Kienböck's Disease —
Lunate AVN
Jacksonville, FL
Wrist pain in a young adult that doesn't resolve after weeks — and X-rays that look normal — is Kienböck's disease until proven otherwise. Dr. R. David Graham at JOI treats lunate avascular necrosis with stage-dependent precision: unloading procedures early to allow revascularization, salvage procedures late to relieve pain from established collapse.
- Stage I–II: radial shortening osteotomy (ulnar-negative) or capitate shortening
- Stage IIIA: unloading still applicable; vascularized bone graft in selected cases
- Stage IIIB: proximal row carpectomy (PRC) or limited fusion
- Stage IV: total wrist fusion for reliable pain relief
- Standard X-rays often normal in Stage I — MRI is the key diagnostic study
Kienböck's disease is one of the few wrist conditions where early diagnosis genuinely changes the treatment menu. Stage I–II caught before collapse can potentially be revascularized through unloading. Stage IIIB–IV requires salvage. The X-ray can look completely normal in early disease — MRI is the diagnosis.
Understanding the Condition
Kienböck's Disease —
Lunate AVN
Kienböck's disease is avascular necrosis (AVN) of the lunate — the central carpal bone of the wrist — where the bone loses its blood supply and progressively dies, collapses, and destroys the surrounding wrist joint. It is a relatively rare condition that typically affects young to middle-aged adults in their dominant hand, and its cause is not fully understood — though it is associated with negative ulnar variance (the ulna being shorter than the radius), prior wrist trauma, and certain systemic conditions.
The Lichtman classification stages the disease from Stage I (normal X-ray, MRI shows avascular signal changes) through Stage IV (generalized wrist arthritis from lunate collapse). The stage at presentation determines the treatment approach — early stages focus on unloading the lunate to allow revascularization; late stages focus on salvage to relieve pain and preserve function.
In Dr. Graham's approach, treatment is stage-dependent. Early disease (Stages I–IIIA) is approached with unloading procedures — radial shortening osteotomy for ulnar-negative wrists or capitate shortening for neutral/positive ulnar variance. Late-stage disease with established collapse and carpal arthritis (Stage IIIB–IV) requires salvage — proximal row carpectomy (PRC) or wrist fusion.
- I MRI shows AVN signal; normal X-ray; lunate intact
- II X-ray shows sclerosis; no collapse; articular surface intact
- IIIA Lunate collapse; carpal alignment maintained
- IIIB Lunate collapse; scaphoid fixed rotatory subluxation
- IV Pancarpal arthritis from lunate collapse
Negative ulnar variance — the ulna is shorter than the radius — increases load concentration on the lunate and is strongly associated with Kienböck's disease.
Stage-Dependent Treatment
Unloading Early — Salvage Late
The treatment goal shifts with stage: early disease aims to relieve lunate load and allow revascularization; late disease aims to relieve pain from established arthritis.
Scroll the table sideways to see all columns
| Stage | Findings | Dr. Graham's Approach |
|---|---|---|
| Stage I–II | AVN on MRI; sclerosis on X-ray; no collapse; articular surface intact. | Unloading procedure. Radial shortening osteotomy (RSO) for ulnar-negative wrists — shortens the radius to equalize load distribution. Capitate shortening osteotomy for neutral or ulnar-positive wrists. Goal: relieve excess lunate loading to allow biological revascularization. |
| Stage IIIA | Lunate collapse but carpal alignment maintained. Scaphoid not yet rotated. | Unloading still applicable — RSO or capitate shortening if ulnar variance appropriate. Some cases: joint-leveling + vascularized bone graft to lunate when collapse is early and bone graft revascularization is feasible. |
| Stage IIIB | Lunate collapse with fixed scaphoid rotatory subluxation. Carpal alignment disrupted. | Salvage. Proximal row carpectomy (PRC) — removes scaphoid, lunate, and triquetrum; allows the capitellum to articulate with the radial facet. Preserves motion. Alternative: limited wrist fusion (scaphocapitate or 4-corner) to stabilize the carpus. |
| Stage IV | Pancarpal arthritis from progressive lunate collapse and carpal destabilization. | Total wrist fusion for reliable pain relief when motion preservation is secondary to pain control. PRC may still be possible in selected cases if the proximal capitate surface is healthy — assessed intraoperatively. |
Radial Shortening Osteotomy — The Early Stage Workhorse
For ulnar-negative wrists (the most common Kienböck's presentation), radial shortening osteotomy is the preferred unloading procedure. By shortening the radius 2–4mm, the load on the lunate is redistributed across the entire proximal carpal row — reducing the focal compressive stress that concentrates at the lunate in ulnar-negative anatomy.
The procedure involves a controlled osteotomy of the radial shaft, removal of a measured bone segment, and plate fixation to maintain the correction. Recovery includes casting while the osteotomy heals, followed by therapy. Outcomes are best in early disease before significant lunate collapse — the earlier the intervention, the greater the potential for lunate revascularization and long-term joint preservation.
Recovery
After Kienböck's Surgery
Cast — Osteotomy Healing
Radial shortening osteotomy requires cast immobilization while the osteotomy heals. Finger motion maintained throughout. No wrist loading.
Motion & Early Therapy
X-rays confirm osteotomy healing. Cast to splint. Formal wrist therapy begins — range of motion and forearm rotation. Strengthening deferred.
Strengthening & Return
Progressive grip and wrist strengthening. Return to light manual work. Serial MRI or bone scan at 6–12 months to assess lunate revascularization response.
Serial Monitoring
Lunate revascularization takes time — serial MRI over 1–2 years monitors response. Early-stage patients may show significant improvement. Stage III/IV salvage patients monitored for pain relief and motion.
FAQs
Frequently Asked Questions
Related Conditions
Next Steps
Wrist pain in a young adult
that won't resolve — get MRI.
Kienböck's disease is most treatable in its earliest stages, before structural collapse. Wrist pain in a younger patient without a clear injury history that fails to improve after 6–8 weeks warrants MRI evaluation — standard X-rays are often normal in Stage I. Early diagnosis opens the door to unloading procedures that may preserve the native wrist for decades.
Jacksonville Beach, FL 32250
MRI can be ordered at the first visit if Kienböck's is suspected.