EVIDENCE-BASED MEDICINE

Perilunate Dislocations
Evidence-Based Medicine

Mark A. Vitale, MD, MPH, Mani Seetharaman, MD, MS,

David E. Ruchelsman, MD

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ASSH Disclaimer: The material presented in this CME activity is made available by the Learning Objectives
ASSH for educational purposes only. This material is not intended to represent the only
Evaluate the current opinion regarding the treatment of perilunate dislocation.
methods or the best procedures appropriate for the medical situation(s) discussed, but
Review the literature regarding the treatment of perilunate dislocation.
rather it is intended to present an approach, view, statement, or opinion of the authors
Explore the timing of open reduction in the absence of median nerve dysfunction.
that may be helpful, or of interest, to other practitioners. Examinees agree to participate
Debate the optimal surgical approach for purely ligamentous perilunate dislocation.
in this medical education activity, sponsored by the ASSH, with full knowledge and
Determine the optimal fixation method for treatment of perilunate dislocation.
awareness that they waive any claim they may have against the ASSH for reliance on any
Deadline: Each examination purchased in 2015 must be completed by January 31, 2016, to
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approval. Copyright ª 2015 by the American Society for Surgery of the Hand. All rights reserved.

THE PATIENT dislocation (PLD) with the carpus dislocated dorsally

A 37-year-old man injured his right wrist in a motor and the lunate tilted volar but still located in the
vehicle collision. In the emergency department he lunate fossa. Post-reduction computed tomography
had severe wrist pain and median nerve paresthesia. scan confirmed no fractures.
Wrist radiographs identified a dorsal perilunate
THE QUESTIONS
From the ONS Foundation for Clinical Research and Education, Greenwich; Greenwich What is the optimal surgical approach for this patient
Hospital, Yale-New Haven Health, New Haven, CT; Newton-Wellesley Hospital, Newton; and with a purely ligamentous (i.e., “lesser arc”1) dorsal
the Department of Orthopaedic Surgery, Tufts University School of Medicine, Boston, MA. PLD? What bones should be immobilized and what is
Received for publication October 2, 2014; accepted in revised form October 4, 2014. the best method of internal fixation?
No benefits in any form have been received or will be received related directly or
indirectly to the subject of this article.
CURRENT OPINION
Corresponding author: David E. Ruchelsman, MD, Division of Hand Surgery, Newton-
Wellesley Hospital, 2000 Washington Street, Blue Building, Suite 201, Newton, MA 02462; PLDs are high-energy carpal injuries that result in
e-mail: [email protected]. wrist stiffness and arthrosis even if good carpal
0363-5023/15/4002-0029$36.00/0 alignment is restored.2e7 PLD merits urgent reduction
http://dx.doi.org/10.1016/j.jhsa.2014.10.006
when there is associated median nerve dysfunction,

358 r  2015 ASSH r Published by Elsevier, Inc. All rights reserved.

 PERILUNATE DISLOCATIONS 359

but otherwise treatment can be planned.8,9 Some sur- Cooney wrist scores (mean score of 84) compared with
geons believe that PLDs and perilunate fracture- those treated percutaneously (mean score of 78). The
dislocations (PLFDs) presenting in a delayed fashion 4 patients treated percutaneously had greater SL dia-

