High-yield overview

High-energy carpal instability | lateral X-ray diagnosis | urgent reduction | definitive fixation

25%Missed on initial X-ray

61%Trans-scaphoid variety

UrgentReduction required

DorsalCarpus displaces dorsally

MAYFIELD STAGES

Stage I

PatternScapholunate ligament rupture

TreatmentLigament repair/reconstruction

Stage II

Pattern+ Lunocapitate disruption

TreatmentUrgent reduction, repair

Stage III

Pattern+ Lunotriquetral disruption

TreatmentPerilunate dislocation

Stage IV

Pattern+ Lunate dislocates volarly

TreatmentLunate dislocation (most severe)

Critical Must-Knows

25% missed initially - always look at lateral wrist X-ray
Lateral X-ray key - capitate should be colinear with radius and lunate
Lesser arc = pure ligamentous, Greater arc = with fractures (trans-scaphoid)
Lunate maintains contact with radius in perilunate; loses contact in lunate dislocation
Urgent reduction - median nerve at risk in carpal tunnel

Clinical Pearls

"
On lateral: look for colinearity of radius-lunate-capitate
"
Spilled teacup sign = lunate dislocates volarly (Stage IV)
"
Trans-scaphoid perilunate = greater arc injury, better prognosis than pure ligamentous
"
Acute carpal tunnel syndrome common - median nerve compression

Critical Perilunate Dislocation Points

25% Missed

One quarter of perilunate dislocations are missed on initial presentation. The injury is subtle on PA view. Always check the lateral - look for colinearity of radius, lunate, and capitate.

Lateral X-ray Sign

On lateral view: radius, lunate, and capitate should be colinear (like cups stacked). In perilunate dislocation, capitate is dorsal to lunate. In lunate dislocation, lunate tips volarly (spilled teacup).

Median Nerve at Risk

Acute carpal tunnel syndrome occurs in up to 25%. The dislocated bones compress the median nerve in the carpal tunnel. Urgent reduction is required - delays risk permanent median nerve damage.

Lesser vs Greater Arc

Lesser arc = pure ligamentous injury (through Mayfield stages). Greater arc = fracture through bone (trans-scaphoid perilunate most common). Greater arc injuries may have better prognosis.

Quick Decision Guide

Pattern	Key Finding	Treatment
Stage I (SL dissociation)	Scapholunate widening, no dislocation	May be isolated or progress
Stage II-III (Perilunate)	Capitate dorsal to lunate on lateral	Urgent reduction, operative repair
Stage IV (Lunate)	Lunate volarly rotated (spilled teacup)	Urgent reduction, operative repair
Trans-scaphoid perilunate	Greater arc with scaphoid fracture	Fix scaphoid + ligament repair
With median nerve symptoms	Acute carpal tunnel syndrome	Urgent reduction, consider CTR
Delayed presentation (greater than 3 weeks)	Chronic dislocation	Complex reconstruction required

Mnemonic

MAYFIELD - SMAYFIELD - Stages of Injury

M	Mechanism starts radially Injury propagates from radial side
A	Arc from scapholunate Stage I - SL ligament ruptures first
Y	Yawning space (SL gap) Terry Thomas sign on PA view
F	Following lunocapitate Stage II - space of Poirier
I	Into lunotriquetral Stage III - complete perilunate
E	Ending with lunate out Stage IV - lunate dislocates volarly
L	Lateral view diagnostic Key radiographic assessment
D	Dorsal-volar distinction Perilunate vs lunate dislocation

M	Mechanism starts radially Injury propagates from radial side	F	Following lunocapitate Stage II - space of Poirier	L	Lateral view diagnostic Key radiographic assessment
A	Arc from scapholunate Stage I - SL ligament ruptures first	I	Into lunotriquetral Stage III - complete perilunate	D	Dorsal-volar distinction Perilunate vs lunate dislocation
Y	Yawning space (SL gap) Terry Thomas sign on PA view	E	Ending with lunate out Stage IV - lunate dislocates volarly

Hook:MAYFIELD stages progress from radial to ulnar, lesser to greater severity

Mnemonic

SPILLED - LSPILLED - Lunate Dislocation Sign

S	Spilled teacup appearance Lunate tips volarly on lateral
P	Palmarly rotated lunate Stage IV Mayfield injury
I	Into carpal tunnel Compresses median nerve
L	Lunate loses radius contact Distinguishes from perilunate
L	Lateral X-ray shows Key diagnostic view
E	Emergency reduction Urgent treatment required
D	Dorsal lip may fracture Associated bony injury

S	Spilled teacup appearance Lunate tips volarly on lateral	L	Lunate loses radius contact Distinguishes from perilunate	D	Dorsal lip may fracture Associated bony injury
P	Palmarly rotated lunate Stage IV Mayfield injury	L	Lateral X-ray shows Key diagnostic view
I	Into carpal tunnel Compresses median nerve	E	Emergency reduction Urgent treatment required

Hook:A SPILLED teacup = lunate dislocation (Stage IV)

Mnemonic

LATERAL - X-LATERAL - X-ray Assessment

L	Line up three C's Radius-Lunate-Capitate colinearity
A	Articulation of lunate Does lunate contact radius?
T	Tilt of lunate DISI or VISI pattern
E	Examine capitate position Dorsal in perilunate
R	Radius-lunate relationship Maintained in perilunate
A	Anterior (volar) rotation Spilled teacup = lunate dislocated
L	Look carefully 25% missed if not careful

L	Line up three C's Radius-Lunate-Capitate colinearity	E	Examine capitate position Dorsal in perilunate	L	Look carefully 25% missed if not careful
A	Articulation of lunate Does lunate contact radius?	R	Radius-lunate relationship Maintained in perilunate
T	Tilt of lunate DISI or VISI pattern	A	Anterior (volar) rotation Spilled teacup = lunate dislocated

Hook:Use LATERAL view to diagnose - look for the three C's colinearity

Overview and Epidemiology

Perilunate dislocations are high-energy injuries representing the most severe end of the carpal instability spectrum. They are frequently missed on initial assessment, with up to 25% of cases not diagnosed at first presentation.

PA and lateral wrist radiographs demonstrating perilunate dislocation — Overview radiograph for perilunate dislocation: PA and lateral wrist views show the diagnostic carpal relationship. The key lateral-film finding is loss of normal radius-lunate-capitate colinearity with the capitate displaced dorsally relative to the lunate.Credit: Reisler T et al. via Eplasty and Open-i (NIH), CC-BY 4.0

Mechanism of injury:

High-energy wrist hyperextension
- Motor vehicle accidents
- Falls from height
- Industrial injuries
Sports injuries - FOOSH with significant force
Force transmitted through palm causes sequential ligament failure

Energy Required

Perilunate dislocations require significant force - these are not minor injuries. The energy required to cause sequential ligament rupture (or fracture through bone in greater arc injuries) indicates high-energy trauma. Always assess for associated injuries.

