EVIDENCE-BASED MEDICINE

Evidence-Based Medicine

Perilunate Dislocations
Mark A. Vitale, MD, MPH, Mani Seetharaman, MD, MS,
David E. Ruchelsman, MD
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THE PATIENT
A 37-year-old man injured his right wrist in a motor
vehicle collision. In the emergency department he
had severe wrist pain and median nerve paresthesia.
Wrist radiographs identied a dorsal perilunate
From the ONS Foundation for Clinical Research and Education, Greenwich; Greenwich
Hospital, Yale-New Haven Health, New Haven, CT; Newton-Wellesley Hospital, Newton; and
the Department of Orthopaedic Surgery, Tufts University School of Medicine, Boston, MA.
Received for publication October 2, 2014; accepted in revised form October 4, 2014.
No benets in any form have been received or will be received related directly or
indirectly to the subject of this article.
Corresponding author: David E. Ruchelsman, MD, Division of Hand Surgery, NewtonWellesley Hospital, 2000 Washington Street, Blue Building, Suite 201, Newton, MA 02462;
e-mail: [email protected].
0363-5023/15/4002-0029$36.00/0
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Editors
David C. Ring, MD, has no relevant conicts of interest to disclose.
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All authors of this journal-based CME activity have no relevant conicts of interest to
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education staff involved with this journal-based CME activity has no relevant conicts of
interest to disclose.
Learning Objectives

Evaluate the current opinion regarding the treatment of perilunate dislocation.

Review the literature regarding the treatment of perilunate dislocation.
Explore the timing of open reduction in the absence of median nerve dysfunction.
Debate the optimal surgical approach for purely ligamentous perilunate dislocation.
Determine the optimal xation method for treatment of perilunate dislocation.

Deadline: Each examination purchased in 2015 must be completed by January 31, 2016, to
be eligible for CME. A certicate will be issued upon completion of the activity. Estimated
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Copyright 2015 by the American Society for Surgery of the Hand. All rights reserved.

dislocation (PLD) with the carpus dislocated dorsally

and the lunate tilted volar but still located in the
lunate fossa. Post-reduction computed tomography
scan conrmed no fractures.
THE QUESTIONS
What is the optimal surgical approach for this patient
with a purely ligamentous (i.e., lesser arc1) dorsal
PLD? What bones should be immobilized and what is
the best method of internal xation?
CURRENT OPINION
PLDs are high-energy carpal injuries that result in
wrist stiffness and arthrosis even if good carpal
alignment is restored.2e7 PLD merits urgent reduction
when there is associated median nerve dysfunction,

but otherwise treatment can be planned.8,9 Some surgeons believe that PLDs and perilunate fracturedislocations (PLFDs) presenting in a delayed fashion
have substantial risk of arthrosis and poorer clinical
outcome.3 Manipulative reduction and fabricating an
orthosis
doesnt
always
restore
carpal
2,3,10e15
and operative treatment is usually
alignment
recommended. Areas of uncertainty and debate
include the timing of open reduction in the absence of
median nerve dysfunction, which surgical approach to
utilize (i.e. dorsal, volar, combined, or arthroscopic),
which carpal intervals to stabilize, when and how to
repair ligaments, and the optimal method of internal
xation.
THE EVIDENCE
Surgical approach
In 1964, Campbell et al described 50 PLDs and PLFDs
treated with closed or open reduction (29 wrists), a
salvage procedure such as lunate excision or proximal
row carpectomy (19 wrists), or no treatment (2 wrists).16
Of 31 attempted closed reductions only 12 could be
reduced with manipulation alone under general anesthesia. Information regarding outcome was limited.
Adkison and Chapman described 55 patients with
dorsal PLDs (9 wrists), volar lunate dislocations (13
wrists), and trans-scaphoid PLFDs (33 wrists) treated
with a variety of methods.10 Among the purely ligamentous injuries, closed reduction and immobilization
achieved and maintained reduction in only 4 of 13
attempted closed reductions (2 of 5 dorsal PLDs and 2
of 8 volar lunate dislocations). Early in the series the
authors abandoned use of an isolated extended carpal
tunnel approach because of suboptimal correction of
carpal alignment and the observation that preoperative
median nerve paresthesia resolved in 8 of 9 patients
treated without carpal tunnel release. Using an isolated
dorsal approach and K-wire xation of the scapholunate (SL) interval alone without ligament repair, the
authors reported maintenance of carpal alignment in
75% of cases.
Innoue and Kuwahata retrospectively reviewed 14
wrists with PLD treated with closed reduction and cast
immobilization (1 wrist); open reduction and casting (1
wrist); closed reduction and percutaneous K-wire stabilization (4 wrists); or open reduction via a dorsal
approach, repair of the dorsal SL ligament, and K-wire
stabilization (8 wrists).14 The 2 patients treated with
reduction and cast immobilization were rated as unsatisfactory. The 8 patients treated with an open
reduction via a dorsal approach and repair of the
SL ligament had slightly, but not signicantly higher
J Hand Surg Am.

