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The Journal of Hand Surgery (European Volume, 2010) 35E: 7: 538–543

T E N Q U E S T I O N S O N K I E N B O¨ C K ’ S D I S E A S E O F T H E
LUNATE
JOSEPH J. DIAS and PETER LUNN
From the Department of Orthopaedic Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK

Kienbo¨ck’s disease (Kienbo¨ck, 1910) affects the lunate bone in patients who are usually in their
twenties, and present with pain, swelling and stiffness of the wrist. Almost every treatment currently
suggested for Kienbo¨ck’s disease is based on an hypothesis rather than proven knowledge. We treat
it in the hope that what we are doing is logical and likely to benefit our patients. There are many
questions that we should be prepared to answer and we list some we must address. A century after
Kienbo¨ck’s description of this disorder a number cannot yet be answered adequately. This paper
explores areas of uncertainty.

Keywords: Kienbo¨ck’s disease, lunate

WHAT CAUSES KIENBO¨CK’S DISEASE OF 1947), there are also patterns of involvement of the
THE LUNATE? lunate itself. The lunate is usually involved on its radial
aspect with wedging of the lunate usually, but not
We now agree that the changes seen on radiographs always, away from the ulnar. The compression when
and histologically are those of avascular necrosis. seen in the 100 cases described by Antun˜a (1966) was
Beyond that, however, there is no agreement on any often on the radial side of the lunate. Eventually the
other aspect. ‘SICK BONE’ – nearly an anagram of the entire lunate gets compressed, loses its height and is
word ‘Kienbo¨ck’s’ – is almost all we know about this fragmented. On the lateral view the lunate appears
condition. Is it trauma, mechanical ‘overloading’, con- elongated, both palmarwards and dorsally (Fig 1). This
stitutional conditions, metabolic abnormality, haemato- is the common presentation of an osteonecrotic lunate
logical disorder or something else that triggers the (Fig 2). The patterns of collapse are therefore:
avascular event? We do not quite know. Keith et al.
(2004) found that over half their 33 cases could not recall
any injury. Although occupational trauma has been (1) Where the cartilage envelope remains intact and the
considered, the evidence for this is poor. fragments are contained within it.
The shape of the lunate (Antun˜a, 1966) and ulnar (2) In many cases, however, the presentation is different
variance (Hulte´n, 1928) are predisposing factors. Antun˜a with a coronal fracture through the anterior half of
(1966), described three shapes of the lunate and noted the lunate. The anterior part of the lunate, to which
that the type 1 trapezoid-shaped lunate was more likely
the long radiolunate ligament is attached, tends to
to develop Kienbo¨ck’s disease. Others have shown that
patients with Kienbo¨ck’s disease have slender wrists. We tilt so its proximal edge is separated from the
know about the three patterns of arterial organization remainder of the lunate. In these cases, the proximal
within the lunate (Gelberman et al., 1980) but do not edge can snag on the front of the distal radius (Fig 3)
know whether patients with this disorder have a partic- in palmar flexion and this movement, in particular,
ular pattern. In the African population asymptomatic causes pain.
Kienbo¨ck’s disease occurs in 1.9% of patients hav- (3) A rarer variant of this is the ulnar sagittal fracture
ing wrist radiographs; most are male (Mennen and with separation of the fragment which overhangs the
Sithebe, 2009). ulnar facet of the distal radius. Ulnar deviation is
We do not, at present know, what triggers the ischaemic likely to be particularly painful. A combination of
event(s) and whether early identification is possible. the sagittal and coronal fractures with displacement
can occur.
ARE THERE DIFFERENT PATTERNS OF
Kristensen et al. (1986) reported that the lunate had
KIENBO¨CK’S DISEASE OF THE LUNATE?
fractured in 16 but had not fractured in 33 of their cases
Apart from the four different stages of this disease which but they did not specify if the fragments were displaced.
have been well described (Lichtman et al., 1977; Sta˚hl, At present we do not know how frequent these three
ß The Author(s), 2010.
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TEN QUESTIONS ON KIENBO¨CK’S DISEASE OF THE LUNATE 539

Fig 1 A collapsed lunate is seen. The compression is greater on the
radial aspect. The compensatory flexion of the scaphoid is
seen. This will pull the dorsoradial aspect of the lunate
dorsally. The triquetrum extends on the hamate pulling the
ulnar palmar corner of the lunate into extension. The
collapsed lunate will therefore significantly restrict wrist
movement as radioulnar movement is compromised. Note
also the negative ulnar variance.