Classification:

Lesser arc injuries: Pure ligamentous (through Mayfield stages)
Greater arc injuries: With fractures (trans-scaphoid most common - 61%)
- Trans-scaphoid perilunate
- Trans-radial styloid perilunate
- Trans-triquetral perilunate
- Combined patterns

Anatomy and Pathomechanics

Carpal anatomy:

Proximal row: Scaphoid, lunate, triquetrum (+ pisiform)
Distal row: Trapezium, trapezoid, capitate, hamate
Lunate: Central keystone, articulates with radius
Capitate: Head articulates with lunate concavity

Key ligaments:

Scapholunate (SL) ligament: Dorsal portion strongest, connects scaphoid to lunate
Lunotriquetral (LT) ligament: Connects lunate to triquetrum
Space of Poirier: Weak area between lunate and capitate (volar)

Mayfield pathomechanics:

Mayfield Stages

Progressive perilunar instability (Mayfield):

Mayfield Classification (Progressive Instability):

Stage I: Scapholunate dissociation
Stage II: Capitolunate dislocation
Stage III: Lunotriquetral dissociation (Perilunate dislocation)
Stage IV: Lunate dislocation (Lunate ejected volar into carpal tunnel)

Lesser vs Greater Arc:

Lesser arc (pure ligamentous): Injury passes through the ligaments connecting carpal bones
Greater arc (with fractures): Injury passes through the bones themselves
- Energy dissipated through bone fracture
- Trans-scaphoid perilunate is most common (61%)
- May have better prognosis - bone heals better than ligament

Key concept - Lunate position:

Perilunate dislocation: Lunate maintains contact with radius; carpus displaces dorsally
Lunate dislocation: Lunate loses contact with radius; rotates volarly into carpal tunnel

Classification Systems

Mayfield Classification (Stages of Perilunar Instability)

Stage	Description	X-ray Finding
I	SL ligament rupture	SL widening (Terry Thomas)
II	+ Space of Poirier	Capitate starts to dorsally dislocate
III	+ LT ligament rupture	Complete perilunate dislocation
IV	+ Dorsal radiocarpal	Lunate dislocates volarly

Clinical Progression

Injury propagates in an arc from radial to ulnar side. Stage I = SL injury alone. Stages progress as more ligaments fail. Stage III = complete perilunate. Stage IV = lunate pushed volarly into carpal tunnel.

Clinical Presentation and Assessment

Perilunate injury is usually not a subtle clinical injury; the subtlety is that the radiographs are often misread. Assessment must document mechanism, timing, median nerve function, skin condition and associated carpal fractures before and after reduction.

History That Changes Management

Question	Why It Matters	Management Consequence
What was the mechanism?	Fall from height, motor vehicle crash, motorcycle injury and industrial trauma imply high-energy carpal disruption.	Look beyond the wrist: associated limb, spine and polytrauma injuries may coexist.
When did it occur?	Acute injuries are usually reducible and reconstructable; delayed injuries develop contracture, chondral injury and carpal malalignment.	Acute reduction and fixation differs from delayed reconstruction or salvage.
Any numbness or paraesthesia?	The volar lunate or swollen carpal tunnel may compress the median nerve.	Document before reduction; persistent symptoms after reduction push toward urgent carpal tunnel release.
Hand dominance, occupation and loading demands?	Manual workers need realistic counselling about grip loss, stiffness and delayed arthritis.	Changes fixation/reconstruction expectations and return-to-work planning.
Previous wrist injury or pain?	Old SL injury, scaphoid nonunion or arthritis may change the interpretation.	Pre-existing pathology may alter reconstruction versus salvage decisions.

Examination Sequence

Step	How To Examine	What It Means
Look	Inspect for swelling, dorsal carpal prominence, volar fullness, skin puckering, open wound, bruising and finger posture.	Massive swelling or skin compromise increases urgency. Volar fullness may reflect lunate displacement into the carpal tunnel.
Feel	Palpate distal radius, scaphoid, SL interval, lunate region, triquetrum, metacarpal bases and DRUJ. Avoid repeated painful stress before imaging.	Localises fracture components and associated carpal/metacarpal injury.
Move	Assess active finger flexion/extension first, then gentle wrist motion only if tolerated. Do not force a locked wrist.	Finger stiffness and tendon irritation matter; a mechanical wrist block supports carpal dislocation.
Median nerve	Check thumb, index, middle and radial ring-finger sensation, two-point discrimination if possible, thenar power and pain with passive finger extension.	Abnormal or worsening median nerve function is an emergency finding.
Vascular and compartment screen	Capillary refill, radial/ulnar pulses, hand temperature, escalating pain and forearm compartment signs.	Rare but important in high-energy trauma.
After reduction	Repeat median nerve, vascular status, skin tension and radiographic alignment.	Improvement supports decompression by reduction; persistent median symptoms need operative decompression.

Acute Carpal Tunnel

Do not simply write "neurovascularly intact." For this injury, explicitly document median nerve symptoms, two-point discrimination where possible, thenar power and whether symptoms improve after reduction. Persistent or progressive symptoms should trigger urgent carpal tunnel release with definitive management.

Investigations

Request PA wrist, true lateral wrist and oblique wrist radiographs immediately. If the mechanism is high energy or the radiograph shows any carpal crowding, add CT of the wrist to define greater-arc fractures and plan fixation. Do not accept a poor lateral film when the diagnosis depends on sagittal carpal alignment.

PA and lateral wrist radiographs with perilunate dislocation — PA and lateral radiographs showing posterior perilunate dislocation. The PA film shows disrupted carpal alignment; the lateral film is decisive for the radius-lunate-capitate relationship.Credit: Chari PR et al. via Indian J Orthop and Open-i (NIH), CC-BY 4.0

How To Read The X-rays

View	What To Check	Abnormal Finding
PA wrist	Trace Gilula arcs, look for SL widening, LT widening, carpal overlap, radial styloid/scaphoid/capitate/triquetral fractures and ulnar styloid injury.	Broken arcs, crowded proximal carpal row or associated carpal fracture should trigger lateral review and CT.
True lateral wrist	Assess whether radius, lunate and capitate are colinear. The lunate should articulate with both radius and capitate.	In perilunate dislocation the capitate lies dorsal to the lunate while the lunate remains in the lunate fossa.
Lunate dislocation	Look for the lunate losing its normal radius relationship and rotating volarly.	The classic spilled-teacup appearance represents Stage IV injury and may compress the median nerve.
Oblique views	Look for scaphoid, triquetral, capitate, hamate or metacarpal base fracture components.	Fractures convert the injury into a greater-arc pattern and change fixation.
Post-reduction films	Repeat PA and lateral after closed reduction.	Residual capitate-lunate malalignment means reduction is inadequate or unstable.

Gilula's Carpal Arcs

Gilula's lines are three smooth arcs on PA X-ray:

Arc 1: Along proximal carpal row proximal surface
Arc 2: Along proximal carpal row distal surface
Arc 3: Along proximal capitate/hamate surfaces Disruption indicates carpal instability or dislocation.

Three-dimensional CT reconstruction of perilunate carpal injury — 3D CT helps define the spatial relationship of the carpus and associated fracture components. It is useful after initial radiographs, especially in greater-arc injury patterns.Credit: Reisler T et al. via Eplasty and Open-i (NIH), CC-BY 4.0

Advanced Imaging

Modality	Indication	What It Changes
CT	High-energy injury, suspected greater-arc fracture, poor radiograph quality, preoperative planning or post-reduction confirmation.	Defines scaphoid, capitate, triquetral, radial styloid and articular fragments; guides fixation approach.
MRI	Subacute or chronic cases when ligament/cartilage viability, occult fracture or osteonecrosis is uncertain.	Rarely needed before urgent reduction; more useful when planning delayed reconstruction versus salvage.
Fluoroscopy	Reduction assessment and intraoperative carpal alignment.	Confirms capitate-lunate reduction, SL/LT interval control and K-wire trajectory.

Missed-injury trap

A PA wrist film can look deceptively acceptable. The lateral film is the safety check: if the capitate is not seated on the lunate, the wrist is not reduced.

