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TC(1079).(05).Orthopedics Case No 155:- Kienböck Disease-2

Kienböck Disease — বাংলায় সাজানো ক্লিনিক্যাল নোট

মূল কথা: Kienböck disease-এ lunate bone-এর blood supply কমে/বন্ধ হয়ে avascular necrosis হয়। কোনো oral medicine lunate-এর blood supply “ফিরিয়ে” দেয় না। ওষুধগুলো মূলত pain, inflammation, swelling, gastric protection এবং selected ক্ষেত্রে bone-health support-এর জন্য ব্যবহৃত হয়। Definitive treatment হলো stage-based immobilization বা hand/wrist surgery।

1) Definition / সংজ্ঞা

Kienböck disease হলো wrist-এর মাঝের carpal bone lunate-এর avascular necrosis / osteonecrosis—অর্থাৎ lunate bone-এ রক্ত সরবরাহ কমে গিয়ে bone দুর্বল, sclerotic, পরে collapse/fragmented হয়ে যায়। ফলে wrist pain, stiffness, grip weakness এবং late stage-এ wrist arthritis হয়।

2) Cause / Etiology & Pathophysiology — কারণগুলো

Kienböck disease-এর exact cause সব সময় জানা যায় না; সাধারণত multifactorial।

প্রধান কারণ / Risk factor

  • Lunate-এর blood supply কম/একক vessel-dependent হওয়া
    কিছু মানুষের lunate bone-এ vascular supply naturally কম বা vulnerable থাকে—তাই injury বা চাপের পর osteonecrosis হতে পারে।
  • Negative ulnar variance
    Ulna যদি radius-এর তুলনায় ছোট হয়, lunate-এর উপর বেশি mechanical load পড়ে। এটি Kienböck disease-এর সাথে classical association। তবে negative ulnar variance থাকলেই disease হবেই—এমন নয়।
  • Repeated microtrauma / heavy manual work
    বারবার wrist loading, vibration tools, push-up type stress, heavy gripping—lunate-এর উপর chronic stress বাড়ায়।
  • Acute trauma
    পড়ে গিয়ে wrist injury, sprain-like trauma-এর পর persistent dorsal wrist pain থাকলে Kienböck suspect করতে হয়।
  • Lunate morphology / radial inclination variation
    Wrist anatomy-এর কিছু variation lunate-এর load distribution বদলাতে পারে।
  • General osteonecrosis risk factors
    Smoking, prolonged steroid use, sickle cell disease, SLE, hypercoagulable state ইত্যাদি general AVN risk factor হিসেবে বিবেচনা করা যায়; তবে Kienböck disease-এ এগুলো সব রোগীর ক্ষেত্রে থাকে না।

3) Symptoms / Clinical Features — লক্ষণগুলো

Early symptoms

  • Dorsal wrist pain
    Wrist-এর পেছনের মাঝামাঝি অংশে pain, বিশেষ করে lunate-এর উপর।
  • Pain increases with activity
    Heavy gripping, push-up, wrist extension, lifting, hammering, typing/working-এর পর pain বাড়ে।
  • Sprain-এর মতো presentation
    অনেক সময় patient ভাবে “wrist sprain”, কিন্তু pain দীর্ঘদিন থাকে।
  • Mild swelling
    Wrist-এর dorsal side-এ swelling থাকতে পারে।

Progressive symptoms

  • Wrist stiffness
    Flexion-extension কমে যায়।
  • Grip strength কমে যায়
    বোতল খোলা, শক্ত করে ধরা, কাজের সময় দুর্বলতা অনুভূত হয়।
  • Tenderness over lunate
    Dorsal central wrist palpation করলে ব্যথা।
  • Pain with axial loading
    Wrist extend করে চাপ দিলে pain বাড়ে।

Late symptoms

  • Persistent pain at rest
  • Marked ROM restriction
  • Clicking/catching sensation
  • Secondary wrist arthritis-এর pain
  • Work disability / daily activity limitation

4) Clinically Diagnosis — কীভাবে clinically suspect করবেন

History

  • Dorsal wrist pain কতদিন?
  • Trauma ছিল কি?
  • Manual work, sports, vibration tool, repeated wrist loading আছে কি?
  • Dominant hand involved কি না?
  • Grip weakness আছে কি?
  • Steroid use, smoking, SLE/sickle cell/hypercoagulable history আছে কি?
  • Previous “wrist sprain” diagnosis কিন্তু pain যাচ্ছে না—এটা গুরুত্বপূর্ণ clue।

