General Guideline Principles for Kienböck Disease

for workers compensation patients

The New York State workers compensation board has developed these guidelines to help physicians, podiatrists, and other healthcare professionals provide appropriate treatment for Kienböck Disease.

These Workers Compensation Board guidelines are intended to assist healthcare professionals in making decisions regarding the appropriate level of care for their patients with ankle and foot disorders.

The guidelines are not a substitute for clinical judgement or professional experience. The ultimate decision regarding care must be made by the patient in consultation with his or her healthcare provider.

Kienböck Disease of Hand, Wrist and Forearm Injuries

The lunate undergoes alterations in Kienböck disease, which eventually cause the lunate bone to collapse and cause severe pain and incapacity. Kienböck disease patients frequently experience chronic discomfort

Diagnostic Studies of Hand, Wrist and Forearm Injuries

  1. Diagnostic Studies of Hand, Wrist and Forearm Injuries X-Rays is recommended the detection of Kienböck disease

    Reason for Recommendation: X-rays are typically taken of both hands and are utilised to confirm the diagnosis.

     

  2. CT

    CT is recommended when x rays are inconclusive or negative and MRI is not recommended in order to identify Kienböck illness.

    Rationale for Recommendation – When x-rays are inconclusive or negative and MRI is not an option, certain patients may benefit from the use of CT to aid in diagnosis and therapy.

     

  3. MRI

    MRI is recommended when x rays are unhelpful or confusing, to identify Kienböck disease.

    Rationale for Recommendation- MRIs are advised because they help in diagnosis and management.

     

  4. Screening for Systemic Disorders

    Screening for Systemic Disorders is recommended for patients with Kienböck disease.

    Rationale for Recommendation – It is believed that a number of diseases predispose people to Kienböck illness. The threshold for evaluating rheumatological investigations, drunkenness, and systemic metabolic conditions (such as diabetes, glucose intolerance), should be low, especially when possibly adjustable hazards may theoretically reduce the rate of advancement.

Medications of Hand, Wrist and Forearm Injuries

Ibuprofen, naproxen, or other NSAIDs from an earlier generation are suggested as first-line treatments for the majority of patients. For patients who are not candidates for NSAIDs, acetaminophen (or the analogue paracetamol) may be a viable alternative, even if the majority of research indicates it is just marginally less effective than NSAIDs.

There is proof that NSAIDs are less dangerous and just as effective in treating pain as opioids, such as tramadol.

  1. Non-Steroidal Anti-inflammatory Drugs (NSAIDs) for Treatment of Acute, Subacute, or Chronic Kienböck disease

    Non-Steroidal Anti-inflammatory Drugs (NSAIDs) for Treatment of Acute, Subacute, or Chronic Kienböck disease is recommended to treat Kienböck Disease, whether it be chronic, subacute, or acute.

    Indications – Treatment with NSAIDs is advised for Kienböck illness that is acute, subacute, or chronic. First, try over-the-counter (OTC) medications to see whether they work.

    Frequency/Duration: Many Patients may find it reasonable to use as needed.

    Indications for Discontinuation: Symptoms go away, the medication is ineffective, or negative side effects arise that require stopping the medication.

     

  2. NSAIDs for Patients at High Risk of Gastrointestinal Bleeding

    NSAIDs for Patients at High Risk of Gastrointestinal Bleeding is recommended for people at high risk of gastrointestinal bleeding to take misoprostol, sucralfate, histamine Type 2 receptor antagonists, and proton pump inhibitors together.

    Indications: Cytoprotective drugs should be taken into consideration for patients with a high-risk factor profile who also have indications for NSAIDs, especially if a prolonged course of treatment is planned. Patients who have a history of gastrointestinal bleeding in the past, the elderly, diabetics, and smokers are at risk.

    Frequency/Dose/Duration: Proton pump inhibitors, misoprostol, sucralfate, H2 blockers recommended. Dose and frequency per manufacturer. There is not generally believed to be substantial differences in efficacy for prevention of gastrointestinal bleeding

    Indications for Discontinuation: Intolerance, the emergence of negative effects, or the stopping of NSAIDs.

