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Perilunate Fracture Dislocations Workup

  • Author: Peter M Murray, MD; Chief Editor: Harris Gellman, MD  more...
 
Updated: Jul 05, 2016
 

Imaging Studies

Radiography

Although perilunate dislocations are frequently missed, the diagnosis should be made on the initial injury plain films.[21, 22] One cause of a missed diagnosis is inadequate posteroanterior (PA) and lateral radiographs. Other causes include radiographs obscured by splints and unfamiliarity with the anatomy of the carpus. When trauma to the carpus is suspected, it is incumbent upon the examining physician to obtain acute plain radiographs that are devoid of splint materials and dressings.

Standard PA, lateral, and oblique radiographs centered over the carpus should be obtained in all patients with significant wrist injury.

The PA radiograph is obtained with the patient seated, the shoulder abducted 90º, and the hand placed palm-down on the radiographic cassette. This positioning of the shoulder places the forearm in neutral rotation. In the acute setting, a PA distraction view of the carpus can be very helpful for better defining the injury anatomy. For example, small fractures or dislocations of the carpal bones may be better depicted by using the distraction PA radiograph. (See the images below.)

Posteroanterior plain radiograph of dorsal perilun Posteroanterior plain radiograph of dorsal perilunate dislocation. Note reduction of radiolunate articulation.
Posteroanterior radiograph demonstrating transradi Posteroanterior radiograph demonstrating transradial styloid dorsal perilunate dislocation.

A series of lines, described by Gilula, can be traced along the proximal edges of the scaphoid, lunate, and triquetrum, as well as along the proximal poles of the capitate and hamate.[23] The lines should be smooth and uninterrupted. The reference lines can be a quick screen for perilunate dislocation or perilunate fracture dislocation.

The lateral radiograph also is obtained with the patient seated. The shoulder is adducted with the hand and wrist at the side, enabling the ulnar border of the hand to be placed on the cassette. Care should be taken to avoid excessive ulnar deviation of the wrist, because this will give the false impression that the lunate is in the extended position. With the lunate in the extended position, the diagnosis of dorsal intercalated instability could be made incorrectly.

A correct lateral radiograph of the wrist should have superimposition of the lunate, proximal scaphoid pole, and triquetrum. The radial styloid should appear centered within the metaphysis of the radius, and the metacarpal shafts should all line up. (See the image below.)

Lateral wrist radiograph demonstrating dorsal peri Lateral wrist radiograph demonstrating dorsal perilunate dislocation.

The lateral radiograph should be observed carefully for the wide carpus sign, in which the capitate is overriding the dorsal aspect of the lunate in the dorsal perilunate dislocation. In the volar lunate dislocation, the lunate is clearly volar to the radius. Although much less common, the perilunate dislocation may occur volar and the lunate dislocation dorsal.

In addition, the lateral scapholunate angle and the capitolunate angle on the lateral radiograph should be evaluated. The lateral scapholunate angle is formed by the intersection of the longitudinal axes of the lunate and the scaphoid. Normally, this angle is 30-60°. The capitolunate angle is normally 0-15°. Disruption of these angles may imply scapholunate dissociation.[24, 25, 26]

The oblique radiograph is taken as a 45º off-plane PA radiograph.

Computed tomography/plain tomography

In most situations, neither computed tomography (CT) nor plain tomography is needed to diagnose perilunate dislocations or perilunate fracture dislocations. However, these studies can be helpful for better defining greater arc fractures, such as scaphoid fractures, capitate fractures, radial styloid fractures, and triquetral fractures.

In most situations, 1-mm CT scan cuts in the sagittal and coronal plane of the capitate are helpful. If a fracture of the scaphoid is suspected, it is more appropriate to obtain the 1-mm cuts in the plane of the scaphoid.

 
 
Contributor Information and Disclosures
Author

Peter M Murray, MD Professor and Chair, Department of Orthopedic Surgery, Mayo Clinic College of Medicine; Director of Education, Mayo Foundation for Medical Education and Research, Jacksonville; Consultant, Department of Orthopedic Surgery, Mayo Clinic, Jacksonville; Consulting Staff, Nemours Children's Clinic and Wolfson's Children's Hospital

Peter M Murray, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Reconstructive Microsurgery, Orthopaedic Research Society, Society of Military Orthopaedic Surgeons, American Association for Hand Surgery, American Society for Surgery of the Hand, Florida Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

N Ake Nystrom, MD, PhD Associate Professor of Orthopedic Surgery and Plastic Surgery, University of Nebraska Medical Center

Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine, Clinical Professor, Surgery, Nova Southeastern School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, Arkansas Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

Michael S Clarke, MD Clinical Associate Professor, Department of Orthopedic Surgery, University of Missouri-Columbia School of Medicine

Michael S Clarke, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Arthroscopy Association of North America, American Academy of Pediatrics, American Association for Hand Surgery, American College of Surgeons, American Medical Association, Clinical Orthopaedic Society, Mid-Central States Orthopaedic Society, Missouri State Medical Association

Disclosure: Nothing to disclose.

