Kienbock Disease Workup

Updated: Sep 11, 2023
  • Author: Brian J Divelbiss, MD; Chief Editor: Harris Gellman, MD  more...
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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.


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