Differential Diagnosis of the Painful, Swollen Post-FOOSH Wrist

Condition	Distinguishing Features	Key Discriminator
Perilunate dislocation	Capitate dorsal to lunate on lateral; lunate stays in radial fossa; broken Gilula arcs.	Lunate maintains radius contact; capitate displaced dorsally.
Lunate dislocation (Mayfield IV)	Spilled-teacup lunate tipped volarly; loses radius contact; often acute carpal tunnel syndrome.	Lunate ejected volarly out of the radial fossa.
Isolated scapholunate dissociation	Terry Thomas sign and SL angle greater than 70 degrees, but normal capitolunate colinearity on lateral.	No carpal dislocation - radius-lunate-capitate remain colinear.
Isolated scaphoid fracture	Anatomical snuffbox/scaphoid tubercle tenderness; intact Gilula arcs and carpal alignment.	No dislocation; carpal arcs preserved.
Distal radius fracture	Metaphyseal cortical break, dorsal/volar tilt; carpus moves with the distal fragment.	Fracture line is in the radius, not a carpal malalignment.
Wrist sprain (true)	Normal radiographs including a good lateral; tenderness without bony or carpal malalignment.	Diagnosis of exclusion only after an adequate lateral film.

Management

Emergency management:

Immediate Assessment

Neurovascular status (median nerve critical)
Skin integrity
Associated injuries
Adequate X-rays (PA AND lateral)

Urgent Closed Reduction

Indicated for all perilunate/lunate dislocations
May be done in ED with sedation
Traction + manipulation technique
Confirm with post-reduction X-ray

Post-Reduction

Splint wrist in neutral to slight flexion
Re-assess median nerve function
Arrange definitive surgical treatment

Closed Reduction Technique

Reduction technique:

Finger-trap traction for 10-15 minutes
Extend wrist while applying pressure to carpus
For lunate: direct pressure on dislocated lunate from palmar side
Flex wrist to lock reduction
Confirm with X-ray
Splint in slight flexion Even with reduction, surgical treatment is almost always required.

Operative management:

Radiographic sequence after operative fixation for perilunate injury — Operative fixation sequence after perilunate/lunate dislocation treatment. Definitive care aims to restore carpal alignment and protect ligament or fracture healing.Credit: Basar H et al. via Indian J Orthop and Open-i (NIH), CC-BY 4.0

Surgical Indications

Essentially all perilunate/lunate dislocations
Closed reduction alone has unacceptable outcomes
Goals:
- Anatomic reduction
- Ligament repair
- Fracture fixation (greater arc)
- Stable fixation allowing early motion

Emergency surgery:

Unreducible dislocation
Median nerve symptoms persisting after reduction
Open injury

All perilunate injuries require surgical stabilization for optimal outcomes.

Surgical Technique

Open Reduction and Stabilisation: Practical Sequence

Stage	What To Do	Key Point
Position	Supine, arm on hand table, tourniquet, image intensifier positioned for true PA and lateral wrist views.	A poor lateral view intraoperatively risks accepting a malreduced capitate-lunate relationship.
Preparation	Mark Lister's tubercle, third/fourth compartments, carpal tunnel incision if volar approach planned, scaphoid and K-wire trajectories.	Plan for both dorsal and volar access when median nerve symptoms, lunate dislocation or reduction difficulty exists.
Dorsal exposure	Longitudinal dorsal incision centred over the carpus. Protect dorsal sensory branches and veins. Open retinaculum as needed, mobilise EPL, perform dorsal capsulotomy.	Preserve capsuloligamentous tissue that may be needed for repair.
Volar exposure	Extended carpal tunnel release when median symptoms, lunate dislocation or routine combined approach is chosen. Release transverse carpal ligament and protect median nerve.	Reassess the nerve and remove compression; volar exposure also helps lunate reduction.
Reduce	Apply traction, derotate lunate/capitate, clear interposed capsule or tendon, restore radius-lunate-capitate colinearity.	Reduction is judged on both direct view and fluoroscopy, not by feel alone.
Fix fractures	In greater-arc injuries, fix scaphoid, radial styloid, capitate or triquetral fractures with appropriate screws, wires or plates.	The scaphoid usually needs stable compression fixation in trans-scaphoid perilunate injuries.
Stabilise carpus	Temporarily pin SL, LT and/or scaphocapitate intervals according to instability pattern.	Pins protect ligament healing and prevent recurrent carpal dissociation.
Repair ligaments	Repair dorsal SL and LT ligaments when tissue allows; repair capsule and dorsal intercarpal/radiocarpal structures as needed.	Do not repair an unreduced carpus.
Confirm and close	Confirm PA/lateral alignment, wire position, fracture fixation and median nerve status. Close capsule/retinaculum without tendon tethering.	Document post-reduction median nerve function and final alignment.

Complications

Complications of Perilunate Dislocations

Complication	Incidence	Management
Post-traumatic arthritis	Up to 50%	Activity modification, salvage procedures
Carpal instability	30-50%	Reconstruction, fusion options
Median neuropathy (permanent)	10-15%	Prevention with urgent treatment
Scaphoid nonunion (trans-scaphoid)	5-10%	Revision fixation, bone graft
Stiffness	Common	Physiotherapy, capsular release
AVN of lunate	Rare with timely treatment	Salvage procedures
Complex regional pain syndrome	5-10%	Early recognition, MDT treatment

Post-traumatic arthritis:

Most significant long-term complication
Radiocarpal and midcarpal joints affected
May progress despite initial good result
Treatment: activity modification, fusion procedures

Carpal instability:

SL ligament heals poorly
May have chronic SL dissociation despite repair
Leads to DISI pattern, SLAC wrist
May need late reconstruction or fusion

Long-Term Prognosis

Despite optimal treatment, post-traumatic arthritis develops in up to 50% of patients over time. Carpal instability is also common. Patients should be counseled that even with good initial treatment, long-term problems may develop.

Median nerve injury:

Acute compression usually resolves with reduction
Delayed treatment = higher risk of permanent deficit
May need neurolysis or secondary procedures

Postoperative Care and Rehabilitation

Postoperative protocol:

Week 0-2

Volar splint, wrist neutral to slight flexion
Elevation
Finger motion immediately
Monitor median nerve function

Week 2-6

Convert to removable splint
Gentle active wrist ROM
Continue finger exercises
Suture removal

Week 6-8

X-ray to assess healing
Consider K-wire removal (8-12 weeks)
Progressive ROM
Light functional activities

Week 8-12

K-wire removal (usually by 12 weeks)
Progressive strengthening
Increase ROM exercises
CT if concerns about union

3-6 months

Full strengthening program
Grip strength recovery
Return to work assessment
Final outcome evaluation

Key rehabilitation principles:

Finger motion from day 1 (prevent stiffness)
Protected wrist motion starts at 2 weeks
K-wires removed before aggressive ROM
Grip strength takes 6-12 months to recover
Long-term monitoring for arthritis

K-wire Duration

K-wires are typically left in place for 8-12 weeks to allow ligament healing. SL ligament is particularly slow to heal. Remove K-wires once adequate healing confirmed, then progress rehabilitation.

Outcomes and Prognosis

Chronic perilunate dislocation treated with K-wire stabilisation sequence — Chronic perilunate dislocation sequence. Delayed injuries are harder to reduce, have more stiffness and cartilage risk, and may require reconstruction or salvage rather than simple acute repair.Credit: Dhillon MS et al. via Indian J Orthop and Open-i (NIH), CC-BY 4.0

Outcome factors:

Factor	Better Outcome	Worse Outcome
Arc type	Greater arc (trans-scaphoid)	Lesser arc (pure ligamentous)
Time to treatment	Less than 7 days	More than 7 days
Reduction quality	Anatomic	Residual malalignment
Nerve symptoms	None	Persistent median neuropathy
Associated injuries	Isolated	Multiple patterns

Prognostic considerations:

Even with optimal treatment, outcomes are guarded
Post-traumatic arthritis common long-term
SL ligament rarely heals to normal
Chronic instability may develop despite repair
Greater arc (trans-scaphoid) may have better outcomes - bone heals better than ligament

Greater Arc Advantage

Greater arc injuries (trans-scaphoid) may have better long-term outcomes than lesser arc (pure ligamentous). The scaphoid fracture, once healed, provides stability. In lesser arc, the SL ligament rarely heals to normal strength.

