Você está na página 1de 9

Review Article

Perilunate Dislocation and

Perilunate Fracture-dislocation

Spencer J. Stanbury, MD Perilunate dislocations and perilunate fracture-dislocations usually
John C. Elfar, MD result from high-energy traumatic injuries to the wrist and are
associated with a characteristic spectrum of bony and ligamentous
damage. Radiographic evaluation of the wrist reveals loss of
normal radiocarpal and intercarpal colinearity and bony insult,
which may be overlooked at the initial presentation. Prompt
recognition is important to optimize outcomes. Closed reduction is
performed acutely, followed by open reduction and ligamentous
and bony repair with internal fixation. Complications include
posttraumatic arthrosis, median nerve dysfunction, complex
regional pain syndrome, tendon problems, and carpal instability.
Despite appropriate treatment, loss of wrist motion and grip
strength, as well as persistent pain, is common. Medium- and long-
term studies demonstrate radiographic evidence of midcarpal and
radiocarpal arthrosis, although this does not correlate with
functional outcomes.

P erilunate dislocations and perilu-

nate fracture-dislocations (PLD-
PLFDs) are challenging, generally
sal perilunate dislocation involves
dorsal dislocation of the capitate
with respect to the lunate while the
high-energy injuries that carry a lunate remains in its normal position
guarded prognosis. Prompt recogni- in the lunate fossa. In a volar lunate
tion and treatment are imperative. dislocation (ie, the final stage of peri-
Diagnosis is typically made by care- lunate injury), the capitate has re-
ful inspection of wrist radiographs, duced from its dorsally dislocated
followed by immediate, gentle closed position to become colinear with the
From the Department of reduction. Historical treatment by radius, dislocating the lunate into the
Orthopaedics and Rehabilitation, closed methods results in unsatisfac- carpal tunnel (Figures 1 and 2).
University of Rochester Medical
tory outcomes; the current standard Herzberg et al2 classified perilunate
Center, Rochester, NY.
is open reduction, ligamentous and dislocations as stage I injuries and lu-
Neither of the following authors nor nate dislocations as stage II. Lunate
any immediate family member has
bony repair, and protection of the re-
pair with supplemental fixation. dislocations are further classified as
received anything of value from or
owns stock in a commercial stage IIA when the lunate has sub-
company or institution related luxated out of its fossa but has ro-
directly or indirectly to the subject of Pathomechanics tated <90°; stage IIB injuries exhibit
this article: Dr. Stanbury and
Dr. Elfar.
lunate rotation >90°. Volar perilu-
PLD-PLFDs comprise a spectrum of nate and dorsal lunate dislocations
J Am Acad Orthop Surg 2011;19:
injury patterns most commonly in- have been reported but are not
curred as a result of a fall from a nearly as common.
Copyright 2011 by the American
height, motor vehicle accident, or in- Although a variety of different
Academy of Orthopaedic Surgeons.
jury during sporting activities.1 Dor- types of PLD-PLFDs have been re-

554 Journal of the American Academy of Orthopaedic Surgeons

Spencer J. Stanbury, MD, and John C. Elfar, MD

Figure 1

Stages of progressive perilunar instability. Stage I involves disruption of the scapholunate ligamentous complex
(arrow). In stage II, the force propagates through the space of Poirier and interrupts the lunocapitate connection
(arrow). In stage III, the lunotriquetral connection is violated, and the entire carpus separates from the lunate. In stage
IV, the lunate dislocates from its fossa into the carpal tunnel, the lunate rotates into the carpal tunnel, and the capitate
becomes aligned with the radius (arrow). (Reproduced from Kozin SH: Perilunate injuries: Diagnosis and treatment. J
Am Acad Orthop Surg 1998;6[2]:114-120.)

