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Kienböck Disease

(Kienböck's Disease)

By David R. Steinberg, MD, Associate Professor, Department of Orthopaedic Surgery, and Director, Hand and Upper Extremity Fellowship, Perelman School of Medicine at the University of Pennsylvania

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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.

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

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.

Diagnosis

  • Imaging

MRI and CT are the most sensitive; plain x-rays show abnormalities later, usually beginning with a sclerotic lunate, then later cystic changes, fragmentation, and collapse.

Differential diagnosis of mid-dorsal wrist pain includes dorsal wrist ganglion, synovitis or arthritis, or extensor tendinitis.

Treatment

  • Surgical procedures

Treatment of Kienböck disease is aimed at relieving pressure on the lunate by surgically shortening the radius (1) or lengthening the ulna. Alternative treatments are done in an attempt to revascularize the lunate (eg, implanting a blood vessel or bone graft on a vascular pedicle; 2). For advanced involvement of the lunate, some surgeons have tried to preserve the bone by using free-vascularized bone grafts from the knee (3).

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 not effective.

Treatment references

  • 1. Salmon J, Stanley JK, Trail IA: Kienböck's disease: Conservative management versus radial shortening. J Bone Joint Surg Br 82(6):820–823, 2000.

  • 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. Bürger HK, Windhofer C, Gaggl AJ, et al: Vascularized medial femoral trochlea osteochondral flap reconstruction of advanced Kienböck disease. J Hand Surg Am39(7):1313-22, 2014. doi: 10.1016/j.jhsa.2014.03.040.

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* This is the Professional Version. *