Evidence Base

Level V (cadaveric biomechanical study)

Mayfield, Johnson & Kilcoyne. Carpal dislocations: pathomechanics and progressive perilunar instability

Key Findings:

Loaded 32 cadaver wrists to failure, producing 13 perilunate and 2 lunate dislocations. Defined the mechanism as extension, ulnar deviation and intercarpal supination, with sequential ligament failure proceeding from radial to ulnar.
Classified injury into four stages of progressive perilunar instability (PLI): Stage I scapholunate diastasis through to Stage IV lunate dislocation (greatest instability).
Reduction was achieved by reversing the mechanism (intercarpal pronation, radial deviation, palmar flexion).

Clinical Implication: The Mayfield classification remains the foundational framework for understanding perilunate injury severity and guiding reduction manoeuvres. Note this is a cadaveric study, not a clinical series.

Source: J Hand Surg Am 1980;5(3):226-41

Verify on PubMed (PMID 7400560)

Level IV (multicentre retrospective series, 7 centres)

Herzberg, Comtet, Linscheid, Amadio, Cooney & Stalder. Perilunate dislocations and fracture-dislocations: a multicenter study

Key Findings:

Series of 166 perilunate dislocations/fracture-dislocations; the diagnosis was missed initially in 41 cases (25%). Displacement was dorsal in 97% and palmar in only 3%.
Trans-scaphoid perilunate fracture-dislocations represented 61% of the whole series; fracture-dislocations outnumbered pure dislocations roughly two to one.
In the 115 cases followed (mean 6 years), open injury and delayed treatment adversely affected results; post-traumatic arthritis occurred in 56% even when treated early.

Clinical Implication: The defining clinical epidemiology paper for this injury. Establishes the 25% miss rate, 61% trans-scaphoid frequency and the high (around 56%) long-term arthritis rate. Early open reduction and internal fixation gave the best radiological results.

Source: J Hand Surg Am 1993;18(5):768-79

Verify on PubMed (PMID 8228045)

Level IV (retrospective therapeutic study)

Krief, Appy-Fedida, Rotari, David, Mertl & Maes-Clavier. Results of perilunate dislocations and perilunate fracture dislocations with a minimum 15-year follow-up

Key Findings:

30 patients (14 dislocations, 16 fracture-dislocations) reviewed at a mean of 18 years. Radiographic arthritis occurred in 70% of cases, yet its clinical and functional impact appeared low.
Mean flexion-extension arc was 68%, grip strength 70% and mean Mayo wrist score 70 relative to the contralateral side.
Six patients developed CRPS type 1; the two lowest Mayo wrist scores corresponded to the patients with the most advanced arthritis.

Clinical Implication: Provides the longest-term outcome data: radiographic arthritis is near-universal over time but is often well tolerated. Counsel patients that good function can persist despite degenerative change.

Source: J Hand Surg Am 2015;40(11):2191-7

Verify on PubMed (PMID 26328900)

Level IV (retrospective series, 11 wrists)

Sotereanos, Mitsionis, Giannakopoulos, Tomaino & Herndon. Perilunate dislocation and fracture dislocation: a critical analysis of the volar-dorsal approach

Key Findings:

Combined volar-dorsal approach in 11 perilunate dislocations/fracture-dislocations, mean 13 hours from injury to surgery, mean follow-up 30 months.
Flexion-extension arc averaged 71% and grip strength 77% of the contralateral side; all 8 wrist fractures united and patient satisfaction was high in 9 of 11.
No scapholunate dissociation or significant DISI persisted, although one wrist developed SLAC arthritis.

Clinical Implication: Supports the combined volar-dorsal approach as a safe, effective way to restore intercarpal alignment and fix associated fractures. The volar limb facilitates carpal tunnel decompression and direct lunate reduction.

Source: J Hand Surg Am 1997;22(1):49-56

Verify on PubMed (PMID 9018612)

Level IV (retrospective observational study, 32 patients)

Garcon, Degeorge, Coulet, Lazerges & Chammas. Perilunate dislocation and fracture dislocation of the wrist: outcomes and long-term prognostic factors

Key Findings:

32 patients (7 dislocations, 25 fracture-dislocations) at mean 9.9-year follow-up; radiographic osteoarthritis in 79% and residual carpal instability in 16%.
The magnitude of lunate displacement (injury stage) and older patient age were significant predictors of poorer long-term functional outcome and arthritis.
Symptoms of median nerve compression generally resolved with reduction alone in this cohort.

Clinical Implication: Confirms that functional sequelae and post-traumatic arthritis are common (around 80%) despite anatomical reduction, and that greater lunate displacement and older age predict worse outcomes.

Source: Orthop Traumatol Surg Res 2022;108(5):103332

Verify on PubMed (PMID 35609818)

Level IV (retrospective salvage series, 45 patients)

Kremer, Sauerbier, Trankle, Dragu, Germann & Baumeister. Functional results after proximal row carpectomy to salvage a wrist

Key Findings:

45 wrists undergoing proximal row carpectomy (PRC), including chronic perilunate dislocation/fracture-dislocation, with mean 32-month follow-up.
Active flexion-extension averaged 70 degrees with grip strength 51% of the unaffected side; pain reduced 71% at rest and 44% after strenuous activity.
PRC is contraindicated when the capitate head or lunate fossa cartilage is degenerate.

Clinical Implication: Supports proximal row carpectomy as a motion-preserving salvage option for chronic or arthritic perilunate injury when the capitate head and lunate fossa remain healthy.

Source: Scand J Plast Reconstr Surg Hand Surg 2008;42(6):308-12

Verify on PubMed (PMID 18991174)

Clinical Decision Scenarios

Use these scenarios to practise clinical reasoning and management decisions

CLINICAL SCENARIOStandard

Scenario 1: Missed Perilunate Dislocation

CLINICAL PROMPT

"A 28-year-old man comes to your clinic referred by his GP. He fell off a motorcycle 3 weeks ago and was seen in another hospital's ED. He was told he had a 'wrist sprain' and given a splint. He has persistent pain and weakness. You obtain new X-rays. What are you looking for and what might you find?"

PRACTICAL APPROACH

This scenario is suspicious for a **missed perilunate dislocation** - a classic presentation. Up to **25% of these injuries are missed** at initial presentation. The delay in diagnosis makes this more complex. **What I Would Look For on X-rays:** **PA View:** - **Gilula's lines** - are the three smooth carpal arcs disrupted? - **Scapholunate widening** - Terry Thomas sign (greater than 3mm) - **Overlapping carpals** - "crowded" appearance - **Piece-of-pie sign** - lunate appears triangular instead of quadrilateral - **Associated fractures** - scaphoid, radial styloid, triquetrum **Lateral View (KEY):** - **Colinearity** - radius, lunate, capitate should line up - **Perilunate pattern**: Capitate dorsal to lunate; lunate maintains radius contact - **Lunate dislocation pattern**: Lunate tilts volarly (spilled teacup); loses radius contact - **DISI pattern** - lunate extended (tilted dorsally) **What I Might Find:** Given the history of high-energy injury and "wrist sprain" diagnosis, I would expect to see either: 1. **Perilunate dislocation** - capitate dorsal to lunate 2. **Lunate dislocation** - lunate tilted volarly 3. **Trans-scaphoid perilunate** - scaphoid fracture with dislocation **Assessment:** - Confirm neurovascular status (median nerve) - Examine for carpal tunnel symptoms - Assess ROM and grip strength - CT scan for surgical planning **Management:** At 3 weeks, this is a **delayed presentation** requiring: - Operative treatment (essentially all need surgery) - May be more difficult to reduce (scar tissue forming) - Combined dorsal and volar approach - Ligament repair +/- scaphoid fixation if trans-scaphoid - K-wire stabilization - Carpal tunnel release (usually) **Prognosis:** Delayed treatment is associated with worse outcomes. I would counsel the patient that even with optimal treatment now, he may develop arthritis and chronic instability over time.

