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Evaluation, Management, and Outcomes of Lunate and Perilunate

Dislocations

Article  in  Orthopedics · November 2018

DOI: 10.3928/01477447-20181102-05

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 n Review Article

Evaluation, Management, and Outcomes

of Lunate and Perilunate Dislocations
Avi D. Goodman, MD; Andrew P. Harris, MD; Joseph A. Gil, MD; Joseph Park, BS; Jeremy Raducha, MD;
Christopher J. Got, MD

aspect. The 4 stages (Table 1) of injury

abstract progression were originally described by
Mayfield et al (Figure 1), with the trans-
Lunate and perilunate dislocations are potentially devastating injuries that lunate/interlunate arc more recently de-
are often unrecognized at initial evaluation. Prompt recognition and treat- scribed.1,6,9-11 However, some variability
ment is necessary to prevent adverse sequelae, including median nerve in injury patterns results from differences
dysfunction, carpal instability, posttraumatic arthritis, reduced functionality, in force vectors and transmission paths.
and avascular necrosis. In patients who are surgical candidates, operative
intervention is warranted to restore carpal kinematics and provide optimal Evaluation
outcomes. [Orthopedics. 2019; 42(1):e1-e6.] Although perilunate dislocations may
occur in isolation, when they occur during
high-energy trauma, Advanced Trauma

P
erilunate dislocations are severe evaluation, management, and understand- Life Support protocols should be followed
pan-carpal injuries that can pres- ing of perilunate and lunate dislocations for evaluation and resuscitation. Addition-
ent in the setting of high-energy are essential. al injuries should be addressed as they are
trauma, and they involve the dissociation discovered, with particular attention paid
of 1 or more of the lunate articulations. If Mechanism of Injury to the ipsilateral upper extremity.
a complete dislocation occurs, this injury Perilunate and lunate dislocations typi- Acute perilunate dislocations typically
is termed a lunate dislocation. Given the cally result from an axial load causing hy- present with pain and swelling over the
severity of confounding injuries, delayed perextension, intercarpal supination, and dorsal and/or volar aspect of the carpus,
presentation, difficult radiographic in- ulnar deviation of the wrist.4,5 In 1980, often with dorsal wrist tenderness over
terpretation, and occasional spontaneous Mayfield et al6 originally described this
The authors are from the Department of Or-
reduction, up to 25% of perilunate dis- method by forcing 32 wrists into hyper- thopaedics (ADG, APH, JAG, JR, CJG), Warren
locations are diagnosed weeks to years extension by applying force to the thenar Alpert Medical School, Brown University (JP),
after the initial injury.1 Although most eminence and recording the injury pat- Providence, Rhode Island.
The authors have no relevant financial rela-
of these injuries have radiographic evi- tern. Most perilunate injuries are asso-
tionships to disclose.
dence of posttraumatic arthritis regardless ciated with high-energy trauma—most Correspondence should be addressed to:
of treatment, a delay in recognition and commonly falls from height, followed Andrew P. Harris, MD, Department of Ortho-
treatment of perilunate dislocations wors- by motor vehicle collisions.7,8 This axial paedics, Warren Alpert Medical School, Brown
University, 593 Eddy St, Providence, RI 02903
ens already tenuous outcomes, including force results in a predictable pattern of
(Aharri26@gmail.com).
median nerve dysfunction, carpal instabil- injury. Beginning from the radial aspect Received: November 12, 2017; Accepted:
ity, reduced functionality, and avascular of the carpus, the force advances through March 7, 2018.
necrosis.2,3 Therefore, the proper initial the midcarpal region, toward the ulnar doi: 10.3928/01477447-20181102-05

