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Kienbock's disease

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Plain radiographs are the initial diagnostic test of choice but may be normal at the onset of the disease. A subtle linear fracture without sclerosis or collapse may be seen on radiographs early in the disease.  As the disease progresses, the lunate demonstrates increased sclerosis, often with one or multiple fracture lines.  The lunate then begins to fragment and collapse leading to proximal migration of the capitate and hyperflexion of the scaphoid (Figure 1: X-ray of wrist with Kienbock's).  The end stage radiographic changes include joint space narrowing and arthritis of the radiocarpal and midcarpal joints.

Advanced imaging studies are also useful in the evaluation and diagnosis of Kienböck’s disease.  Magnetic resonance imaging is the most sensitive test for detecting early Kienböck’s that may not yet show any radiographic changes.  Uniformly decreased T1 signal throughout the lunate is highly suggestive of Kienböck’s disease (Figure 2: MRI of wrist with Kienbock's).  Computed tomography (CT) best demonstrates the degree of bony destruction and structural collapse once there is radiographic evidence of sclerosis, fracture, or fragmentation of the lunate.