Your Orthopaedic Connection: Kienböck's Disease

Kienböck's Disease

Bones of the hand and wrist. H=hamate; C=capitate; TZ=trapezoid; TP=trapezium; TQ=triquetrum; L=lunate; S=scaphoid; U=ulna; R=radius. Numbers denote fifth, fourth, third, and second metacarpals.

Reproduced with permission from Lichtman DM, Joshi A: Acute Injuries of the Distal Radioulnar Complex and Triangular Fibrocartilage Complex. Instr Course Lect 2003;52:175-183.

Bone is living tissue that requires a regular supply of blood for nourishment. If the blood supply to a bone stops, the bone can die. This is known as osteonecrosis. In Kienböck's disease, the blood supply to one of the small bones of the hand near the wrist (the lunate) is interrupted.

Cause

The cause of Kienböck's disease is not known. Many people with Kienböck's disease think they have a sprained wrist at first. They may have experienced some form of trauma to the wrist, such as a fall. This type of trauma can disrupt the blood flow to the lunate.

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Symptoms

In most people, two vessels supply blood to the lunate, but in some people there is only one source. This puts them at greater risk for developing the disease. As the disease progresses, other signs and symptoms are noted, including:

A painful and sometimes swollen wrist
Limited range of motion in the affected wrist (stiffness)
Decreased grip strength in the hand
Tenderness directly over the bone (on the top of the hand at about the middle of the wrist)
Pain or difficulty in turning the hand upward

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Diagnosis

Kienböck's disease progresses through four stages. In its early stages, Kienböck's disease may be difficult to diagnose because the symptoms are so similar to those of a sprained wrist. Even X-rays of the wrist may appear normal.

Stage 1: Symptoms are similar to those of a wrist sprain.

X-rays may be normal or suggest a possible fracture. Magnetic resonance imaging (MRI) may also be helpful in making the diagnosis in this early stage.

Stage 2: The lunate bone begins to harden.

X-ray showing how the lunate bone becomes brighter and whiter as the bone dies (sclerosis) and collapses.

Reproduced with permission from Bozentka D, Beredjiklan P: Kienböck's Disease, in Grana WA (ed): Orthopaedic Knowledge Online. Rosemont, Illinois, American Academy of Orthopaedic Surgeons, accessed February 22, 2007 http://www5.aaos.org/oko/page.cfm?topic=HAN011

Brighter or whiter areas on X-rays indicate that the bone is dying. Either MRI or computed tomography (CT) may be used to assess the bone. Wrist pain, swelling, and tenderness are common.

Stage 3: The dead bone begins to collapse and break into pieces.

As the bone begins to break apart, the surrounding bones may begin to shift position. Increasing pain, weakness in gripping, and limited motion may be experienced.

Stage 4: The surfaces of adjoining bones are affected.

One result may be arthritis of the wrist.

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Treatment

Although there is no cure, there are several nonsurgical and surgical options for treating this disease. The goals of treatment are to relieve the pressure on the lunate and to try to restore blood flow within the bone.

Nonsurgical Treatment

The wrist may be splinted or casted for two to three weeks. Anti-inflammatory medications, such as aspirin or ibuprofen, will help relieve any pain and reduce swelling. If the pain continues, your physician may refer you to an orthopaedic or hand surgeon for further evaluation.

Surgical Options

There are several surgical options for treating the more-advanced stages of Kienböck's disease. The choice of procedure will depend on several factors, including disease progression, activity level, personal goals, and the surgeon's experience with the procedures.

In some cases, it may be possible to return the blood supply to the bone (revascularization). This procedure takes portion of bone (graft) from the inner bone of the lower arm. A metal device (an external fixator) may be used to relieve pressure on the lunate and preserve the spacing between bones.

If the bones of the lower arm are uneven in length, a joint leveling procedure may be recommended. Bones can be made longer using bone grafts or shortened by removing a section of the bone. This leveling procedure reduces the forces that bear down on (compress) the lunate and seems to halt progression of the disease.

If the lunate is severely collapsed or fragmented into pieces, it can be removed. In this procedure, the two bones on either side of the lunate are also removed. This procedure, called a proximal row carpectomy, will relieve pain while maintaining partial wrist motion.

Another procedure that eases pressure on the bone is fusion. In this procedure, several of the small bones of the hand are fused together. If the disease has progressed to severe arthritis of the wrist, fusing the bones will reduce pain and help maintain function. The range of wrist motion, however, will be limited.

Do not hesitate to discuss these options with your orthopaedic or hand surgeon.

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Last reviewed and updated: October 2007

Co-developed with the American Society for Surgery of the Hand

AAOS does not review or endorse accuracy or effectiveness of materials, treatments or physicians.