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