359

Cooney wrist scores (mean score of 84) compared with

those treated percutaneously (mean score of 78). The
4 patients treated percutaneously had greater SL diastasis (mean, 3.0 mm) than patients treated with open
reduction and ligament repair (mean, 1.8 mm).
Sotereanos et al used a combined dorsal and volar
approach to treat 11 patients with PLD or PLFD.7 An
average of 30 months after surgery, 7 of 11 had
satisfactory pain relief, exion-extension arc averaged 71% of the opposite wrist, grip strength averaged 77% of the opposite wrist, and one patient
developed scapholunate advanced collapse arthritis.
Melone et al followed 28 of 42 PLD/PLFDs
treated with a combined dorsal and volar approach
for a mean of 56 months.17 Twenty-four of 28 wrists
were rated good-to-excellent on the modied GreenOBrien system, 11% developed midcarpal arthritis,
and 95% returned to preinjury activities.
Hildebrand et al described 23 PLDs and PLFDs
treated through combined open dorsal and volar-ulnar
(extended carpal tunnel) approaches including carpal
tunnel release, proximal row xation, and ligament
repairs.4 At 3-year follow-up, the arc of wrist exion
and extension motion averaged 57% of the uninjured
wrist and grip strength averaged 73% of the uninjured
wrist. Average Mayo wrist scores were 66 (categorically rated as satisfactory function in this system).
Over time, the SL angle increased and the revised
carpal height ratio decreased signicantly. Four patients had salvage procedures, and half the remaining
patients had carpal collapse and degenerative radiographic changes.
Intercarpal xation and ligament repair
Kremer et al described 16 PLD and 23 PLFD injuries.6
They started with a dorsal exposure alone (13 wrists),
adding a volar approach when anatomic reduction was
not possible or when median nerve symptoms were
present (23 wrists). Three patients were treated with an
isolated volar exposurea strategy that was abandoned early in the study period. Patients treated with a
combined approach had signicantly lower Mayo
wrist scores (mean, 64 vs 79) and Krimmer scores
(mean, 61 vs 83; a German wrist score similar to the
Mayo score), as well as greater upper-extremity specic disability as assessed by Disabilities of the Arm,
Shoulder, and Hand (DASH) scores (mean, 33 vs 11)
compared with those treated with an isolated dorsal or
volar approach.
Palmer et al described 10 patients with PLD undergoing open reduction, comparing those treated
with open reduction via combined volar and dorsal
approaches and K-wire xation of the SL interval
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without ligament repair or reconstruction (6 wrists)

with those with acute SL ligament reconstruction (4
wrists) via a technique modied from Taleisnik using
exor carpi radialis tendon graft passed through bone
tunnels in the scaphoid and lunate.18 They found no
difference in range of motion, grip strength, or patient
satisfaction between groups, but those undergoing
ligament reconstruction had more consistent maintenance of SL angle and SL diastasis (although statistical comparison was not performed).
Minami and Kaneda reported a series of 32 patients
with PLDs and lunate dislocations that were treated
with or without SL repair/reconstruction.19 Repair
of the SL complex was performed when possible
with nonasborbable sutures through 3 drill holes in
the scaphoid and reconstruction was performed with
extensor carpi radialis longus tendon graft passed
through drill holes in the scaphoid and lunate, in both
cases stabilized with 3 K-wires. The 12 patients undergoing SL ligament repair/reconstruction had higher
average modied Green-OBrien scores (82 vs 59)
compared with the 20 cases treated without repair/
reconstruction. Furthermore, the authors reported no
increased SL diastasis and an average SL angle of 50
in patients undergoing repair/reconstruction versus
4 of 20 patients with an increased SL diastasis and an
average SL angle of 71 in patients without repair/
reconstruction (no statistical analysis was performed
on radiographic results).
Among 13 PLDs/PLFDs treated with closed or
open reduction, Minami et al did not stabilize or
repair the disrupted LT interval in any wrist and they
stabilized the SL interval but did not repair the SL
ligament in 4 of 7 open reductions.20 Two years after
surgery those with residual LT incongruity (N 2)
did as well as patients with anatomic carpal relationships, and patients with an SL gap greater than
3 mm (N 3) had signicantly greater pain, worse
range of motion, and weaker grip.
Forli et al reported the results of 18 PLD/PLFDs in
which the LT interval was stabilized with temporary
K-wires in 7 of the 11 PLDs without repair of the LT
ligament and found no cases of LT dissociation or
gap, nor any cases of volar intercalated segment
instability (VISI).12 Thirteen years after surgery, 12
of 18 wrists had arthrosis and 10 of 18 were graded as
fair or poor on the Mayo wrist score.
Knoll et al described 25 patients with transscaphoid PLFDs treated with screw xation of the
scaphoid, repair of the LT ligament with a small bone
anchor, and temporary K-wire stabilization of the LT
interval.21 At more than 3-year follow-up (average,
44 months; range, 25e79 months) there was no LT
J Hand Surg Am.