Figure 2 ported, most of these injuries lie its proximal volar attachments and
along a particular spectrum with a dislocate into the carpal tunnel.3 The
common etiologic force. The path- high-energy force may disrupt liga-
omechanical force of traditional ments (ie, scapholunate, lunotrique-
PLD-PLFDs, as described by May- tral, radiocarpal), bones (ie, radial
field,3 is that of extension, ulnar de- styloid, scaphoid, capitate, lunate,
viation, and intercarpal supination. triquetrum, hamate), or combina-
The resultant pattern of injury is de- tions of these. Injuries that cross
pendent on the type of three- bone are greater arc injuries; those
dimensional loading, the magnitude with purely ligamentous disruption
and duration of the forces involved, are lesser arc injuries4 (Figure 3). The
the position of the hand at the time term translunate arc has been used to
Perilunar instability. Stage I (top) of impact, and the biomechanical describe the rare, usually high-energy
refers to perilunate dislocations properties of the bones and liga-
with dorsal dislocation on the left injury in which perilunate disloca-
ments. The sequence of injury propa-
and the rarer volar perilunate tion occurs in the setting of a lunate
dislocation on the right. Stage II gates in an ulnar direction about the
fracture. This injury pattern further
(bottom) refers to lunate lunate, with initial disruption
dislocations with volar lunate destabilizes the carpus. Initial stabili-
through the scapholunate interval.
dislocation on the left and the rarer zation of the lunate should occur be-
This force continues on to the space
dorsal lunate dislocation on the fore further reconstruction.5 In nam-
right. Stage II can be broken down of Poirier, which is located at the
ing greater arc injuries, the prefix
into stage IIA with <90° of lunate volar aspect of the proximal capitate,
rotation and stage IIB with >90° of trans- is used before the name of the
lying between the volar radiocapitate
lunate rotation, or enucleation. fractured bone.
(Redrawn with permission from and volar radiotriquetral ligaments,
Herzberg G: Acute dorsal trans- and disrupts the capitolunate articu-
scaphoid perilunate dislocations: lation before disrupting the lunotri- Diagnosis and Imaging
Open reduction and internal quetral articulation. Finally, the dor-
fixation. Tech Hand Up Extrem
Surg 2000;4:2-13.) sal radiocarpal ligament fails, PLD-PLFDs can defy radiographic
allowing the lunate to rotate about and clinical examination and are

September 2011, Vol 19, No 9 555

Perilunate Dislocation and Perilunate Fracture-dislocation

Figure 3 Figure 4

The lesser and greater carpal arcs

of perilunate instability.
(Reproduced from Kozin SH:
Perilunate injuries: Diagnosis and Preoperative PA (A) and lateral (B) radiographs demonstrating transscaphoid
treatment. J Am Acad Orthop Surg perilunate fracture-dislocation. (Reproduced with permission from Hildebrand
1998;6[2]:114-120.) K, Ross D, Patterson S, Roth J, MacDermid JC, King GJW: Dorsal perilunate
dislocations and fracture dislocations: Questionnaire, clinical, and
radiographic evaluation. J Hand Surg Am 2000;25[6]:1069-1079.)
missed on clinical and radiographic
examination in up to 25% of cases.2
This has notable implications; retro- curves produced by the anatomic proximal rotation of the lunate
spective analyses demonstrate that alignment of the carpal row bones. about its attached palmar ligaments13
delayed or chronic injuries have The first arc represents the proximal (Figure 5). Traction radiographs with
worse outcomes.6,7 Although defor- convexity of the triquetrum, lunate, 5 kg of weight, in conjunction with
mity may be mild, the injury usually and scaphoid. The second arc repre- anesthesia, can be particularly help-
presents with swelling, pain, and lim- sents the concave distal surfaces of ful in further delineating the injury
ited wrist motion. Approximately those bones. The third arc is pro- pattern, especially with respect to
10% are open injuries, and 26% are duced by the proximal hamate and identifying fractures on the PA radio-
associated with polytrauma.8 Re- capitate. Any disruption or gapping graph.14
ported rates of acute median nerve of these arcs should raise the suspi- MRI without contrast is sensitive
symptoms range from 24% to cion of ligamentous or bony injury.
and specific for intercarpal ligamen-
45%.9-12 Median nerve symptoms, PLD-PLFD injury is often seen on PA
tous ruptures and occult fractures or
which present shortly after injury, radiographs as a loss of carpal height
bone bruises.15,16 Preoperative high-
are likely secondary to contusion with overlapping of the carpal bones,
resolution CT is helpful in assessing
from the trauma. Delayed onset of particularly the capitate and lunate. On
the position of fracture fragments
symptoms is likely the result of in- PA radiographs, evidence of scapholu-
and the degree of comminution as
creasing pressures caused by hemor- nate interosseous ligament (SLIL) dis-
well as in identifying occult fracture.
rhage and edema resulting in carpal ruption is represented by a scapholu-
tunnel syndrome. nate interval >2 mm or a scaphoid ring
Standard wrist PA and lateral ra- sign created by rotation of the scaphoid Management
diographs are typically sufficient for with overlapping of the distal pole and
diagnosis in most injuries. The PA the tubercle.1 On lateral radiographs, Historically, PLD-PLFD injuries were
radiograph should be scrutinized for the hallmark of PLD-PLFDs is loss of managed with closed reduction and
uneven gapping in the carpal bones, colinearity of the radius, lunate, and casting. In a review by Adkison and
and the three smooth carpal arcs of capitate (Figure 4). In lunate disloca- Chapman,17 more than half of 32 pa-
Gilula should be free of discontinu- tion, the spilled teacup sign seen on tients with PLD-PLFD treated with
ity. The arcs of Gilula refer to the the lateral radiograph is created by closed reduction failed to maintain