     

  3. NSAIDs for Patients at Risk for Cardiovascular Adverse Effects

    The advantages and disadvantages of NSAID therapy for pain should be explored with patients who have a history of cardiovascular disease or who have several cardiovascular risk factors.

     

  4. NSAIDs for Patients at Risk for Cardiovascular Adverse Effects

     

    1. NSAIDs for Patients at Risk for Cardiovascular Adverse Effects are recommended As far as harmful cardiovascular effects go, acetaminophen or aspirin as first-line therapy seem to be the safest options. Hand, wrist, and forearm injuries reported to

       

    2. NSAIDs for Patients at Risk for Cardiovascular Adverse Effects are recommended If necessary, non-selective NSAIDs are recommended to COX-2-specific medications. To reduce the chance that an NSAID will negate the protective effects of low-dose aspirin in individuals receiving it for primary or secondary cardiovascular disease prevention, the NSAID should be taken at least 30 minutes after or eight hours before the daily aspirin.

       

  5. Acetaminophen for Treatment of Kienböck disease Pain

    Acetaminophen for Treatment of Kienböck disease Pain is recommended for the treatment of pain caused by Kienböck illness, especially in patients who have NSAID contraindications.

    Indications: All Kienböck disease patients have pain, which can be acute, subacute, chronic, or post-operative.

    Dose/Frequency: As per the manufacturer’s recommendations; can be used as required. Over four gm/day, there is evidence of liver toxicity.

    Indications for Discontinuation: Resolution of pain, adverse effects or intolerance.

     

  6. Topical Medications

    Topical Medications is recommended for the management of pain in a few people who have acute, subacute, or chronic Kienböck illness. includes lidocaine patches, topical creams, and ointments

    Rationale for Recommendation – TOPICAL DRUG DELIVERY (e.g., capsaicin, lidocaine, NSAIDs, salicylates, and nonsalicylates) may be an acceptable form of treatment in some patients.

    To achieve the desired benefit while avoiding potential toxicity, a topical agent should be prescribed with strict application instructions and a maximum number of applications per day. Because the long-term effects of most patients are unknown, they may be better used episodically.

    These medications could be used in patients who prefer topical treatments over oral medications. Depending on the medication agent used, localised skin reactions may occur. Prescribers should keep in mind that topical medications can cause toxic blood levels.

    Capsaicin offers a secure and efficient substitute for systemic NSAIDs, albeit local stinging or burning that usually goes away with regular use limits its use. To prevent accidental contact with eyes and mucous membranes, patients should be instructed to apply the cream with a plastic glove or cotton applicator to the afflicted region. The prolonged usage of capsaicin is not advised.

    Topical Lidocaine is only suggested when a diagnosis of neuropathic pain has been made in writing. In this case, a trial lasting no longer than four weeks may be taken into consideration, with the requirement of functional gains being documented as a requirement for further usage.

    Topical NSAIDs (for example, diclofenac gel) may reach potentially therapeutic tissue levels. Overall, the low level of systemic absorption can be advantageous, allowing these medications to be applied topically when systemic administration is generally contraindicated (such as patients with hypertension, cardiac failure, peptic ulcer disease or renal insufficiency).

    Topical Salicylates or Nonsalicylates (such as methyl salicylate) do not generally seem to be more efficient than topical NSAIDs. Especially in individuals with chronic illnesses where systemic therapy is generally contraindicated, it may be administered for a short course or as an adjuvant to systemic medication.

     

  7. Opioids of Kienböck Disease

    Opioids are not recommended for acute, subacute, or chronic Kienböck disease.

    Opioids are recommended for limited use (not more than seven days) for postoperative pain management as adjunctive therapy to more effective treatments.

