Perilunate injuries

Abstract

Perilunate dislocations and fracture dislocations are most often a result of high-energy trauma, exerting an axial load with hyperextension and ulnar deviation of the wrist, along with intercarpal supination. Early treatment of perilunate injuries is necessary to optimize the clinical outcome. Although closed management has been the more commonly reported treatment for perilunate injuries, the current consensus is that anatomic restoration of carpal alignment has better results. The combined dorsal-volar approach offers the advantages of both approaches and is the preferred choice for the authors since it allows assessment of all the injured structures. The surgical techniques to restore carpal alignment and repair the scapholunate interosseous ligament are discussed. Current literature regarding treatment and prognosis is also included.

Keywords: Dislocation; Fracture; Perilunate; Treatment; Wrist.

Fig. 1

a Posterior–anterior radiograph of a stage III trans-styloid perilunate dislocation. b Same radiograph outlining the abnormal triangular appearance of the lunate that has disrupted Gilula's arcs

Fig. 2

a Lateral radiograph of a stage III perilunate dislocation (same patient as in Fig. 1. b Same radiograph showing the lunate (outlined) is still articulating with the distal radius; however, there is dislocation of luno-capitate articulation. There is loss of co-linearity between the radius, lunate, and capitate

Fig. 3

Intraoperative photograph of a volar approach for a perilunate injury. The transverse carpal ligament has been divided longitudinally, and the content of the carpal canal (including the median nerve, small arrow) is retracted ulnarly. The lunate (large arrow) is seen dislocated into the canal

Fig. 4

Intraoperative photograph of a dorsal approach for a perilunate injury. The dorsal radiocarpal (DRC) ligament is disrupted from the radius and is extended into a “v-flap” capsulotomy (outlined by black dots). The capsule (yellow arrow) is retracted behind the self-retaining retractor. The proximal poles of the scaphoid (S) and capitate are well seen because the lunate (not seen) is still in the dislocated position volarly

Fig. 5

A close-up photograph of the same patient as in Fig. 4. The lunate (L) has been reduced, but there is still a dorsal intercalated segment instability pattern of the carpus. The dorsal part of the SLIL (arrow) has avulsed from the lunate and remains attached to the scaphoid (S). C capitate, T triquetrum

Fig. 6

Intraoperative fluoroscopy showing K-wire positions used. In this case, a radiolunate K-wire was used to stabilize the lunate to the radius, and the rest of the carpus was then reduced to the lunate. Also shown is fixation of a trans-styloid fragment which may be part of the injury pattern

Fig. 7

a Posterior–anterior and (b) lateral radiographs of the typical pattern of intercarpal pinning for a perilunate dislocation. In this particular case, two suture anchors were used to repair the SLIL to the lunate