• Avascular necrosis of the lunate leading to abnormal carpal motion

• Most common in males between 20-40 years old, with history of trauma

• Risk factors

  • Ulnar negative variance : leads to increased radial-lunate contact stress

  • Decreased radial inclination

  • Repetitive trauma

• Presentation :

  • Dorsal wrist pain (Usually activity related, more often in dominant hand)

  • limited ROM

Imaging:

• Xrays are needed, bilateral

• Scan: useful when collapse occurs

• MRI: for early detection (Decreased T1 signal)

Treatment:

Conservative

• Cast + NSAIDs : onbly for stage 1 patients. BUT later procedures are often needed.

Operative

• Temporary scaphotrapeziotrapezoidal pinning : in adolescent with radiographic evidence of Kienbock’s and progressive wrist pain

• Joint leveling procedure ( radial shortening)

  • Stage I, II, IIIA disease with ulnar negative variance 

• Radial wedge osteotomy

  • Stage I, II, IIIA disease with ulnar positive or neutral variance

• Vascularized bone grafts: stage I to IIIB. Needs long term results

• Core decompression: stage I, II ad IIIA

• Partial wrist fusions

  • STT

  • capitate shortening osteotomy +/- capitohamate fusion

  • scaphocapitate

  • indications

    • Stage II disease with ulnar neutral or positive variance

    • Stage IIIA or IIIB disease

    • must address internal collapse pattern (DISI)

• Proximal row carpectomy (PRC) : stage IIIB or IV

• Wrist fusion : stage IV

• Total wrist arthroplasty: stage IV