History and Physical Examination

Most patients present acutely after a fall from a height onto a dorsiflexed wrist. Patients with perilunate dislocations and perilunate fracture dislocations may demonstrate obvious clinical deformities, such as marked swelling, or they can present rather innocuously, complaining of a sprained wrist. In the dorsal perilunate dislocation or one of its transosseous variants, the carpus is dislocated dorsally, and the radius is prominent volarly; in the pure lunate dislocation, the lunate alone is prominent volarly. These injuries are diagnosed late in as many as 25% of cases.

Because of the high-energy nature of perilunate fracture dislocations, a careful, thorough trauma survey with assessment for associated injuries of the head, thorax, and extremities is imperative. Damage to the median nerve is the most common associated injury in lunate and perilunate dislocations of the wrist. In certain situations, volar skin lacerations could represent an open dislocation or fracture dislocation.

Additionally, the volar skin can become ischemic because of pressure from the volar radius (resulting from dorsal dislocation of the hand). With long-standing perilunate dislocations, patients may present with arterial compromise or established compartment syndromes.

Workup

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Media Gallery

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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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 of 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, Florida Medical Association, Florida Orthopaedic 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.