Kienböck's Disease
Upper LimbOverview
Kienböck's disease is idiopathic avascular necrosis of the lunate carpal bone, resulting in progressive collapse and degenerative changes of the wrist. The condition typically affects middle-aged adults and can lead to significant functional impairment and arthritis if untreated. Early diagnosis and intervention are critical to prevent disease progression and preserve wrist function.
Pathophysiology
Kienböck's disease develops due to disrupted blood supply to the lunate bone, leading to osteonecrosis and progressive structural failure. The lunate’s limited and variable blood supply (fed from both dorsal and volar vessels) and its central position in the proximal carpal row make it vulnerable to ischaemic injury. As necrosis progresses through four pathological stages—initial ischaemia, fragmentation, collapse, and secondary arthritis—the lunate loses architectural integrity, causing pain, loss of motion, and eventual wrist dysfunction.
Patient Education
Kienböck's disease requires early diagnosis and appropriate medical management to prevent progression; avoid high-impact activities and repetitive wrist loading, and maintain regular follow-up imaging to monitor disease stage.
Typical Presentation
Site
Central wrist pain over the lunate, typically on the palmar aspect; dorsal wrist swelling possible; pain may be localised to the third metacarpal axis
Quality
Dull, aching pain with superimposed sharp discomfort on certain movements; progressive stiffness and clicking sensations
Intensity
Mild to moderate initially (Stage I-II), progressing to severe pain with functional loss in advanced stages; pain typically 4-7/10 initially, increasing with disease progression
Aggravating
Gripping activities, wrist extension and radial deviation, repetitive loading, forceful pinching, prolonged wrist use
Relieving
Rest, immobilisation, ice application, anti-inflammatory medications, wrist support or splinting
Associated
Progressive loss of grip strength, reduced wrist range of motion (especially extension), swelling and stiffness, clicking or clunking sensation, possible carpal tunnel syndrome symptoms, eventual post-traumatic arthritis
Orthopaedic Tests
Test descriptions are written with AI assistance from standard clinical texts. Where a test lists Sources, its description has been checked against them; those sources are independent and do not endorse OsteoKit. Accuracy figures and grades (A–D) appear only when checked against the published study; tests without one are marked “No accuracy study”.
Further reading: full test procedures are described in standard clinical examination texts, e.g. Magee & Manske, Orthopedic Physical Assessment (7th ed.), and Cook & Hegedus, Orthopedic Physical Examination Tests: An Evidence-Based Approach (2nd ed.).
Scaphoid Shift Test (Watson's Test)
Procedure
Forearm pronated. Press your thumb on the palmar scaphoid tubercle and move the wrist from ulnar deviation with slight extension into radial deviation with slight flexion, then release the pressure. Test both wrists.
Positive Finding
A painful clunk as the scaphoid shifts dorsally and reduces on release, or reproduction of dorsal wrist pain.
Interpretation
Not a test for Kienböck's disease; it assesses scapholunate instability. Advanced Kienböck's with carpal collapse can produce secondary carpal instability, but staging is done on imaging, not with this test. This test assesses scapholunate instability. No study reports its accuracy for Kienböck's disease, so no figure is shown.
Sources
- Educational sitePhysiopedia. Scaphoid Shift Test.
- RelatedWatson HK, Weinzweig J, Zeppieri J. The natural progression of scaphoid instability. Hand Clin. 1997;13(1):39-49.
Lunate Ballottement Test
Procedure
Stabilise the radius and gently move the lunate palmar and dorsal between your thumb and index finger. Compare with the other wrist.
Positive Finding
Pain over the lunate, or more movement than on the other side.
Interpretation
Not a recognised diagnostic test for Kienböck's disease. Pain localised to the lunate is a reason to X-ray, and if X-rays are normal but symptoms persist, to arrange an MRI, which shows early disease.
Further reading
Axial Load Test (Lunate Compression)
Procedure
Palpate the dorsal lunate (just distal to Lister's tubercle, in line with the third metacarpal), then gently push along the third metacarpal towards the wrist.
Positive Finding
Localised tenderness over the dorsal lunate, or pain on axial loading of the third ray.
