Fracture of the Lunate Bone

R. Cetti, S-E. Christensen and K. Reuther, Soro, Denmark

F R A C T U R E OF T H E L U N A T E B O N E
R. C E T T I , S-E. C H R I S T E N S E N and K. R E U T H E R , Sor6, Denmark

SUMMARY
Three cases o f f r e s h h m a t e f r a c t u r e s are p r e s e n t e d . The rarity o f this p a r t i c u l a r
f r a c t u r e is discussed a n d correlated to Kienbi~ck's disease. A regimen o f t r e a t m e n t is
recommended.

INTRODUCTION
Fractures o f the wrist usually result f r o m a fall on the hyperflexed or
hyperextended hand. C o m m o n l y the distal part of the radius is involved, either
alone or in combination with the ulna or the carpal bones. Among the carpal bones,
fracture o f the scaphoid is most frequent. The incidence o f lunate fracture is quoted
by Boyes (1970) as 5.3--6.5 per cent, but no further information is given. In
particular, there are no details which can exclude KienbOck's disease. Other m a j o r
reviews on carpal fractures do not give special attention to lunate fracture (Campbell
1964, Stewart 1968, Linscheid 1972, Pellegrino 1973, Dunn 1973).
Review of the literature revealed only three well documented cases of fresh
lunate fractures: Brolin (1964) examined 5000 x-ray pictures of the wrist and found
158 cases o f pathological changes in the lunate bone. O f these only two were fresh
lunate fractures. No details o f the treatment were given, but the fractures healed
with slight deformation o f the bones. Noble (1979) published a case o f fresh lunate
fracture and pointed out that in other publications on carpal fractures no evidence
of fresh fracture of the lunate bone were presented. We have, therefore, considered
it worthwhile to report our experience with three cases o f fresh lunate fractures.

CASE REPORTS
Case one: A seventy-one year old man fell and fractured the distal part o f the
right radius and the right lunate bone. Both fractures were verified on radiological
examination (Fig. 1). At the time of the accident the patient was admitted to hospital
on account of his general condition and chronic alcoholism.
The treatment consisted of immobilization in a high circular plaster for seven
weeks. During the rehabilitation period the general condition declined and the
patient died due to pneumonia and hepatic insuffiency.
At postmortem examination the lunate bone was found macroscopically
healed. Microscopical examination established rich formation o f callus with no sign
o f avascular necrosis (Fig. 2).
Case two: A fifty-nine year old man fell and fractured the right lunate bone
(Fig. 3). The treatment consisted of a high circular plaster for six weeks leading to
uneventful healing. Clinical examination eighteen weeks after the trauma revealed
no pathological signs.

R. Cetti, M.D., Betty Nansens All6 31, 2500 Valby, Copenhagen, Denmark. From the Hospital of
Orthopaedic Surgery, Sor6, Denmark.

9 1982 British Society for Surgery of the Hand 0072-968X-82-00190080 $02.00

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 Fracture o f the Lunate Bone
R, Cetti, S-E. Christensen and K. Reuther

Fig. 1. The arrow indicates the lunate fracture.

Case three: A thirty-nine year old woman fell on the hyperextended right hand
and fractured the lunate bone (Fig. 4). The treatment consisted o f a high circular
plaster for seven weeks followed by physiotherapy. Clinical examination twelve
weeks after the trauma revealed normal conditions.
Patients two and three were re-examined clinically and radiologically twenty-
four and thirty-eight months respectively after the accident. No pathological signs
were noted.
DISCUSSION
Kienb6ck (1910) stated that Kienb6ck's disease of the lunate bone is a condition
arising from interference with the blood supply. This interference he attributed to
injuries such as subluxation of the lunate bone. Fracture of the lunate bone he
regarded as secondary.
Persson (1945) agreed with the view originally advanced by Hult6n (1928) that
an important aetiological factor to the Kienb6ck's disease was a relative shortening
o f the lower end of the ulna (ulna minus) with increased prominence o f the articular
surface of the radius. In injuries to the wrist the lunate bone is hereby exposed to
greater stress.
Gelberman (1980) discussed the causes of Kienb6ck's disease in the light o f
investigations of the internal and external vascular anatomy of the lunate bone. He
concluded that the vascular anatomy supports the theory of a mechanism of
repeated trauma to the wrist with compression fracture as the most likely cause of
Kienb6ck's disease. He also stated that horizontal fractures of the lunate bone
theoretically could lead to avascular necrosis of the proximal pole, thus mimicking
the conditions seen in scaphoid fractures. However he pointed out that a horizontal
fracture of the lunate bone has never been found.

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Fracture o f the Lunate Bone
R. Cetti, S-E. Christensen and K. Reuther

Fig. 2. Microscopic appearance of healed lunate fracture, silverstaining PASM x 30.

1. Replacement fibrosis in healing bone.
2. Bone sequestrum from fracture.
3. Callus.
4. Cancellous bone and fat-marrow.
5. Cartilage.
(From Department of Pathology, Frederiksberg Hospital, Copenhagen).

Beckenbaugh (1980) investigated forty-five patients with KienbOck's disease.

