene. Studies in horses have implicated specific genetic defects.
Schmorl's nodes or Schmorl's nodules are protrusions of the nucleus pulposus of the intervertebral disc through the vertebral body endplate and into the adjacent vertebra.
Persons suffering from metallosis can experience any of the following symptoms:
- Extreme pain (even when not moving);
- Swelling and inflammation;
- Loosening of the implant;
- Dislocation;
- Bone deterioration;
- Aseptic fibrosis, local necrosis;
- Hip replacement failure;
- Metal toxicity from grinding metal components; and
- Necessary subsequent hip replacement revision or surgeries.
Freiberg disease, also known as a Freiberg infraction, is a form of avascular necrosis in the metatarsal bone of the foot. It generally develops in the second metatarsal, but can occur in any metatarsal. Physical stress causes multiple tiny fractures where the middle of the metatarsal meets the growth plate. These fractures impair blood flow to the end of the metatarsal resulting in the death of bone cells (osteonecrosis). It is an uncommon condition, occurring most often in young women, athletes, and those with abnormally long metatarsals. Approximately 80% of those diagnosed are women.
Initial treatment is generally 4–6 weeks of limited activity, often with crutches or orthotics. In rare cases, surgery is necessary to reduce the bone mass of the metatarsal.
The condition was first described by Dr. Alfred H. Freiberg in 1914. He initially thought the condition was caused by acute physical trauma, which is why it was initially called an infraction.