    Indications: For post-operative pain management, a brief prescription of opioids as an adjunct to more effective treatments (particularly NSAIDs and acetaminophen) is frequently required, particularly at night.

    Frequency/Duration: As needed during the day, solely at night thereafter, and finally completely discontinued.

    Rationale for Recommendation: When NSAIDs are ineffective in relieving a patient’s pain, opioids should be used sparingly, especially at night. Opioids are advised for brief, selective usage in postoperative patients, with nighttime use being the main recommendation for achieving postoperative sleep.

Rehabilitation of Hand, Wrist and Forearm Injuries

Rehabilitation (supervised formal therapy) required as a result of a work-related injury should focus on restoring functional ability required to meet the patient’s daily and work activities and return to work, with the goal of restoring the injured worker to pre-injury status to the greatest extent possible.

Active therapy calls for the patient to put in an internal effort to finish a particular activity or assignment. The procedures known as passive therapy rely on modalities that are administered by a therapist rather than the patient exerting any effort on their side.

Passive therapies are typically seen as a way to speed up an active therapy programme and achieve concurrently objective functional gains. Over passive interventions, active initiatives should be prioritised.

As an extension of the therapy process, the patient should be advised to continue both active and passive therapies at home in order to sustain improvement levels.

To facilitate functional gains, assistive devices may be included as an adjunctive measure in the rehabilitation plan.

Therapy: Active of Kienböck Disease

Therapeutic Exercise

  1. Therapeutic Exercise

    Therapeutic Exercise – Acute Phase is not recommended during acute presentations of Kienböck disease

     

  2. Therapeutic Exercise – Post-Operative/Recovery

    Therapeutic Exercise – Post-Operative/Recovery is recommended for patients post-operatively.

    Rationale for Recommendation – In general, acute activity is not recommended; however, recuperation or post-operative stages may require exercise. Increased grip strength, critical pinch strength, range of motion, and the development of work skills should all be considered functional goals.

    Frequency/Dose/Duration –Total visits may be as few as two to three for patients with mild functional deficits or as many as 12 to 15 for patients with more severe deficits who have documented ongoing objective functional improvement.

    If there is evidence of functional improvement toward particular objective functional targets, more than 12 to 15 visits may be necessary when there are persistent functional deficiencies (e.g., increased grip strength, key pinch strength, range of motion, advancing ability to perform work activities).

    A home exercise regimen should be created as part of the rehabilitation strategy and carried out alongside the therapy.

2. Therapy: Passive of Kienböck Disease

Therapy: Passive

  1. Self-Application of Ice

    Self-Application of Ice is recommended to treat Kienböck disease that is acute, subacute, or chronic.

     

  2. Self-application of Heat

    Self-application of Heat is recommended Kienböck disease, whether acute, subacute, or chronic.

    Splints are recommended for the treatment of a subset of patients with Kienböck illness, whether it be acute, subacute, or chronic.

    Rationale for Recommendations – To determine whether splinting relieves symptoms, a trial may be helpful. Long-term use, however, raises questions about the possibility of increased wrist weakness and debility.

Surgical treatments of Kienböck Disease

Surgical treatments

Surgical treatments are recommended if not improved eight weeks after the injury or after six weeks of non-operative treatment for Kienböck disease, as a treatment option for individuals with moderate to severe impairment. The decision to perform surgery depends on the disease’s stage and the surgeon’s judgement.

What our office can do if you have Kienböck Disease

We have the experience to help you with their workers compensation injuries. We understand what you are going through and will meet your medical needs and follow the guidelines set by the New York State Workers Compensation Board.

We understand the importance of your workers compensation cases. Let us help you navigate through the maze of dealing with the workers compensation insurance company and your employer.

We understand that this is a stressful time for you and your family. If you would like to schedule an appointment, please contact us so we will do everything we can to make it as easy on you as possible.

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I am fellowship trained in joint replacement surgery, metabolic bone disorders, sports medicine and trauma. I specialize in total hip and knee replacements, and I have personally written most of the content on this page.

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