Interpretation
Localised lunate tenderness supports Kienböck's disease but also occurs with other central wrist problems such as scapholunate injury or a dorsal ganglion. X-ray first; MRI shows early disease when X-rays are normal.
Further reading
Grip Strength Testing (Dynamometry)
Procedure
Patient seated, elbow at 90° by the side, forearm in neutral. Measure grip with a hand dynamometer, three trials per hand, and record the mean.
Positive Finding
Weaker grip on the affected side, or pain during gripping.
Interpretation
Grip is often reduced by pain in Kienböck's disease and is a useful baseline for tracking treatment; it does not help make the diagnosis.
Radial-Sided Wrist Pain Provocation (Combined Test)
Procedure
Resist wrist extension and ask the patient where it hurts, then take the wrist into extension with light overpressure.
Positive Finding
Central dorsal wrist pain over the lunate.
Interpretation
Not a recognised named test. Central dorsal wrist pain on loading fits Kienböck's disease, a dorsal ganglion or scapholunate injury, and points towards imaging rather than a diagnosis.
Further reading
⚠ Red Flags
- •Rapidly progressive wrist pain with acute collapse on imaging suggesting advanced stage disease requiring urgent surgical consultation
- •Signs of compartment syndrome or acute vascular compromise (colour changes, temperature changes, pins and needles)
- •Severe functional loss with inability to perform activities of daily living requiring specialist medical review
- •Imaging evidence of Stage III-IV disease (lunate collapse, scaphoid-lunate dissociation, or secondary osteoarthritis) necessitating urgent orthopaedic referral
- •Systemic signs suggesting infection or malignancy (fever, weight loss, night sweats) requiring medical investigation
⚡ Yellow Flags
- •Catastrophic thinking regarding wrist function and prognosis leading to activity avoidance
- •Occupational stress with job demands requiring heavy wrist loading incompatible with conservative management
- •Psychosocial distress related to potential loss of occupational capacity or hand dominance involvement
- •Poor adherence to activity modification or splinting recommendations
- •Kinesiophobia (fear of movement) limiting rehabilitation engagement
Osteopathic Techniques
Refer first
Kienböck disease (avascular necrosis of the lunate) is staged with imaging and managed by a hand surgeon. Stage I, and stage II with incomplete necrosis, may be treated with a splint or cast; later stages generally need joint-levelling or other surgery. Refer before using manual techniques on the wrist.
- Reference bookNasr & Koay · StatPearls 2023
Rehabilitation Exercises
Wrist Pendulum Mobilisation
Forearm Flexor Stretch (Supinated Wrist Extension)
Forearm Extensor Stretch (Pronated Wrist Flexion)
Wrist Circumduction in Neutral
Grip Strength Training with Therapeutic Putty (Pain-Free Resistance)
Isometric Wrist Stabilisation (Four Directions)
Proprioceptive Wrist Stabilisation on Unstable Surface
Scapular Stabilisation and Posture Awareness
Progressive Wrist Loading with Progressive Resistance Band
Activity-Specific Simulation (Simulated Occupational Tasks)
Upper Limb Ergometer Training (Seated Arm Cycling)
Pronation and Supination Strengthening with Progressive Resistance
Referral Criteria
- •Initial diagnosis or suspected Kienböck's disease — refer to orthopaedic hand surgeon or rheumatologist for imaging (MRI/CT), staging, and medical management
- •Stage I-II disease with persistent pain despite conservative management for 6-8 weeks — refer for consideration of surgical intervention (revascularisation, lunate decompression, or levelling osteotomy)
- •Stage III-IV disease with lunate collapse or secondary osteoarthritis — refer for surgical consultation regarding arthrodesis or proximal row carpectomy
- •Progressive functional loss or wrist instability — refer for advanced imaging and specialist assessment
- •Suspected secondary conditions such as carpal tunnel syndrome or scaphoid-lunate dissociation — refer for nerve conduction studies or advanced imaging
- •Psychological distress or occupational stress affecting rehabilitation — refer to occupational psychologist or vocational rehabilitation specialist
- •Inadequate pain relief or concerning systemic symptoms — refer to general practitioner for medical review and analgesia optimisation