KEY CLINICAL POINTS

25% of perilunate dislocations are missed initially

Lateral X-ray is KEY - look for colinearity

PA view: Gilula's lines, SL gap, crowded carpus

3 weeks = delayed presentation, worse prognosis

Still requires operative treatment

May be technically more difficult (scarring)

Combined dorsal and volar approach

Assess median nerve function

CT scan for planning

Counsel about guarded long-term prognosis

COMMON PITFALLS

Not obtaining lateral X-ray

Accepting 'wrist sprain' diagnosis without careful evaluation

Not assessing median nerve

Attempting non-operative management

Not counseling about long-term prognosis

FURTHER QUESTIONS

"What if this was 8 weeks delayed?"

"What salvage options exist for late presentation?"

CLINICAL SCENARIOChallenging

Scenario 2: Acute Lunate Dislocation with Median Nerve Symptoms

CLINICAL PROMPT

"A 35-year-old woman is brought to ED after a high-speed MVA. She has numbness and tingling in her thumb, index, and middle fingers. Her wrist is swollen and painful. X-rays show a lunate dislocation (Stage IV Mayfield). What is your management?"

PRACTICAL APPROACH

This is an **acute lunate dislocation (Mayfield Stage IV)** with **acute carpal tunnel syndrome**. This is an orthopaedic emergency requiring urgent treatment. **Key Concerns:** 1. **Median nerve compression** - numbness in median distribution indicates compression in carpal tunnel 2. **Stage IV injury** - most severe perilunate injury; lunate has completely dislocated volarly 3. **High-energy mechanism** - MVA; assess for other injuries **Immediate Assessment:** - Complete neurovascular examination - Document median nerve function precisely: - Light touch sensation - Two-point discrimination - Thenar motor function (APB) - Examine for associated injuries (high-energy MVA) - Adequate X-rays confirming diagnosis **X-ray Findings (Stage IV):** - **Lateral**: Lunate tilted volarly ("spilled teacup"), lunate loses radius contact - **PA**: Disrupted Gilula's lines, piece-of-pie sign **Emergency Management:** **Option 1: Closed Reduction in ED (Attempt first):** - Under adequate sedation - Finger-trap traction - Direct pressure on lunate from palmar side while extending then flexing wrist - Aim to reduce median nerve compression urgently - Post-reduction X-ray to confirm - Re-assess median nerve function **Option 2: If Reduction Fails or Symptoms Persist:** - Proceed directly to operating theater - Open reduction and carpal tunnel release **Definitive Surgical Treatment:** Even with successful closed reduction, **surgery is required urgently** (within 24-48 hours): **Approach:** Combined dorsal and volar - **Volar**: Carpal tunnel release, visualize lunate reduction - **Dorsal**: Ligament repair, K-wire stabilization **Procedure:** 1. Carpal tunnel release (through volar approach) 2. Inspect and reduce lunate 3. Reduce capitate and distal carpal row 4. Repair SL and LT ligaments (dorsal approach) 5. K-wire stabilization (SL, SC, LT intervals) 6. Capsular repair **Postoperative:** - Monitor median nerve recovery - Splint protection - Early finger motion - K-wires removed at 8-12 weeks

KEY CLINICAL POINTS

Stage IV Mayfield = lunate dislocation (most severe)

Acute carpal tunnel syndrome = orthopaedic emergency

Document median nerve function precisely

Attempt closed reduction to decompress nerve

Even if reduced, surgery required urgently

Combined dorsal and volar approach

Carpal tunnel release is mandatory

Ligament repair and K-wire stabilization

K-wires for 8-12 weeks

Monitor nerve recovery postoperatively

COMMON PITFALLS

Not recognizing urgency of median nerve compression

Delaying treatment

Thinking closed reduction alone is sufficient

Not doing carpal tunnel release

Missing the diagnosis on X-ray

FURTHER QUESTIONS

"What if the closed reduction was unsuccessful?"

"What is the prognosis for median nerve recovery?"

CLINICAL SCENARIOCritical

Scenario 3: Trans-Scaphoid Perilunate Dislocation

CLINICAL PROMPT

"A 25-year-old construction worker falls from scaffolding onto his outstretched hand. X-rays show a perilunate dislocation with a scaphoid fracture through the waist. How does this change your management compared to a pure ligamentous injury?"

PRACTICAL APPROACH

This is a **trans-scaphoid perilunate dislocation** - a **greater arc injury**. The presence of the scaphoid fracture actually changes some aspects of management and may actually be prognostically favorable. **Understanding Greater Arc Injuries:** - In a **lesser arc** (pure ligamentous), injury passes through the SL, lunocapitate, and LT ligaments - In a **greater arc**, injury passes through bone (scaphoid most commonly - 61%) - Paradoxically, bone may heal better than ligament, potentially offering better long-term stability **Key Differences in Management:** **1. Scaphoid Fracture Fixation:** This is the major difference. The scaphoid fracture must be fixed: - **Headless compression screw** (Herbert-type) - Central axis placement - Provides stable radial column - May improve overall carpal stability **2. SL Ligament:** - The SL ligament may be partially intact (injury went through bone) - Still assess and repair if needed - May have better healing potential **3. Blood Supply Consideration:** - Assess scaphoid for AVN risk - Waist fracture = moderate risk - MRI may be helpful post-operatively **Surgical Plan:** **Approach:** Combined dorsal and volar **Sequence:** 1. Carpal tunnel release (volar approach) 2. Reduce perilunate dislocation 3. **Fix scaphoid** with headless compression screw (KEY) - Through volar approach usually - Anatomic reduction critical 4. Assess SL ligament - repair if needed (dorsal) 5. K-wire stabilization (SC interval at minimum) 6. LT repair if disrupted 7. Capsular closure **Scaphoid Considerations:** - Use fluoroscopy/mini-open for screw placement - Central axis placement - May need to expose more for comminuted fractures - Confirm screw length (not proud) **Potential Advantages of Greater Arc:** - Bone heals more predictably than ligament - Once scaphoid united, provides stable radial column - May have lower rate of chronic SL dissociation - Some studies show better long-term outcomes **Postoperative:** - Same as lesser arc - Additional attention to scaphoid healing - CT at 6-8 weeks to confirm scaphoid union - K-wires out once scaphoid united

KEY CLINICAL POINTS

Trans-scaphoid = greater arc injury

Injury through bone rather than ligament

61% of perilunate dislocations have scaphoid fracture

Scaphoid fixation is the key additional step

Headless compression screw for scaphoid

SL ligament may be partially intact

May have better long-term prognosis than lesser arc

Bone heals better than ligament

Confirm scaphoid union before K-wire removal

Still requires aggressive surgical treatment

COMMON PITFALLS

Missing the scaphoid fracture

Not fixing the scaphoid adequately

Thinking it's worse than lesser arc (may actually be better)

Poor screw position in scaphoid

Not monitoring scaphoid healing

FURTHER QUESTIONS

"What if the scaphoid was proximal pole?"