Evidence-Based Medicine
have substantial risk of arthrosis and poorer clinical stasis (mean, 3.0 mm) than patients treated with open
outcome.3 Manipulative reduction and fabricating an reduction and ligament repair (mean, 1.8 mm).
orthosis doesn’t always restore carpal Sotereanos et al used a combined dorsal and volar
2,3,10e15
alignment and operative treatment is usually approach to treat 11 patients with PLD or PLFD.7 An
recommended. Areas of uncertainty and debate average of 30 months after surgery, 7 of 11 had
include the timing of open reduction in the absence of satisfactory pain relief, flexion-extension arc aver-
median nerve dysfunction, which surgical approach to aged 71% of the opposite wrist, grip strength aver-
utilize (i.e. dorsal, volar, combined, or arthroscopic), aged 77% of the opposite wrist, and one patient
which carpal intervals to stabilize, when and how to developed scapholunate advanced collapse arthritis.
repair ligaments, and the optimal method of internal Melone et al followed 28 of 42 PLD/PLFDs
fixation. 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 modified Green-
THE EVIDENCE O’Brien system, 11% developed midcarpal arthritis,
Surgical approach and 95% returned to preinjury activities.
In 1964, Campbell et al described 50 PLDs and PLFDs Hildebrand et al described 23 PLDs and PLFDs
treated with closed or open reduction (29 wrists), a treated through combined open dorsal and volar-ulnar
salvage procedure such as lunate excision or proximal (extended carpal tunnel) approaches including carpal
row carpectomy (19 wrists), or no treatment (2 wrists).16 tunnel release, proximal row fixation, and ligament
Of 31 attempted closed reductions only 12 could be repairs.4 At 3-year follow-up, the arc of wrist flexion
reduced with manipulation alone under general anes- and extension motion averaged 57% of the uninjured
thesia. Information regarding outcome was limited. wrist and grip strength averaged 73% of the uninjured
Adkison and Chapman described 55 patients with wrist. Average Mayo wrist scores were 66 (categor-
dorsal PLDs (9 wrists), volar lunate dislocations (13 ically rated as satisfactory function in this system).
wrists), and trans-scaphoid PLFDs (33 wrists) treated Over time, the SL angle increased and the revised
with a variety of methods.10 Among the purely liga- carpal height ratio decreased significantly. Four pa-
mentous injuries, closed reduction and immobilization tients had salvage procedures, and half the remaining
achieved and maintained reduction in only 4 of 13 patients had carpal collapse and degenerative radio-
attempted closed reductions (2 of 5 dorsal PLDs and 2 graphic changes.
of 8 volar lunate dislocations). Early in the series the
authors abandoned use of an isolated extended carpal Intercarpal fixation and ligament repair
tunnel approach because of suboptimal correction of Kremer et al described 16 PLD and 23 PLFD injuries.6
carpal alignment and the observation that preoperative They started with a dorsal exposure alone (13 wrists),
median nerve paresthesia resolved in 8 of 9 patients adding a volar approach when anatomic reduction was
treated without carpal tunnel release. Using an isolated not possible or when median nerve symptoms were
dorsal approach and K-wire fixation of the scapholu- present (23 wrists). Three patients were treated with an
nate (SL) interval alone without ligament repair, the isolated volar exposure—a strategy that was aban-
authors reported maintenance of carpal alignment in doned early in the study period. Patients treated with a
75% of cases. combined approach had significantly lower Mayo
Innoue and Kuwahata retrospectively reviewed 14 wrist scores (mean, 64 vs 79) and Krimmer scores
wrists with PLD treated with closed reduction and cast (mean, 61 vs 83; a German wrist score similar to the
immobilization (1 wrist); open reduction and casting (1 Mayo score), as well as greater upper-extremity spe-
wrist); closed reduction and percutaneous K-wire sta- cific disability as assessed by Disabilities of the Arm,
bilization (4 wrists); or open reduction via a dorsal Shoulder, and Hand (DASH) scores (mean, 33 vs 11)
approach, repair of the dorsal SL ligament, and K-wire compared with those treated with an isolated dorsal or
stabilization (8 wrists).14 The 2 patients treated with volar approach.
reduction and cast immobilization were rated as un- Palmer et al described 10 patients with PLD un-
satisfactory. The 8 patients treated with an open dergoing open reduction, comparing those treated
reduction via a dorsal approach and repair of the with open reduction via combined volar and dorsal
SL ligament had slightly, but not significantly higher approaches and K-wire fixation of the SL interval