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n Review Article

Radiographic Findings and

Table 1 Classification
Anteroposterior, lateral, and oblique
Progression of Perilunate Injuries (Mayfield Classification)
radiographs of the wrist must be obtained
Stage Description
during initial evaluation. Lateral radio-
I—Scapholunate dissociation Force is initially transferred directly through the scaph- graphs with normal findings should reveal
oid, resulting in a transscaphoid fracture or tear through
the scapholunate ligament, leading to a scapholunate a collinear axis of the radius, lunate, and
dissociation capitate (Figure 2).9 This longitudinal
II—Perilunate dislocation The injury travels as a series of ligament disruptions axis may be interrupted by displacement
around the lunate, from radial to ulnar, starting with the of the capitate in relation to the radius,
disruption of the lunocapitate association
indicating a perilunate dislocation of the
III—Triquetrum dislocation Disruption of the lunotriquetral interosseous ligament
and lunotriquetral ligament separates the carpus from same direction.8 Posteroanterior radio-
the lunate. The lunate dislocates dorsally, misaligning graphs should also be assessed for any
both the carpus and the lunate with the distal radius. patterns of instability. The 3 arcs of Gi-
IV—Lunate dislocation Disruption of the dorsal radiolunate ligament causes a lula’s lines, smooth and continuous carpal
palmar lunate dislocation into the carpal tunnel. The
remaining carpus often self-reduces. lines on the anteroposterior/posteroanteri-
or radiograph, consist of the borders of the
radiocarpal row, the midcarpal row, and
the proximal surface of the distal carpal
row (Figure 3).12 Any disruption of these
arcs suggests a lunate, perilunate, and car-
pal dislocation or fracture, respectively.7,12
Advanced imaging is rarely indicated in
the initial evaluation of ligamentous peri-
lunate dislocations; however, a computed
tomography scan may aid the diagnosis of
and better define some carpal bone frac-
tures.
Perilunate injuries are most commonly
classified using the system of Mayfield et
al6 (Figure 1, Table 1). In a stage I injury
(disruption of the scapholunate ligament
or transscaphoid fracture), radiographs
may reveal a widening of the scapholu-
nate space. The images should also be
Figure 1: Sequential pattern of perilunate injury progressing to lunate dislocation. The 4 stages of perilu- carefully inspected for a scaphoid or other
nate injury progress from I to IV in a clockwise fashion: (I) disruption of the radioscaphocapitate ligament carpal bone fracture.
(orange line) and scapholunate ligament (blue line), or fracture through the scaphoid; (II) disruption of A stage II injury (lunocapitate articu-
the lunocapitate articulation (yellow line) or fracture through the capitate; (III) lunotriquetral ligament (red
lation disruption) often presents with the
line) or fracture through the triquetrum; and (IV) radiolunate ligament (green line).
capitate dislocated dorsally, in addition to
stage I findings. A posteroanterior view
the scapholunate ligament, limited range tations, a thorough neurovascular assess- of a perilunate dislocation may reveal an
of motion, and frank deformity.7 However, ment and orthogonal radiographs are nec- overlap of the distal and proximal carpal
low-impact injuries may result in minimal essary to obtain a better understanding of rows with possible scaphoid fracture and
deformity with or without any associated the extent of injury.9 If median (or other) subluxation.7 An overlap of the triquetrum
nerve or tendon damage. The lunate may nerve compromise exists (eg, acute pares- on the lunate suggests a stage III perilu-
dislocate into the carpal tunnel or self- thesias or abnormal 2-point discrimina- nate injury (disruption of the lunotriqu-
reduce entirely, depending on the kinetic tion in the median nerve distribution), this etral interosseous ligaments), and an as-
profile and mechanism of injury. Given adds urgency to the treatment algorithm sociated volar fracture of the triquetrum
the spectrum of possible clinical presen- and must be documented. may be exhibited.7

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 n Review Article

With a stage IV injury, a lunate disloca-

tion, rotation of the lunate in the volar di-
rection presents as a triangular appearance
known as the “piece of pie” sign (Figure
4) on a posteroanterior view. This rotation
in the lateral view yields the “spilled tea-
cup” sign, in which the lunate resembles a
teacup tipped in the volar direction.7
Alternatively, perilunate dissociation
injuries may be described using the arc
methodology: the loading mechanism re-
sults in fracture through the greater arc, Figure 3: Anteroposterior radiograph of the right
ligamentous disruption through the lesser wrist with normal findings showing Gilula’s 3 car-
arc, and/or fracture through the translunate/ pal arcs.

