Perilunate Fractures and Dislocations



Young men in 20's and 30's




High energy injuries

- fall from heights



Mayfield Classification


Injury progresses from radial to ulna

- usually disruption proximal row either side of lunate


1.  Capitate usually displaces dorsally initially

- volar lunate dislocation is end stage


2.  Volar capitate dislocations do occur

- dorsal lunate dislocation as end stage


Spontaneous reduction can also occur


Cadaver study 


Stage 1 - SL dissociation 


Stage 2 - CL dissociation / capitate dislocates


Stage 3 - LT dissociation


Stage 4 - Lunate dislocates




Swollen and painful wrist

- +++ clinical suspicion


Volar lunate dislocations

- fingers semiflexed


1/3 have median nerve symptoms


Unusual to have compound wound

- usually palmar




Disruption of Gilula's 3 smooth carpal arcs


Progressive Injury


1.  Capitate dorsal

- lunate remains with radius

- lunate looks triangular on AP


Scapholunate Dislocation Capitate Dorsal


Perilunate Dislocation 1Perilunate Dislocation 2


2.  Lunate dislocates

- usually volar


2 main groups of injury


1.  Dorsal trans-scaphoid dislocation

- 2/3 of cases


Transscaphoid Perilunate DislocationTransscaphoid Perilunate Dislocation Lateral


2.  Dorsal perilunate dislocation

- 1/3 of cases


Associated Injuries


Scaphoid fracture

Radial styloid fracture

Capitate fracture


Chronic presentations


Missed in 20%

- reasonable ROM

- little pain


May present with CTS


May present with flexor tendon ruptures




A.  Acute perilunate dislocation


Initial Reduction


Traction under anaesthesia / conscious sedation

- dorsiflex wrist

- counterpressure on palmar lunate

- gradual wrist flexion with pressure on dorsal capitate


Perilunate Reduced 1Perilunate Reduced 2




Poor results with non operative management

- require anatomical repair of proximal row

- wait 3-5 days for swelling to settle


1.  No scaphoid fracture


Reduce lunate

- closed reduction

- open reduction


Dorsal approach

- longitudinal incision

- 3/4 extensor compartment

- mobilise EPL laterally

- open dorsal between DRC and DIC ligaments

- joysticks in scaphoid and lunate

- reduce DISI deformity

- K wires SC / SL / LT (areas of ligament rupture)

- repair SL ligament back onto scaphoid with anchors / transosseous sutures

- ORIF any capitate fractures

- repair LT ligament + augment with capsule


+/- Volar approach

- difficulties reducing lunate

- perform CTD

- repair rent in volar capsule / Space of Poirier


Perilunate Dislocation ORIF APPerilunate Dislocation ORIF Lateral


Perilunate Dislocation APPerilunate Dislocation Lateral ORIF


Perilunate ORIF 1Perilunate ORIF 2


Recent trends

- add SL screw

- add Blatt capsulodesis

- repair rent in volar capsule

- make wrist as stiff as possible to prevent late OA


2.  Trans Scaphoid Perilunate


Perilunate Dislocation Closed ReductionTrans scaphoid Perilunate Pre ORIF


Trans scaphoid Perilunate ORIF


Dorsal approach

- ORIF scaphoid fracture

- repair LT ligament

- K wires LT and TC (SL ligament is intact)

- ORIF capitate


+/- Volar approach


- repair rent in capsule


Post op


Aim is for a stable but stiff wrist

- 8 weeks in cast, then removal of K wires

- begin ROM




80% strength


Reduced ROM

- usually 100o F/E


Chronic unreduced perilunate dislocations


< 6 months


Attempt open reduction





- scaphoidectomy + 4 corner fusion


- wrist arthrodesis