Summary Kienbock's Disease is the avascular necrosis of the lunate which can lead to progressive wrist pain and abnormal carpal motion. Diagnosis can be made with wrist radiographs in advanced cases but may require MRI for detection of early disease. Treatment is NSAIDs and observation in minimally symptomatic patients. A variety of operative procedures are available depending on severity of disease and patient's symptoms. Epidemiology Incidence most common in males between 20-40 years old Risk factors history of trauma Etiology Pathophysiology thought to be caused by multiple factors biomechanical factors login to view 4 more bullets anatomic factors login to view 5 more bullets Anatomy Blood supply to lunate 3 variations Y-pattern X-pattern I-pattern login to view 2 more bullets Classification Lichtman Classification Stage Description Treatment Stage I No visible changes on xray, changes seen on MRI Immobilization and NSAIDS Stage II Sclerosis of lunate Joint leveling procedure (ulnar negative patients) Radial wedge osteotomy or STT fusion (ulnar neutral patients) Distal radius core decompression Revascularization procedures Stage IIIA Lunate collapse, no scaphoid rotation Same as Stage II above Stage IIIB Lunate collapse, fixed scaphoid rotation Proximal row carpectomy, STT fusion, or SC fusion Stage IV Degenerated adjacent intercarpal joints Wrist fusion, proximal row carpectomy, or limited intercarpal fusion Presentation Symptoms dorsal wrist pain usually activity related more often in dominant hand Physical exam inspection and palpation +/- wrist swelling often tender over radiocarpal joint range of motion decreased flexion/extension arc decreased grip strength Imaging Radiographs recommended views AP, lateral, oblique views of wrist findings (see table above) CT most useful once lunate collapse has already occurred best for showing extent of necrosis trabecular destruction lunate geometry MRI best for diagnosing early disease rule out ulnar impaction findings decreased T1 signal intensity reduced vascularity of lunate Treatment Nonoperative observation, immobilization, NSAIDS indications login to view 1 more bullet outcomes login to view 1 more bullet Operative temporary scaphotrapeziotrapezoidal pinning indications login to view 1 more bullet joint leveling procedure indications login to view 2 more bullets technique login to view 2 more bullets radial wedge osteotomy indications login to view 1 more bullet vascularized bone grafts indications login to view 1 more bullet outcomes login to view 2 more bullets distal radius core decompression indications login to view 1 more bullet technique login to view 1 more bullet partial wrist fusions STT capitate shortening osteotomy +/- capitohamate fusion scaphocapitate indications login to view 3 more bullets proximal row carpectomy (PRC) indications login to view 2 more bullets outcomes login to view 1 more bullet wrist fusion indications login to view 1 more bullet technique login to view 1 more bullet total wrist arthroplasty indications login to view 1 more bullet outcomes login to view 1 more bullet Techniques Vascularized bone grafts technique many options have been described including login to view 5 more bullets temporary pinning of the STT joint, SC joint or external fixation may be used to unload lunate after revascularization Impact of surgical procedure on radiolunate contact stress Impact of surgical procedure on radiolunate contact stress Operative Procedure % decrease on radiolunate contact stress STT fusion 3% Scaphocapitate fusion 12% Capitohamate fusion 0% Ulnar lengthening of 4mm 45% Radial shortening of 4mm 45% Capitate shortening and capitohamate fusion 66%, but 26% increase in radioscaphoid load Prognosis Progressive and potentially debilitating condition if unrecognized and untreated