556 Journal of the American Academy of Orthopaedic Surgeons

Spencer J. Stanbury, MD, and John C. Elfar, MD

reduction despite immobilization. In tive and could damage the short ra- Figure 5
a comparison by Apergis et al18 of diolunate ligament and its vascular
patients with PLD-PLFD, 12 of 20 contribution. Closed reduction of
wrists managed with open reduction stage IIA lunate dislocation has been
and internal fixation had good or ex- described. It begins with wrist flex-
cellent results, whereas the 8 treated ion to release tension on the volar
with closed reduction and casting ligaments, followed with dorsally di-
had fair or poor outcomes. Based on rected pressure placed on the lunate,
these studies and others, surgical re- thereby usually reducing it into the
pair is now favored.2,9-12 lunate fossa. After reduction of the
Management of PLD-PLFD typically lunate, the wrist is extended, traction
starts with immediate, gentle, closed re- is exerted, and the wrist is flexed, all
duction. This is followed by open re- while maintaining a volar buttress
duction, ligament and bone repair, with a digit to the lunate. This ma-
and supplemental fixation performed neuver should relocate the capitate
within 3 to 5 days as swelling subsides. back onto the recently reduced lu-
Immediate closed reduction is neces- nate stabilized by volar pressure.19
sary to decrease pressures on critical After reduction, the injured ex- Lateral radiograph of stage IIA
neurovascular structures and cartilage. tremity is placed in neutral rotation volar lunate dislocation. (Courtesy
Stable closed reduction is typically into a sugar tong splint to allow ele- of Peter J. Stern, Cincinnati, OH.)
achieved, with reported maintenance of vation and full range of motion
reduction in >90% of cases.9,10 Sig- (ROM) of the fingers. If an accept- proach (in the absence of carpal tun-
nificant muscle relaxation improves able, stable reduction is achieved, nel syndrome) point out that the
the chances for a successful closed surgery is typically performed 3 to 4 volar ligaments and capsule become
reduction. At our institution, muscle days later when swelling has im- opposed upon reduction and heal
relaxation is typically performed in proved. For the open injury or one in during immobilization without any
the emergency department with the which adequate reduction is not pos- need for direct repair; also, the addi-
use of local anesthetic block and sible or is difficult to maintain, tional volar exposure may impart
conscious sedation. prompt surgical intervention is ad- further swelling, wound problems,
Although no published evidence in- vised. carpal devascularization, and diffi-
dicates the need for immediate closed culty regaining digital flexion and
reduction of a PLD-PLFD without grip.8
acute carpal tunnel symptoms, the Surgical Management Dorsal approaches to PFD-PFLD
authors prefer immediate reduction are typically performed through lon-
to decrease pressure that could lead Approach gitudinal incisions centered at or ul-
to damage to both the median nerve The approach used in surgical man- nar to the Lister tubercle. The long
and the cartilage of dislocated bones agement of these injuries remains thumb extensor is usually transposed
of the wrist. Reduction is performed controversial. Isolated dorsal, iso- radially, and the wrist capsule is
with the elbow flexed to 90° and the lated volar, and combined ap- opened with either a longitudinal or
hand placed into finger traps. Ten to proaches have been described, with dorsal capsule ligament–sparing inci-
15 pounds of longitudinal traction is comparable outcomes.8-12 The dorsal sion (V-shaped). Volar approaches
applied for at least 10 minutes. Dor- approach provides excellent expo- include a standard carpal tunnel re-
sal perilunate dislocations are re- sure of the proximal carpal row and lease incision that usually extends
duced by initial wrist extension, ap- midcarpal joints. Proponents of the proximal to the volar wrist crease for
plying traction, and then flexing the combined dorsal and volar ap- improved ligamentous exposure. The
wrist. The reduction usually occurs proaches feel that the added volar incision typically veers ulnarly at the
with a palpable clunk.19 approach provides the benefits of im- proximal wrist crease to avoid injur-
As recommended by Herzberg,14 proved exposure, ease of reduction, ing the palmar sensory branch of the
we feel that closed reduction should access to distal scaphoid fractures, median nerve while crossing the
not be attempted for stage IIB lunate the ability to repair volar ligaments, crease at an acute angle.
dislocations (>90° rotation) because and carpal tunnel decompression.20 Unknown is the role of carpal tun-
closed reduction is typically ineffec- Advocates of an isolated dorsal ap- nel release in patients who lack any