Fig 3 A sagittal CT scan of an affected lunate shows the tilted
palmar fragment with its proximal edge abutting the palmar
rim of the distal radius.

collapse permits the dorsoradial fragment to flex with
the scaphoid, increasing dorsal loading and the pal-
mar ulnar fragment extends with the triquetrum. This
will increase the abnormal mobility and lead to early
secondary degenerative change.

WHAT IS THIS DISORDER CONFUSED WITH?
This disorder may be confused with benign cysts and
traumatic fractures which can also cause some collapse
of the lunate. Occasionally, ulnar impaction causes cystic
Fig 2 A coronal CT scan of a collapsed lunate shows the
preservation of the joint cartilage, a greater collapse of the
change in the lunate followed by collapse, with appear-
radial aspect of the lunate and an oblique fracture. ances similar to those seen in Kienbo¨ck’s disease, but
with a definite ulnar positive configuration. However,
these conditions are uncommon and Kienbo¨ck’s disease
should be the first to be considered.
patterns are in Stage 3 of this disorder after the lunate
has collapsed.
There may also be different patterns based on the
WHAT DO PATIENTS COMPLAIN OF?
alteration of stability of the proximal carpal row. Two
situations could exist: (1) collapse without instability In the early stages, this disorder can be confused with
where the lunate has lost some height but the entire almost any inflammatory condition of the wrist as
structure is in continuity and the way the proximal row the clinical features are similar. It is only imaging that
moves has been restricted as the scaphoid cannot fully confirms that the disorder affects the lunate alone. Many
extend in ulnar deviation; and (2) the fracture during patients do not remember a specific injury or accident
540 THE JOURNAL OF HAND SURGERY VOL. 35E No. 7 SEPTEMBER 2010

(Keith et al., 2004). Assessment of the wrist demon- WHAT IS THE NATURAL HISTORY OF
strates some diffuse swelling around the front and KIENBO¨CK’S DISEASE?
back of the wrist without any particular increase in
warmth. There is mild local tenderness to deep pressure Delaere and colleagues (1998) from Strasbourg reported
over the lunate itself when palpated dorsally. The range on 22 cases treated nonoperatively and reviewed over
of wrist movement is restricted in all directions and 5 years later. They recorded increased stiffness in those
sometimes flexion causes pain. In most patients the pain treated surgically with a loss of wrist movement in 24%.
occurs at the extremes of movement, either extreme Most patients treated nonoperatively demonstrated an
flexion or extreme extension, but careful examination improvement in pain over the period and retained grip
shows that mid-range movements are usually not strength and range of wrist movement. Evans et al.
painful. (1986) reported their experience of nonoperative treat-
Dornan (1949) noted in the 43 patients he reported ment of Kienbo¨ck’s disease in 14 patients reviewed at an
average of 20 years after diagnosis. Only three patients
wrist stiffness did not predict function but that pain did.
complained of moderate pain and restriction of move-
Keith et al. (2004) reported the long-term outcome of
ment. Kristensen et al. (1986) noted marked improve-
non-surgically managed Kienbo¨ck’s disease in 33
ment in the level of pain over 30 years regardless of
patients and found that grip strength deteriorated by
changes within the lunate. Their results were consistent
40% and there was a decrease in the range of motion
with those of Beckenbaugh et al. (1980) who reported on
with time, particularly of wrist flexion. The mean
46 cases and who also found that patients were relieved
duration of symptoms was 8 years.
of pain and had good results and function regardless of
Taniguchi et al. (2002) reported on 16 patients with
whether they had surgical treatment or not. All these
stage 4 Kienbo¨ck’s disease and chronic subluxation of