Examination

  • Inspection: dorsal wrist swelling, muscle wasting, deformity।
  • Palpation: lunate tenderness—dorsal central wrist, distal to Lister’s tubercle area।
  • Range of motion: flexion, extension, radial/ulnar deviation compare with opposite side।
  • Grip strength: dynamometer থাকলে quantify করা ভালো।
  • Pain provocation: wrist extension + axial loading করলে pain বাড়ে।
  • Neurovascular exam: sensation, capillary refill, radial/ulnar pulse।
  • Associated instability: scapholunate tenderness/click, carpal alignment।

Clinical diagnosis alone confirmatory নয়; diagnosis নিশ্চিত করতে imaging লাগে।

5) Investigations — specific test

1. Plain X-ray wrist — PA, lateral, oblique view

কেন করবেন:
Stage II onward sclerosis, lunate collapse, carpal alignment, arthritis, ulnar variance দেখা যায়।

Early stage limitation:
Stage I-এ X-ray normal হতে পারে।

2. MRI wrist — best early investigation

কেন করবেন:
Early occult Kienböck disease ধরতে MRI সবচেয়ে sensitive। Diffuse low T1 signal lunate osteonecrosis-এর important feature। Contrast MRI করলে vascularity/perfusion idea পাওয়া যায়।

3. CT scan wrist

কেন করবেন:
Lunate collapse, fragmentation, coronal fracture, surgical planning, carpal architecture evaluation-এর জন্য CT useful।

4. Bone scan / SPECT

আজকাল MRI availability থাকলে routine নয়। MRI contraindicated/unavailable হলে selected case-এ ব্যবহার করা যায়; specificity কম।

5. Lab tests

Kienböck disease diagnose করার জন্য routine blood test লাগে না। তবে differential diagnosis থাকলে:

  • CBC, ESR, CRP — infection/inflammatory arthritis suspect হলে
  • RA factor/anti-CCP — rheumatoid arthritis suspect হলে
  • Uric acid — gouty wrist arthritis suspect হলে
  • Hb electrophoresis — sickle cell disease suspicion থাকলে

6) Lichtman Staging — সহজভাবে

StageImaging findingClinical meaning
Stage IX-ray normal; MRI abnormalEarly AVN
Stage IILunate sclerosis, shape preservedBone dead/hard কিন্তু collapse হয়নি
Stage IIIALunate collapse, carpal alignment preservedCollapse শুরু
Stage IIIBCollapse + scaphoid flexion/carpal height lossCarpal instability
Stage IIICCoronal fracture of lunateFragmentation
Stage IVLunate collapse + wrist arthritisAdvanced degenerative disease

7) Differential Diagnosis

  • Chronic wrist sprain
  • Occult scaphoid/lunate fracture
  • Scapholunate ligament injury
  • Ulnar impaction syndrome
  • Lunate intraosseous ganglion
  • Wrist osteoarthritis
  • Rheumatoid arthritis
  • De Quervain tenosynovitis
  • Osteoid osteoma
  • Bone contusion

8) Complications — বাংলায় সহজভাবে

  • Lunate collapse:
    Blood supply কমে lunate bone শক্ত/মরা হয়ে পরে চ্যাপ্টা হয়ে যায়।
  • Fragmentation:
    Lunate bone টুকরো টুকরো হতে পারে, ফলে pain ও instability বাড়ে।
  • Carpal instability:
    Lunate collapse হলে wrist-এর অন্যান্য carpal bones alignment হারায়; scaphoid flexion/rotation হতে পারে।
  • Scapholunate dissociation:
    Scaphoid-lunate relation নষ্ট হয়ে chronic wrist instability তৈরি হয়।
  • Secondary wrist arthritis:
    Long-standing collapse ও malalignment থেকে radiocarpal/midcarpal osteoarthritis হয়।
  • Grip weakness ও ROM loss:
    Patient কাজ করতে পারে না, heavy work অসম্ভব হয়ে যায়।
  • Chronic pain/disability:
    Late stage-এ pain constant হয় এবং surgery যেমন proximal row carpectomy বা wrist fusion লাগতে পারে।

