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Kienbocks Disease

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Other Names

  • Avascular Necrosis of the Lunate
  • Osteonecrosis of the lunate
  • Kienbock's Disease
  • Kienbock Disease
  • Lunatomalacia


  • This page refers to Kienbock's disease, or avascular necrosis of the Lunate


  • Named after Viennese radiologist Robert Kienbock, who termed it lunatomalacia[1]


  • Poorly described in the literature
  • Affects dominant hand of men between age 20 - 40 (need citation)



  • Disease of unclear etiology resulting in avascular necrosis or osteonecrosis of the carpal Lunate
  • Ulnar variance leads to scaphoid exhibiting excessive loads across the lunate
  • Can lead to progressive wrist pain, abnormal carpal motion

Risk Factors

  • Negative ulnar variance
  • History of trauma
  • Occupational Risk factors
    • Manual laborer
    • Repetitive loading occupations

Differential Diagnosis

Clinical Features


  • Patients report dorsal wrist pain
  • Decreased wrist motion and grip strength
  • Patients may endorse a history of or have clinically swelling and tenderness at the radiocarpal joint
  • Worse with activity
  • Dominant hand more commonly affected

Physical Exam: Physical Exam Wrist

  • Tenderness along the lunate, radiocarpal joint
  • Swelling may or may not be present
  • Decreased range of motion in flexion/extension of wrist
  • Decreased grip strength


Patient number 3, left wrist, Stage IIIa Kienböck's disease in 1992. B) the same wrist in 2012, 20 years later, still at Stage IIIa.[2]



  • Useful for staging
    • Especially once Lunate collapse has occurred
  • Useful for describing
    • Extent of necrosis
    • Trabecular destruction
    • Lunate geometry


  • Valuable in early disease staging
  • Findings
    • Decreased T1 signal intensity
    • Reduced lunate vascularity


Lichtman Classification

  • Based upon radiographs
  • Stage I - Normal radiograph (however changes seen on MRI)
  • Stage II - Increased radiodensity or sclerosis of lunate
  • Stage IIIa - Lunate collapse, no scaphoid rotation
  • Stage IIIb - Lunate collapse, fixed scaphoid rotation
  • Stage IV - Degenerative changes around the lunate




  • Indications
    • Surgery indicated for Stage II - IV
  • Technique[3]
    • Temporary scaphotrapeziotrapezoidal pinning
    • Joint leveling procedure
    • Radial wedge osteotomy
    • Vascularized bone grafts
    • Distal radius core decompression
    • Partial wrist fusions
    • Proximal row carpectomy (PRC)
    • Wrist fusion
    • Total wrist arthroplasty

Rehab and Return to Play


  • Needs to be updated

Return to Play/ Work

  • Unknown, no clear guidelines

Complications and Prognosis


  • Progressive, debilitating if not recognized and treated appropriately (need citation)
  • Better in the pediatric and elderly patients, than the typical 20- to 40-year-old patient[4]
  • Irisarri et al study divided pediatric patients into infantile (12 years and younger) and juvenile (13 years to skeletal maturity)[5]
    • Infantile group: treated nonoperatively, excellent outcomes, including lunate revascularization on magnetic resonance imaging (MRI)
    • Juvenile group: treated with immobilization,, 30% had progression and required a joint leveling procedure


  • Radiocarpal arthritis

See Also




  1. Kienböck R. Über traumatische Malazie des Mondbeins und ihre Folgezustände: Entartungsformen und Kompressionsfrakturen. Fortschr Geb Rontgenstr. 1910;XVI(2):77–103.
  2. Viljakka, T., K. Tallroth, and M. Vastamäki. "Long-Term Natural Outcome (7–26 Years) of Lichtman Stage III Kienböck’s Lunatomalacia." Scandinavian Journal of Surgery 105.2 (2016): 125-132.
  3. https://www.orthobullets.com/hand/6050/kienbocks-disease
  4. Lichtman D M, Degnan G G. Staging and its use in the determination of treatment modalities for Kienböck's disease. Hand Clin. 1993;9(3):409–416.
  5. Irisarri C, Kalb K, Ribak S. Infantile and juvenile lunatomalacia. J Hand Surg Eur Vol. 2010;35(7):544–548.
Created by:
John Kiel on 30 June 2019 20:51:40
Last edited:
7 October 2023 13:45:42
Osteology | Hand | Wrist | Upper Extremity | Overuse