September 2011, Vol 19, No 9 557

Perilunate Dislocation and Perilunate Fracture-dislocation

Figure 6 Figure 7

A, Intraoperative photograph demonstrating open treatment of dorsal

perilunate dislocation, with the digits inferior. B, PA radiograph obtained
following open repair and pinning. (Reproduced from Kozin SH: Perilunate
injuries: Diagnosis and treatment. J Am Acad Orthop Surg Postoperative PA radiograph of a
1998;6[2]:114-120.) volar lunate dislocation managed
with a combined dorsal and volar
approach using a 20-gauge
symptoms of median nerve dysfunc- injuries is fixation of the bony in- intraosseous cerclage wire.
tion following PLD-PLFD. The pres- volvement before soft-tissue repair. (Reproduced with permission from
ence of such symptoms in patients Trumble T, Verheyden J: Treatment
Scaphoid fractures are typically fixed
of isolated perilunate and lunate
with PFD-PFLD is 24% to 45%.10,12 using cannulated headless screw sys- dislocations with combined dorsal
Carpal tunnel release is supported by tems. Comminuted fractures can be and volar approach and
most authors when symptoms are treated with Kirschner wire (K-wire) intraosseous cerclage wire. J Hand
Surg Am 2004;29[3]:412-417.)
present.21 We perform an open carpal fixation and autologous bone graft-
tunnel release whenever we suspect ing from the distal radius. When
that median nerve trauma exists. We concomitant scaphoid fracture and repair of the SLIL (Figure 6). The lig-
also recommend that patients with SLIL injury are present, both injuries ament typically avulses from the sca-
severe displacement of fracture frag- should be treated surgically. K-wire phoid, and repair is commonly per-
ments or fragments within the carpal and headless screw fixation have formed using suture anchors, with a
tunnel (in the absence of carpal tun- been described for lunate and trique- horizontal mattress suture through the
nel syndrome) be treated with a com- tral fracture fixation.3,14 Capitate SLIL.22 Unicortical K-wires can be used
bined dorsal and volar approach for fractures or osteochondral fragments as joysticks for aiding reduction. Tra-
open reduction, ligamentous stabili- should be managed with headless ditionally, K-wires were used to protect
zation, and carpal tunnel decompres- screw fixation and are best visualized the SLIL repair. However, concerns
sion. No evidence exists to support through a dorsal approach.14 Frac- over pin tract infection, soft-tissue ir-
such a strategy over an isolated dor- ture of the radial styloid should be ritation, delayed motion, inability to
sal exposure. Nonetheless, com- managed with rigid fixation by can- provide compression, and biomechan-
parable results for the different ap- nulated screws, headless screws, ical weakness have led some to advo-
proaches have been published, and K-wires, or radial column plates. Ex- cate more rigid fixation of the scapho-
there are no prospective randomized cision of the radial styloid is not rec- lunate interval.22
comparisons available to advocate a ommended.14,22 Any extruded carpal Temporary intercarpal screw fixa-
particular exposure over any other. bone should be reduced to its ana- tion and intraosseous cerclage wiring
tomic position and stabilized, with (Figures 7 and 8) have been de-
Technique ligamentous repair undertaken in the scribed as methods of protection of
Surgical management of PLD-PLFDs hope of achieving a stable wrist after the soft-tissue repair.9,23 Theoretic
includes open reduction, ligamentous healing.22 benefits include subdermal location,
repair, and supplemental fixation. Many surgeons feel that the most decreased infection risk, increased
The surgical maxim for greater arc critical issue in lesser arc injury is the biomechanical stability, and the abil-

