Bone Scintigraphy in Kienbock's Disease

Pradeep K. Varma, M.D.

J. Stevan Nagel, M.D.

September 5, 1989

Clinical History:

Otherwise healthy 20 year-old female presented to her clinician with a few months history of intermittent wrist pain, exacerbated by full extension and possibly mitigated with Tylenol and Aspirin, now referred for bone scintigraphy.

Findings:

A bone scintigram of the wrist showed focal uptake of Tc-99m MDP in the region of the lunate (shown by arrow). Within this area of uptake, there is a second smaller more intense focus of uptake. Correlative plain radiograph showed sclerosis of the lunate (shown by arrow) with a central radiolucency.

KIENBOCK'S DISEASE:

The changes seen in Kienbock's disease are due to avascular necrosis of the lunate bone. It has an insidious onset, frequently without known prior injury. Patients present with wrist pain, decreased motion and have sclerosis of the lunate. Although pathogenesis is not conclusively established, transverse fractures, numerous compression fractures secondary to repeated compression strain and lunate dislocation, all leading to avascular necrosis in "at risk" individuals, have been proposed explanations. Four stages of Kienbock's disease have been described based on clinical and roentgenographic findings. Stage I, the acute stage, is indistinguishable from wrist sprain and symptoms abate after several weeks. During stage II, there is a change in the density of the lunate, but the size, shape and configuration are normal. This stage is clinically characterized by pain and swelling due to reactive synovitis. Stage III is associated with increasing wrist stiffness and collapse of the lunate, proximal migration of the capitate and disruption of the carpal architecture. In Stage VI, further degenerative changes are present in the carpus. The uptake of the Tc-99m MDP in the lunate is variable. Generally there is focal accumulation of Tc-99m MDP; however, no abnormality may be present on bone scintigarapy if the examination is performed during the time of impaired vascular supply, before reactive changes and increased metabolism result in increased tracer uptake..

OSTEOID OSTEOMA:

Originally described by Jaffe in 1935 as a benign osteoblastic tumor with a central core of highly vascular osteoid tissue (nidus) within a peripheral zone of sclerotic bone. These tumors are most frequently seen in patients between ages seven and twenty-five. There is a 3:1 male to female predominance. It comes to clinical attention most commonly because of a dull, aching, inconstant pain, worse at night and characteristically relieved with salicylates. Generally, these lesions are less than 1.5 cm and occur more commonly in long bones (50-60%), with the hand and feet accounting for about 20% of the cases. On plain radiographs, the classic appearance is that of a centrally located oval or round radiolucency surrounded by a zone of uniform dense bone sclerosis. When the carpal bones are involved, the osteoid osteoma usually arises in the medullary spongiosa and the extensive reactive sclerosis is generally absent. Scintigraphically, these lesions avidly accumulate bone-seeking radiotracers in a double density configuration, i.e., more intense uptake of Tc-99m centrally (correlating with the nidus), and less intense accumulation peripherally.

REFERENCES:

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J. Anthony Parker, MD PhD, jap@nucmed.bih.harvard.edu