What might still be causing wrist pain even after treatment?

Question

Hello doctor,

For the past one year, I have been suffering a pain in the middle-upper wrist area where I could not support myself while getting up from the chair. I went to an orthopedist and was given some medication and wrist brace with metal support to stabilize the movement. The pain started declining for six months, but it did not go. I did an MRI for it, and another orthopedic surgeon recommended PRP injection with a month cast as he could see it as a partial TFCC. After the injection and one month cast, 15 sessions of physiotherapy, the pain persisted, so another MRI was done to check the progress. The MRI comparison showed the following:

A comparison was made with the previous MRI.
The previously noted and described reactive bone marrow edema in the medial corner of the proximal lunate is progressed and also showed mild diffuse edema involving the whole lunate bone. I would highly suggest further follow-up for the lunate bone to exclude the possibility of lunate bone avascular necrosis.
Minimal reactive bone marrow edema noted in the triquetral bone.
The stable appearance of the lunotriquetral ligament with preserved joint space.
Stable central and ulnar side intrasubstance TFCC signals with no evidence of major TFCC tears.
More prominent joint fluid, especially in the recess around the ulnar styloid process.
Slightly more prominent ganglion cyst measuring 4 mm noted in the dorsal aspect of the wrist at the level of the radiocarpal joint.
No lunate or perilunate dislocation.
Normal flexor and extensor tendons.
Intact carpal tunnel and median nerve.
No bony fractures.

I am concerned about the avascular necrosis as the doctor mentioned we should wait another three months then reconduct the MRI to identify the need for surgery "bone drilling" and another cast for six weeks. It is now ten months, and I am losing most of my right-hand function, and I do not want to reach the final stage of my lunate bone dying. Please advise if there are any potential solutions without surgery, and if the surgery is needed, what is the recommendation.

Answer 1

Hello,

Welcome to icliniq.com.

I have gone through your medical history in detail. It seems that you are having stage 2-3 avascular necrosis of lunate (Kienbock's disease). I do not feel that you should wait as the disease progresses irreversibly. So it will not come back to normal by any means. I would suggest an immediate surgery (either bone decompression drilling or bone graft). The last stage needs bone excision and fusion of other bones. If you could get the latest x ray of the wrist, I can precisely tell you which surgery is needed.

Answer 2

Hello,

Welcome back to icliniq.com.

I have seen both the X-rays. (attachment removed to protect patient identity). The good news is that the architecture of the lunate is still maintained. It means an early stage of necrosis and good post-operative results. You do not need prosthesis replacement surgery at present. Drilling decompression with or without a bone graft will give you good results. Grip and wrist range of movements should be minimum 80 % to 90 % of normal postoperatively if good physiotherapy is done after surgery.