diastasis and no VISI deformity, with 92% of patients

returning to their pre-injury occupation.
Trumble and Verheyden22 described cerclage wire
xation of the SL interval in 22 dorsal perilunate and
lunate dislocations utilizing a combined dorsal/volar
approach, stabilization of the LT interval with 2 Kwires, and suture anchor repair of SL and LT ligaments
with selective volar capsular ligament repair. An
average of 4 years after surgery in 15 of the 22 patients,
the exion-extension arc averaged 80% and grip
strength 77% of the contralateral extremity. SL angles
and gaps were maintained. The cerclage wire was
removed in 73% of patients for pain or after breaking.
Arthroscopic treatment
Souer et al described retrospective cohorts of 18 patients with PLDs/PLFDs treated with a dorsal
approach, SL and LT ligament repair, and temporary
stabilization of the SL and LT intervals with either a
3.0-mm cannulated screw (9 wrists; no midcarpal
immobilization) or 0.062-inch K-wires (9 wrists; all
with midcarpal immobilization as well).23 K-wires
and screws were removed an average of 3 months and
5 months after surgery, respectively. An average of
44 months postoperatively the mean nal exionextension arc was 71% of the contralateral wrist in
those with screw xation compared with 55% in
those with K-wire xation, grip strength was 76%
versus 67%, Mayo score 71 versus 66, and DASH
score 31 versus 11, but none of these differences were
statistically signicant with the numbers available.
One of patient in the K-wire group presented a septic
wrist. Three of 8 patients in the screw cohort and 6 of
8 patients in the K-wire cohort developed advanced
midcarpal arthritis within 4 years of follow-up. Two
patients (1 in each cohort) were treated with wrist
arthrodesis.
Park and Ahn described 3 PLDs/PLFDs treated
with arthroscopic-assisted reduction and K-wire xation without direct ligament repair.24 Patients were
immobilized in a short-arm cast for 12 weeks, after
which time K-wires were removed. Wrist motion
averaged 85% of the contralateral wrist an average of
2 years after surgery. There was no radiographic
evidence of carpal instability or arthritis at this relatively short-term follow-up.
Kim et al25 treated 20 PLDs/PLFDs with arthroscopic reduction and percutaneous K-wire xation.
The wires were removed 10 weeks after surgery. An
average of 2.5 years later, patients had an average
79% exion-extension arc and 78% grip compared
with the contralateral wrist. The mean DASH and
Patient-Rated Wrist Evaluation scores were 18 and
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30, respectively, and according to modied Mayo

wrist scores (mean, 79) the overall functional outcomes were rated as excellent in 3 patients, good in 8,
fair in 7, and poor in 2. Radiographic reduction was
maintained in 75% of cases, although the mean SL
gap and SL angles both increased signicantly on
average from the initial postoperative radiograph to
the nal postoperative radiograph. At latest follow-up
there were no instances of arthritis, although 1 patient
with a transscaphoid perilunate fracture dislocation
was treated with a 4-corner fusion and scaphoid
excision for a scaphoid nonunion.
SHORTCOMINGS OF THE EVIDENCE
The data on PLD is limited to small retrospective case
series with varying injury types and operative techniques. Very few series compare two techniques used
in similar patients, and there are no prospective
studies. There is likely selection bias, with patients
treated with more surgery (eg, combined volar and
dorsal exposure) having more severe or complex injuries. The radiographic, motion, and return to activity outcomes of various series are surprisingly
different between studies and its not clear why.
Some studies seem to emphasize what went well,
whereas others emphasize the shortcomings.
DIRECTIONS FOR FUTURE RESEARCH
A method to reliably and accurately diagnose chondral
injury (reported in 29% to 35% of PLD4,26) might help
explain the variable outcomes observed.17,26,27 Large
prospective randomized studies could help determine
the advantages and disadvantages of specic techniques. Alternatively, large multicenter prospective
cohorts or studies based on large retrospective databases might provide useful information. Specically,
we are interested in the inuence of the following
factors: (1) initial time to reduction; (2) use of capsulodesis techniques to supplement intercarpal ligament
repair; (3) repair/stabilization of the lunotriquetral (LT)
interval versus no treatment of that articulation; and (4)
intercarpal xation techniques. Studies of long-term
motion, symptoms, disability, and radiographic ndings would be useful for counseling patients regarding
expected outcomes.
OUR CURRENT CONCEPTS FOR THIS PATIENT
For this patient, we prefer an extensile dorsal approach
to allow visualization of the radiocarpal and midcarpal
joints, precise anatomic reduction of the carpus, and
direct repair of the dorsal part of the SL and LT interosseous ligaments.8,28 We prefer to perform a ligament
J Hand Surg Am.