558 Journal of the American Academy of Orthopaedic Surgeons

Spencer J. Stanbury, MD, and John C. Elfar, MD

Figure 8 Figure 9

Postoperative AP (A) and lateral (B) radiographs of screw fixation of the

scaphoid, suture anchor repair of the lunotriquetral ligament, and K-wire
stabilization of the lunotriquetral joint. (Reproduced with permission from
Postoperative PA radiograph in a Knoll VD, Allan C, Trumble TE: Trans-scaphoid perilunate fracture
36-year-old man injured in a motor dislocation: Results of screw fixation of the scaphoid and lunotriquetral repair
vehicle collision. Management with a dorsal approach. J Hand Surg Am 2005;30[6]:1145-1152.)
consisted of open reduction, carpal
tunnel release, interosseous
ligament repair with suture
cision to repair the dorsal ligament PLD-PLFD is an emerging manage-
anchors, and open reduction and
internal fixation of the radial styloid or the stronger volar component is ment option that combines fluoros-
with temporary screw fixation of the also unclear and is surgeon depen- copy and traction to obtain ar-
carpal bones. (Reproduced with dent.14 throscopic reduction and fixation.
permission from Souer JS, Rutgers
M, Andermahr J, Jupiter J, Ring D: Ulnocarpal translation is an emerg- This method promises improved
Perilunate fracture-dislocations of ing concern as a cause of persistent visualization of the carpal bones,
the wrist: Comparison of temporary radiocarpal instability. This transla- joints, and fractures while poten-
screw versus K-wire fixation. J tion may be secondary to injury to
Hand Surg Am 2007;32[3]: tially decreasing surgical insult. A
318-325.) the palmar and dorsal radiocarpal drawback, however, is the inability
ligaments. The clinical implications to perform direct ligamentous re-
of this translation are yet to be eluci-
ity to impart compression. Potential dated; however, in the sole study
drawbacks include the need for a published to date on this topic, pin-
secondary surgical procedure as well ning the lunate to the radius with re- Treatment of Chronic
as difficult implant placement. Re- moval at approximately 8 weeks led PLD-PLFD
sults with these methods are at least to significantly less ulnocarpal trans-
comparable to reported results of lation in PLD-PLFDs than did not With up to 25% of PLD-PLFDs
K-wire fixation, with trends toward pinning the lunate to the radius in missed at initial evaluation, delayed
improved outcomes possibly limited wrists with similar injuries.24 diagnosis of PLD-PLFD is not un-
to study size and type.9,23 The longitudinal arthrotomy in the common.5 A multicenter study found
The surgical management of luno- dorsal capsule should be repaired an- that the average clinical score of
triquetral interosseous ligament atomically whenever possible. Alter- PLD-PLFDs managed between 7 and
(LTIL) injury varies by surgeon; no natively, use of the dorsal intercarpal 45 days was not statistically signifi-
published studies directly compare or dorsal radiocarpal ligament, when cant compared with the scores of
outcomes of treatment method. it is intact, to reinforce SLIL or LTIL those treated within 1 week, whereas
Some surgeons address LTIL injury repairs has been described.22 If a the group treated after 45 days was
with K-wire pinning of the joint; oth- volar approach was incorporated, significantly worse.5 A comparison
ers stress the additional need for then repair of the volar capsule can by Komurcu et al7 reported that sur-
LTIL repair to protect against the de- be performed.22 gically treated dorsal transscaphoid
velopment of volar intercalated seg- Arthroscopically assisted and per- PFLDs managed from 10 to 40 days
ment instability10 (Figure 9). The de- cutaneous fixation of less severe postinjury had an average Green and