"What is the evidence for greater arc prognosis?"

MCQ Practice Points

Mayfield Stages Question

Q: In Mayfield Stage III, which structures are disrupted? A: SL ligament + lunocapitate joint (space of Poirier) + LT ligament. This represents complete perilunate dislocation. Stage IV adds dorsal radiocarpal ligament failure with lunate dislocating volarly.

X-ray Question

Q: What is the key X-ray finding on lateral view for perilunate vs lunate dislocation? A: In perilunate: lunate maintains contact with radius, capitate is dorsal to lunate. In lunate dislocation: lunate loses radius contact and tips volarly ("spilled teacup" sign).

Miss Rate Question

Q: What percentage of perilunate dislocations are missed on initial presentation? A: 25% (approximately one quarter). This is usually due to inadequate lateral X-ray or not recognizing the abnormal carpal alignment. Always look at the lateral view for colinearity of radius-lunate-capitate.

Arc Classification Question

Q: What is the difference between lesser arc and greater arc injuries? A: Lesser arc = pure ligamentous (injury through SL, lunocapitate, LT ligaments). Greater arc = with fractures (most commonly trans-scaphoid - 61%). Greater arc injuries may have better long-term prognosis as bone heals better than ligament.

Nerve Question

Q: Why is median nerve assessment critical in perilunate dislocations? A: Acute carpal tunnel syndrome occurs in up to 25% of cases. The dislocated carpal bones compress the median nerve. This is an urgent indication for reduction - delay risks permanent nerve damage.

Guidelines, Registries & Global Practice

Global epidemiology (PubMed-verifiable):

Parameter	Figure	Source
Proportion of all wrist injuries	Rare, high-energy injury pattern	Herzberg multicentre series (PMID 8228045)
Missed at initial presentation	25% (41 of 166)	Herzberg 1993 (PMID 8228045)
Dorsal displacement	97% (palmar only 3%)	Herzberg 1993 (PMID 8228045)
Trans-scaphoid (greater-arc) variant	61% of whole series	Herzberg 1993 (PMID 8228045)
Long-term radiographic arthritis	56-80%	Herzberg 1993 (PMID 8228045); Garcon 2022 (PMID 35609818)
Demographics	Young adults, male predominance, high-energy MVA/fall/industrial mechanisms	Herzberg 1993 (PMID 8228045)

There is no orthopaedic device registry that tracks perilunate dislocation outcomes, because management relies on K-wires, screws and ligament repair rather than registered implants. Arthroplasty registries (AOANJRR in Australia, NJR in England/Wales, AJRR in the USA) therefore do not capture this injury. Evidence is confined to retrospective single-centre and multicentre series; there are no randomised trials.

Side-by-side guidance and society position (global):

Body / Region	Position on perilunate injury	Evidence level
BSSH / BOA (UK)	Carpal dislocation is a surgical emergency; urgent reduction, then open reduction, ligament repair and internal fixation in a hand unit	Expert consensus / Level IV
AAOS / ASSH (USA)	Open reduction and internal fixation with ligament repair is the standard of care; closed treatment alone is inadequate	Expert consensus / Level IV
EFORT / European hand societies	Combined volar-dorsal or dorsal-only ORIF with carpal stabilisation; carpal tunnel decompression for persistent median symptoms	Expert consensus / Level IV
AO Foundation (AO Surgery Reference)	Emergent closed reduction followed by ORIF; scaphoid fixed with headless compression screw in trans-scaphoid patterns	Expert consensus / Level IV

Practice variation

Genuine debate persists over (1) dorsal-only versus combined volar-dorsal approach, (2) whether to routinely release the carpal tunnel - Garcon et al. (PMID 35609818) found median symptoms usually resolve with reduction alone - and (3) the role of dorsal spanning plates for early load-bearing. None of these is settled by Level I evidence.

Australian context (allowed references only): These are high-energy injuries (motor vehicle and motorcycle crashes, falls from height, industrial trauma) that should be managed in centres with hand-surgery capability. Urgent closed reduction can and should be performed locally to decompress the median nerve before transfer for definitive fixation. There is no specific Australian device registry for this injury, and antibiotic prophylaxis for any open component follows eTG (Therapeutic Guidelines) recommendations.

Exam Context

Be prepared to discuss Mayfield stages, X-ray interpretation (especially lateral view), lesser vs greater arc, acute carpal tunnel syndrome, and surgical approach. Understanding why 25% are missed (inadequate lateral film) is commonly tested.

PERILUNATE DISLOCATIONS

Clinical summary

MAYFIELD STAGES

•Stage I: Scapholunate ligament rupture
•Stage II: + Lunocapitate (space of Poirier)
•Stage III: + Lunotriquetral (complete perilunate)
•Stage IV: + Dorsal radiocarpal → lunate dislocates volarly

KEY X-RAY FINDINGS

•LATERAL VIEW IS KEY
•Normal: radius-lunate-capitate colinear
•Perilunate: capitate dorsal, lunate maintains radius contact
•Lunate dislocation: lunate tilts volarly (spilled teacup)

LESSER VS GREATER ARC

•Lesser arc: pure ligamentous
•Greater arc: with fractures (trans-scaphoid 61%)
•Greater arc may have better prognosis
•Bone heals better than ligament

CRITICAL POINTS

•25% missed on initial presentation
•Acute carpal tunnel syndrome in 25%
•Urgent reduction required
•Surgery almost always required

SURGICAL APPROACH

•Combined dorsal and volar approach
•Volar: CTR, visualize reduction
•Dorsal: ligament repair, K-wire fixation
•Fix scaphoid if trans-scaphoid

PROGNOSIS

•50% develop arthritis long-term
•30-50% chronic instability
•SL ligament rarely heals to normal
•Even optimal treatment has guarded prognosis

Pattern

Key Finding

Treatment

Stage I (SL dissociation)

Scapholunate widening, no dislocation

May be isolated or progress

Stage II-III (Perilunate)

Capitate dorsal to lunate on lateral

Urgent reduction, operative repair

Stage IV (Lunate)

Lunate volarly rotated (spilled teacup)

Urgent reduction, operative repair

Trans-scaphoid perilunate

Greater arc with scaphoid fracture

Fix scaphoid + ligament repair

With median nerve symptoms

Acute carpal tunnel syndrome

Urgent reduction, consider CTR

Delayed presentation (greater than 3 weeks)

Chronic dislocation

Complex reconstruction required

Stage

Description

X-ray Finding

SL ligament rupture

SL widening (Terry Thomas)

+ Space of Poirier

Capitate starts to dorsally dislocate

III

+ LT ligament rupture

Complete perilunate dislocation

+ Dorsal radiocarpal

Lunate dislocates volarly

Question

Why It Matters

Management Consequence

What was the mechanism?

Fall from height, motor vehicle crash, motorcycle injury and industrial trauma imply high-energy carpal disruption.

Look beyond the wrist: associated limb, spine and polytrauma injuries may coexist.

When did it occur?

Acute injuries are usually reducible and reconstructable; delayed injuries develop contracture, chondral injury and carpal malalignment.

Acute reduction and fixation differs from delayed reconstruction or salvage.

Any numbness or paraesthesia?

The volar lunate or swollen carpal tunnel may compress the median nerve.

Document before reduction; persistent symptoms after reduction push toward urgent carpal tunnel release.

Hand dominance, occupation and loading demands?

Manual workers need realistic counselling about grip loss, stiffness and delayed arthritis.

Changes fixation/reconstruction expectations and return-to-work planning.

Previous wrist injury or pain?