9) Treatment / Management

A) Non-pharmacological management

Stage I / early Stage II

  • Wrist immobilization: short-arm cast বা rigid wrist splint সাধারণত 6–12 weeks, অনেক surgeon 3 months পর্যন্ত করেন।
  • Activity modification: heavy lifting, push-up, hammering, vibration tool avoid।
  • Follow-up imaging: pain কমছে কি না, MRI/X-ray progression আছে কি না।
  • Hand therapy: immobilization শেষ হলে ROM ও grip strengthening।

Stage II–IIIA

  • Joint leveling procedure
    Negative ulnar variance থাকলে radial shortening osteotomy commonly done।
  • Vascularized bone graft / revascularization
  • Distal radius core decompression
  • Patient age, stage, ulnar variance, cartilage status দেখে decision।

Stage IIIB–IV

  • Proximal row carpectomy
  • Limited intercarpal fusion
  • Scaphotrapeziotrapezoid / scaphocapitate fusion
  • Total wrist fusion — severe arthritis/painful stiff wrist-এ।

Treatment stage-based; no single best operation for every patient।

10) Pharmacological Treatment — Bangladesh prescription practical list

Adult dose ধরে বলা হলো। Pregnancy, CKD, liver disease, peptic ulcer, anticoagulant use, asthma, elderly patient—এসব থাকলে dose/choice বদলাতে হবে।

1. Generic name: Paracetamol / Acetaminophen

  • Therapeutic category: Non-opioid analgesic, antipyretic
  • Pharmacological class: Para-aminophenol derivative; central COX/prostaglandin inhibition
  • Bangladesh available brand name:
    • Napa 500 mg, Napa Extend 665 mg, Napa One 1000 mg
    • Ace 500 mg
    • Tamen 500 mg
    • Renova 500 mg
    • Paragesic 500 mg

  • Dose: 500–1000 mg orally every 6–8 hours PRN
  • Maximum: 4 g/day; liver disease/alcohol use হলে কম dose
  • Duration: 3–5 days, persistent pain হলে reassess
  • কেন used হয়: mild–moderate wrist pain control; NSAID contraindication থাকলে first choice
  • Side effects: nausea, rash, liver toxicity in overdose
  • Interaction: warfarin-এর সাথে regular high-dose use করলে INR বাড়তে পারে; alcohol, enzyme inducer, অন্য paracetamol-containing medicine avoid

2. Generic name: Ibuprofen

  • Therapeutic category: NSAID analgesic, anti-inflammatory
  • Pharmacological class: Propionic acid derivative; non-selective COX inhibitor
  • Bangladesh available brand name:
    • Advel 400 mg
    • Flamex 400 mg
    • Profen 400 mg
    • Reumafen 400 mg
    • Intaflam 400 mg

  • Dose: 400 mg orally 2–3 times daily after meal
  • Usual max: OTC 1200 mg/day; prescription setting-এ selected patient-এ higher dose short course
  • Duration: 3–7 days
  • কেন used হয়: pain + inflammatory swelling কমাতে; early symptomatic relief
  • Side effects: dyspepsia, gastritis, peptic ulcer, GI bleeding, renal injury, BP rise, edema, bronchospasm, dizziness
  • Interaction: warfarin/DOAC, aspirin, clopidogrel, steroid, SSRI, ACEi/ARB + diuretic, lithium, methotrexate, cyclosporine, tacrolimus, quinolone—caution/avoid
  • Avoid: active ulcer, severe CKD, severe heart failure, NSAID-induced asthma, late pregnancy

3. Generic name: Naproxen

  • Therapeutic category: NSAID analgesic, anti-inflammatory
  • Pharmacological class: Propionic acid derivative; non-selective COX inhibitor
  • Bangladesh available brand name:
    • Naprosyn 500 mg
    • Naprox 250 mg / 500 mg
    • Naxin 250 mg / 500 mg
    • Napryn 250 mg / 500 mg
    • Napsod 275 mg / 550 mg

  • Dose: 250–500 mg orally twice daily after meal
  • Maximum: usually 1000 mg/day
  • Duration: 5–10 days, then review
  • কেন used হয়: longer-acting NSAID; wrist pain ও swelling কমাতে
  • Side effects: gastritis, ulcer/bleeding, renal impairment, edema, BP rise, dizziness
  • Interaction: anticoagulant/antiplatelet/steroid/SSRI-এর সাথে bleeding risk; ACEi/ARB + diuretic-এর সাথে AKI risk; lithium/methotrexate toxicity risk