interlunate arc13 (Figure 5). Greater arc in-

jury results in fracture of the respective car- of displacement was predominantly dorsal
pal bone or radial styloid, whereas lesser (97%) compared with volar (3%).3
arc injury is associated with ligamentous
disruption.6 Mayfield et al6 showed that Management
higher velocity axial loads result in pure- Closed Reduction and Immobilization
ly ligamentous injury of the lesser arc, Carpal dislocations require urgent hand
whereas lower velocity axial loads tend to surgery consultation. Studies comparing
result in fractures within the greater arc. As nonsurgical with surgical intervention
described by Mayfield et al,6 the greater have consistently shown better outcomes
arc begins at the scaphoid, traverses the for the latter.9 Because of the disruption of
capitate, and ends at the triquetrum (Fig- Figure 2: Lateral radiograph with normal findings structurally crucial ligaments, closed re-
revealing a collinear axis of the radius (red), lunate
ure 5). Perilunate or lunate dislocations (yellow), and capitate (green). duction and immobilization alone is inad-
that only involve greater arc fractures are equate to provide necessary architectural
described by the fractures involved.1,6 For support.
example, an associated scaphoid fracture In 2008, the translunate arc concept was Closed reduction and splinting is more
is described as a transscaphoid perilunate described by Bain et al11 (Figure 5). Ap- effective with perilunate dislocations and
dislocation, a scaphoid fracture with a proximately 34 cases have been reported in less so with lunate dislocations because
capitate fracture is termed a transscaphoid, the literature since 1976.10 This arc may be of the extent of ligamentous damage.7
transcapitate perilunate dislocation, and more easily understood as fracture of the Initial management of lunate dislocations
so on. Each of these fracture fragments is lunate associated with ligament disruption involves a closed reduction and immobili-
associated with its respective ligament of on the opposite end of the greater arc.10 All zation using a sugar-tong splint.9 Patients
the lesser arc. The intact scapholunate and injuries can occur in isolation or in combi- are discouraged from applying any axial
lunotriquetral ligaments remain in continu- nation with another type (Figure 6). load to the injured wrist.
ity to the scaphoid, capitate, and triquetral Approximately 60% of perilunate inju- Under intravenous sedation (either a
fracture fragments.1,2,6 ries present with transscaphoid fractures, benzodiazepine such as diazepam or seda-
The lesser arc represents the ligamen- 72% of which are transverse fractures tives such as propofol), the patient’s arm
tous injuries that may occur.6 As with through the middle third.14 In a retrospective is held in longitudinal traction prior to
greater arc injuries, the force pattern pro- multicenter study of 166 perilunate disloca- (or during) the reduction attempt. Hang-
gresses from radial to ulnar. The lesser arc tions, perilunate fracture-dislocations were ing the hand in finger traps with weight
begins at the scapholunate ligament, tra- more common than ligamentous perilunate hanging from the biceps may be a useful
verses the lunocapitate joint and lunotri- dislocations, occurring at a ratio of 2 to 1.3 adjunct, as countertraction is mandatory
quetral ligament, and ends at the short ra- In the same series, dorsal transscaphoid to achieve sufficient distraction for reduc-
diolunate ligament (Figure 5).6 The fourth perilunate fracture-dislocations accounted tion. The classic teaching at the authors’
stage (short radiolunate ligament disrup- for 96% of perilunate fracture dislocations institution is 10-10-10: 10 mg of diaze-
tion) results in a lunate dislocation.2 and 61% of the entire series.3 The direction pam, hanging in 10 pounds of traction, for

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Figure 5: Anteroposterior radiograph of a left wrist

showing the greater arc (A), lesser arc (B), and
translunate arc (C). Injury to the greater arc results
in transscaphoid, transcapitate, and/or transtri-
quetral fracture. The lesser arc injuries result in
scapholunate, lunocapitate, and/or lunotriquetral
Figure 4: A stage IV lunate dislocation. Note the “piece of pie” sign on the anteroposterior (A) and oblique ligament injury. Injury to the translunate arc results
(B) radiographs and the “spilled teacup” sign on the lateral (C) radiograph. in lunate fracture. All injury arc patterns may occur
in isolation or in combination.

