The Kienböck’s Dilemma — How to Cope

Abstract

Etiology, blood supply, early diagnosis, staging, and treatment in Kienböck’s disease are the subjects of numerous manuscripts in the literature. We present an insight into Kienböck’s disease as we understand it and a rationale for approaching the Kienböck’s dilemma. Kienböck’s disease is an isolated disorder of the lunate manifested by radiodensity changes and often accompanied by fracture lines, fragmentation, and progressive collapse. Ultimately, its etiology is vascular insufficiency, but contributing factors that put the lunate at risk include negative ulnar variance, limited extraosseous blood supply, limited intraosseous blood supply and repeated “microtrauma.” Though there are numerous treatment modalities, we recommend several methods based on staging and ulnar variance. For Stage I, immobilization is helpful to establish the diagnosis with certainty and theoretically may allow the lunate to revascularize. In patients with Stage II or IIIA and ulnar negative variance, radial shortening is recommended. If there is positive ulnar variance, a revascularization procedure is preferred (DML) but radial shortening (AHA) also has been successful. In Stage HIB, there being fixed deformity of the lunate and carpus, scapho-trapezio-trapezoid fusion or scaphocapitate fusion is utilized. If there is significant synovitis, then the lunate is excised as well. In Stage IV (pan-carpal arthrosis), proximal row carpectomy or wrist arthrodesis is indicated.

The opinions or assertions expressed herein are those of the authors and are not to be construed as official or as necessarily reflecting the views of the Department of the Navy or of the Naval service at large.