Imaging Studies

Plain radiography

Plain films form the basis for staging and treatment of Kienböck disease.^{[21, 22]}Lichtman's modification of Stahl's classification, the system that has been most widely used, divided 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 for indirectly demonstrating revascularization after operative treatment.

Bae et al proposed an MRI-based classification system for Kienböck disease, which they found to be more reliable than the modified Lichtman system and more appropriate for classification into stages IIIA and IIIB.^[23]

Other Tests

MacLean et al evaluated the use of wrist arthroscopy to assess the lunate and concluded that the procedure can also be a therapeutic tool for performing debridement, resection, or arthrodesis procedures.^[24]

Bain and Begg used arthroscopy to develop an articular-based classification of Kienböck disease that included the following grades^[25]:

Grade 0 - All articular surfaces are functional
Grade 1 - The proximal lunate articular surface is nonfunctional
Grade 2A - The proximal articular surface of the lunate and the lunate fossa are both nonfunctional
Grade 2B - The proximal and distal articular surfaces of the lunate are nonfunctional
Grade 3 - Three articular surfaces are nonfunctional; usually, there will be only a functional capitate articular surface
Grade 4 - All four articular surfaces are nonfunctional

Treatment & Management

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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: 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, Pennsylvania Orthopaedic Society

Disclosure: Received royalty from Integra Life Sciences; Received consulting fee from Integra Life Sciences for speaking and teaching; Received grant/research funds from Integra Life Sciences; 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 of 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, Florida Medical Association, Florida Orthopaedic 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.

Kienbock Disease Workup

Imaging Studies

Plain radiography

Tomography

Bone scanning

Magnetic resonance imaging

Other Tests

References

Tables

Contributor Information and Disclosures

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