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 360 PERILUNATE DISLOCATIONS

without ligament repair or reconstruction (6 wrists) diastasis and no VISI deformity, with 92% of patients
Evidence-Based Medicine

with those with acute SL ligament reconstruction (4 returning to their pre-injury occupation.
wrists) via a technique modified from Taleisnik using Trumble and Verheyden22 described cerclage wire
flexor carpi radialis tendon graft passed through bone fixation of the SL interval in 22 dorsal perilunate and
tunnels in the scaphoid and lunate.18 They found no lunate dislocations utilizing a combined dorsal/volar
difference in range of motion, grip strength, or patient approach, stabilization of the LT interval with 2 K-
satisfaction between groups, but those undergoing wires, and suture anchor repair of SL and LT ligaments
ligament reconstruction had more consistent mainte- with selective volar capsular ligament repair. An
nance of SL angle and SL diastasis (although statis- average of 4 years after surgery in 15 of the 22 patients,
tical comparison was not performed). the flexion-extension arc averaged 80% and grip
Minami and Kaneda reported a series of 32 patients strength 77% of the contralateral extremity. SL angles
with PLDs and lunate dislocations that were treated and gaps were maintained. The cerclage wire was
with or without SL repair/reconstruction.19 Repair removed in 73% of patients for pain or after breaking.
of the SL complex was performed when possible
with nonasborbable sutures through 3 drill holes in Arthroscopic treatment
the scaphoid and reconstruction was performed with Souer et al described retrospective cohorts of 18 pa-
extensor carpi radialis longus tendon graft passed tients with PLDs/PLFDs treated with a dorsal
through drill holes in the scaphoid and lunate, in both approach, SL and LT ligament repair, and temporary
cases stabilized with 3 K-wires. The 12 patients un- stabilization of the SL and LT intervals with either a
dergoing SL ligament repair/reconstruction had higher 3.0-mm cannulated screw (9 wrists; no midcarpal
average modified Green-O’Brien scores (82 vs 59) immobilization) or 0.062-inch K-wires (9 wrists; all
compared with the 20 cases treated without repair/ with midcarpal immobilization as well).23 K-wires
reconstruction. Furthermore, the authors reported no and screws were removed an average of 3 months and
increased SL diastasis and an average SL angle of 50 5 months after surgery, respectively. An average of
in patients undergoing repair/reconstruction versus 44 months postoperatively the mean final flexion-
4 of 20 patients with an increased SL diastasis and an extension arc was 71% of the contralateral wrist in
average SL angle of 71 in patients without repair/ those with screw fixation compared with 55% in
reconstruction (no statistical analysis was performed those with K-wire fixation, grip strength was 76%
on radiographic results). versus 67%, Mayo score 71 versus 66, and DASH
Among 13 PLDs/PLFDs treated with closed or score 31 versus 11, but none of these differences were
open reduction, Minami et al did not stabilize or statistically significant with the numbers available.
repair the disrupted LT interval in any wrist and they One of patient in the K-wire group presented a septic
stabilized the SL interval but did not repair the SL wrist. Three of 8 patients in the screw cohort and 6 of
ligament in 4 of 7 open reductions.20 Two years after 8 patients in the K-wire cohort developed advanced
surgery those with residual LT incongruity (N ¼ 2) midcarpal arthritis within 4 years of follow-up. Two
did as well as patients with anatomic carpal re- patients (1 in each cohort) were treated with wrist
lationships, and patients with an SL gap greater than arthrodesis.
3 mm (N ¼ 3) had significantly greater pain, worse Park and Ahn described 3 PLDs/PLFDs treated
range of motion, and weaker grip. with arthroscopic-assisted reduction and K-wire fix-
Forli et al reported the results of 18 PLD/PLFDs in ation without direct ligament repair.24 Patients were
which the LT interval was stabilized with temporary immobilized in a short-arm cast for 12 weeks, after
K-wires in 7 of the 11 PLDs without repair of the LT which time K-wires were removed. Wrist motion
ligament and found no cases of LT dissociation or averaged 85% of the contralateral wrist an average of
gap, nor any cases of volar intercalated segment 2 years after surgery. There was no radiographic
instability (VISI).12 Thirteen years after surgery, 12 evidence of carpal instability or arthritis at this rela-
of 18 wrists had arthrosis and 10 of 18 were graded as tively short-term follow-up.
fair or poor on the Mayo wrist score. Kim et al25 treated 20 PLDs/PLFDs with arthro-
Knoll et al described 25 patients with trans- scopic reduction and percutaneous K-wire fixation.
scaphoid PLFDs treated with screw fixation of the The wires were removed 10 weeks after surgery. An
scaphoid, repair of the LT ligament with a small bone average of 2.5 years later, patients had an average
anchor, and temporary K-wire stabilization of the LT 79% flexion-extension arc and 78% grip compared
interval.21 At more than 3-year follow-up (average, with the contralateral wrist. The mean DASH and
44 months; range, 25e79 months) there was no LT Patient-Rated Wrist Evaluation scores were 18 and

