Joint Program in Nuclear Medicine

Bone Scintigraphy in Kienbock's Disease

Pradeep K. Varma, MD
J. Stevan Nagel, MD

September 5, 1989

Presentation

Imaging Findings

Discussion

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

1. Helm CA, Hattner RS, Vogler JB. Osteoid Osteoma: Radionuclide Diagnosis. Radiology 1984; 151:779-784.

2. Koenig H. Lucus D, Meissner R. The Wrist: A Preliminary Report on High-Resolution MR Imaging. Radiology 1986; 160:463-467.

3. Reinus WR, Conway WF, Totty WG, et al. Carpal Avascular Necrosis: MR Imaging. Radiology 1986; 160:689-693.

4. Gilday DL, Ash JM. Benign Bone Tumors. Seminars in Nuclear Medicine; January 1976; Vol. 6, No. 1.

5. Gelberman RH, Szabo RM. Kienbock's Disease. Orthopedic Clinics of North America. April 1984; Vol. 15, No. 2.

6. Amadio PC, Hanssen AD, et al. The Genesis of Kienbock's Disease: Evaluation of a case by Magnetic Resonance Imaging. J Hand Surg 1987; 12A:1044-9.

7. Winter PG, Johnson PM, et al. Scintigraphic Detection of Osteoid Osteoma. Radiology. January 1977; 122:177-178.

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