References
  1. Muppavarapu RC, Capo JT. Perilunate Dislocations and Fracture Dislocations. Hand Clin. 2015 Aug. 31 (3):399-408. [Medline].

  2. Dobyns JH, Linscheid RL. Traumatic instability of the wrist. Am Acad Orthop Surg. 1985. 34:182-99.

  3. Campbell R. Lunate and perilunate dislocations. J Bone and Joint Surg. 1964. 46B:55-72.

  4. Cooney WP, Linscheid RL. Fractures and dislocation of the wrist. Rockwood CA, Green DP, Bucholz RW, et al, eds. Rockwood and Green's Fractures in Adults. 4th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 1996. vol 1:

  5. Cooney WP, Linscheid RL, Dobyns JH, eds. The Wrist: Diagnosis and Treatment. St Louis, Mo: Mosby; 1998.

  6. Song D, Goodman S, Gilula LA, Wollstein R. Ulnocarpal translation in perilunate dislocations. J Hand Surg Eur Vol. 2009 Jun. 34(3):388-90. [Medline].

  7. Takase K. Dorsal transscaphoid transtriquetral perilunate dislocation with pseudoarthrosis of the scaphoidy. Orthopedics. 2008 Oct. 31(10):[Medline].

  8. Bain GI, McLean JM, Turner PC, Sood A, Pourgiezis N. Translunate fracture with associated perilunate injury: 3 case reports with introduction of the translunate arc concept. J Hand Surg Am. 2008 Dec. 33(10):1770-6. [Medline].

  9. Budoff JE. Treatment of acute lunate and perilunate dislocations. J Hand Surg Am. 2008 Oct. 33(8):1424-32. [Medline].

  10. Martinage A, Balaguer T, Chignon-Sicard B, Monteil MC, Dréant N, Lebreton E. [Perilunate dislocations and fracture-dislocations of the wrist, a review of 14 cases]. Chir Main. 2008 Feb. 27(1):31-9. [Medline].

  11. 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 Jan. 35(1):62-8. [Medline].

  12. Stanbury SJ, Elfar JC. Perilunate dislocation and perilunate fracture-dislocation. J Am Acad Orthop Surg. 2011 Sep. 19(9):554-62. [Medline].

  13. Kannikeswaran N, Sethuraman U. Lunate and perilunate dislocations. Pediatr Emerg Care. 2010 Dec. 26(12):921-4. [Medline].

  14. Destot E. Atkinson FRB, trans. Injuries of the Wrist: A Radiological Study. New York, NY: Paul B Hoeber; 1926.

  15. Linscheid RL, Dobyns JH, Beabout JW. Traumatic instability of the wrist. Diagnosis, classification, and pathomechanics. J Bone Joint Surg Am. 1972 Dec. 54(8):1612-32. [Medline].

  16. Mayfield JK, Johnson RP, Kilcoyne RK. Carpal dislocations: pathomechanics and progressive perilunar instability. J Hand Surg [Am]. 1980 May. 5(3):226-41. [Medline].

  17. Kobayashi M, Berger RA, Linscheid RL. Intercarpal kinematics during wrist motion. Hand Clin. 1997 Feb. 13(1):143-9. [Medline].

  18. Berger RA. The gross and histologic anatomy of the scapholunate interosseous ligament. J Hand Surg [Am]. 1996 Mar. 21(2):170-8. [Medline].

  19. Capo JT, Corti SJ, Shamian B, Nourbakhsh A, Tan V, Kaushal N, et al. Treatment of dorsal perilunate dislocations and fracture-dislocations using a standardized protocol. Hand (N Y). 2012 Dec. 7(4):380-7. [Medline]. [Full Text].

  20. Krief E, Appy-Fedida B, Rotari V, David E, Mertl P, Maes-Clavier C. Results of Perilunate Dislocations and Perilunate Fracture Dislocations With a Minimum 15-Year Follow-Up. J Hand Surg Am. 2015 Nov. 40 (11):2191-7. [Medline].

  21. Goldfarb CA. Traumatic wrist instability: what's in and what's out. Instr Course Lect. 2007. 56:65-8. [Medline].

  22. Scalcione LR, Gimber LH, Ho AM, Johnston SS, Sheppard JE, Taljanovic MS. Spectrum of carpal dislocations and fracture-dislocations: imaging and management. AJR Am J Roentgenol. 2014 Sep. 203(3):541-50. [Medline].

  23. Gilula LA. Carpal injuries: analytic approach and case exercises. AJR Am J Roentgenol. 1979 Sep. 133(3):503-17. [Medline]. [Full Text].