4. Generic name: Naproxen + Esomeprazole

  • Therapeutic category: NSAID + anti-ulcerant combination
  • Pharmacological class: Naproxen = NSAID; Esomeprazole = proton pump inhibitor
  • Bangladesh available brand name:
    • Naprox Plus 500 mg + 20 mg
    • Naprosyn Plus 500 mg + 20 mg
    • Naxin Plus 500 mg + 20 mg
    • Naprozol 500 mg + 20 mg
    • Progesic 500 mg + 20 mg

  • Dose: 1 tablet twice daily before meal/according to formulation instruction
  • Duration: 5–10 days or as clinically indicated
  • কেন used হয়: NSAID pain control + gastric ulcer risk কমানোর জন্য
  • Side effects: naproxen-related GI/renal/CV effects; esomeprazole-related headache, diarrhea, hypomagnesemia with long-term use
  • Interaction: same NSAID interactions; PPI may affect absorption of some drugs; anticoagulant/antiplatelet use হলে caution

5. Generic name: Aceclofenac

  • Therapeutic category: NSAID, analgesic, anti-inflammatory
  • Pharmacological class: Phenylacetic acid derivative; COX inhibitor
  • Bangladesh available brand name:
    • Flexi 100 mg, Flexi SR 200 mg
    • Reservix 100 mg, Reservix SR 200 mg
    • Avenac 100 mg
    • Movex 100 mg, Movex SR 200 mg
    • Mervan 100 mg, Mervan SR 200 mg

  • Dose: 100 mg orally twice daily after meal; SR 200 mg once daily
  • Duration: 5–7 days, then review
  • কেন used হয়: Bangladesh prescription-এ musculoskeletal pain/inflammation-এর জন্য commonly used NSAID
  • Side effects: dyspepsia, ulcer, GI bleeding, renal injury, edema, BP rise, rash, liver enzyme elevation
  • Interaction: anticoagulant, antiplatelet, steroid, SSRI, ACEi/ARB, diuretic, lithium, methotrexate—caution
  • Avoid: active peptic ulcer, severe renal/hepatic/cardiac disease, NSAID hypersensitivity/asthma

6. Generic name: Etoricoxib

  • Therapeutic category: NSAID analgesic, anti-inflammatory
  • Pharmacological class: Selective COX-2 inhibitor
  • Bangladesh available brand name:
    • Etorix 60 mg / 90 mg / 120 mg
    • Oricox 30 mg / 60 mg / 90 mg / 120 mg
    • Ribox 60 mg / 90 mg / 120 mg
    • Recox 60 mg / 90 mg / 120 mg
    • Etoshine 60 mg / 90 mg / 120 mg
    • Etocox 60 mg / 90 mg / 120 mg

  • Dose: 60 mg orally once daily after meal for acute musculoskeletal pain
  • Duration: shortest possible, usually 3–7 days
  • কেন used হয়: once-daily analgesia; GI irritation তুলনামূলক কম হতে পারে, তবে CV risk বিবেচনা জরুরি
  • Side effects: hypertension, edema, dyspepsia, renal impairment, cardiovascular thrombotic risk
  • Interaction: warfarin/anticoagulant, ACEi/ARB, diuretic, lithium, methotrexate, rifampicin—caution
  • Avoid: uncontrolled hypertension, ischemic heart disease, stroke/TIA, heart failure, severe CKD

7. Generic name: Diclofenac sodium topical gel

  • Therapeutic category: Topical NSAID analgesic
  • Pharmacological class: Phenylacetic acid derivative; COX inhibitor
  • Bangladesh available brand name:
    • Diclofen Gel 1%
    • Voligel 1%, Voligel Max 2%
    • Volicool 1%
    • Volifen 1%
    • Voltagel 1%
    • Emov Gel 1%
    • Erdon Gel 1%

  • Dose: wrist area-তে thin layer apply 3–4 times daily; hand/wrist joint-এ commonly 2 g per application
  • Duration: 7–14 days, তারপর review
  • কেন used হয়: local pain relief; oral NSAID avoid করতে হলে useful
  • Side effects: local burning, rash, itching, photosensitivity; large area/long use-এ systemic NSAID effect হতে পারে
  • Interaction: systemic interaction কম, কিন্তু oral NSAID-এর সাথে overuse করলে total NSAID exposure বাড়ে
  • Avoid: broken skin, infected skin, occlusive dressing, NSAID hypersensitivity

