Der Unfallchirurg
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Kienböck's disease, also known as avascular necrosis of the lunate bone describes the slowly progressive osteonecrosis of the lunate bone with secondary development of osteoarthritis and carpal collapse. In order to emphasize the atraumatic origin of the disease, this is normally referred to as aseptic, idiopathic or avascular lunate necrosis. ⋯ New sophisticated classification methods provide the basis for a differentiated treatment. This article provides an overview of the current state of knowledge about the etiology and pathogenesis as well as the clinically relevant diagnostic procedures and classifications.
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Typical lesions of the carpal ligaments are mostly found after a fall on the wrist in hyperextension or as complex injuries after severe trauma, e. g. after a fall from a significant height, motorcycle accident or as accompanying lesions in multiple trauma. The typical mechanisms, patterns and diagnostic algorithms are well known for the common ligamentous injuries (e.g. scapholunate, lunotriquetral and perilunate); therefore, consistent diagnostic procedures and adequate therapy are increasingly performed after such lesions, e. g. by early ligament repair or by ligament reconstruction through augmentation. ⋯ If followed by immobilization with a cast or stable brace, healing can be achieved in most cases; however, more problems occur if ligamentous lesions or instabilities are not clearly due to a trauma mechanism and more the result of laxity or hypermobile situations due to a congenital predisposition. In such cases, wrist pain is often described and misdiagnosed as the result of overload or tenovaginitis.
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There still is no standard therapy that predictably results in healing of avascular necrosis of the lunate bone. Nevertheless, there exists a wide spectrum of operative treatment options for different stages. ⋯ According to the presented algorithms a stage-dependent therapy of necrosis of the lunate bone is possible. It should not be ignored that there are still no scientific and evidence-based arguments for some of these treatment options. This is also true for maximally invasive procedures, where superiority to more simple procedures have not been proven. Therefore, their application should be restricted and based on an individual decision.
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Perilunate injuries are one of the most severe injuries of the hand. They occur relatively rarely but necessitate that diagnostic procedures should be carried out thoroughly and as soon as possible. The therapeutic strategy must consider the age, exact type and full extent of the injury. The key for successful treatment is exact anatomic reduction and stable fixation of all injured structures.