Question
A 28 year old man presents with dorsal wrist pain and stiffness.
- What is the diagnosis?
- How is it classified?
- What are the management options?
Answer
Diagnosis
- Kienböck disease, avascular necrosis of the lunate
- Associated with ulnar negative variance, a single vessel or limited intraosseous blood supply and repetitive loading
Classification (Lichtman)
| Stage | Features |
|---|---|
| I | Normal radiograph, MRI signal change |
| II | Lunate sclerosis without collapse |
| IIIA | Lunate collapse without fixed scaphoid rotation |
| IIIB | Lunate collapse with fixed scaphoid flexion (ring sign, radioscaphoid angle over 60 degrees) |
| IV | Radiocarpal and midcarpal arthritis |
Management
- Stage I, immobilisation and activity modification
- Stages II and IIIA with ulnar negative variance, radial shortening osteotomy to unload the lunate
- Ulnar neutral or positive variance, capitate shortening or a vascularised bone graft such as the 4,5 extensor compartmental artery graft
- Stage IIIB, proximal row carpectomy or scaphotrapeziotrapezoid or scaphocapitate fusion
- Stage IV, total wrist fusion or arthroplasty
- Children and adolescents often do well with immobilisation alone
Related pages
Author Contributions
Orthofracs team
Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.