Kienbock Disease Workup
- Author: Brian J Divelbiss, MD; Chief Editor: Harris Gellman, MD more...
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.
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 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.
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