361

sparing capsulotomy29 as it can be readily converted to

a dorsal intercarpal ligament capsulodesis to augment
the SL repair, but we utilize pre-existing capsular aps
based on the traumatic dorsal capsulotomy6 in the
acute setting when a ligament sparing capsulotomy is
not possible. When avulsion of the dorsal radiotriquetral complex is repairable, we repair it to the
dorsal rim of the distal radius with suture anchors
following intercarpal reduction and stabilization. We
perform a dorsal capsulodesis when we think that the
quality of the ruptured SL ligament is suboptimal for
isolated primary repair. Although the effect of capsulodesis on outcome has not been discretely studied in
the setting of PLD injuries, we assume it augments SL
integrity based on the published experience in SL reconstructions for isolated SL instability.
We nd it difcult to obtain anatomic intercarpal
reduction without an open approach. We prefer open
repair of the intercarpal ligaments, and we consider
arthroscopic-assisted treatment experimental. In patients with median nerve dysfunction that persists
after closed reduction, we perform a standard open
(not extensile) carpal tunnel release. We use an
extended volar exposure when the lunate is dislocated
palmarward29 and we repair the volar capsular rent.
There is not good clinical evidence supporting an
isolated volar approach to open reductions of PLDs,
despite mention in many review articles.
We prefer buried K-wire xation (removed at
approximately 8 to 10 weeks) of the SL and LT intervals
with direct dorsal ligament repairs using suture anchors
as restoration of SL integrity has been shown to be a key
determinant in outcome.4,6,18e20 We sometimes use
supplemental scaphocapitate K-wire xation based on
the theory that it will neutralize the tendency of the
scaphoid to volar ex following SL repair.
Although there is wide variation in reported outcomes for PLDs, in our experience long-term prognosis is guarded. Wrist motion is impaired and
midcarpal arthrosis is commonplace.
REFERENCES
1. Johnson RP. The acutely injured wrist and its residuals. Clin Orthop
Relat Res. 1980;(149):33e44.
2. Apergis E, Maris J, Theodoratos G, Pavlakis D, Antoniou N. Perilunate dislocations and fracture-dislocations. Closed and early open
reduction compared in 28 cases. Acta Orthop Scand Suppl. 1997;275:
55e59.
3. Herzberg G, Comtet JJ, Linscheid RL, Amadio PC, Cooney WP,
Stalder J. Perilunate dislocations and fracture-dislocations: a multicenter study. J Hand Surg Am. 1993;18(5):768e779.
4. Hildebrand KA, Ross DC, Patterson SD, Roth JH, MacDermid JC,
King GJ. Dorsal perilunate dislocations and fracture-dislocations:
questionnaire, clinical, and radiographic evaluation. J Hand Surg
Am. 2000;25(6):1069e1079.

