J Wrist Surg 2016; 05(04): 248-254
DOI: 10.1055/s-0036-1583755
Special Review: Kienböck Disease
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

The Etiology and Pathogenesis of Kienböck Disease

Gregory Ian Bain
1   Department of Orthopaedic Surgery, Flinders University, Adelaide, South Australia, Australia
Simon Bruce Murdoch MacLean
1   Department of Orthopaedic Surgery, Flinders University, Adelaide, South Australia, Australia
Chong Jin Yeo
2   Hand and Microsurgery Section, Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore
Egon Perilli
3   School of Computer Science, Engineering and Mathematics, Flinders University, Adelaide, South Australia, Australia
David M. Lichtman
4   Uniformed Services University, Bethesda, Maryland
5   University of North Texas Health Science Center, Fort Worth, Texas
› Author Affiliations
Further Information

Publication History

23 March 2016

06 April 2016

Publication Date:
02 May 2016 (online)


Kienböck disease is a condition that typically occurs in the “at-risk” patient, in the “at-risk” aspect of the proximal condyle of the “at-risk” lunate. In the active male, repetitive loading causes the stress fracture that commences in the single layer proximal subchondral bone plate. The lunate fracture commences at the point the lunate cantilevers over the edge of the distal radius, and then takes on the shape of the radius. We postulate that the stress fracture violates the parallel veins of the venous subarticular plexus—leading to localized venous hypertension and subsequent ischemia and edema of the fatty marrow. The increased osseous compartment pressure further potentiates the venous obstruction, producing avascular necrosis.

If the fracture remains localized, it can heal or settle into a stable configuration, so that the wrist remains functional. Fractures of the subchondral bone plate produce irregularity of the lunate articular surfaces and secondary “kissing lesions” of the lunate facet and capitate, and subsequent degeneration. The lunate collapses when the fracture is comminuted, or there is disruption of the spanning trabeculae or a coronal fracture.

The secondary effect of the lunate collapse is proximal migration of the capitate between the volar and dorsal fragments, producing collapse of the entire central column. The proximal carpal row is now unstable, and is similar to scapholunate instability, where the capitate migrates between the scaphoid and lunate. The scaphoid is forced into flexion by the trapezium, however, degeneration of the scaphoid and scaphoid facet only occurs in late disease or following failed surgery.

In Kienböck disease, the secondary effects of the collapsing lunate are a “compromised” wrist, including: deformity and collapse of the central column, degeneration of the central column (perilunate) articulations, proximal row instability (i.e., between the central and radial columns), and degeneration of the radial column.

