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Kienböck's Disease (Lunate Avascular Necrosis)

advanced
6 min
28 marks
6 questions
Clinical Scenario
A 28-year-old right-hand dominant manual laborer presents with 12 months of progressive right wrist pain and stiffness. He cannot recall any specific injury. Pain is worse with gripping and loading the wrist. On examination, there is dorsal wrist tenderness over the lunate, reduced grip strength, and decreased wrist range of motion (40° extension, 30° flexion). X-ray shows a sclerotic lunate with preserved carpal alignment. Ulnar variance is -3mm.
PA wrist radiograph demonstrating Kienböck's disease (lunate AVN). The lunate shows increased sclerosis (white appearance) with loss of height compared to adjacent carpal bones. There is no carpal collapse or fixed scaphoid rotation (Stage IIIA). Negative ulnar variance is evident. MRI would show low signal on T1 and variable T2 signal indicating avascular necrosis.
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PA wrist radiograph demonstrating Kienböck's disease (lunate AVN). The lunate shows increased sclerosis (white appearance) with loss of height compared to adjacent carpal bones. There is no carpal collapse or fixed scaphoid rotation (Stage IIIA). Negative ulnar variance is evident. MRI would show low signal on T1 and variable T2 signal indicating avascular necrosis.

Source: MRI Modeling to Enhance Osteochondral Transfer in Segmental Kienböck Disease • PMC4297129 • CC-BY

Questions

Question 1 (4 marks)

Describe the anatomy and blood supply of the lunate relevant to AVN.

Question 2 (5 marks)

What is the Lichtman classification and how does it guide treatment?

Question 3 (6 marks)

Describe the surgical treatment options by stage.

Question 4 (5 marks)

What is the technique for radial shortening osteotomy?

Question 5 (4 marks)

Discuss revascularization procedures for Kienböck's disease.

Question 6 (4 marks)

What are the salvage procedures and outcomes?

Exam Day Cheat Sheet

Must Mention

  • •Negative ulnar variance = increased lunate load (78%)
  • •Single vessel blood supply = vulnerability
  • •IIIA vs IIIB = scaphoid rotation (SL >60°)
  • •Radial shortening for negative UV
  • •Capitate shortening for neutral/positive UV
  • •PRC requires preserved capitate head

Common Pitfalls

  • •Wrong stage
  • •Missing UV significance
  • •Wrong treatment for stage
  • •Confusing IIIA/IIIB
  • •Missing revasc options
  • •Wrong PRC indication