September 2011, Vol 19, No 9 559

Perilunate Dislocation and Perilunate Fracture-dislocation

O’Brien score of 72.5 versus an aver- splinting or weighted wrist stretches, Most published studies include
age score of 89.2 in those treated be- as tolerated. Progressive hand, wrist, short- and medium-term results; one
fore 7 days postinjury. Sample size, and forearm strengthening is also ini- recent publication included long-
however, did not allow a statistical tiated with graduated weights. As term follow-up.9-12,28,32 In these stud-
comparison. early as 12 weeks after surgery, some ies, most patients maintain adequate
These studies reinforce the need for patients can be returned to unre- reduction, have scaphoid union, and
prompt diagnosis and management. stricted use of the hand in daily ac- are employed but demonstrate radio-
Reports of acceptable results with open tivity, with progressive return to graphic evidence of midcarpal or ra-
reduction and internal fixation have sport or work conditioning. Typi- diocarpal arthrosis.9-11,23,28,32 Several
been published when treatment was de- cally, implants are removed at 12 studies found that, despite radio-
layed up to 6 months.7,26 Proximal graphic evidence of midcarpal and
row carpectomy has successfully radiocarpal arthrosis, the findings
been used in cases delayed >2 Complications did not correlate with Mayo wrist
months, although some authors be- scores and that pain was often mild
lieve that a prerequisite for proximal Complications related to the original to moderate, occasional, and
row carpectomy is an intact and un- trauma include posttraumatic arthro- activity-related.12,28,32
injured proximal capitate.26 Delayed sis, median nerve dysfunction, complex In a review of 10 professional foot-
cases managed with isolated (sca- regional pain syndrome, hand or wrist ball players with PLD treated by closed
phoid or lunate) carpal bone excision weakness, tendon ruptures or dysfunc- reduction and percutaneous pinning or
have had poor results.26,27 Total wrist tion, residual carpal instability, and open reduction and K-wire fixation,
arthrodesis is an option in the wrist or hand stiffness.5,11,28-31 Surgi- none of the injuries forced retirement,
chronic, unreduced PLD-PLFD with cal complications include pin tract and 9 of the athletes returned to play
extensive degenerative changes.14 infection, superficial or deep wound by the following season.34 Forli et
infection (including septic arthritis), al28 recently reported on a retrospec-
skin irritation, implant failure, flexor tive review of 18 patients with PLD-
Postoperative Care tendon adhesions, loss of reduction, PLFD treated surgically, with an av-
scaphoid nonunion or malunion, and erage follow-up of 13 years. These
Our postoperative care regimen typi-
painful implant.9-11,23 Transient ische- authors reported Mayo wrist scores,
cally begins with placement of a
mia of the lunate is a known sequela grip strength measures, and flexion-
short arm thumb spica splint in the
of PLF-PLFD injury; its presence extension arcs similar to those re-
operating room, with transition to a
should not be overinterpreted be- ported in studies with average
short arm thumb spica cast at 10 to
cause it is usually a benign, self- follow-ups less than half as long. Ra-
14 days. Initial rehabilitation focuses
limiting event.30 diographic evidence of carpal degen-
on active movement of the shoulder,
erative changes, however, were 20%
elbow, and fingers to prevent stiff-
to 34% higher than those of the
ness. At 6 to 8 weeks postopera- Outcomes studies with shorter follow-ups, indi-
tively, the cast is removed, and a
cating that long-term progression of
thermoplastic static wrist and thumb PLD-PLFDs are severe injuries with a
degenerative changes may increase,
splint, with free motion of the thumb poor prognosis for return to full pre-
although functional outcome may be
interphalangeal joint, is fabricated vious function. Open injuries, those
independent of these changes.28
for protective wear between exercise with delayed treatment, those with
sessions. Active, active-assisted, and osteochondral fractures of the head
gentle passive ROM exercises are ini- of the capitate, and the presence of Summary
tiated at the wrist, forearm, and persistent carpal malalignment all
thumb. These exercises are per- imply poorer outcomes.8,19,32 Out- PLD-PFLDs comprise a spectrum of
formed in 10-minute sessions six to comes are improved by early, accu- traumatic soft-tissue and bony in-
eight times daily. Lifting is limited to rate reduction and stable internal fix- sults typically incurred through high-
<1 lb. ation, with repair or reconstruction energy mechanisms. Accurate early
At 8 to 10 weeks postoperatively, of the dorsal SLIL undertaken when diagnosis is essential; delayed treat-
passive ROM exercises with unre- it is compromised.4,33 Nearly all pa- ment worsens outcomes. The diagno-
stricted extension are initiated, with tients experience decreased grip sis is typically made on wrist radio-
supplemental use of dynamic wrist strength and loss of ROM (Table 1). graphs, with loss of carpal height