are not amenable to early definitive open

reduction and internal fixation. Associated
comminuted distal radius fractures, severe
soft tissue injuries, and severe ligament
disruption may require spanning external
fixation for additional stabilization and
result in further complications.9 The use
of external fixation with percutaneous K-
wire fixation has shown acceptable return
to work and satisfactory functional and
Figure 6: Anteroposterior (A), oblique (B), and lateral (C) radiographs of a left wrist showing a transscaph- radiographic outcomes in most patients at
oid, transtriquetral perilunate fracture-dislocation associated with a distal radius fracture. 3 years.18
Open reduction and internal fixation
10 minutes before attempting reduction. Surgical Management and closed reduction with percutaneous
The precise reduction maneuver depends A variety of surgical options have been pinning have been shown to have better
on the patient’s injury; however, for the proposed for treatment: closed reduction long-term outcomes than closed reduc-
most common dorsal perilunate disloca- with percutaneous pinning (Figure 7), tion and casting.3,19,20 Open reduction
tions, the patient’s wrist is held in longi- open reduction and internal fixation, ar- can be performed through volar or dorsal
tudinal traction and the surgeon’s thumb throscopic repair, external fixation, and surgical approaches or through a com-
is placed on the volar aspect of the lunate acute proximal row carpectomy. Regard- bination of the 2. The volar approach is
and used to apply a dorsal-directed force less of fixation method, patients should be favorable when the lunate has dislocated
while the wrist is slowly brought into managed acutely—within 6 weeks of in- volarly, as beginning with the side of dis-
flexion, guiding the lunate back into the jury—as late treatment may impact surgi- location allows primary reduction of the
radiolunate fossa and lunocapitate articu- cal outcomes because of fibrosis, soft tis- lunate and provides easy access to release
lation.9,15 Described as the “paradox of re- sue scarring, and avascular necrosis.9,16,17 the transverse carpal ligament. The volar
duction,” restoration of the scapholunate Herzberg et al3 reported that perilunate approach also allows for direct repair of
relation by means of radial deviation re- dislocations/fracture dislocations treated the volar capsule’s space of Poirier, be-
sults in a widening of the torn palmar liga- 6 weeks after injury or those with open tween the volar radiocapitate and the
ments and the inability to restore scaphoid injuries had significantly worse clinical volar radiotriquetral ligaments, through
flexion, which would, conversely, require outcome scores (P<.05) than those treated which the lunate typically dislocates. It
ulnar deviation for correction.6,9 within 6 weeks. Certain injury patterns also allows repair of the volar lunotriqu-

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 n Review Article

etral ligament and removal of any osteo-

chondral fragments.9
Alternatively, the dorsal approach pro-
vides direct access to the carpus, which
is optimal for realignment. The scaph-
oid and other fractured carpal bones, as
well as the scapholunate interosseous
ligament, are accessible for direct re-
pair. The volar lunotriquetral and dorsal
scapholunate interosseous ligaments are
the strongest portions of their respective
ligaments. Proper exposure and restora-
A B
tion of the scapholunate interosseous liga-
Figure 7: Anteroposterior (A) and lateral (B) radiographs of the wrist following closed reduction and
ment is believed to play a significant role percutaneous pinning of a lesser arc perilunate dislocation.
in a successful long-term outcome.9 The
combined dorsal–volar approach offers
the advantages of both approaches and al- sial.9 Even with these options, inappro- Conclusion
lows the surgeon complete visualization priate (or no) initial treatment risks poor Perilunate and lunate dislocations are
and dual access to all structures requiring outcomes. severe injuries that warrant vigilance in
repair.9 The complexity of the intercarpal patients with a concerning mechanism of
relationship disruptions involved in lunate Complications injury. After a radiographic and clinical
dislocations often requires the combined Despite predictable injury patterns, lu- workup, the dislocation must be addressed
dorsal–volar approach.21 nate and perilunate dislocations are often with prompt reduction and splinting, often
Other techniques have been described misdiagnosed, leading to serious compli- followed by surgery. All operative tech-
with mid-term outcomes comparable to cations and a poor clinical prognosis. For niques have similar mid- to long-term-
those of open reduction and internal fixa- various reasons, up to 25% of perilunate functional and radiographic outcomes,
tion. Kim et al22, showed that arthroscopic dislocations are undiagnosed or misdiag- so the authors recommend that surgeons
reduction and percutaneous fixation with nosed in the acute setting.7 Carpal inju- choose the method with which they are
K-wires and headless compression screws ries can often be overshadowed by more most comfortable and that is most suited
allows for minimal incisions and blood severe, life-threatening injuries sustained for the particular injury pattern.3,18,20,22,23
loss, with a lower rate of posttraumatic in the high-energy trauma. Furthermore, However, even the most effective treat-
arthritis on radiographs at an average radiographic images may be inadequately ment usually falls short of restoring nor-
follow-up of 31 months. Muller et al23 assessed or what they reveal may go un- mal function in these severe injuries, but
reported that acute proximal row carpec- recognized by a physician unfamiliar with early treatment can reduce the rates of
tomy can be used to manage perilunate perilunate or lunate dislocations.21 pain, instability, and nerve damage and
dislocations, with outcomes similar to Delayed treatment may result in re- improve functionality.
those of open reduction and internal fixa- duced functionality and range of motion,
tion at approximately 3-year follow-up. carpal instability, pain, and carpal tunnel References
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