The FIHS will post each month a new issue related to pathologies
of the upper extremity. After a month, the text will be available
in the « files » section.
issue for the month will be : The
Dr Constantin SOKOLOW/F.I.H.S
What is the Preiser's disease?
This disease is defined as an aseptic necrosis of one of the carpal
bones : the carpal (or wrist) is made of a very precise assembly
of eight small bones, in two rows, under the two bones of the
row : the scaphoïd, the lunate, the triangular making a united
chain linked by strong ligaments (the pisiform is in front of
the triangular), authorises torsion movements.
row : the trapezium, the trapezoid, the capitate and the hamate,
is forming a rigid bloc between the first row and the base of
These various bones – as any tissue in the organism –
are living elements and therefore need a nutritive blood supply
brought by very small arteries (arterioles) that have been well
studied thanks to anatomic dissections and radiological injections:
in the case of suppression of the blood supply to one of the bones,
the bone suffers and the bone tissues “die”: that
is the necrosis. At a physiological state, the tissues –
and the bones – are constantly facing destruction due to
the aging of the cells, balanced by a tissue creation thanks to
the supply of young cells (these cells being brought by the blood);
in the case of a rarefaction of the blood supply, a disequilibrium
happens and the destruction is more important than the reconstruction.
Thus appears the necrosis.
At the carpal level, the necrosis process more often affects two
: from far the most frequent ; its necrosis has been described
by KIENBOCK in 1910,
very rare, was described by PREISER in 1910,
The scaphoïd, one of the biggest carpal bones, is located
on the exterior side of the wrist, it is extremely mobile in all
the wrist movements.
This pathology is extremely rare, and thus quite unknown. The
reason why it happens remains mysterious. This necrosis happens
without any trauma or any triggering factor and generally affects
young adults : the very small number of published cases makes
it really hard to propose any precise statistics concerning this
What are the clinical signs ?
The patient suffers from a vague wrist pain located on the outside
(on the thumb side). The clinical examination is quite poor :
there sometimes is a scaphoïd sensibility and a constant
loss of strength. The lack of results during the examination usually
leads to “diagnosis wanderlust”.
What are the complementary exams ?
Standard radiological shots must be taken, the face and the profile
(often, at the first stages of the disease, one will have to take
picture of the sane side to compare both images).
They will have to be interpreted according to the context: the
most common error is to mistake it for a pseudo-arthrosis (non-union
fracture), which will lead to a therapeutic error heavy of consequences.
Complementary examinations will have to be done as soon as the
diagnosis is made :
will give precise details on the state of the lesions,
will precise the state of the bone structure and especially the
state of the cartilages of the scaphoïd and the radius: these
two elements are important when deciding upon the surgery option.
Some radiological modifications seems to be quite similar with
the Kienböck’s disease :
I: normal radiological image ; that’s the beginning. The
MRI and the scintigraphy are abnormal ;
II : alteration of the contrasts in the scaphoïd, predominant
on the proximal pole, near the radius : the shape of the scaphoïd
III : the shape of the scaphoïd is altered, and it sometimes
is fragmented ; the upper portion is collapsed and the image witnesses
IV : important collapse of the scaphoïd, with images of a
wrist’s arthrosis between the scaphoïd and the radius.
What are the possible treatments?
The surgery option has been very simple for a long time : the
scaphoïd was taken out and two options were offered :
of the first row of the carpal bones,
the scaphoïd by a prosthetics.
Each intervention had advantages and inconveniences and it seems
that only the first type of intervention had had good results
in the long term.
Currently, it seems that, in certain cases, we can avoid excising
the scaphoïd, mainly when its shape is still more or less
conserved and when the cartilage is still fine ; at this stage
we recommend a bonegraft :
microsurgery, by the supply of vascular bonegraft.
These interventions are more technically difficult but have given
What is the prognosis ?
This pathology is exceptional and has benefited
from recent findings in vascular anatomy and microsurgery that
have led to a different approach of the surgery treatment. However
it must remain in the realm of highly specialised hand surgeons.