studies allow patients to be reassured and challenge the
the scaphoid. All had received nonoperative treatment view that surgery alone improves symptoms.
and were seen at a mean of 30 years. The articular Some have observed that there is ‘inevitable’ progres-
surface of the radius had remodelled to the subluxed sion between the stages, described by Sta˚hl (1947) and
scaphoid but the joint space was maintained. Fifteen of later modified by Lichtman et al. (1977). Keith et al.
the 16 cases had either an excellent or good outcome. All (2004) observed that more patients with prolonged
patients were either asymptomatic or had only minor symptoms had stage 3B collapse of the lunate.
symptoms, so the result of progression of the stage of However, inevitable progression through the stages has
Kienbo¨ck’s disease need not be a disaster. not been borne out by other studies. Sta˚hl (1947)
In the early phases the increased pressure within the reported on 185 patients with Kienbo¨ck’s disease treated
lunate probably causes pain. Subchondral fracture by immobilization alone and found that two-thirds of
during fragmentation will cause a period of pain which patients, particularly those who were younger than
will improve over 6 to 12 weeks. Abnormal movement 25 years, retained a normal structure of the lunate
and point loading of the deformed lunate will also cause when re-examined. Delaere et al. (1998), reporting on 22
synovitis and pain. Impingement of a fractured fragment patients who did not have surgery, found that there was
will be painful on certain movement such as flexion or no change in the degree of lunate collapse over 5 years.
ulnar deviation; finally degenerative change may cause What is particularly interesting in the paper written by
aching and activity related sharp pain. The pain will be Kristensen et al. (1986) is that when they compared
sharp and intense just after a fracture or on impingement radiographs taken at the time of diagnosis and at follow-
of a fractured fragment. Whether the effects of the up almost 20 years later there was little difference in the
condition progress relentlessly or whether there are amount of deformation or fragmentation of the lunate.
periods of acute symptoms with periods of less acute They felt that the lunate, at the time of diagnosis, had
pain has not been established but the latter seems to be reached its final deformed shape in most cases.
the most common pattern. The changes within the lunate behave differently in
Patients find that pain rather than restriction of range different age groups. For instance, those under the age of
causes disability. Any intervention therefore should 12 have a very good prognosis with nonoperative
reliably improve both pain and range. Patients with treatment regaining most of their range and having
quite marked collapse of the lunate can have, apart almost no pain. It could well be that, as in nerve injuries,
from restriction of wrist movement, little pain and little the age at onset predicts outcome. Salmon et al. (2000)
wrist dysfunction. The radiological changes may not reported their experience of conservative management
consistently relate to symptoms. Taniguchi et al. (2002) versus radial shortening. There were 33 patients of which
reported late outcome of untreated Kienbo¨ck’s disease 18 had been treated nonoperatively. The follow-up was
on the range of wrist movement as a percentage of 3.6 years. Both groups showed some worsening of the
the normal side. The poorest range was 46% and stage of the lunate involvement, particularly from 3A
the best range was 93%, with most having a very to 3B. The only patient requiring an arthrodesis,
satisfactory wrist range between 70 and 90% of the however, was one who had had a radial shortening
opposite wrist. osteotomy. Of particular note were the five patients who
TEN QUESTIONS ON KIENBO¨CK’S DISEASE OF THE LUNATE 541

