A case of a 27 years old female with history of pain in left wrists is presented. Investigations revealed necrosis of left lunate (Kienbock disease)

Rabah, SM

Salati, SA

English

Cognitive Sciences ePrint Archive

Case Report:
Kienbock Disease
Sajad Ahmad Salati, Assistant Consultant,
Sari M Rabah, Consultant,
Department of Plastic & Reconstructive Surgery, King Fahad Medical City, Riyadh, Saudi Arabia
Address For Correspondence:
Dr Sajad Ahmad Salati,
Assistant Consultant,
Department of Plastic &Reconstructive Surgery,
King Fahad Medical City, Riyadh, Saudi Arabia. 
E-mail: docsajad@yahoo.co.in
Citation: Salati SA, Rabah SM. Kienbock Disease. Online J Health Allied Scs. 2009;8(4):15
URL: http://www.ojhas.org/issue32/2009-4-15.htm
Open Access Archives: http://cogprints.org/view/subjects/OJHAS.html and http://openmed.nic.in/view/subjects/ojhas.html
Submitted: Nov 1, 2009; Accepted: Apr 1, 2010; Published: Apr 30, 2010
Abstract:
A case of a 27 years old female with history of pain in left 
wrists is presented. Investigations revealed necrosis of left lun-
ate (Kienbock disease).
Key Words: Kienbock disease, Lunate necrosis
Case Reports:
A 27 years old female reported with pain in left wrist of about 
18 months duration, mostly felt while typing on the keyboard 
of computer. There was no significant past history. Patient was 
getting relief   by regular use of analgesics (NSAIDS). Physic-
al  examination  did  not  reveal  any  significant  abnormality. 
Plain films of left wrist (Fig.1) revealed features of necrosis of 
lunate (Kienbock disease).
Kienbock disease is the eponym for avascular necrosis of the 
lunate.1 It is named after Robert Kienbock, a Viennese radiolo-
gist  in the early 1900's. The exact etiology is poorly under-
stood particularly2 as it occurs most often in the absence of ob-
vious trauma. Most  patients are men in their third to fourth 
decades and are either manual laborers or actively participat-
ing in  recreational  activities  that  repetitively  load the wrist. 
Patients  present  with  complaints  of  activity-related  dorsal 
wrist  pain,  decreased  wrist  motion  in  the  flexion-extension 
arc,  and  poor  grip  strength.  On  examination,  dorsal  wrist 
swelling and tenderness are frequently present over the radio 
carpal joint. Kienbock disease has been found to be associated 
with ulnar minus variance. It is thought that these patients are 
predisposed to abnormally increased stresses across the lunate 
resulting in repeated micro trauma leading to necrosis.  With 
time, there is resultant abnormal rotation of the scaphoid lead-
ing  to  increased  lunate  loading  and  further  necrosis.  Plain 
films  and MRI are the most  useful modalities  for diagnosis 
and staging. There are four stages of this disease based upon 
the radiological progression of the disease:3
Stage I: Radiographic findings are normal, but the bone scan 
findings are positive for disease. MRI shows a decreased sig-
nal on T1- and T2-weighted images.
Stage II: Sclerotic changes and fractures are visible on radio-
graphs; however, carpal integrity is intact.
Stage III (A and B): This stage occurs when the lunate col-
lapses and the capitate migrates proximally. In stage IIIA, no 
fixed carpal  derangement  is  noted.  In  stage  IIIB,  decreased 
carpal height, ulnar migration of the triquetrum, scapholunate 
dissociation, and flexion of the scaphoid are noted. 
Stage IV: This stage is associated with additional carpal de-
generation and generalized arthritis.
Initially treatment is conservative and includes analgesia and 
immobilization with splints.4 When unsuccessful, various sur-
gical options are available which include lunate excision with 
or without silicon replacement arthroplasty, osteotomy of the 
radius to compensate for ulna minus variance, intercarpal fu-
sion and revascularization. Radial shortening (joint levering)5 
is most commonly used, resulting in decreased pain and im-
proved function in up to 90% of patients. In spite of surgical 
correction, collapse and degeneration of the lunate may con-
tinue.
(See Fig on Page 2)
References:
1. Alexander AH, Lichtman DM. Kienböck disease. 
Orthop Clin North Am. Jul 1986;17(3):461-72 
2. Watson HK, Guidera PM. Aetiology of Kienbock 
disease. J Hand Surg [Br] 1997;22(1):5-7 
3. Morhart M, Tredget EE, Jarman ATA, Ghahary A. 
Hand, Wrist Fractures and Dislocations Available 
at  http://emedicine.medscape.com/article/1285825-
overview Updated: Oct 6, 2008
4. Delaere  O,  Dury  M,  Molderez  A.  Conservative 
versus operative treatment for Kienbock disease- A 
retrospective  study.  J  Hand  Surg  [Br] 
1998;23(1):33-6
5. Takahara M, Watanabe T, Tsuchida H, Yamahara 
S,  et al. Long-term follow-up of radial shortening 
osteotomy  for  Kienbock  disease.  Surgical  tech-
nique. J Bone Joint Surg Am 2009;91 Suppl 2:184-
90 
1
This work is licensed under a Creative 
Commons Attribution-No Derivative Works 
2.5 India License
Online Journal of Health and Allied Sciences
Peer Reviewed, Open Access, Free Online Journal
Published Quarterly :  Mangalore, South India : ISSN 0972-5997
Volume 8, Issue 4; Oct - Dec 2009
Fig  1: Plain  radiographs  of  left  wrist:  Oblique view (A) 
and Antero-posterior view (B) showing lunate necrosis
2


5 India License Online Journal of Health and Allied Sciences Peer Reviewed, Open Access, Free Online

Aetiology of Kienbock disease.

Conservative versus operative treatment for Kienbock disease- A retrospective study.

Kienböck disease. Orthop Clin North Am.

Long-term follow-up of radial shortening osteotomy for Kienbock disease. Surgical technique.

Wrist Fractures and Dislocations Available at http://emedicine.medscape.com/article/1285825-overview Updated: Oct 6,

Kienbock Disease

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Sajad Ahmad Salati

Sari M Rabah

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Kienbock Disease

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