This exploratory study investigates the feasibility and diagnostic value of high-resolution peripheral quantitative computed tomography (HR-pQCT) in detecting structural and microarchitectural changes in lunate avascular necrosis (AVN), or Kienböck’s disease. Five adult patients with unilateral AVN underwent either MRI or CT, alongside HR-pQCT of both wrists. Imaging features such as subchondral remodeling, joint space narrowing, and bone fragmentation were assessed across modalities. HR-pQCT detected at least one additional pathological feature not seen on MRI or CT in four of five patients and revealed early subchondral changes in two contralateral asymptomatic wrists. Quantitative measurements of bone volume fraction (BV/TV) further indicated altered trabecular structure correlating with disease stage. These findings suggest that HR-pQCT may offer enhanced sensitivity for early-stage AVN and better delineation of disease extent, which is critical for informed surgical planning. While limited by small sample size, this study provides preliminary evidence supporting HR-pQCT as a complementary imaging tool in the assessment of lunate AVN, with potential to improve early detection, staging accuracy, and individualized treatment strategies.