Kienböck disease is avascular necrosis of the lunate bone. Symptoms include wrist pain and tenderness. Diagnosis is with imaging. Treatment is with various surgical procedures.
(See also Overview and Evaluation of Hand Disorders.)
Kienböck disease occurs most commonly in the dominant hand of men aged 20 to 45, usually in workers doing heavy manual labor. Overall, Kienböck disease is relatively rare. Its cause is unknown. The lunate can eventually collapse and cause fixed rotation of the scaphoid and subsequent degeneration of the carpal joints.
Symptoms and Signs of Kienböck Disease
Symptoms of Kienböck disease generally start with insidious onset of wrist pain, localized to the region of the lunate carpal bone; patients have no recollection of trauma. Kienböck disease is bilateral in 10% of cases. There is localized tenderness in the lunate bone, most commonly over the dorsal wrist along the midline. Mild swelling is possible.
Diagnosis of Kienböck Disease
Imaging
To diagnose Kienböck disease, MRI and CT are the most sensitive; radiographs show abnormalities later, usually beginning with a sclerotic lunate, then later cystic changes, fragmentation, and collapse.
Radiograph courtesy of David R. Steinberg, MD.
Radiograph courtesy of David R. Steinberg, MD.
Differential diagnosis of mid-dorsal wrist pain includes dorsal wrist ganglion, synovitis or arthritis, or extensor tendinitis.
Treatment of Kienböck Disease
Wrist splinting and analgesics for early stages
Surgical procedures
In early stages of Kienböck disease, wrist splinting may decrease pressure on the lunate, relieving pain and possibly helping to restore blood flow. Analgesics are given for pain.
Surgical treatment of Kienböck disease is aimed at relieving pressure on the lunate by shortening the radius (1) or lengthening the ulna. Alternative treatments are done in an attempt to revascularize the lunate directly (eg, implanting a blood vessel or bone graft on a vascular pedicle) or indirectly (eg, core decompression of the radius) (2, 3). For advanced involvement of the lunate, some surgeons have tried to preserve the bone by using free-vascularized bone grafts from the knee (4).
Salvage procedures (eg, proximal row carpectomy or intercarpal fusions) may help preserve some wrist function if the carpal joints have degenerated.
Total wrist arthrodesis can be done as a last resort to relieve pain. Nonsurgical treatments are rarely effective.
Treatment references
1. Shin YH, Kim JK, Han M, et al: Comparison of long-term outcomes of radial osteotomy and nonoperative treatment for Kienböck disease: a systematic review. J Bone Joint Surg 100(14):1231-1240, 2018. doi: 10.2106/JBJS.17.00764.
2. Afshar A, Eivaziatashbeik K: Long-term clinical and radiological outcomes of radial shortening osteotomy and vascularized bone graft in Kienböck disease. J Hand Surg Am 38(2):289-296, 2013. doi: 10.1016/j.jhsa.2012.11.016.
3. Illarramendi AA, De Carli P: Radius decompression for treatment of kienböck disease. Tech Hand Up Extrem Surg. 2003;7(3):110-113. doi:10.1097/00130911-200309000-00007
4. Bürger HK, Windhofer C, Gaggl AJ, et al: Vascularized medial femoral trochlea osteochondral flap reconstruction of advanced Kienböck disease. J Hand Surg Am 39(7):1313-1322, 2014. doi: 10.1016/j.jhsa.2014.03.040.