  • References

  • 1 Kienböck R. Concerning traumatic malacia of the lunate and its consequences: joint degeneration and compression. Fortsch Geb Roentgen 1910; 16: 77-103
  • 2 Müller W. Über die Erweichung und Verdichtung des Os lunatum, eine typische Erkrankung des Handgelenks. Beitr Klin Chir 1920; 119: 664
  • 3 Ringsted A. Kienböck bei 2 Br ü dern. Acta Chir Scand 1932; xx: 185-196
  • 4 Templeman D, Engber W. Kienbock's Disease—Case Report of Familial Occurrence. Iowa Orthop J 1985; 5: 107-109
  • 5 Gelberman RH, Bauman TD, Menon J, Akeson WH. The vascularity of the lunate bone and Kienböck's disease. J Hand Surg Am 1980; 5 (3) 272-278
  • 6 Lee ML. The intraosseus arterial pattern of the carpal lunate bone and its relation to avascular necrosis. Acta Orthop Scand 1963; 33: 43-55
  • 7 Therkelsen F, Andersen K. Lunatomalacia. Acta Chir Scand 1949; 97 (6) 503-526
  • 8 Stahl S, Stahl AS, Meisner C, Rahmanian-Schwarz A, Schaller H-E, Lotter O. A systematic review of the etiopathogenesis of Kienböck's disease and a critical appraisal of its recognition as an occupational disease related to hand-arm vibration. BMC Musculoskelet Disord 2012; 13 (1) 225
  • 9 van Leeuwen WF, Janssen SJ, Ter Meulen DP, Ring D. What Is the Radiographic Prevalence of Incidental Kienböck Disease?. Clin Orthop Relat Res 2016; 474 (3) 808-813
  • 10 Bain GI, Yeo CJ, Morse LP. Kienböck Disease: Recent Advances in the Basic Science, Assessment and Treatment. Hand Surg 2015; 20 (3) 352-365
  • 11 McLean JM, Turner PC, Bain GI, Rezaian N, Field J, Fogg Q. An association between lunate morphology and scaphoid-trapezium-trapezoid arthritis. J Hand Surg Eur Vol 2009; 34 (6) 778-782
  • 12 Low SC, Bain GI, Findlay DM, Eng K, Perilli E. External and internal bone micro-architecture in normal and Kienböck's lunates: a whole-bone micro-computed tomography study. J Orthop Res 2014; 32 (6) 826-833
  • 13 Rock MG, Roth JH, Martin L. Radial shortening osteotomy for treatment of Kienböck's disease. J Hand Surg Am 1991; 16 (3) 454-460
  • 14 Hultén O. Uber anatomische variationen der handgelenkknochen. Acta Radiol 1928; 9 (2) 155-168
  • 15 Viegas SF, Wagner K, Patterson R, Peterson P. Medial (hamate) facet of the lunate. J Hand Surg Am 1990; 15 (4) 564-571
  • 16 Rhee PC, Moran SL, Shin AY. Association between lunate morphology and carpal collapse in cases of scapholunate dissociation. J Hand Surg Am 2009; 34 (9) 1633-1639
  • 17 Bain GI, Clitherow HD, Millar S , et al. The effect of lunate morphology on the 3-dimensional kinematics of the carpus. J Hand Surg Am 2015; 40 (1) 81-9.e1
  • 18 Zapico J. Malacia del semilunar. Valladolid, Spain: Universidad de Valladolid, Servicio de Publicaciones; 1966
  • 19 Zapico JA. Enfermedad de Kienböck. Rev Ortop Traumatol (B Aires) 1993; 37 IB (Supl. I): 100-113
  • 20 Nakanishi A, Yajima H, Kisanuki O. Post-traumatic osteonecrosis of the lunate after fracture of the distal radius. J Plast Surg Hand Surg 2014; 48 (6) 434-436
  • 21 Wilke B, Kakar S. Delayed Avascular Necrosis and Fragmentation of the Lunate Following Perilunate Dislocation. Orthopedics 2015; 38 (6) e539-e542
  • 22 Solomon L. Idiopathic necrosis of the femoral head: pathogenesis and treatment. Can J Surg 1981; 24 (6) 573-578
  • 23 Frerix M, Kröger K, Szalay G, Müller-Ladner U, Tarner IH. Is osteonecrosis of the lunate bone an underestimated feature of systemic sclerosis? A case series of nine patients and review of literature. Semin Arthritis Rheum 2016; 45 (4) 446-454
  • 24 Rennie C, Britton J, Prouse P. Bilateral Avascular Necrosis of the Lunate in a Patient with Severe Raynaud's Phenomenon and Scleroderma. J Clin Rheumatol 1999; 5 (3) 165-168
  • 25 Jensen CH. Intraosseous pressure in Kienböck's disease. J Hand Surg Am 1993; 18 (2) 355-359
  • 26 Schiltenwolf M, Martini AK, Mau HC, Eversheim S, Brocai DR, Jensen CH. Further investigations of the intraosseous pressure characteristics in necrotic lunates (Kienböck's disease). J Hand Surg Am 1996; 21 (5) 754-758
  • 27 Crock HV. An Atlas of Vascular Anatomy of the Skeleton and Spinal Cord. 1st ed. Martin Dunitz; 1996
  • 28 Lichtman DM, Mack GR, MacDonald RI, Gunther SF, Wilson JN. Kienböck's disease: the role of silicone replacement arthroplasty. J Bone Joint Surg Am 1977; 59 (7) 899-908
  • 29 Bain GI, Smith ML, Watts AC. Arthroscopic core decompression of the lunate in early stage Kienbock disease of the lunate. Tech Hand Up Extrem Surg 2011; 15 (1) 66-69
  • 30 Bain GI, Begg M. Arthroscopic assessment and classification of Kienbock's disease. Tech Hand Up Extrem Surg 2006; 10 (1) 8-13
  • 31 Lichtman DM, Degnan GG. Staging and its use in the determination of treatment modalities for Kienböck's disease. Hand Clin 1993; 9 (3) 409-416
  • 32 Watson HK, Ballet FL. The SLAC wrist: scapholunate advanced collapse pattern of degenerative arthritis. J Hand Surg Am 1984; 9 (3) 358-365
  • 33 Lichtman DM, Bain GI. Kienbock's Disease: Advances in Diagnosis and Treatment. Berlin, Germany: Springer; 2016