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5. Inoue G, Shionoya K. Late treatment of unreduced perilunate dislocations. J Hand Surg Br. 1999;24(2):221e225.
6. Kremer T, Wendt M, Riedel K, Sauerbier M, Germann G, Bickert B.
Open reduction for perilunate injuriesclinical outcome and patient
satisfaction. J Hand Surg Am. 2010;35(1):1599e1606.
7. Sotereanos DG, Mitsionis GJ, Giannakopoulos PN, Tomaino MM,
Herndon JH. Perilunate dislocation and fracture dislocation: a critical
analysis of the volar-dorsal approach. J Hand Surg Am. 1997;22(1):
49e56.
8. Herzberg G. Perilunate and axial carpal dislocations and fracturedislocations. J Hand Surg Am. 2008;33(9):1659e1668.
9. Stanbury SJ, Elfar JC. Perilunate dislocation and perilunate fracturedislocation. J Am Acad Orthop Surg. 2011;19(9):554e562.
10. Adkison JW, Chapman MW. Treatment of acute lunate and perilunate dislocations. Clin Orthop Relat Res. 1982;(164):199e207.
11. Cooney WP, Bussey R, Dobyns JH, Linscheid RL. Difcult wrist
fractures. Perilunate fracture-dislocations of the wrist. Clin Orthop
Relat Res. 1987;(214):136e147.
12. Forli A, Courvoisier A, Wimsey S, Corcella D, Moutet F. Perilunate
dislocations and transscaphoid perilunate fracture-dislocations: a
retrospective study with minimum ten-year follow-up. J Hand Surg
Am. 2010;35(1):62e68.
13. Gellman H, Schwartz SD, Botte MJ, Feiwell L. Late treatment of a
dorsal transscaphoid, transtriquetral perilunate wrist dislocation with
avascular changes of the lunate. Clin Orthop Relat Res. 1988;(237):
196e203.
14. Inoue G, Kuwahata Y. Management of acute perilunate dislocations
without fracture of the scaphoid. J Hand Surg Br. 1997;22(5):
647e652.
15. Weil WM, Slade JF 3rd, Trumble TE. Open and arthroscopic treatment
of perilunate injuries. Clin Orthop Relat Res. 2006;445:120e132.
16. Campbell RD Jr, Thompson TC, Lance EM, Adler JB. Indications for
open reduction of lunate and perilunate dislocations of the carpal
bones. J Bone Joint Surg Am. 1965;47:915e937.
17. Melone CP Jr, Murphy MS, Raskin KB. Perilunate injuries. Repair
by dual dorsal and volar approaches. Hand Clin. 2000;16(3):
439e448.

18. Palmer AK, Dobyns JH, Linscheid RL. Management of posttraumatic instability of the wrist secondary to ligament rupture.
J Hand Surg Am. 1978;3(6):507e532.
19. Minami A, Kaneda K. Repair and/or reconstruction of scapholunate
interosseous ligament in lunate and perilunate dislocations. J Hand
Surg Am. 1993;18(6):1099e1106.
20. Minami A, Ogino T, Ohshio I, Minami M. Correlation between
clinical results and carpal instabilities in patients after reduction of
lunate and perilunar dislocations. J Hand Surg Br. 1986;11(2):
213e220.
21. Knoll VD, Allan C, Trumble TE. Trans-scaphoid perilunate fracture
dislocations: Results of screw xation of the scaphoid and lunotriquetral repair with a dorsal approach. J Hand Surg Am. 2005;30(6):
1145e1152.
22. Trumble T, Verheyden J. Treatment of isolated perilunate and lunate
dislocations with combined dorsal and volar approach and intraosseous cerclage wire. J Hand Surg Am. 2004;29(3):412e417.
23. Souer JS, Rutgers M, Andermahr J, Jupiter JB, Ring D. Perilunate
fracture-dislocations of the wrist: Comparison of temporary screw
versus K-wire xation. J Hand Surg Am. 2007;32(3):318e325.
24. Park MJ, Ahn JH. Arthroscopically assisted reduction and percutaneous xation of dorsal perilunate dislocations and fracture-dislocations. Arthroscopy. 2005;21(9):1153.
25. Kim JP, Lee JS, Park MJ. Arthroscopic reduction and percutaneous
xation of perilunate dislocations and fracture-dislocations.
Arthroscopy. 2012;28(2):196e203. e192.
26. Herzberg G, Forissier D. Acute dorsal trans-scaphoid perilunate
fracture-dislocations: medium-term results. J Hand Surg Br.
2002;27(6):498e502.
27. Green DP, OBrien ET. Open reduction of carpal dislocations: indications and operative techniques. J Hand Surg Am. 1978;3(3):
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surgical exposure of the wrist. Ann Plast Surg. 1995;35(1):54e59.

JOURNAL CME QUESTIONS

Perilunate Dislocations
Areas of uncertainty and debate about surgical
management of perilunate dislocation include all
except which of the following?
a. Timing of treatment in the presence of median
nerve dysfunction
b. Which surgical approach to utilize
c. Which carpal intervals to stabilize
d. When and how to repair ligaments
e. The optimal method of internal xation

Which of the following statements is most accurate

regarding perilunate dislocation and fracture
dislocation?
a. Long-term outcome includes impaired wrist
motion and midcarpal arthrosis in many cases.
b. Restoration of good carpal alignment will minimize wrist stiffness and arthrosis.
c. Closed reduction and cast immobilization often
result in a satisfactory outcome.
d. Following ligament repair and internal xation,
the scapholunate angle is expected to decrease
over time.
e. Failure to repair the lunotriquetral ligament will
result in diastasis of this joint.

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