had stage 2 disease: in four the lunate was either maximum weakness between the dead necrotic bone
unchanged or improved. proximally and the revascularizing softer bone distally.
Kristensen et al. (1986) provided late results on 49 A subchondral fracture occurs at this interface. Any
patients with Kienbo¨ck’s disease who were treated excess loading either due to repeated use or due to a fall
nonoperatively. They noted that 83% of the wrists in on the hand could initiate this fracture between the
those who had just plaster immobilization were pain free revascularization zone and the proximal dead necrotic
or reported pain only on heavy work but found no wrist bone. The subchondral fracture could increase the pain
with a normal looking lunate. Dornan (1949) found that felt in the transition to stage 3.
63% of those not treated surgically returned to full work The progression from stage 2 to stage 3 could be due to
and 63% (17 of 27) of their cases had excellent or good revascularization rather than just the collapse of necrotic
results. Delaere et al. (1998) documented that of 22 bone. Any successful attempt to revascularize this bone
patients treated nonoperatively only one changed occu- could theoretically increase the chance of collapse of the
pation. The degree of collapse, therefore, does not relate lunate bone. Some have attempted to avoid this by not
to symptoms or disability. only attempting to revascularize the bone but also
unloading the bone using an external fixator (Bochud
and Bu¨chler, 1994).
DOES OPERATING CHANGE THE The question of whether collapse can be prevented by
surgical intervention has not been answered. We know
NATURAL HISTORY?
from numerous studies of joint levelling that some
Dornan (1949) reported on the nonoperative treatment patients will go on to develop progressive changes
of Kienbo¨ck’s disease in 27 of 43 patients. The only within the lunate just as after nonoperative treatment.
patient to have a wrist arthrodesis was one that had the This is expected, as the intra-lunate stresses will be
lunate excised for Kienbo¨ck’s disease. At present unaltered by joint levelling although the radiocarpal
although many case series suggest improvement of force transmission will alter. As it is the stresses within
symptoms after different operations, none are able to the lunate that cause it to collapse as adjacent trabeculae
show that this improvement does not simply reflect the fail, techniques that unload the lunate, such as the use of
natural history of the disorder. fixators, internal distraction, or capitate shortening,
Both the disorder and the interventions change the should prevent collapse. However, at present we do not
way the wrist works and we do not understand these have good comparative data to test this hypothesis. One
changes. The wrist has accommodated to a short ulna must also consider the changes in the stresses within the
during growth. We assume that joint levelling probably lunate as it collapses. These will decrease as the
has no consequence on neighbouring joints. However, if scaphocapitate joint takes greater load as the lunate
joint levelling alters the load distribution across the decreases in height. This would predict greater point
radiocarpal and ulnocarpal joints, it will also alter the loading between the capitate and scaphoid with conse-
way load is transferred across the midcarpal and quent gradual flexion of the scaphoid to accommodate
intercarpal joints. We need to investigate and understand the loss of height within the lunate. Degenerative change
these changes and their impact on the natural history of could occur in the scaphocapitate joint and later to the
the disorder. Further, as there is an alteration of the dorsum of the radioscaphoid joint with the shift in
ligament positions on the radial side compared to the loading to this joint.
ulnar side, the way the carpal bones move under load will
also alter. The impacts of shortening on muscle function
are likely to be tiny. At present we assume that these IS OSTEOARTHRITIS INEVITABLE?
changes are inconsequential. As we learn to investigate
the wrist better we may discover that this is not so. The next question is whether significant osteoarthritis is
a common event as it appears to be after scapholunate
ligament disruption or scaphoid nonunion. In a large
number of papers reporting on interventions for arthritis
CAN COLLAPSE BE PREVENTED?
of the radiocarpal joint there are very few that report
If the mechanism of collapse of the osteonecrotic lunate untreated Kienbo¨ck’s disease as the indication for
bone is similar to that seen in Perthes’ disease and surgery. Commonly apart from inflammatory disease
osteonecrosis of the head of the femur then the collapse of the distal radius such as rheumatoid arthritis, post-
is a manifestation of revascularization. If we think of this traumatic arthritis is seen after scaphoid nonunion or
disorder as an osteonecrotic disease in which there is loss a scapholunate dissociation, the SNAC and SLAC
of blood supply within the lunate due to whatever cause wrists. Although the scaphoid flexes to accommodate
then we are aware from the studies done by Glimcher the narrower lunate, the SLAC pattern of degenerative
and Kenzora (1979) that as the revascularization front arthritis does not occur (Taniguchi et al., 2002). Eleven
moves towards the surface of the proximal part of the of 16 cases reported by Taniguchi et al. (2002) had slight
lunate it meets the convex surface and this is the area of joint space narrowing but none had complete loss of
542 THE JOURNAL OF HAND SURGERY VOL. 35E No. 7 SEPTEMBER 2010

