Kienbock’s Disease

Definition

• Avascular necrosis & subsequent disintegration of lunate
• Described 1910 by Kienbock (Vienese radiologist)

Aetiology

• Avascular necrosis of lunate
• Probably result of trauma
• Mechanical & vascular theories

Vascular Theory

• Due to trauma disrupting vascularity
• May be
  • Single incident with disruption of blood supply
  • Multiple compression fractures with loss of blood supply to fragments
• Lunate vascularity (Gelberman dye studies)
  • 8% Single incomplete palmar feeder
    • Hence higher risk AVN
    • Severe hyperextension may disrupt it
  • 92% Dorsal & Palmar blood vessels
    • “X” “I” “Y” configuration
    • Well-vascularised
    • Need intra & extraosseous disruption
    • Low risk AVN

Mechanical Theory

• Ulnar variance
  • Normal +3 to -6 mm (2 SD mean)
  • Ulnar minus variance
    • Subjects lunate to greater compression & shear forces
    • More common in Kienbock’s
    • Gelberman 1975
    • 75% with Kienbock’s cf. 25% in unaffected patients
    • Assess on standard XR
• Realise that true Kienbock’s rarely seen as result of perilunate/ lunate dislocations (<1%)

Epidemiology

• Occurs in young active adults
• Age 20-40
• Usually dominant hand
• Rarely bilateral

Anatomy

• Lunate articulates with radius, scaphoid, triquetrum, capitate and, in type 2 lunates, hamate
• Mostly covered in cartilage, with vessel entry limited to dorsal and volar surfaces
• Gelberman intraosseous patterns Y, I and X, with the I pattern possibly at higher risk
• Negative ulnar variance associated with Kienbock disease (Hultén)

Pathology

• Avascular necrosis of the lunate with progressive collapse
• Sclerosis, then fragmentation and loss of lunate height
• Proximal migration of the capitate and fixed scaphoid flexion
• Carpal collapse leading to radiocarpal and midcarpal arthritis
• Articular cartilage status graded arthroscopically (Bain)

Classification

Lichtmann

Classified into 4 stages according to X-ray

Stage	Findings
1 Normal	No radiographic changes. May be possible to see on MRI
2 Sclerosis	Density changes. Sclerosis of proximal pole
3A Fragmentation	May be evidence of compression fracture. Radiolucent or radiodense line
3B Collapse	Collapse of lunate. Flattening
4 Degeneration	Pancarpal arthritis

Original publication Lichtman DM, Mack GR, MacDonald RI, Gunther SF, Wilson JN. Kienböck’s disease: the role of silicone replacement arthroplasty. J Bone Joint Surg Am. 1977;59(7):899-908.

• Operations aimed at promoting revascularisation for stages 1 & 2

History

• Gradual onset of pain & stiffness in wrist
• Usually no history of trauma (but seen in up to 50%)

Examination

• Tenderness over lunate
• Passive dorsiflexion MF pain
• Diminished grip strength
• In later stages ↓ ROM from Osteoarthritis

Investigations

Plain X-ray

• Progressive changes of avascular necrosis
  • Mottling
  • Collapse
  • Degenerative arthritis
• XR for Ulna Variance
  • AP film with wrist in neutral
  • Elbow flexed 90°
  • Shoulder abducted 90°

Bone Scan

• Increased uptake in early stages

MRI

• Shows changes before bone scan becomes positive

Differential Diagnosis

• Ulnar impaction syndrome
• Intraosseous ganglion of the lunate
• Acute lunate fracture
• Preiser disease
• Inflammatory arthritis
• SLAC or SNAC wrist

Treatment

Non-operative

• No treatment is satisfactory way of managing Kienbock’s
  • Beckenbaugh 1980 70% no worse at 7 years
  • Kristensen 1986 77% minimal pain at 18 years
  • Saffar 1982 few changed work at 10-30 years

Splintage

• ? Allows fractures to heal & revascularise
• Rarely effective

Operative

Early – Stage 1, 2 & 3

• Ulna Minus
  • Radial shortening
    • Rationale is to redistribute stresses
    • Decreased stress on lunate may allow it to revascularise
    • Try to achieve ulnar neutral wrist
    • ~ 2mm shortening
      • 2mm = 20% ↓ in radial load
    • Volar T Plate
    • Good-excellent results 80-90% success
    • Can consider combining with vascularised graft into lunate using metacarpal artery
  • Ulnar lengthening
    • Other form of joint levelling
    • Don’t do as high rates of nonunion
• Neutral Ulna Variance
  • Radial closing wedge
  • Ulna opening wedge
  • Capitate-Hamate Fusion
  • Arthroscopic drilling (forage)

Late – Stage 4 (? 3 Also)

• Limited fusion
  • Scaphotrapeziotrapezoid (STT) fusion
  • Unloads lunate fossa & transfers load to scaphoid fossa
  • Unpredictable
• Silicone replacement
  • Poor long-term results
  • No longer advocated
• Proximal row carpectomy
  • ? Best procedure for late cases
• Can consider Buck-Gramko denervation if pain is main symptom

Operative Salvage Procedures

• Arthrodesis of wrist
  • Manual laborers
• Proximal Row Carpectomy
  • Good if Low Demand
• Lunate Excision
  • Controversial
  • Good results in 1 study (Kawai)

Management Approach

• Literature not proven to show operative approach better than observation alone
• Therefore observation is reasonable option for all stages of Kienbocks
• Stage 1
  • Observe
• Stage 2
  • Observe
  • Arthroscopic drilling (forage)
  • Radial osteotomy ± vascularised bone graft
• Stage 3
  • Observe
  • Radial osteotomy ± VBG
  • If carpal collapse then scapholunate capsulorraphy
• Stage 4
  • Observe
  • Radial osteotomy
  • Denervation
  • Total fusion

Complications

• Progressive collapse and wrist arthritis
• Nonunion of radial shortening osteotomy
• Ulnar wrist and DRUJ pain after radial shortening
• Hardware irritation
• Radiocapitate arthritis after proximal row carpectomy
• Stiffness and loss of motion after partial or total wrist fusion
• CRPS

Prognosis

• STT fusion or Radial Shortening doesn’t prevent collapse

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.