Old SL injury, scaphoid nonunion or arthritis may change the interpretation.

Pre-existing pathology may alter reconstruction versus salvage decisions.

Step

How To Examine

What It Means

Look

Inspect for swelling, dorsal carpal prominence, volar fullness, skin puckering, open wound, bruising and finger posture.

Massive swelling or skin compromise increases urgency. Volar fullness may reflect lunate displacement into the carpal tunnel.

Feel

Palpate distal radius, scaphoid, SL interval, lunate region, triquetrum, metacarpal bases and DRUJ. Avoid repeated painful stress before imaging.

Localises fracture components and associated carpal/metacarpal injury.

Move

Assess active finger flexion/extension first, then gentle wrist motion only if tolerated. Do not force a locked wrist.

Finger stiffness and tendon irritation matter; a mechanical wrist block supports carpal dislocation.

Median nerve

Check thumb, index, middle and radial ring-finger sensation, two-point discrimination if possible, thenar power and pain with passive finger extension.

Abnormal or worsening median nerve function is an emergency finding.

Vascular and compartment screen

Capillary refill, radial/ulnar pulses, hand temperature, escalating pain and forearm compartment signs.

Rare but important in high-energy trauma.

After reduction

Repeat median nerve, vascular status, skin tension and radiographic alignment.

Improvement supports decompression by reduction; persistent median symptoms need operative decompression.

View

What To Check

Abnormal Finding

PA wrist

Trace Gilula arcs, look for SL widening, LT widening, carpal overlap, radial styloid/scaphoid/capitate/triquetral fractures and ulnar styloid injury.

Broken arcs, crowded proximal carpal row or associated carpal fracture should trigger lateral review and CT.

True lateral wrist

Assess whether radius, lunate and capitate are colinear. The lunate should articulate with both radius and capitate.

In perilunate dislocation the capitate lies dorsal to the lunate while the lunate remains in the lunate fossa.

Lunate dislocation

Look for the lunate losing its normal radius relationship and rotating volarly.

The classic spilled-teacup appearance represents Stage IV injury and may compress the median nerve.

Oblique views

Look for scaphoid, triquetral, capitate, hamate or metacarpal base fracture components.

Fractures convert the injury into a greater-arc pattern and change fixation.

Post-reduction films

Repeat PA and lateral after closed reduction.

Residual capitate-lunate malalignment means reduction is inadequate or unstable.

Modality

Indication

What It Changes

High-energy injury, suspected greater-arc fracture, poor radiograph quality, preoperative planning or post-reduction confirmation.

Defines scaphoid, capitate, triquetral, radial styloid and articular fragments; guides fixation approach.

MRI

Subacute or chronic cases when ligament/cartilage viability, occult fracture or osteonecrosis is uncertain.

Rarely needed before urgent reduction; more useful when planning delayed reconstruction versus salvage.

Fluoroscopy

Reduction assessment and intraoperative carpal alignment.

Confirms capitate-lunate reduction, SL/LT interval control and K-wire trajectory.

Condition

Distinguishing Features

Key Discriminator

Perilunate dislocation

Capitate dorsal to lunate on lateral; lunate stays in radial fossa; broken Gilula arcs.

Lunate maintains radius contact; capitate displaced dorsally.

Lunate dislocation (Mayfield IV)

Spilled-teacup lunate tipped volarly; loses radius contact; often acute carpal tunnel syndrome.

Lunate ejected volarly out of the radial fossa.

Isolated scapholunate dissociation

Terry Thomas sign and SL angle greater than 70 degrees, but normal capitolunate colinearity on lateral.

No carpal dislocation - radius-lunate-capitate remain colinear.

Isolated scaphoid fracture

Anatomical snuffbox/scaphoid tubercle tenderness; intact Gilula arcs and carpal alignment.

No dislocation; carpal arcs preserved.

Distal radius fracture

Metaphyseal cortical break, dorsal/volar tilt; carpus moves with the distal fragment.

Fracture line is in the radius, not a carpal malalignment.

Wrist sprain (true)

Normal radiographs including a good lateral; tenderness without bony or carpal malalignment.

Diagnosis of exclusion only after an adequate lateral film.

Stage

What To Do

Key Point

Position

Supine, arm on hand table, tourniquet, image intensifier positioned for true PA and lateral wrist views.

A poor lateral view intraoperatively risks accepting a malreduced capitate-lunate relationship.

Preparation

Mark Lister's tubercle, third/fourth compartments, carpal tunnel incision if volar approach planned, scaphoid and K-wire trajectories.

Plan for both dorsal and volar access when median nerve symptoms, lunate dislocation or reduction difficulty exists.

Dorsal exposure

Longitudinal dorsal incision centred over the carpus. Protect dorsal sensory branches and veins. Open retinaculum as needed, mobilise EPL, perform dorsal capsulotomy.

Preserve capsuloligamentous tissue that may be needed for repair.

Volar exposure

Extended carpal tunnel release when median symptoms, lunate dislocation or routine combined approach is chosen. Release transverse carpal ligament and protect median nerve.

Reassess the nerve and remove compression; volar exposure also helps lunate reduction.

Reduce

Apply traction, derotate lunate/capitate, clear interposed capsule or tendon, restore radius-lunate-capitate colinearity.

Reduction is judged on both direct view and fluoroscopy, not by feel alone.

Fix fractures

In greater-arc injuries, fix scaphoid, radial styloid, capitate or triquetral fractures with appropriate screws, wires or plates.

The scaphoid usually needs stable compression fixation in trans-scaphoid perilunate injuries.

Stabilise carpus

Temporarily pin SL, LT and/or scaphocapitate intervals according to instability pattern.

Pins protect ligament healing and prevent recurrent carpal dissociation.

Repair ligaments

Repair dorsal SL and LT ligaments when tissue allows; repair capsule and dorsal intercarpal/radiocarpal structures as needed.

Do not repair an unreduced carpus.

Confirm and close

Confirm PA/lateral alignment, wire position, fracture fixation and median nerve status. Close capsule/retinaculum without tendon tethering.

Document post-reduction median nerve function and final alignment.

Complication

Incidence

Management

Post-traumatic arthritis

Up to 50%

Activity modification, salvage procedures

Carpal instability

30-50%

Reconstruction, fusion options

Median neuropathy (permanent)

10-15%

Prevention with urgent treatment

Scaphoid nonunion (trans-scaphoid)

5-10%

Revision fixation, bone graft

Stiffness

Common

Physiotherapy, capsular release

AVN of lunate

Rare with timely treatment

Salvage procedures

Complex regional pain syndrome

5-10%

Early recognition, MDT treatment

Factor

Better Outcome

Worse Outcome

Arc type

Greater arc (trans-scaphoid)

Lesser arc (pure ligamentous)

Time to treatment

Less than 7 days

More than 7 days

Reduction quality

Anatomic

Residual malalignment

Nerve symptoms

None

Persistent median neuropathy

Associated injuries

Isolated

Multiple patterns

Level V (cadaveric biomechanical study)

Mayfield, Johnson & Kilcoyne. Carpal dislocations: pathomechanics and progressive perilunar instability

Key Findings:

Loaded 32 cadaver wrists to failure, producing 13 perilunate and 2 lunate dislocations. Defined the mechanism as extension, ulnar deviation and intercarpal supination, with sequential ligament failure proceeding from radial to ulnar.
Classified injury into four stages of progressive perilunar instability (PLI): Stage I scapholunate diastasis through to Stage IV lunate dislocation (greatest instability).
Reduction was achieved by reversing the mechanism (intercarpal pronation, radial deviation, palmar flexion).