560 Journal of the American Academy of Orthopaedic Surgeons

Spencer J. Stanbury, MD, and John C. Elfar, MD

Table 1
Outcomes in Surgically Treated Perilunate Dislocation and Perilunate Fracture-dislocation
With Acute Flexion/
Carpal Tunnel Extension Arc Average Grip
No. of Average Syndrome Employed (% of contra- Strength (% of
Study Cases Follow-up Type (%) (%) lateral) contralateral)

Trumble 22 49 mo Dislocation only 32 100 80 77

and Ver-
Knoll et al10 25 44.3 mo Fracture- 24 100 83 80
Sotereanos 11 30 mo Both 45 45 71 77
et al12
Hildebrand 23 37 mo Both 35 82 57 73
et al11
Herzberg 14 8 yr Fracture- 29 86 N/A 79
and Foris- dislocation
ser32 only
Forli et al28 18 13 yr Both N/A N/A 76 87

N/A = not available

and disruption of carpal arcs identi- 1. Weil WM, Slade JF III, Trumble TE: 9. Trumble T, Verheyden J: Treatment of
Open and arthroscopic treatment of isolated perilunate and lunate dislo-
fied on the AP radiograph and loss perilunate injuries. Clin Orthop Relat cations with combined dorsal and volar
of the colinearity of the radius, lu- Res 2006;445:120-132. approach and intraosseous cerclage wire.
nate, and capitate found on the lat- 2. Herzberg G, Comtet JJ, Linscheid RL,
J Hand Surg Am 2004;29(3):412-417.
eral radiograph. Initial gentle, closed Amadio PC, Cooney WP, Stalder J: 10. Knoll VD, Allan C, Trumble TE: Trans-
Perilunate dislocations and fracture- scaphoid perilunate fracture dislocations:
reduction is performed, followed by dislocations: A multicenter study. J Hand Results of screw fixation of the scaphoid
delayed open reduction, ligamentous Surg Am 1993;18(5):768-779.
and lunotriquetral repair with a dorsal
and bony repair, and internal fixa- 3. Mayfield JK: Mechanism of carpal approach. J Hand Surg Am 2005:30(6):
tion. Despite optimum treatment, injuries. Clin Orthop Relat Res 1980; 1145-1152.
this injury carries a guarded progno- 11. Hildebrand KA, Ross DC, Patterson SD,
4. Johnson RP: The acutely injured wrist Roth JH, MacDermid JC, King GJ:
sis, with permanent partial loss of and its residuals. Clin Orthop Relat Res Dorsal perilunate dislocations and
wrist motion and grip strength. 1980;(149):33-44. fracture-dislocations: Questionnaire,
5. Bain GI, McLean JM, Turner PC, Sood clinical, and radiographic evaluation.
A, Pourgiezis N: Translunate fracture J Hand Surg Am 2000;25(6):1069-1079.
References with associated perilunate injury: 3 case
12. Sotereanos DG, Mitsionis GJ,
reports with introduction of the
translunate arc concept. J Hand Surg Am Giannakopoulos PN, Tomaino MM,
Evidence-based Medicine: Levels of 2008;33(10):1770-1776. Herndon JH: Perilunate dislocation and
fracture dislocation: A critical analysis of
evidence are described in the table of 6. Inoue G, Kuwahata Y: Management of the volar-dorsal approach. J Hand Surg
contents. In this article, references acute perilunate dislocations without Am 1997;22(1):49-56.
fracture of the scaphoid. J Hand Surg Br
10, 23, and 33 are level III studies. 1997;22(5):647-652. 13. Green DP, O’Brien ET: Classification
References 2, 5-9, 11, 12, 18, 20, 24- 7. Komurcu M, Kürklü M, Ozturan KE,
and management of carpal dislocations.
Clin Orthop Relat Res 1980;(149):55-
28, 30, 32, and 34 are level IV stud- Mahirogullari M, Basbozkurt M: Early 72.
ies. The remaining references are re- and delayed treatment of dorsal
transscaphoid perilunate fracture- 14. Herzberg G: Perilunate and axial carpal
view articles and level V expert dislocations. J Orthop Trauma 2008; dislocations and fracture-dislocations.
opinion. 22(8):535-540. J Hand Surg Am 2008;33(9):1659-1668.

