What is the initial management for a patient with Kienbock's disease of the lunate?

Management of Kienböck's Disease

For initial management of Kienböck's disease, begin with activity modification to avoid excessive wrist loading, and proceed with stage-based treatment: immobilization for stage I disease, joint-unloading procedures (radial shortening or capitate shortening osteotomy) for stages II-IIIA, carpal collapse correction procedures for stage IIIB, and salvage procedures for stage IV. 1, 2

Diagnostic Confirmation First

Before initiating treatment, confirm the diagnosis and stage:

• Obtain plain wrist radiographs initially (anteroposterior, lateral, and oblique views) to assess for lunate sclerosis, collapse, or carpal alignment changes 3
• Order non-contrast MRI when radiographs are normal or nonspecific, as this is the gold standard for detecting early osteonecrosis before radiographic changes appear 4, 3
• Consider CT without contrast for surgical planning when the degree of collapse or bone fragment size is uncertain from radiographs 4, 3

Stage-Based Treatment Algorithm

Stage I (Normal Radiographs, MRI-Positive)

• Initiate conservative management with immobilization using a short-arm cast or splint 2, 5
• Add analgesics and anti-inflammatory medications for symptom control 5
• Activity modification to avoid excessive wrist loading is essential 1
• If symptoms persist despite 3-6 months of conservative treatment, proceed to surgical options 2

Stage II (Lunate Sclerosis ± Early Collapse)

The surgical approach depends on ulnar variance:

• For negative ulnar variance: perform radial shortening osteotomy to unload the lunate 2, 5, 6
• For neutral or positive ulnar variance: perform capitate shortening osteotomy 2, 6
• Vascularized bone grafting can be performed alone or combined with osteotomy procedures to attempt direct revascularization 2, 6

Stage IIIA (Severe Lunate Collapse, Carpus Intact)

• Continue with joint-unloading procedures as in Stage II, since the remainder of the carpus is still uninvolved 2
• Vascularized pedicled scaphoid graft combined with partial radioscaphoid arthrodesis is a promising technique that provides excellent pain management and prevents carpal collapse 6
• Alternative: radial-wedge osteotomy for neutral or positive ulnar variance 2

Stage IIIB (Carpal Collapse with Scaphoid Rotation)

Treatment must address the carpal collapse pattern:

• Perform scaphotrapeziotrapezoid arthrodesis or scaphocapitate arthrodesis to correct scaphoid hyperflexion and proximal capitate migration 2
• These limited intercarpal arthrodeses stabilize carpal alignment while preserving some wrist motion 5

Stage IV (Degenerative Arthritis Present)

Salvage procedures are required:

• Proximal-row carpectomy is an option when radiocarpal cartilage is preserved 2, 5
• Total wrist arthrodesis for pan-carpal arthritis with severe pain 2, 6
• Total wrist arthroplasty may be considered in select cases 6
• Wrist denervation can provide pain relief while preserving motion in some patients 5

Post-Treatment Monitoring

• Implement protected weight-bearing and regular radiographic follow-up after any surgical intervention to monitor for disease progression 3
• Serial radiographs are essential to detect early signs of treatment failure or continued collapse 1

Critical Pitfalls to Avoid

• Do not rely solely on radiographic staging to guide treatment, as radiographic features may not correspond directly to clinical symptoms, particularly in early disease 6
• Avoid delaying surgical intervention in young, symptomatic patients with Stage II-IIIA disease, as conservative treatment does not provide good results in adults 7
• Do not assume that osteotomy procedures heal the necrosis—they protect the lunate from collapse to allow time for biological healing 7
• Be aware that some osteotomies may place excessive pressure on the ulnar side of the lunate or fail to reduce transmitted loads 7

Special Consideration for Young Patients

• Pyrocarbon lunate implant arthroplasty is a newer option for young patients in whom vascularized bone grafting has failed but arthritis has not yet developed, preserving the remainder of the proximal carpal row 8