Surgical Management of Perilunate Dislocations and Fracture-Dislocations

High-Yield Summary

• Perilunate dislocations and fracture-dislocations represent high-energy wrist injuries with disruption of carpal ligamentous and bony architecture, requiring prompt recognition and surgical intervention to restore carpal alignment and prevent chronic instability or arthritis.
• The Mayfield classification guides understanding of progressive perilunate instability, while the Herzberg classification directs treatment by distinguishing pure dislocations from fracture-dislocations.
• Surgical management prioritizes open reduction, carpal ligament repair or reconstruction, and stable fixation of associated fractures, typically via combined dorsal and volar approaches.
• Early surgery within 1–2 weeks optimizes outcomes; delayed treatment increases risk of median nerve injury, carpal collapse, and posttraumatic arthritis.
• Mastery of carpal anatomy, ligamentous repair techniques, and intraoperative fluoroscopic assessment is essential to avoid residual instability and optimize functional recovery.

Clinical Fundamentals

Anatomy and Biomechanics

The perilunate complex comprises the lunate, capitate, scaphoid, triquetrum, and associated intrinsic and extrinsic ligaments. The scapholunate ligament and lunotriquetral ligament maintain carpal stability, while the volar radiolunate ligament secures the lunate to the radius. The lunate acts as a keystone, transmitting axial load from the hand to the forearm. Disruption of these ligaments leads to carpal instability patterns, with perilunate dislocations representing a failure of the carpal ring.

Epidemiology

Perilunate dislocations and fracture-dislocations occur predominantly in young males following high-energy trauma such as falls on an outstretched hand or motor vehicle accidents. They account for approximately 7% of all carpal injuries but carry a high risk of morbidity due to delayed diagnosis and complex ligamentous injury.

Classification & Diagnosis

Diagnostic Pearls

• Obtain true lateral wrist radiographs to assess lunate alignment relative to the radius and capitate; the lunate should be collinear with the radius.
• Look for the “spilled teacup” sign indicating lunate dislocation.
• CT scans assist in characterizing fracture patterns and subtle carpal malalignment.
• MRI may be useful for assessing ligamentous integrity but is rarely required acutely.
• Beware of missed diagnosis in polytrauma patients or those with distracting injuries.

Decision-Making Algorithm

Surgical Approach Rationale

• Dorsal approach provides access for reduction, scapholunate ligament repair, and dorsal capsulodesis.
• Volar approach is indicated for median nerve decompression and volar ligament repair.
• Combined approaches are often necessary for fracture fixation and comprehensive ligamentous repair.
• Fixation with headless compression screws for scaphoid fractures and Kirschner wires or suture anchors for ligament repair is standard.

Surgical Mastery & Pearls

Step-by-Step Conceptual Overview

1. Exposure and Assessment: Begin with a dorsal approach to visualize carpal bones and assess ligamentous disruption. Confirm lunate position and capitate alignment under fluoroscopy.
2. Reduction: Achieve anatomic reduction of the capitate into the lunate fossa and realign the lunate with the radius. Temporary K-wire fixation may assist.
3. Fracture Fixation: Address scaphoid or radial styloid fractures with headless compression screws or mini-fragment plates as indicated.
4. Ligament Repair: Repair or reconstruct the scapholunate and lunotriquetral ligaments using suture anchors or transosseous sutures. Augment with dorsal capsulodesis if needed.
5. Volar Approach: If median nerve symptoms are present, perform carpal tunnel release and repair volar ligaments.
6. Stabilization: Use K-wires to maintain carpal alignment across scapholunate and lunotriquetral intervals, typically for 6–8 weeks.
7. Closure and Immobilization: Close in layers, apply a well-molded splint or cast.

Intraoperative Red Flags

• Persistent lunate malalignment despite reduction attempts signals unaddressed ligamentous injury or fracture fragments.
• Excessive soft tissue tension may indicate incomplete reduction or need for additional ligament reconstruction.
• Median nerve swelling or discoloration requires urgent decompression.
• Fluoroscopic confirmation of carpal height and Gilula’s arcs is essential before closure.

Evidence-Based Synthesis

Recent literature underscores the superiority of early open reduction and internal fixation over closed management for perilunate injuries. Studies demonstrate that combined dorsal-volar approaches yield better restoration of carpal kinematics and reduce rates of posttraumatic arthritis. Randomized trials comparing fixation techniques remain limited; however, biomechanical data favor headless compression screws for scaphoid fractures and suture anchor repair for ligaments.

Controversy persists regarding the role of primary ligament reconstruction versus repair, with emerging evidence supporting augmented reconstruction in chronic or high-grade injuries. The timing of surgery remains critical, with delays beyond two weeks correlating with poorer functional outcomes and higher complication rates.

Long-term follow-up studies reveal that even with optimal management, some patients develop carpal collapse or arthritis, emphasizing the need for meticulous surgical technique and patient counseling.

Master Class Pro-Tip

When performing perilunate dislocation repair, prioritize restoration of the scapholunate interval with precise tensioning of the ligament repair under direct visualization and fluoroscopic guidance. Use intraoperative dynamic fluoroscopy to assess carpal motion after fixation—subtle residual instability often predicts failure. Incorporate a dorsal capsulodesis selectively to offload repaired ligaments and prevent rotatory subluxation of the scaphoid. Mastery of these nuanced steps distinguishes a competent surgeon from one who consistently achieves durable, pain-free wrist function.

Last Updated on March 12, 2026 by OrthoNet AI