References printed in bold type are 8. Herzberg G: Acute dorsal trans-scaphoid 15. Tanaka T, Ogino S, Yoshioka H:
perilunate dislocations: Open reduction Ligamentous injuries of the wrist. Semin
those published within the past 5 and internal fixation. Tech Hand Up Musculoskelet Radiol 2008;12(4):359-
years. Extrem Surg 2000;4(1):2-13. 377.

September 2011, Vol 19, No 9 561

Perilunate Dislocation and Perilunate Fracture-dislocation

16. Karantanas A, Dailiana Z, Malizos K: perilunate dislocations. J Hand Surg Am 29. Green DP, O’Brien ET: Open reduction
The role of MR imaging in scaphoid 2008;33(8):1424-1432. of carpal dislocations: Indications and
disorders. Eur Radiol 2007;17(11):2860- operative techniques. J Hand Surg Am
2871. 23. Souer JS, Rutgers M, Andermahr J, 1978;3(3):250-265.
Jupiter JB, Ring D: Perilunate fracture-
17. Adkison JW, Chapman MW: Treatment dislocations of the wrist: Comparison of 30. White RE Jr, Omer GE Jr: Transient
of acute lunate and perilunate temporary screw versus K-wire fixation. vascular compromise of the lunate after
dislocations. Clin Orthop Relat Res J Hand Surg Am 2007;32(3):318-325. fracture-dislocation or dislocation of the
1982;(164):199-207. carpus. J Hand Surg Am 1984;9(2):181-
24. Song D, Goodman S, Gilula LA, 184.
18. Apergis E, Maris J, Theodoratos G, Wollstein R: Ulnocarpal translation in
Pavlakis D, Antoniou N: Perilunate perilunate dislocations. J Hand Surg Eur 31. Blazar PE, Murray P: Treatment of
dislocations and fracture-dislocations: Vol 2009;34(3):388-390. perilunate dislocations by combined
Closed and early open reduction dorsal and palmar approaches. Tech
compared in 28 cases. Acta Orthop 25. Park MJ, Ahn JH: Arthroscopically Hand Up Extrem Surg 2001;5(1):2-7.
Scand Suppl 1997;275:55-59. assisted reduction and percutaneous
fixation of dorsal perilunate dislocations 32. Herzberg G, Forissier D: Acute dorsal
19. Trumble T: Fractures and dislocations of and fracture-dislocations. Arthroscopy trans-scaphoid perilunate fracture-
the carpus, in Trumble T, ed: Principles 2005;21(9):1153. dislocations: Medium-term results.
of Hand Surgery and Therapy. J Hand Surg Br 2002;27(6):498-502.
Philadelphia, PA, WB Saunders, 2000, 26. Inoue G, Shionoya K: Late treatment of
pp 90-125. unreduced perilunate dislocations. 33. Minami A, Kaneda K: Repair and/or
J Hand Surg Br 1999;24(2):221-225. reconstruction of scapholunate
20. Papadonikolakis A, Mavrodontidis AN, interosseous ligament in lunate and
Zalavras C, Hantes M, Soucacos PN: 27. Siegert JJ, Frassica FJ, Amadio PC: perilunate dislocations. J Hand Surg Am
Transscaphoid volar lunate dislocation: Treatment of chronic perilunate 1993;18(6):1099-1106.
A case report. J Bone Joint Surg Am dislocations. J Hand Surg Am 1988;
2003;85(9):1805-1808. 13(2):206-212. 34. Raab DJ, Fischer DA, Quick DC: Lunate
and perilunate dislocations in
21. DiGiovanni B, Shaffer J: Treatment of 28. Forli A, Courvoisier A, Wimsey S, professional football players: A five-year
perilunate and transscaphoid perilunate Corcella D, Moutet F: Perilunate retrospective analysis. Am J Sports Med
dislocations of the wrist. Am J Orthop dislocations and transscaphoid peilunate 1994;22(6):841-845.
(Belle Mead NJ) 1995;24(11):818-826. fracture-dislocations: A retrospective
study with minimum ten-year follow-up.
22. Budoff JE: Treatment of acute lunate and J Hand Surg Am 2010;35(1):62-68.

562 Journal of the American Academy of Orthopaedic Surgeons