Seventy-two per cent could recall an earlier injury to the wrist. Sixty-seven per cent
o f the patients had x-ray evidence of fracture or fragmentation of the lunate bone at
the time of the re-examination. In no case did the x-ray taken at the time of primary
injury give the impression that the fragmentation due to KienbOck's disease
represented a fracture that had not healed. He also claimed that the cause for
KienbOck's disease still remains unclarified.
A wellknown feature of scaphoid fractures is delayed radiological
confirmation. Therefore a secondary x-ray examination is routinely recommended
ten to fourteen days after the trauma to avoid the consequences of untreated
fractures viz. pseudo-arthrosis or avascular necrosis. However minute clinical
examination will disclose most scaphoid fractures. By contrast lunate fractures are
difficult to diagnose due to variable symptomatology. One might suspect therefore
that patients with lunate fractures are misdiagnosed as sprains of the wrist, again
due to the delayed radiological appearance. These misdiagnosed fractures may be

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 Fracture o f the Lunate Bone
R. CettL S-E. Christensen and K. Reuther

Fig. 3. The arrow indicates the lunate fracture.

Fig. 4. The arrow indicates the lunate fracture.

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Fracture o f the Lunate Bone
R. Cetti, S-E. Christensen and K. Reuther

the ones giving rise to d e v e l o p m e n t o f K i e n b 6 c k ' s disease. A s e c o n d a r y x-ray

e x a m i n a t i o n carried o u t ten to fourteen days after the t r a u m a m a y make diagnosis
m o r e certain, thus p e r h a p s decreasing the incidence o f KienbOck's disease.
In the period 1970 to 1980 273 patients presented with carpal fractures in o u r
d e p a r t m e n t . Three patients (1.1 per cent) had fresh l u n a t e fracture. In the same period
KienbOck's disease was diagnosed in fourteen patients. The incidence o f fresh l u n a t e
fracture plus KienbOck's disease could be estimated to 6.2 per cent, which is close to
the incidence o f l u n a t e fractures in other p u b l i c a t i o n s (Boyes 1970). The true inci-
dence o f fresh l u n a t e fractures might be s o m e w h a t less t h a n previously estimated.
The t r e a t m e n t o f the present cases has been clinically a n d radiologically
sufficient. F u r t h e r m o r e there was histological evidence o f a d e q u a t e healing in case
one. In the p a t i e n t presented by Noble (1979) fracture healing was evident six
m o n t h s after the t r a u m a . E x a m i n a t i o n two years later revealed radiological n o n -
u n i o n , b u t only occasional slight pain in the wrist. The t r e a t m e n t consisted of
fixation with a Kirschner wire a n d plaster for seven weeks.
Based o n the presented cases a n d the o n e described b y Noble (1979), we w o u l d
r e c o m m e n d the t r e a t m e n t o f an u n d i s l o c a t e d fresh l u n a t e fracture to consist o f
plaster for seven weeks, followed b y radiological a n d clinical e x a m i n a t i o n to ensure
a d e q u a t e healing. However there is also a p o s t t r a u m a t i c vascular p r o b l e m similar to
that o f scaphoid fractures, a n d there is a diagnostic p r o b l e m which p r e s u m a b l y is o f
equal i m p o r t a n c e as seen in scaphoid fractures. T o elucidate these p r o b l e m s f u r t h e r
investigations are necessary.

REFERENCES
BECKENBAUGH, R. D., SH1VES, T. C. DOBYNS, J. H. and LINSCHEID, R. L. (1980) Kienb6ck's
Disease: The Natural History of KienbOck'sDisease and Consideration of Lunate Fractures, Clinical
Orthopaedics and Related Research, 149: 98-106.
BOYES, J. H. Bunnell's Surgery of the Hand, J. B. Lippincott Company: (1970) 590-593.
BROLIN, I. (1964) Post-Traumatic Lesions of the Lunate Bone, Acta Orthopaedica Scandinavica, 34:
167-182.
CAMPBELL, R. D. Jr., LANCE, E. M. and YEOH, C. B. (1964) Lunate and Perilunar Dislocations,
The Journal of Bone and Joint Surgery, 46B: 55-72.
DUNN, A. W. (1973) Fractures and Dislocations of the Carpus, The Journal of Bone and Joint Surgery,
55A: 1319.
GELBERMANN, R. H. BAUMAN, T. D., MENTON, J. and AKESON, W. H. (1980) The vascularity
of the lunate bone and Kienb6ck's disease, The Journal of Hand Surgery, 5: 272-278.
HULTI~N, O. (1928) {]ber Anatomisehe Variationen Der Handgelenkknochen. Ein Beitrag zur Kenntnis
der Genese zwei verschiedner Mondbeinver~inderuugen,Acta Radiologica, 9: 155-168.
KIENBOCK, R. (1910) Llber traumatische Malazie dex Mondbeins und ihre Folgezust~inde:
Entartungsformen und Kompressionsfrakturen, Fortschritte auf dem Gebiete der ROntgenstrahlen,
16: 77-115.
LINSCHEID, R. L., DOBYNS, J. H., BEABOUT, J. W. and BRYAN, R. S. (1972) Traumatic
Instability of the Wrist. Diagnosis, Classifications and Pathomechanics, The Journal of Bone and
Joint Surgery, 54A: 1612-1632.
NOBLE, J. and LAMB, D. W. (1979) Translunate Scaphoradial Fracture. A Case Report. The Hand, 11:
47-49.
PELLEGRINO, E. A. Jr. and PETERSON, E. D. (1973) Trans-scaphoid Perilunate Dislocations of the
Wrist, The Journal of Bone and Joint Surgery, 55A: 1319.
PERSSON, M. (1945) Pathogenese und Behandlung der KienbOckschen Lunatummalazie, Acta
Chirurgica Scandinavica, 92 (suppl 98): 15-25.
STEWART, M. and CROSS, H. (1968) The Management of Injuries of the Carpal Lunate with a Review
of Sixty Cases, The Journal of Bone and Joint Surgery, 50A: 1489.
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