  24. Lavernia CJ, Cohen MS, Taleisnik J. Treatment of scapholunate dissociation by ligamentous repair and capsulodesis. J Hand Surg [Am]. 1992 Mar. 17(2):354-9. [Medline].

  25. Taleisnik J. Scapholunate dissociation. Strickland JW, Steichen JB, eds. Difficult Problems in Hand Surgery. St Louis, Mo: Mosby; 1982.

  26. Gajendran VK, Peterson B, Slater RR Jr, et al. Long-term outcomes of dorsal intercarpal ligament capsulodesis for chronic scapholunate dissociation. J Hand Surg [Am]. 2007 Nov. 32(9):1323-33. [Medline].

  27. Sotereanos DG, Mitsionis GJ, Giannakopoulos PN. Perilunate dislocation and fracture dislocation: a critical analysis of the volar-dorsal approach. J Hand Surg [Am]. 1997 Jan. 22(1):49-56. [Medline].

  28. Herzberg G, Burnier M, Marc A, Merlini L, Izem Y. The role of arthroscopy for treatment of perilunate injuries. J Wrist Surg. 2015 May. 4 (2):101-9. [Medline]. [Full Text].

  29. Kim JP, Lee JS, Park MJ. Arthroscopic reduction and percutaneous fixation of perilunate dislocations and fracture-dislocations. Arthroscopy. 2012 Feb. 28(2):196-203.e2. [Medline].

  30. Souer JS, Rutgers M, Andermahr J, et al. Perilunate fracture-dislocations of the wrist: comparison of temporary screw versus K-wire fixation. J Hand Surg [Am]. 2007 Mar. 32(3):318-25. [Medline].

  31. Minami A, Kaneda K. Repair and/or reconstruction of scapholunate interosseous ligament in lunate and perilunate dislocations. J Hand Surg [Am]. 1993 Nov. 18(6):1099-106. [Medline].

  32. Haase SC, Berger RA, Shin AY. Association between lunate morphology and carpal collapse patterns in scaphoid nonunions. J Hand Surg [Am]. 2007 Sep. 32(7):1009-12. [Medline].

  33. Herzberg G, Comtet JJ, Linscheid RL. Perilunate dislocations and fracture-dislocations: a multicenter study. J Hand Surg [Am]. 1993 Sep. 18(5):768-79. [Medline].

  34. Yasuda M, Ando Y, Masada K. Treatment of scaphoid nonunion using volar biconcave cancellous bone grafting. Hand Surg. 2007. 12(2):135-40. [Medline].

 
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Posteroanterior plain radiograph of dorsal perilunate dislocation. Note reduction of radiolunate articulation.
Posteroanterior radiograph demonstrating transradial styloid dorsal perilunate dislocation.
Lateral wrist radiograph demonstrating dorsal perilunate dislocation.
Postoperative posteroanterior radiograph after open reduction and percutaneous pinning of dorsal perilunate dislocation. Note that suture anchors have been placed in scaphoid to directly repair scapholunate interosseous ligament. Suture anchors have also been used in distal radius to perform capsulodesis using dorsal intercarpal ligament.
Capsulotomy approach to scapholunate interosseous interval, with preservation of dorsal intercarpal and dorsal radiocarpal ligaments. Image adapted from The Wrist: Diagnosis and Operative Treatment (Mosby, 1998).
Reflected dorsal wrist capsulotomy preserving dorsal intercarpal and dorsal radiocarpal ligaments. Image adapted from The Wrist: Diagnosis and Operative Treatment (Mosby, 1998).
Dorsal approach to wrist demonstrating disruption of scapholunate interosseous ligament.
Volar wrist approach for repair of transverse capsular rupture (injury typically seen in perilunate dislocations).
Drawing demonstrating 3 regions of scapholunate interosseous ligament: (A) dorsal portion, which is strongest and most important to repair; (B) central portion, which is often found to have atraumatic, asymptomatic, and biomechanically insignificant perforations; and (C) volar portion.
Drawing showing reduction of scapholunate interval with Kirschner wire (K-wire) joysticks. Drill holes are made with straight needles for subsequent passage of suture. This scapholunate repair technique was originally described by Taleisnik.
Drawing showing repair of the scapholunate interosseous ligament using drill holes and suture passed with straight needles, as described by Taleisnik. Image adapted from The Wrist: Diagnosis and Operative Treatment (Mosby, 1998).
Drawing demonstrating suture anchor placement for repair of scapholunate interosseous ligament. Image adapted from The Wrist: Diagnosis and Operative Treatment (Mosby, 1998).
Drawing showing final repair of scapholunate interosseous ligament using drill holes, as described by Taleisnik. Image adapted from The Wrist: Diagnosis and Operative Treatment (Mosby, 1998).
 
 
 
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