8. Generic name: Pantoprazole

  • Therapeutic category: Anti-ulcerant, gastric acid suppressant
  • Pharmacological class: Proton pump inhibitor
  • Bangladesh available brand name:
    • Pantonix 20 mg / 40 mg
    • Pantolok 20 mg / 40 mg
    • Pantogut 20 mg / 40 mg
    • Pantogen 20 mg / 40 mg
    • Pantopra 20 mg / 40 mg
    • Protozin 20 mg / 40 mg

  • Dose: 20–40 mg orally once daily, breakfast-এর 30 minutes আগে
  • Duration: NSAID course চলাকালীন; high GI risk হলে 2–4 weeks or more as indicated
  • কেন used হয়: NSAID-induced gastritis/ulcer risk কমাতে
  • Side effects: headache, diarrhea/constipation, nausea; long-term use-এ hypomagnesemia, B12 deficiency, infection risk
  • Interaction: clopidogrel-এর সাথে clinically consider; high-dose methotrexate, warfarin monitoring, ketoconazole/iron absorption কমতে পারে

9. Generic name: Tramadol

  • Therapeutic category: Opioid analgesic
  • Pharmacological class: Weak µ-opioid receptor agonist + serotonin/noradrenaline reuptake inhibition
  • Bangladesh available brand name:
    • Anadol 50 mg capsule
    • Anadol SR 100 mg
    • Anadol suppository 100 mg
    • Dolonil 50 mg capsule
    • Doloran 50 mg / 100 mg

  • Dose: 50 mg orally every 6–8 hours PRN
  • Maximum: 400 mg/day
  • Duration: very short course, usually 2–3 days; severe pain only
  • কেন used হয়: severe pain যখন paracetamol/NSAID যথেষ্ট নয়, surgery/orthopedic review পর্যন্ত bridging analgesic
  • Side effects: nausea, vomiting, dizziness, sedation, constipation, dependence, respiratory depression, seizure risk
  • Interaction: alcohol, benzodiazepine, sedative, SSRI/SNRI/TCA/MAOI, linezolid, triptan—serotonin syndrome/CNS depression risk; epilepsy patient-এ caution
  • Advice: driving/operating machine avoid

10. Generic name: Calcium + Vitamin D3 / Cholecalciferol

Kienböck disease cure করার medicine নয়। Vitamin D deficiency, osteopenia, low dietary calcium, fracture risk থাকলে use করা যায়।

  • Therapeutic category: Mineral + vitamin supplement
  • Pharmacological class: Calcium salt + fat-soluble vitamin D analogue
  • Bangladesh available brand name:
    • G-Cal D 500 mg + 200 IU
    • Ipical-D 500 mg + 200 IU
    • Carbocal-D 500 mg + 200 IU
    • Labcal-D 500 mg + 200 IU
    • Carben DS 600 mg + 400 IU
    • Aristo D3 2000 IU / 20000 IU / 40000 IU
    • D-Rise 2000 IU / 20000 IU / 40000 IU
    • D-2000 / D-20000 / D-40000
    • Defrol 50000 IU

  • Dose:
    • Calcium 500 mg + D3 200 IU: 1 tablet twice daily with meal
    • Calcium 600 mg + D3 400 IU: 1 tablet once/twice daily
    • Vitamin D deficiency: Cholecalciferol 40,000 IU weekly for 7 weeks, then maintenance 1400–2000 IU/day
  • কেন used হয়: deficiency correction ও general bone health
  • Side effects: constipation, bloating, hypercalcemia, renal stone risk
  • Interaction: tetracycline, quinolone, levothyroxine, iron—4 hours gap; thiazide diuretic/digoxin-এর সাথে caution

11) Bangladesh doctors prescription pattern — কী কী drug commonly used হয় এবং কেন

Kienböck disease-এর prescription সাধারণত symptom control + immobilization + referral focused হয়।

  1. Paracetamol
    • Mild pain control
    • NSAID contraindicated হলে safer option
  2. NSAID: Ibuprofen / Naproxen / Aceclofenac
    • Pain + inflammation + swelling কমাতে
    • Short course, after meal
  3. COX-2 inhibitor: Etoricoxib
    • Once daily pain relief
    • Gastric irritation concern থাকলে selected patient-এ
    • CV risk থাকলে avoid
  4. Topical diclofenac gel
    • Local pain relief
    • Oral NSAID avoid করতে চাইলে useful
  5. PPI: Pantoprazole / Esomeprazole combination
    • NSAID-induced gastritis/ulcer prevention
    • Elderly, ulcer history, anticoagulant/steroid use থাকলে important
  6. Tramadol
    • Severe pain only
    • Routine long-term use নয়
  7. Calcium + Vitamin D3
    • Vitamin D deficiency/osteopenia থাকলে
    • Kienböck disease-এর specific curative drug নয়

