Preiser Disease – Presentation and Treatment

Preiser disease is avascular necrosis of the scaphoid bone. Avascular necrosis of the carpal bones is a rare and  can affect the lunate, the pisiform, the capitate, and the scaphoid. Preiser disease was described by Preiser in 1910. He described this  in 5 patients, all with

previous history of wrist trauma, and scaphoid fractures in 3 of them.

The diagnosis is based on radiographic evidence of sclerosis and fragmentation of the proximal pole of the scaphoid.

 It is mandatory in all cases of scaphoid nonunion to exclude osteonecrosis by MRI scans before surgery is undertaken.

Presentation

Patients with Preiser disease present with wrist pain on radial-side which starts insidiously.

On examination, there would be  swelling and tenderness around the dorsoradial aspect of the wrist. There would be restriction of range of motion and grip strength.

Imaging

Early presentation may not reveal any radiological abnormality. In cases with clinical suspicion and normal radiographs, bone scan is helpful.

Changes in xrays would depend on the stage of the disease. Herbert and Lanzetta classified the stages of Preiser disease according to the radiographic appearance.

Stage I

Normal radiographs, positive bone scan.

Stage II

Increased density of proximal pole, generalized osteoporosis.

Stage III

Fragmentation of proximal pole. There could be presence of a pathological fracture.

Stage IV

Carpal collapse, osteoarthritis.

Treatment

Treatment options fro Preiser disease include

• Conservative immobilization
• Arthroscopic debridement of the necrotic scaphoid and degenerative scapholunate ligament
• Revascularization procedures
• Radial osteotomy
• Silicone replacement arthroplasty
• Four Bone fusion (capitate, hamate, lunate, and triquetrum)
• Scaphoid excision
• Poximal row carpectomy combined with scaphoid excision.
• Pronator quadratus pedicle bone graft may also be considered.

Arthroscopic debridement and drilling of the lesion is a minimally invasive technique that seems to provide pain relief for a long period of time in patients with Preiser’s disease  and can be employed initially along with connserative measures like rest, splintage, and electrical stimulation.

If these measures are unsuccessful and Preiser disease progresses with the scaphoid showing collapse similar to that seen in a nonunion, a vascularized bone graft is recommended.  The bone graft can be harvested from distal radius dorsally or volarly  in the form of a pronator quadratus graft, or from the second metacarpal.

Preiser Disease Complications

• Degenerative changes
• Stiffness
• Weakness of wrist
• Complex Regional Pain Syndrome
• Continued pain
• Wrist instability