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 PERILUNATE DISLOCATIONS 361

30, respectively, and according to modified Mayo sparing capsulotomy29 as it can be readily converted to
wrist scores (mean, 79) the overall functional out- a dorsal intercarpal ligament capsulodesis to augment
comes were rated as excellent in 3 patients, good in 8, the SL repair, but we utilize pre-existing capsular flaps

Evidence-Based Medicine
fair in 7, and poor in 2. Radiographic reduction was based on the traumatic dorsal capsulotomy6 in the
maintained in 75% of cases, although the mean SL acute setting when a ligament sparing capsulotomy is
gap and SL angles both increased significantly on not possible. When avulsion of the dorsal radio-
average from the initial postoperative radiograph to triquetral complex is repairable, we repair it to the
the final postoperative radiograph. At latest follow-up dorsal rim of the distal radius with suture anchors
there were no instances of arthritis, although 1 patient following intercarpal reduction and stabilization. We
with a transscaphoid perilunate fracture dislocation perform a dorsal capsulodesis when we think that the
was treated with a 4-corner fusion and scaphoid quality of the ruptured SL ligament is suboptimal for
excision for a scaphoid nonunion. isolated primary repair. Although the effect of capsu-
lodesis on outcome has not been discretely studied in
SHORTCOMINGS OF THE EVIDENCE the setting of PLD injuries, we assume it augments SL
The data on PLD is limited to small retrospective case integrity based on the published experience in SL re-
series with varying injury types and operative tech- constructions for isolated SL instability.
niques. Very few series compare two techniques used We find it difficult to obtain anatomic intercarpal
in similar patients, and there are no prospective reduction without an open approach. We prefer open
studies. There is likely selection bias, with patients repair of the intercarpal ligaments, and we consider
treated with more surgery (eg, combined volar and arthroscopic-assisted treatment experimental. In pa-
dorsal exposure) having more severe or complex in- tients with median nerve dysfunction that persists
juries. The radiographic, motion, and return to ac- after closed reduction, we perform a standard open
tivity outcomes of various series are surprisingly (not extensile) carpal tunnel release. We use an
different between studies and it’s not clear why. extended volar exposure when the lunate is dislocated
Some studies seem to emphasize what went well, palmarward29 and we repair the volar capsular rent.
whereas others emphasize the shortcomings. There is not good clinical evidence supporting an
isolated volar approach to open reductions of PLDs,
despite mention in many review articles.
DIRECTIONS FOR FUTURE RESEARCH
We prefer buried K-wire fixation (removed at
A method to reliably and accurately diagnose chondral approximately 8 to 10 weeks) of the SL and LT intervals
injury (reported in 29% to 35% of PLD4,26) might help with direct dorsal ligament repairs using suture anchors
explain the variable outcomes observed.17,26,27 Large as restoration of SL integrity has been shown to be a key
prospective randomized studies could help determine determinant in outcome.4,6,18e20 We sometimes use
the advantages and disadvantages of specific tech- supplemental scaphocapitate K-wire fixation based on
niques. Alternatively, large multicenter prospective the theory that it will neutralize the tendency of the
cohorts or studies based on large retrospective data- scaphoid to volar flex following SL repair.
bases might provide useful information. Specifically, Although there is wide variation in reported out-
we are interested in the influence of the following comes for PLDs, in our experience long-term prog-
factors: (1) initial time to reduction; (2) use of capsu- nosis is guarded. Wrist motion is impaired and
lodesis techniques to supplement intercarpal ligament midcarpal arthrosis is commonplace.
repair; (3) repair/stabilization of the lunotriquetral (LT)
interval versus no treatment of that articulation; and (4)
intercarpal fixation techniques. Studies of long-term REFERENCES
motion, symptoms, disability, and radiographic find- 1. Johnson RP. The acutely injured wrist and its residuals. Clin Orthop
ings would be useful for counseling patients regarding Relat Res. 1980;(149):33e44.
2. Apergis E, Maris J, Theodoratos G, Pavlakis D, Antoniou N. Per-
expected outcomes. ilunate dislocations and fracture-dislocations. Closed and early open
reduction compared in 28 cases. Acta Orthop Scand Suppl. 1997;275:
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3. Herzberg G, Comtet JJ, Linscheid RL, Amadio PC, Cooney WP,
For this patient, we prefer an extensile dorsal approach Stalder J. Perilunate dislocations and fracture-dislocations: a multi-
to allow visualization of the radiocarpal and midcarpal center study. J Hand Surg Am. 1993;18(5):768e779.
joints, precise anatomic reduction of the carpus, and 4. Hildebrand KA, Ross DC, Patterson SD, Roth JH, MacDermid JC,
King GJ. Dorsal perilunate dislocations and fracture-dislocations:
direct repair of the dorsal part of the SL and LT inter- questionnaire, clinical, and radiographic evaluation. J Hand Surg
osseous ligaments.8,28 We prefer to perform a ligament Am. 2000;25(6):1069e1079.