Antibiotic, steroid injection, uric-acid lowering drug—Kienböck disease-এর routine treatment নয়, unless অন্য diagnosis থাকে।

12) Prevention — কীভাবে risk কমাবেন

Kienböck disease পুরোপুরি prevent করার guaranteed method নেই, কারণ cause often idiopathic। তবে risk/progression কমাতে:

  • Wrist injury হলে persistent dorsal pain থাকলে early orthopedic evaluation
  • Heavy gripping, repeated wrist loading, push-up, vibration tool avoid/modify
  • Wrist brace/splint ব্যবহার করা, বিশেষ করে painful activity-তে
  • Ergonomic work habit
  • Smoking stop
  • Unnecessary long-term steroid avoid
  • Manual worker হলে periodic rest, tool grip modification
  • Pain 2–3 weeks-এর বেশি থাকলে X-ray normal হলেও MRI consider
  • Early stage-এ immobilization ও follow-up করলে collapse delay/avoid হতে পারে

Overview / Summary

Kienböck disease হলো lunate bone-এর avascular necrosis। Early stage-এ X-ray normal হলেও MRI diagnosis করতে পারে। Disease progress করলে lunate collapse, carpal instability এবং wrist arthritis হয়। Medicine শুধু pain/inflammation control করে; definitive management হলো stage-based immobilization বা surgery।

Actionable Plan / Steps

  1. Suspect করুন: chronic dorsal wrist pain + grip weakness + activity-related pain।
  2. Initial test: wrist X-ray PA/lateral/oblique + ulnar variance assessment।
  3. X-ray normal কিন্তু suspicion high: MRI wrist।
  4. Stage determine করুন: Lichtman staging।
  5. Stage I/early II: splint/cast + analgesic + activity modification।
  6. Stage II–III: hand/wrist orthopedic surgeon referral for joint leveling/revascularization options।
  7. Stage IV: arthritis management—PRC/limited fusion/total wrist fusion depending case।
  8. Drug use: paracetamol ± short NSAID ± PPI; severe pain হলে short tramadol; calcium-D only if deficiency।

Reference List

Textbook references

  1. Green’s Operative Hand Surgery, 8th ed. — Osteonecrosis of the lunate / Kienböck disease section.
  2. Campbell’s Operative Orthopaedics, 14th ed. — Hand and wrist disorders; lunate osteonecrosis.
  3. Apley & Solomon’s System of Orthopaedics and Trauma, 10th/11th ed. — Wrist disorders and osteonecrosis principles.
  4. Maheshwari’s Essential Orthopaedics — Avascular necrosis and wrist pathology overview.

Guideline / clinical reference

  1. AAOS OrthoInfo — Kienböck’s Disease.
  2. StatPearls — Kienböck Disease, clinical features, imaging, staging, treatment.
  3. Orthobullets — Kienböck Disease treatment by stage, updated 2026.
  4. BNF/NICE drug monographs for NSAID/opioid/topical NSAID dosing.

Peer-reviewed journals with DOI

  1. Arnaiz J, Piedra T, Cerezal L, et al. Imaging of Kienböck Disease. AJR Am J Roentgenol. 2014. DOI: 10.2214/AJR.13.11606.
  2. Innes L, Strauch RJ. Systematic review of the treatment of Kienböck’s disease in its early and late stages. J Hand Surg Am. 2010;35:713–717. DOI: 10.1016/j.jhsa.2010.02.002.
  3. Lichtman DM, Pientka WF, Bain GI. Kienböck Disease: Moving Forward. J Hand Surg Am. 2016. DOI: 10.1016/j.jhsa.2016.02.013.
  4. van Leeuwen WF, Janssen SJ, Ring D. Negative Ulnar Variance and Kienböck Disease. J Hand Surg Am. 2016. DOI: 10.1016/j.jhsa.2015.10.014.

Md.Rafiqul Islam Lipu,Date:-24-06-2026 Wednesday,Time:-04-21-12 Pm

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