This document discusses Kienböck disease, an avascular necrosis of the lunate bone in the wrist. It begins by defining the disease and its discovery. The cause is unknown but is thought to be due to repetitive trauma causing microfractures. Those with an ulnar minus variance are at higher risk. It predominantly affects young men unilaterally in their dominant wrist. Imaging shows progressive sclerosis, fragmentation, and collapse of the lunate bone leading to wrist arthritis. Treatment involves casting for early stages or surgical options like ulnar lengthening, radial shortening, prosthesis, fusions, or resections depending on the stage of disease.

1. KIENBOCK DISEASE
DR. MANOJ BHAMA
SENIOR RESIDENT,
DEPT. OF ORTHOPAEDICS,
S.P. MEDICAL COLLEGE,
BIKANER, INDIA
mbhama@gmail.com

2. KIENBOCK DISEASE
• Synonyms: Avascular Necrosis of Lunate
• First Described by Robert Kienbock in
1910; as “traumatic softening” of Lunate
bone
• It is a painful disorder of wrist, due to
avascular necrosis of carpal lunate, due to
unknown cause

3. AETIOLOGY
• Aetiology = unknown, but several cause have
been proposed
• vascular compromise from repetitive trauma
causes microfracture & excessive stress on
microscopic architecture (sports injury)
• Ulnar minus variant:- Individual having ulnar
minus variance are at increased risk. Short Ulna
 increases shear force across the lunate 
Causes vascular insufficiency

4. EPIDIMIOLOGY
• Age= 15-40 (young individuals)
• Sex= Men
• Location= Unilateral, Dominant wrist

5. PATHOLOGY
Pathological changes proceed in 4 stages:-
• Stage 1: Ischemia with naked eye or radiological
examination
• Stage 2: Trabeculae Necrosis with reactive new
bone formation & increased radiographic
density, but little or no distortion of shape.
• Stage 3: Collapse of Bone
• Stage 4: Disruption of Radio-carpal congruence
& secondary OA

6. PATHOLOGY
• The natural history of Kienbock’s disease
is
Progressive Sclerosis
 Fragmentation
 Arthrosis

7. CLINICAL FEATURE
• There may be history of trauma with wrist in
severe dorsiflexion
The lesion presents with
1. Dorsal wrist pain:- Pain may be produced in
lunate region by axial strike/injury at distal end of
middle finger
2. Swelling
3. Decreased Grip strength
4. Decreased range of motion; particularly in
extension. In later stage movement may be
painful

8. IMAGING
• X-ray at first show no abnormality but
bone scan may reveals increased activity
• Later x-ray may show either mottled or
diffuse density of bone – to – osteoarthritic
changes in wrist
• MRI Most reliable way of detecting the
early change

9. CLASSIFICATION
• Kienbock disease advances through 4
radiological stages
• Stage I : Normal architecture; consistent with
Microfracture
(Lunate abnormal on bone scan)
• Stage II : Lunate sclerosis without collapse
• Stage III : Lunate collapse or Fragmentation &
proximal migration of capitate
• Stage IV : Perilunate arthritis changes

10. TREATMENT
A Conservative
Casting of wrist for several wks ; for
early stages of disease ( St I or II, before
sclerosis, fragmentation or collapse)
But- Unacceptable & Ineffective
B Operative
• Surgery is only definitive treatment

11. Early Disease Stage I & II
• Unloading the Lunate*
• 1. Ulnar lengthening
• Transverse osteotomy at distal ulna 
Distraction  Cortical iliac graft 
Tightening of plate screw

12. Early Disease Stage I & II
2. Radial Shortening
Indication
– Negative ulnar variance
– Lunate compression fracture without fragmentation or
flattening
Procedure
Transverse osteotomy shortening of radius
3” proximal to distal by 2 cm
articulating surface
fixing the bone with
compression plate

13. In stage III
1. Ulnar lengthening
2. Silicon prosthesis
- silicon synovitis
- foreign body cyst
3. Interacarpal fusion
4. Lunate excision
5. Arthrodesis Tri scaphe
Scaphocapitate

14. In stage IV
• Proximal carpal row resection
• Wrist arthrodesis