Kienbock's Disease: Diagnosis and Treatment
Diagnostic Approach
Start with plain wrist radiographs (anteroposterior, lateral, and oblique views) to assess for lunate sclerosis, collapse, or carpal alignment changes, but proceed immediately to MRI if radiographs are normal or nonspecific, as MRI is the gold standard for detecting early osteonecrosis before radiographic changes appear. 1, 2, 3
Imaging Algorithm
Initial imaging: Plain wrist radiographs are the first-line study for chronic wrist pain, looking specifically for lunate sclerosis, compression fracture, or collapse 1, 2, 3
When radiographs are normal or nonspecific: Non-contrast MRI is mandatory, as it detects early osteonecrosis in Stage I disease before any radiographic changes are visible 1, 2, 3
For surgical planning: CT without contrast is appropriate when you need to assess the degree of collapse or bone fragment size more precisely than radiographs can provide 1, 2, 3
The key pitfall here is relying solely on radiographs in early disease—Stage I Kienbock's appears completely normal on plain films, and you will miss the diagnosis without MRI. 4
Treatment Algorithm Based on Disease Stage
Activity modification to avoid excessive wrist loading is essential across all stages, with treatment selection primarily determined by disease stage and ulnar variance. 1, 2
Early Stage Disease (Stages I-II)
Nonoperative management is generally preferred at the earliest stages, focusing on activity modification and protected weight-bearing 2, 5
Serial radiographic follow-up is essential to detect early signs of disease progression or treatment failure 1, 2
Stage II-IIIA (Lunate Collapse Without Carpal Collapse)
The surgical approach depends critically on ulnar variance:
Negative ulnar variance: Radial shortening osteotomy is the recommended procedure 5, 4
Neutral or positive ulnar variance: Capitate shortening osteotomy or radial-wedge osteotomy are the recommended options 5, 4
Vascularized bone grafting can be performed alone or combined with the above osteotomies to attempt direct revascularization of the lunate 5, 4, 6
Most promising technique for Stage III: Vascularized pedicled scaphoid graft combined with partial radioscaphoid arthrodesis provides excellent pain management and prevents carpal collapse 5
The rationale for these osteotomies is to decompress and unload the lunate, protecting it from collapse while biological healing occurs. 6 While these procedures don't heal the necrosis directly, they shield the lunate from shear and compression loads. 6
Stage IIIB (Carpal Collapse Present)
- Scaphotrapeziotrapezoid or scaphocapitate arthrodesis to correct scaphoid hyperflexion and address the carpal collapse 4
Stage IV (Degenerative Changes Present)
Salvage procedures are required when midcarpal or radiocarpal joint degeneration has occurred:
Proximal row carpectomy is an effective salvage option that provides significant pain relief and improved wrist function in advanced disease 7, 4
Total wrist fusion or total wrist arthroplasty are often required in end-stage disease 5, 4
Post-Treatment Monitoring
Protected weight-bearing and regular radiographic follow-up after any surgical intervention are mandatory to monitor for disease progression. 1, 3
Serial radiographs detect early signs of treatment failure or continued collapse 1
This monitoring is essential regardless of which surgical procedure was performed 3
Critical Clinical Pearls
The Lichtman classification system is essential for guiding treatment decisions, as radiographic stage directly determines surgical approach. 7 However, a common pitfall is that radiographic features may not correspond directly to initial clinical symptoms and can differ among age groups. 5 Despite this discordance, stage-based treatment algorithms remain the standard of care.
The etiology remains poorly understood, but likely involves inflammatory biological venous thrombosis leading to intraosseous compartment syndrome. 6 Common risk factors include anatomical features (ulnar variance, blood supply variations), increased intraosseous pressure, direct trauma, and repetitive loading. 5