Perilunate Fracture Dislocations Workup

  • Author: Peter M Murray, MD; Chief Editor: Harris Gellman, MD   more...
 
Updated: Feb 17, 2012
 

Imaging Studies

  • Although perilunate dislocations are missed frequently, the diagnosis should be made on the initial injury plain films.[16] Reasons for overlooking this injury are inadequate posteroanterior (PA) and lateral radiographs, such as the oblique, lateral, or PA film. Other reasons for missing this diagnosis are 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. A PA distraction view of the carpus can be very helpful in the acute setting to better define the injury anatomy. For example, small fractures or dislocations of the carpal bones may be better depicted using the distraction PA radiograph. See PA radiographs in the images below. Posteroanterior plain radiograph of a dorsal perilPosteroanterior plain radiograph of a dorsal perilunate dislocation. Notice the reduction of the radiolunate articulation. Posteroanterior radiograph demonstrating trans-radPosteroanterior radiograph demonstrating trans-radial 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.[19]
      • 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 image below. Lateral wrist radiograph demonstrating dorsal periLateral 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.[20, 21, 22]
    • The oblique radiograph is taken as a 45º off-plane, PA radiograph.
  • Computed tomography (CT) scanning/plain tomography
    • In most situations, neither CT scanning nor plain tomography is needed to diagnose perilunate dislocations or perilunate fracture dislocations.
    • However, these studies can be helpful to better define 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.
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Other Tests

  • See Preoperative Details.
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Contributor Information and Disclosures
Author

Peter M Murray, MD  Professor 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 Association for Hand Surgery, American Orthopaedic Association, American Society for Reconstructive Microsurgery, American Society for Surgery of the Hand, Florida Medical Association, Orthopaedic Research Society, and Society of Military Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

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, American Academy of Pediatrics, American Association for Hand Surgery, American College of Surgeons, American Medical Association, Arthroscopy Association of North America, Clinical Orthopaedic Society, Mid-Central States Orthopaedic Society, and Missouri State Medical Association

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

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

Disclosure: Nothing to disclose.

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

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

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, and Arkansas Medical Society

Disclosure: Nothing to disclose.

References

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

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

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Posteroanterior plain radiograph of a dorsal perilunate dislocation. Notice the reduction of the radiolunate articulation.
Posteroanterior radiograph demonstrating trans-radial styloid dorsal perilunate dislocation.
Lateral wrist radiograph demonstrating dorsal perilunate dislocation.
Postoperative posteroanterior radiograph following open reduction and percutaneous pinning of a dorsal perilunate dislocation. Note that suture anchors have been placed in the scaphoid to directly repair the scapholunate interosseous ligament. Suture anchors have also been used in the distal radius to perform a capsulodesis using the dorsal intercarpal ligament.
Capsulotomy approach to the scapholunate interosseous interval, with preservation of the dorsal intercarpal and dorsal radiocarpal ligaments. Image adapted from The Wrist: Diagnosis and Operative Treatment (Mosby, 1998).
Reflected dorsal wrist capsulotomy preserving the dorsal intercarpal and dorsal radiocarpal ligaments. Image adapted from The Wrist: Diagnosis and Operative Treatment (Mosby, 1998).
Dorsal approach to the wrist demonstrating disruption of the scapholunate interosseous ligament.
Volar wrist approach for the repair of the transverse capsular rupture, an injury that is typically seen in perilunate dislocations.
Drawing demonstrating the 3 regions of the scapholunate interosseous ligament: A) the dorsal portion, which has the greatest strength and is the most important section to repair; B) the central portion, which is often found to have atraumatic, asymptomatic, and biomechanically insignificant perforations; C) the volar portion.
Drawing showing the reduction of the scapholunate interval using Kirschner wire (K-wire) joysticks. Drill holes are made using 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 the repair of the scapholunate interosseous ligament. Image adapted from The Wrist: Diagnosis and Operative Treatment (Mosby, 1998).
Drawing showing the final repair of the 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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