Imaging and staging of avascular osteonecroses at the wrist and hand

Avascular ostenecroses (AVN) are unspecific focal sceletal lesions of vascular origin. At the wrist, AVNs are mainly seen in the lunate (Kienbock's disease) and the proximal scaphoid fragment in the presence of a nonunion disease (pseudarthrosis). Other types of osteonecroses are rare. The natural process of devitalization proceeds in steps: initially, there is a bone marrow oedema, followed by trabecula sclerosis, cystic transformation of the spongiosa, and bone fragmentation. End stages include carpal collapse (SLAC wrist) and osteoarthritis. For imaging of the sceletal morphology in AVN computed tomography is most useful, whereas initial stages and perfusion damages are better detected with contrast enhanced magnetic resonance imaging (MRI). In this paper a staging classification for Kienböck's disease and the scaphoid nonunion, considering the diagnostic and therapeutic consequences, is presented.