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5. Inoue G, Shionoya K. Late treatment of unreduced perilunate dislo- 18. Palmer AK, Dobyns JH, Linscheid RL. Management of post-
Evidence-Based Medicine

cations. J Hand Surg Br. 1999;24(2):221e225. traumatic instability of the wrist secondary to ligament rupture.
6. Kremer T, Wendt M, Riedel K, Sauerbier M, Germann G, Bickert B. J Hand Surg Am. 1978;3(6):507e532.
Open reduction for perilunate injuries—clinical outcome and patient 19. Minami A, Kaneda K. Repair and/or reconstruction of scapholunate
satisfaction. J Hand Surg Am. 2010;35(1):1599e1606. interosseous ligament in lunate and perilunate dislocations. J Hand
7. Sotereanos DG, Mitsionis GJ, Giannakopoulos PN, Tomaino MM, Surg Am. 1993;18(6):1099e1106.
Herndon JH. Perilunate dislocation and fracture dislocation: a critical 20. Minami A, Ogino T, Ohshio I, Minami M. Correlation between
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dislocation. J Am Acad Orthop Surg. 2011;19(9):554e562. triquetral repair with a dorsal approach. J Hand Surg Am. 2005;30(6):
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ilunate dislocations. Clin Orthop Relat Res. 1982;(164):199e207. 22. Trumble T, Verheyden J. Treatment of isolated perilunate and lunate
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fractures. Perilunate fracture-dislocations of the wrist. Clin Orthop osseous cerclage wire. J Hand Surg Am. 2004;29(3):412e417.
Relat Res. 1987;(214):136e147. 23. Souer JS, Rutgers M, Andermahr J, Jupiter JB, Ring D. Perilunate
12. Forli A, Courvoisier A, Wimsey S, Corcella D, Moutet F. Perilunate fracture-dislocations of the wrist: Comparison of temporary screw
dislocations and transscaphoid perilunate fracture-dislocations: a versus K-wire fixation. J Hand Surg Am. 2007;32(3):318e325.
retrospective study with minimum ten-year follow-up. J Hand Surg 24. Park MJ, Ahn JH. Arthroscopically assisted reduction and percuta-
Am. 2010;35(1):62e68. neous fixation of dorsal perilunate dislocations and fracture-disloca-
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JOURNAL CME QUESTIONS

Perilunate Dislocations Which of the following statements is most accurate

regarding perilunate dislocation and fracture
Areas of uncertainty and debate about surgical dislocation?
management of perilunate dislocation include all a. Long-term outcome includes impaired wrist
except which of the following?
motion and midcarpal arthrosis in many cases.
a. Timing of treatment in the presence of median
b. Restoration of good carpal alignment will mini-
nerve dysfunction mize wrist stiffness and arthrosis.
b. Which surgical approach to utilize
c. Closed reduction and cast immobilization often
c. Which carpal intervals to stabilize result in a satisfactory outcome.
d. When and how to repair ligaments d. Following ligament repair and internal fixation,
e. The optimal method of internal fixation 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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J Hand Surg Am. r Vol. 40, February 2015