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Kienbock Disease Workup

  • Author: Brian J Divelbiss, MD; Chief Editor: Harris Gellman, MD  more...
 
Updated: Oct 26, 2015
 

Imaging Studies

Plain radiography

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 five 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 for an adequate determination of ulnar variance.

Tomography

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.

In view of the limited availability of tomograms at this time, a computed tomography (CT) scan would be the best imaging modality for evaluating the bony architecture of the lunate.

Bone scanning

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.

Magnetic resonance imaging

Magnetic resonance imaging (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 for detecting the presence of marrow changes consistent with osteonecrosis. MRI has also been used to indirectly demonstrate revascularization following operative treatment.

 
 
Contributor Information and Disclosures
Author

Brian J Divelbiss, MD Attending Staff, Dickson-Diveley Midwest Orthopedic Clinic, Inc, and Kansas City Orthopedic Institute; Associate Clinical Professor, Department of Orthopedic Surgery, University of Missouri-Kansas City

Brian J Divelbiss, MD is a member of the following medical societies: Alpha Omega Alpha, American Society for Surgery of the Hand

Disclosure: Nothing to disclose.

Coauthor(s)

Mark E Baratz, MD Orthopedic Specialists of UPMC

Mark E Baratz, MD is a member of the following medical societies: Orthopaedic Research Society, Pennsylvania Orthopaedic Society, Allegheny County Medical Society, American Academy of Orthopaedic Surgeons, American Association for Hand Surgery, American Orthopaedic Association, American Society for Surgery of the Hand

Disclosure: Received royalty from Integra Life Sciences for none; Received consulting fee from Integra Life Sciences for speaking and teaching; Received grant/research funds from Integra Life Sciences for none; Received consulting fee from Elizur for consulting.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

N Ake Nystrom, MD, PhD Associate Professor of Orthopedic Surgery and Plastic Surgery, University of Nebraska Medical Center

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, Leonard M Miller School of Medicine, Clinical Professor, Surgery, Nova Southeastern 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, Arkansas Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

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.

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