cartilage at a mean of 30 years after the disease was osteonecrotic lunate itself and involve surgery to other
identified. As the scapholunate and lunotriquetral liga- uninvolved bones and joints in the forearm and carpus.
ments are uninvolved, sagittal translation of the scaph- Most doctors would agree that the primary objectives
oid does not occur as it does in the SLAC or SNAC of treatment are to ease the patient’s pain, to reduce the
wrists. Osteoarthritis in the radioscaphoid joint is likely risks of progressive collapse of the lunate, and to prevent
to be delayed. or delay subsequent degenerative change and the asso-
However, when fragmentation involves a mobile ciated deterioration in wrist function.
displaced lunate fracture the part attached to the scaph- Patients with Kienbo¨ck’s disease experience pain for a
oid translates dorsally as the scaphoid flexes to accom- variety of reasons but in many the pain improves in time
modate the loss in lunate height. This causes a shift in even if nothing is done. However, we have inconclusive
load and consequent degenerative change in this loca- evidence about the rate and progression of collapse and
tion. The remainder of the lunate may extend with the degenerative change, and how these changes relate to
triquetrum with preservation of the articular cartilage symptoms. More importantly, we have not established
covering this part of the lunate and adjacent distal radius. whether and by how much our various interventions
At 3.6 years only one of 33 patients treated operatively affect collapse and osteoarthritis.
and nonoperatively had degenerative change (Salmon At present we have not answered the primary question
et al., 2000). Keith et al. (2004) recorded 33 cases treated of whether surgical intervention improves on the natural
nonoperatively with a mean duration of symptoms of 8 history of this disorder. The evidence that we have
years and noted arthritic changes in eight, but did not suggests that any difference between those having sur-
record the severity of arthritis. Kristensen et al. (1986) gery and those not having surgery is likely to be small
found that there was some radiocarpal arthritis in 67% and the range of wrist movement is likely to be poorer in
(33/49) of patients who had been reviewed for more than those having surgery than in those who do not.
18 years. The severity of arthritis was not defined, but it Another area of difficulty is knowing exactly what in
was not disabling and 16 showed no arthritic change the intervention has helped. If there has been some
over this period of time. denervation of the wrist during the surgical procedure,
We do not know whether surgery reduces the risk of whatever its nature, then that in itself could provide pain
degenerative change, and whether degenerative change, relief. It would therefore be difficult to attribute the
seen on radiographs, is associated with severe symptoms benefit to operations described. It is of note that,
and loss of function. The surgical options, in the regardless of the method of intervention, the reported
presence of painful degenerative arthritis, are denerva- improvement in pain in different studies seems similar.
tion, debridement or salvage procedures. Dornan (1949) reported on 43 patients with this dis-
order. The cases were drawn from a mining community
in Sheffield, UK. He commented that, ‘In fairly compa-
WHAT IS THE BEST TREATMENT? rable groups the results of treatment whether by conser-
vative measures or by removal of the lunate bone were
Ever since Kienbo¨ck described this disorder in 1910 after not strikingly different.’ This seems to be the common
radiographic examination of wrists, many interventions theme in most retrospective comparative groups.
have been described, ranging from attempts at revascu-
larizing the osteonecrotic lunate to unloading it either by
manipulations of carpal bones or by adjustment of the
HOW SHOULD THIS CONDITION BE ASSESSED?
relative lengths of the radius and ulna. Once a lunate has
fragmented then various techniques have been used to Assessment of treatment options must describe not just
restore, replace or ablate the lunate using techniques to the rate of benefit in terms of improving pain, retaining
bone graft the lunate, excise it, replace it with bone, the height of the lunate and the development of osteo-
pronator quadratus, vascularized grafts from the iliac arthritis but should clearly document any significant
crest, the pisiform or with artificial materials such as morbidity associated with the treatment itself, such as
silicone, ceramic and steel. The salvage options of further loss of wrist movement, and a reasonable
proximal row carpectomy, joint replacement or fusion estimate of risks. The baseline should be the natural
have also been reported. There are numerous publica- history of this condition.
tions now that report late outcomes of several of these The main relevant outcomes are (1) pain relief, (2)
interventions. prevention of lunate collapse and (3) prevention or delay
Most of the interventions that are in common use aim of osteoarthritis. The secondary outcomes are (4) to
to ‘unload’ the lunate. They are based on the hypothesis retain or improve wrist range, (5) hand strength and (6)
that it is possible to unload the lunate and prevent function. We find the Patient Rated Wrist Evaluation
progressive collapse, and also on a more tenuous and (MacDermid et al., 1998) gives a good assessment of
unproven hypothesis, that unloading the lunate will ease pain and function, radiographs provide assessment of
symptoms and reduce the risk of degenerative change. lunate height and osteoarthritis, and ranges of move-
Most of these treatments avoid the direct treatment of the ment and strength can be measured. We strongly urge
TEN QUESTIONS ON KIENBO¨CK’S DISEASE OF THE LUNATE 543

those writing on Kienbo¨ck’s disease to record and report get a more objective view of the condition itself before
these six outcomes. advising surgical treatment.
Although the patients would like to have less or no
pain and improvement in range of wrist movement the Conflict of interests
surgeon would like to (1) promote revascularization of
the lunate, (2) prevent collapse of the lunate and as a None declared.
consequence (3) reduce the rate of degenerative change
in the radiolunate joint. The intention of the surgeon is References
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In summary, most of these issues could be addressed Received: 17 March 2010
by adequate studies into the epidemiology and natural Accepted after revision: 2 May 2010
Professor Joseph Dias, Department of Orthopaedic Surgery, University Hospitals of Leicester
history of Kienbo¨ck’s disease. There is a danger that NHS Trust, Groby Road, Leicester, LE3 9QP, UK. Tel.: þ44 (0)116 2583089.
E-mail: Joseph.dias@uhl-tr.nhs.uk.
current inadequate treatment may tempt us to proceed to
more invasive and more radical procedures, whereas a
more scientific approach would be to ‘stand back’ and doi: 10.1177/1753193410373703 available online at http://jhs.sagepub.com