eMedicine Specialties > Orthopedic Surgery > Hand & Upper Extremity

Kienböck Disease: Workup

Author: Brian J Divelbiss, MD, Consulting Staff, Dickson-Diveley Midwest Orthopaedic Clinic, Inc, Kansas City Orthopaedic Institute
Coauthor(s): Mark E Baratz, MD, Professor, Department of Orthopaedics, Drexel University College of Medicine; Residency Director, Department of Orthopaedics, Allegheny General Hospital; Consulting Staff, Allegheny Orthopaedic Associates
Contributor Information and Disclosures

Updated: Jul 11, 2007

Workup

Imaging Studies

  • Plain radiographs
    • Plain films form the basis for staging and treatment of Kienböck disease. Lichtman's modification of Stahl's classification is most widely used and divides the disease into 5 stages, as follows:
      • Stage I - Normal radiograph
      • Stage II - Increased radiodensity of lunate with possible decrease of lunate height on radial side only
      • Stage IIIa - Lunate collapse, no scaphoid rotation
      • Stage IIIb - Lunate collapse, fixed scaphoid rotation
      • Stage IV - Degenerative changes around the lunate
    • Plain films must also be examined to determine the amount of ulnar variance present. This will directly impact the choice of operative technique. A true posteroanterior view of the wrist is necessary to adequately determine ulnar variance.
  • Tomograms
    • Tomograms may be useful in determining the true extent of disease.
    • Tomograms have been found to result in the upgrading of many patients with stage II disease to stage III by more clearly demonstrating collapse.
    • In addition, coronal fractures that split the lunate into volar and dorsal halves are more evident with tomograms.
    • Due to the limited availability of tomograms at this time, a CT scan would be the best imaging modality to evaluate the bony architecture of the lunate.
  • Bone scan
    • Bone scanning may help exclude the presence of Kienböck disease, but it is not specific enough to exclude the many other causes of increased uptake in the area of the lunate.
    • It may be of some help in the patient with known Kienböck disease who develops wrist pain in the contralateral side.
  • MRI
    • MRI is most helpful early in the course of the disease when plain films are not diagnostic.
    • T1- and T2-weighted images reveal decreased signal intensity.
    • Patterns of signal loss can be focal or generalized; however, primary involvement of the ulnar proximal portion of the lunate indicates potential ulnar abutment syndrome.
    • T1-weighted images showing focal loss on the radial half of the lunate suggest early involvement, particularly if the corresponding T2-weighted images show normal or increased intensity.
    • MRI is an extremely sensitive and specific test to detect the presence of marrow changes consistent with osteonecrosis.
    • MRI has also been used to indirectly demonstrate revascularization following operative treatment.

More on Kienböck Disease

Overview: Kienböck Disease
Workup: Kienböck Disease
Treatment: Kienböck Disease
Follow-up: Kienböck Disease
References
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References

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Further Reading

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Keywords

avascular necrosis of the lunate, osteonecrosis of the carpal lunate, wrist injury, wrist pain, lunatomalacia, Kienbock disease, triangular fibrocartilage complex, TFCC, ulnar, ulnar variance, negative ulnar variance, positive ulnar variance, radial shortening, ulnar lengthening, lunate collapse, scaphoid rotation, lunate excision, scaphotrapeziotrapezoid, triscaphe, STT, STT fusion, STT arthrodesis, scaphocapitate, capitohamate, carpectomy, proximal row carpectomy, PRC, ulnar-negative variance, ulnar-positive variance

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Contributor Information and Disclosures

Author

Brian J Divelbiss, MD, Consulting Staff, Dickson-Diveley Midwest Orthopaedic Clinic, Inc, Kansas City Orthopaedic Institute
Brian J Divelbiss, MD is a member of the following medical societies: Alpha Omega Alpha and American Society for Surgery of the Hand
Disclosure: Nothing to disclose.

Coauthor(s)

Mark E Baratz, MD, Professor, Department of Orthopaedics, Drexel University College of Medicine; Residency Director, Department of Orthopaedics, Allegheny General Hospital; Consulting Staff, Allegheny Orthopaedic Associates
Mark E Baratz, MD is a member of the following medical societies: Allegheny County Medical Society, American Academy of Orthopaedic Surgeons, American Association for Hand Surgery, American Orthopaedic Association, American Society for Surgery of the Hand, Orthopaedic Research Society, and Pennsylvania Orthopaedic Society
Disclosure: Nothing to disclose.

Medical Editor

A Lee Osterman, MD, Director of Hand Surgery Fellowship, Director, Philadelphia Hand Center; Director, Professor, Department of Orthopedic Surgery, Division of Hand Surgery, University Hospital, Thomas Jefferson University
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

N Ake Nystrom, MD, PhD, Associate Professor of Orthopedic Surgery and Plastic Surgery, University of Nebraska Medical Center
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD, Consulting Surgeon, Broward Hand Center, Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine
Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society
Disclosure: Nothing to disclose.

 
 
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