Kienböck Disease: Diagnosis and Management
Initial Diagnostic Approach
Start with plain wrist radiographs (PA, lateral, and oblique views) to assess for lunate sclerosis, collapse, or carpal alignment changes—this is your first-line imaging study. 1, 2, 3
Key Radiographic Findings to Identify:
- Lunate sclerosis, compression fractures, or collapse 1, 4
- Ulnar variance (negative, neutral, or positive)—critical for treatment planning 1, 5
- Carpal collapse patterns (scaphoid rotation, capitate migration) 4
- Secondary osteoarthritic changes at radiocarpal or midcarpal joints 4, 6
When Radiographs Are Normal or Nonspecific:
Order non-contrast MRI immediately—this is the gold standard for detecting early osteonecrosis before radiographic changes appear. 2, 3 MRI demonstrates bone marrow edema and avascular changes in stage I disease when plain films appear normal 1, 4.
Advanced Imaging for Surgical Planning:
Consider CT without contrast when the degree of lunate collapse or bone fragment size is uncertain from radiographs and this information will change your surgical approach 1, 2, 3. CT provides superior bone detail for preoperative planning but adds little diagnostic value over MRI for early disease 1.
Avoid bone scans and arthrography—these are not routinely used and provide no additional diagnostic benefit. 1
Treatment Algorithm Based on Disease Stage
Stage I (Normal Radiographs, MRI-Positive):
- Immobilization with splinting or casting 7
- Activity modification to avoid excessive wrist loading 2, 3
- NSAIDs for pain control 7
- Serial radiographs every 3-6 months to monitor progression 2, 3
Stage II (Lunate Sclerosis Without Collapse):
For negative ulnar variance: Perform radial shortening osteotomy to unload the lunate. 4, 6, 7 This indirectly revascularizes the lunate by reducing compressive forces 4.
For neutral or positive ulnar variance: Perform capitate shortening osteotomy or consider vascularized bone grafting. 4, 6 Direct revascularization procedures may be attempted at this stage 4, 7.
Stage IIIA (Lunate Collapse, Preserved Carpal Alignment):
Vascularized bone grafting is the most promising option—specifically a vascularized pedicled scaphoid graft combined with partial radioscaphoid arthrodesis provides excellent pain relief and prevents further carpal collapse. 6 This can be combined with radial shortening (negative ulnar variance) or capitate shortening (neutral/positive variance) 4, 6.
Stage IIIB (Lunate Collapse With Carpal Malalignment):
Address the carpal collapse pattern with scaphotrapeziotrapezoid or scaphocapitate arthrodesis to correct scaphoid hyperflexion and capitate migration. 4 Limited intercarpal arthrodesis stabilizes the carpus and prevents further collapse 5, 7.
Stage IV (Secondary Osteoarthritis):
Salvage procedures are required: proximal row carpectomy for younger, active patients or total wrist arthrodesis for heavy laborers. 4, 6, 8 Proximal row carpectomy provides significant pain relief and preserves some wrist motion in advanced disease 8. Total wrist arthroplasty is an emerging option but has limited long-term data 6.
Critical Management Principles
Post-Treatment Monitoring:
Implement protected weight-bearing and obtain serial radiographs every 3-6 months after any surgical intervention to detect treatment failure or continued collapse early. 2, 3 Radiographic progression may occur despite initial clinical improvement 6.
Common Pitfalls to Avoid:
- Do not rely solely on clinical symptoms to stage disease—radiographic findings often lag behind or exceed clinical presentation 6
- Do not perform ulnar lengthening procedures in neutral or positive ulnar variance—this worsens outcomes 5, 4
- Do not delay surgical intervention in stage II/IIIA disease with negative ulnar variance—radial shortening has excellent outcomes when performed early 4, 6
- Do not use silicone lunate replacement—this has fallen out of favor due to complications 5, 7
Special Consideration for Your 30-Year-Old Patient:
Given the negative ulnar variance, radial shortening osteotomy is the definitive treatment if radiographs confirm stage II or IIIA disease. 4, 6 If MRI shows early stage I disease with normal radiographs, start with immobilization and close radiographic surveillance 7.