Preiser's disease (aseptic scaphoid necrosis)

Anatomy: Role of the scaphoid in the wrist

The scaphoid bone (os scaphoid) lies on the thumb side of the carpus and connects the proximal and distal carpal rows. It is central to the power transmission and fine kinematics of the wrist. Its blood supply is naturally vulnerable: the majority of the vessels enter distally and run backwards towards the pole near the body. This peculiarity explains why circulatory disorders in the scaphoid can lead to structural problems.

• Joint partners: radius (radius), lunate (lunate), large polygonal bone (trapezium), etc.
• Function: Guidance and stability during flexion/extension and side bending
• Blood flow: retrograde inflow – anatomically vulnerable proximal pole

What is Preiser's disease?

Preiser's disease is an aseptic (non-infectious) bone necrosis of the scaphoid bone without a previous fracture. At times the bone does not receive enough blood, which can lead to bone marrow edema, hardening (sclerosis), micro-fractures and, in late stages, changes in shape and joint wear. The disease must be distinguished from pseudoarthrosis (false joint) following a fracture of the scaphoid bone and should not be confused with Kienböck's disease (lunar bone necrosis).

Causes and risk factors

The exact cause is often unclear (idiopathic). An interplay between anatomical vascular susceptibility, repeated micro-stress and individual risk factors is suspected.

• Microtrauma/overload (e.g. repetitive supporting and gripping loads, vibration tools)
• Smoking (impairs microcirculation)
• Systemic factors: long-term corticosteroid therapy, alcohol abuse, coagulation disorders
• Metabolic/autoimmune diseases (e.g. lupus, sickle cell disease) – rare
• Anatomical variations of the blood supply

A broken scaphoid bone that has not healed typically does not lead to Preiser's disease, but rather to a nonunion - both conditions differ in their development and treatment.

Symptoms: How do I recognize Preiser’s disease?

• Stress-dependent pain on the front of the spoke side of the wrist (Tabatière/scaphoid fossa)
• Pressure pain over the scaphoid, especially when bending back/bending to the side
• Decreased grip strength, uncertainty during supporting movements
• Occasionally swelling, morning stiffness
• Reinforcement during sports (e.g. calisthenics, tennis) or work with tools

Diagnostics in practice

The diagnosis is based on history, clinical examination and imaging techniques. In the early stages, x-rays are often unremarkable, which is why magnetic resonance imaging (MRI) plays a central role.

Laboratory may be useful if systemic causes are suspected (e.g. coagulation disorders, inflammatory diseases). The stage-appropriate classification helps to realistically define therapy goals.

Stages and course

Clinical and imaging findings are combined for classification. Various classifications describe a similar course from early vital disorders to structural collapse and subsequent osteoarthritis.

• Early stage: MRI shows bone marrow edema; X-rays are often normal
• Intermediate stage: sclerosis zones on x-ray, pain with weight; Still in shape
• Advanced: microfractures, beginning flattening/collapse of the scaphoid
• Late stage: fragmentation, carpal instability and secondary osteoarthritis v. a. radioscaphal

The process is individual. The aim is to relieve symptoms, maintain function and slow progression.

Conservative therapy – what we exhaust first

The guiding strategy is adapted to the stage and load. In early and intermediate stages, conservative treatment is very important. It requires patience and consistent cooperation.

• Immobilization/relief: temporary thumb-wrist orthosis (splint) or plaster; Pain-adapted wearing time
• Activity modification: avoiding support and impact loads, ergonomic adjustments at work
• Medication: anti-inflammatory painkillers for a short time; gentle on the stomach and according to indications
• Physio/hand therapy: mobilization that is gentle on the joints, stabilization of the surrounding muscles, proprioceptive training
• Address risk factors: quitting smoking, reducing stressful medications (e.g. systemic steroids) – only in coordination with the prescribing doctor
• Optimize bone metabolism: vitamin D status, calcium intake, if necessary osteological examination

Possible bone-effective medications (e.g. bisphosphonates) in analogy to other aseptic necroses can be explained individually. Evidence for Preiser's disease is limited; If used at all, it is carefully considered and off-label.

Apparatus procedures such as ultrasound bone stimulation or hyperbaric oxygen therapy are discussed, but are not proven to be standard. We discuss benefits and limitations transparently.

Regenerative/biological processes – realistic classification

Platelet concentrates (PRP) or cell-based procedures are not established for scaphoid necrosis. Data availability and approval are limited. In our practice, evidence-based, conservative options are paramount; We only consider experimental procedures - if at all - in an individual context and after informed consent.

Surgical options – when conservative is not enough

If the symptoms are severe, progress despite consistent protection or structural damage, surgery may make sense. The selection depends on the stage and is made by experienced hand surgeons. We advise, compile findings and coordinate the referral.

• Drilling/decompression and microfracture-like procedures for reperfusion in early stages
• Vascularized bone grafts (e.g. pediculated 1,2-ICSRA flaps) to improve vitality
• corrective interventions for mold collapse; If necessary, radial styloidectomy if there is a bottleneck
• Pain and maintenance operations for osteoarthritis: partial wrist fusion, four-corner fusion, proximal carpal resection (proximal row carpectomy) or selective denervation - depending on the findings

Surgical procedures have different recovery times and functional profiles. We discuss goals and alternatives in advance without promising a specific result.

Prognosis, everyday life and rehabilitation

Recovery takes weeks to months. In conservative courses, the increase in stress depends on pain and imaging. The aim is to have a resilient hand that is suitable for everyday use with the best possible mobility.

• Sports: contact and support-intensive sports only after approval, start with cyclic, low-impact activities
• Work: ergonomic adjustment, break management, temporary rest/lighter tasks if necessary
• Pain management: graded, with medication for as short a period as possible; additional physical measures
• Control appointments: clinical and imaging to coordinate course and resilience

Prevention and self-help

• Quitting smoking and a healthy lifestyle to promote microcirculation
• Ergonomics: Work wrist-neutrally, reduce shock and vibration loads
• Strength-endurance balance of the forearm muscles, technique that is gentle on the joints
• Early evaluation of persistent radial wrist pain, especially if there are risk factors

Differentiation from other diseases

It is important to differentiate between scaphoid pseudoarthrosis after a fracture and Kienböck's disease (lunar bone necrosis). Both require different strategies. Ligament-related instabilities and arthritic changes can also cause similar problems.

When should you come to us?

• Wrist pain on the side of the thumb lasting more than 2-3 weeks
• Pressure pain in the scaphoid fossa, loss of strength or swelling
• Pain after a fall/overexertion despite protection
• If there are known risk factors (e.g. long-term steroid therapy, smoking)

The earlier the clarification, the easier it is to plan conservative measures.