Source: J Hand Surg Am 1980;5(3):226-41

Verify on PubMed (PMID 7400560)

Level IV (multicentre retrospective series, 7 centres)

Herzberg, Comtet, Linscheid, Amadio, Cooney & Stalder. Perilunate dislocations and fracture-dislocations: a multicenter study

Key Findings:

Series of 166 perilunate dislocations/fracture-dislocations; the diagnosis was missed initially in 41 cases (25%). Displacement was dorsal in 97% and palmar in only 3%.
Trans-scaphoid perilunate fracture-dislocations represented 61% of the whole series; fracture-dislocations outnumbered pure dislocations roughly two to one.
In the 115 cases followed (mean 6 years), open injury and delayed treatment adversely affected results; post-traumatic arthritis occurred in 56% even when treated early.

Source: J Hand Surg Am 1993;18(5):768-79

Verify on PubMed (PMID 8228045)

Level IV (retrospective therapeutic study)

Krief, Appy-Fedida, Rotari, David, Mertl & Maes-Clavier. Results of perilunate dislocations and perilunate fracture dislocations with a minimum 15-year follow-up

Key Findings:

30 patients (14 dislocations, 16 fracture-dislocations) reviewed at a mean of 18 years. Radiographic arthritis occurred in 70% of cases, yet its clinical and functional impact appeared low.
Mean flexion-extension arc was 68%, grip strength 70% and mean Mayo wrist score 70 relative to the contralateral side.
Six patients developed CRPS type 1; the two lowest Mayo wrist scores corresponded to the patients with the most advanced arthritis.

Source: J Hand Surg Am 2015;40(11):2191-7

Verify on PubMed (PMID 26328900)

Level IV (retrospective series, 11 wrists)

Sotereanos, Mitsionis, Giannakopoulos, Tomaino & Herndon. Perilunate dislocation and fracture dislocation: a critical analysis of the volar-dorsal approach

Key Findings:

Combined volar-dorsal approach in 11 perilunate dislocations/fracture-dislocations, mean 13 hours from injury to surgery, mean follow-up 30 months.
Flexion-extension arc averaged 71% and grip strength 77% of the contralateral side; all 8 wrist fractures united and patient satisfaction was high in 9 of 11.
No scapholunate dissociation or significant DISI persisted, although one wrist developed SLAC arthritis.

Source: J Hand Surg Am 1997;22(1):49-56

Verify on PubMed (PMID 9018612)

Level IV (retrospective observational study, 32 patients)

Garcon, Degeorge, Coulet, Lazerges & Chammas. Perilunate dislocation and fracture dislocation of the wrist: outcomes and long-term prognostic factors

Key Findings:

32 patients (7 dislocations, 25 fracture-dislocations) at mean 9.9-year follow-up; radiographic osteoarthritis in 79% and residual carpal instability in 16%.
The magnitude of lunate displacement (injury stage) and older patient age were significant predictors of poorer long-term functional outcome and arthritis.
Symptoms of median nerve compression generally resolved with reduction alone in this cohort.

Source: Orthop Traumatol Surg Res 2022;108(5):103332

Verify on PubMed (PMID 35609818)

Level IV (retrospective salvage series, 45 patients)

Kremer, Sauerbier, Trankle, Dragu, Germann & Baumeister. Functional results after proximal row carpectomy to salvage a wrist

Key Findings:

45 wrists undergoing proximal row carpectomy (PRC), including chronic perilunate dislocation/fracture-dislocation, with mean 32-month follow-up.
Active flexion-extension averaged 70 degrees with grip strength 51% of the unaffected side; pain reduced 71% at rest and 44% after strenuous activity.
PRC is contraindicated when the capitate head or lunate fossa cartilage is degenerate.

Clinical Implication: Supports proximal row carpectomy as a motion-preserving salvage option for chronic or arthritic perilunate injury when the capitate head and lunate fossa remain healthy.

Source: Scand J Plast Reconstr Surg Hand Surg 2008;42(6):308-12

Verify on PubMed (PMID 18991174)

Parameter

Figure

Source

Proportion of all wrist injuries

Rare, high-energy injury pattern

Herzberg multicentre series (PMID 8228045)

Missed at initial presentation

25% (41 of 166)

Herzberg 1993 (PMID 8228045)

Dorsal displacement

97% (palmar only 3%)

Herzberg 1993 (PMID 8228045)

Trans-scaphoid (greater-arc) variant

61% of whole series

Herzberg 1993 (PMID 8228045)

Long-term radiographic arthritis

56-80%

Herzberg 1993 (PMID 8228045); Garcon 2022 (PMID 35609818)

Demographics

Young adults, male predominance, high-energy MVA/fall/industrial mechanisms

Herzberg 1993 (PMID 8228045)

Body / Region

Position on perilunate injury

Evidence level

BSSH / BOA (UK)

Carpal dislocation is a surgical emergency; urgent reduction, then open reduction, ligament repair and internal fixation in a hand unit

Expert consensus / Level IV

AAOS / ASSH (USA)

Open reduction and internal fixation with ligament repair is the standard of care; closed treatment alone is inadequate

Expert consensus / Level IV

EFORT / European hand societies

Combined volar-dorsal or dorsal-only ORIF with carpal stabilisation; carpal tunnel decompression for persistent median symptoms

Expert consensus / Level IV

AO Foundation (AO Surgery Reference)

Emergent closed reduction followed by ORIF; scaphoid fixed with headless compression screw in trans-scaphoid patterns

Expert consensus / Level IV

Type	Lunate Position	Capitate Position
Perilunate	Contact with radius maintained	Dorsal to lunate
Lunate	Dislocated volarly	May be dorsal or anatomic
Volar perilunate	Contact maintained	Volar to lunate (rare)

Pattern	Fixation / Repair	Why
Pure ligamentous lesser-arc	SL and LT interval K-wires, ligament repair and capsular repair.	Ligament healing requires protected carpal alignment.
Trans-scaphoid perilunate	Headless compression screw or appropriate scaphoid fixation plus carpal pinning and ligament repair.	Stable scaphoid fixation restores the radial column and improves carpal stability.
Trans-radial styloid or trans-triquetral	Fix the fracture component if displaced or destabilising, then stabilise the carpus.	Greater-arc fragments are part of the instability pathway.
Chronic reducible injury	Open reduction, staged distraction in selected cases, ligament reconstruction or salvage depending cartilage.	Soft tissues contract and cartilage injury increases with time.
Arthritic or irreconstructable injury	PRC, limited fusion, four-corner fusion or total wrist fusion depending cartilage and demand.	Late cases may no longer be ligament-repair problems.

Type	Lunate Position	Capitate Position
Perilunate	Contact with radius maintained	Dorsal to lunate
Lunate	Dislocated volarly	May be dorsal or anatomic
Volar perilunate	Contact maintained	Volar to lunate (rare)

Pattern	Fixation / Repair	Why
Pure ligamentous lesser-arc	SL and LT interval K-wires, ligament repair and capsular repair.	Ligament healing requires protected carpal alignment.
Trans-scaphoid perilunate	Headless compression screw or appropriate scaphoid fixation plus carpal pinning and ligament repair.	Stable scaphoid fixation restores the radial column and improves carpal stability.
Trans-radial styloid or trans-triquetral	Fix the fracture component if displaced or destabilising, then stabilise the carpus.	Greater-arc fragments are part of the instability pathway.
Chronic reducible injury	Open reduction, staged distraction in selected cases, ligament reconstruction or salvage depending cartilage.	Soft tissues contract and cartilage injury increases with time.
Arthritic or irreconstructable injury	PRC, limited fusion, four-corner fusion or total wrist fusion depending cartilage and demand.	Late cases may no longer be ligament-repair problems.