n Review Article

Evaluation, Management, and Outcomes

of Lunate and Perilunate Dislocations
Avi D. Goodman, MD; Andrew P. Harris, MD; Joseph A. Gil, MD; Joseph Park, BS; Jeremy Raducha, MD;
Christopher J. Got, MD

aspect. The 4 stages (Table 1) of injury

abstract progression were originally described by
Mayfield et al (Figure 1), with the trans-
Lunate and perilunate dislocations are potentially devastating injuries that lunate/interlunate arc more recently de-
are often unrecognized at initial evaluation. Prompt recognition and treat- scribed.1,6,9-11 However, some variability
ment is necessary to prevent adverse sequelae, including median nerve in injury patterns results from differences
dysfunction, carpal instability, posttraumatic arthritis, reduced functionality, in force vectors and transmission paths.
and avascular necrosis. In patients who are surgical candidates, operative
intervention is warranted to restore carpal kinematics and provide optimal Evaluation
outcomes. [Orthopedics. 2019; 42(1):e1-e6.] Although perilunate dislocations may
occur in isolation, when they occur during
high-energy trauma, Advanced Trauma

P
erilunate dislocations are severe
pan-carpal injuries that can pres-
ent in the setting of high-energy
trauma, and they involve the dissociation
of 1 or more of the lunate articulations. If
a complete dislocation occurs, this injury
is termed a lunate dislocation. Given the
severity of confounding injuries, delayed
presentation, difficult radiographic in-
terpretation, and occasional spontaneous
reduction, up to 25% of perilunate dis-
locations are diagnosed weeks to years
after the initial injury.1 Although most
of these injuries have radiographic evi-
dence of posttraumatic arthritis regardless
of treatment, a delay in recognition and
treatment of perilunate dislocations wors-
ens already tenuous outcomes, including
median nerve dysfunction, carpal instabil-
ity, reduced functionality, and avascular
necrosis.2,3 Therefore, the proper initial
evaluation, management, and understand-
ing of perilunate and lunate dislocations
are essential.
Mechanism of Injury
Perilunate and lunate dislocations typi-
cally result from an axial load causing hy-
perextension, intercarpal supination, and
ulnar deviation of the wrist.4,5 In 1980,
Mayfield et al6 originally described this
method by forcing 32 wrists into hyper-
extension by applying force to the thenar
eminence and recording the injury pat-
tern. Most perilunate injuries are asso-
ciated with high-energy trauma—most
commonly falls from height, followed
by motor vehicle collisions.7,8 This axial
force results in a predictable pattern of
injury. Beginning from the radial aspect
of the carpus, the force advances through
the midcarpal region, toward the ulnar
Life Support protocols should be followed
for evaluation and resuscitation. Addition-
al injuries should be addressed as they are
discovered, with particular attention paid
to the ipsilateral upper extremity.
Acute perilunate dislocations typically
present with pain and swelling over the
dorsal and/or volar aspect of the carpus,
often with dorsal wrist tenderness over
The authors are from the Department of Or-
thopaedics (ADG, APH, JAG, JR, CJG), Warren
Alpert Medical School, Brown University (JP),
Providence, Rhode Island.
The authors have no relevant financial rela-
tionships to disclose.
Correspondence should be addressed to:
Andrew P. Harris, MD, Department of Ortho-
paedics, Warren Alpert Medical School, Brown
University, 593 Eddy St, Providence, RI 02903
(Aharri26@gmail.com).
Received: November 12, 2017; Accepted:
March 7, 2018.
doi: 10.3928/01477447-20181102-05

JANUARY/FEBRUARY 2019 | Volume 42 • Number 1 e1

n Review Article
Table 1
Progression of Perilunate Injuries (Mayfield Classification)
Stage Description
I—Scapholunate dissociation Force is initially transferred directly through the scaph-
oid, resulting in a transscaphoid fracture or tear through
the scapholunate ligament, leading to a scapholunate
dissociation
II—Perilunate dislocation The injury travels as a series of ligament disruptions
around the lunate, from radial to ulnar, starting with the
disruption of the lunocapitate association
III—Triquetrum dislocation Disruption of the lunotriquetral interosseous ligament
and lunotriquetral ligament separates the carpus from
the lunate. The lunate dislocates dorsally, misaligning
both the carpus and the lunate with the distal radius.
IV—Lunate dislocation Disruption of the dorsal radiolunate ligament causes a
palmar lunate dislocation into the carpal tunnel. The
remaining carpus often self-reduces.
Figure 1: Sequential pattern of perilunate injury progressing to lunate dislocation. The 4 stages of perilu-
nate injury progress from I to IV in a clockwise fashion: (I) disruption of the radioscaphocapitate ligament
(orange line) and scapholunate ligament (blue line), or fracture through the scaphoid; (II) disruption of
the lunocapitate articulation (yellow line) or fracture through the capitate; (III) lunotriquetral ligament (red
line) or fracture through the triquetrum; and (IV) radiolunate ligament (green line).
the scapholunate ligament, limited range tations, a thorough neurovascular assess-
of motion, and frank deformity.7 However, ment and orthogonal radiographs are nec-
low-impact injuries may result in minimal essary to obtain a better understanding of
deformity with or without any associated the extent of injury.9 If median (or other)
nerve or tendon damage. The lunate may nerve compromise exists (eg, acute pares-
dislocate into the carpal tunnel or self- thesias or abnormal 2-point discrimina-
reduce entirely, depending on the kinetic tion in the median nerve distribution), this
profile and mechanism of injury. Given adds urgency to the treatment algorithm
the spectrum of possible clinical presen- and must be documented.
e2
Radiographic Findings and
Classification
Anteroposterior, lateral, and oblique
radiographs of the wrist must be obtained
during initial evaluation. Lateral radio-
graphs with normal findings should reveal
a collinear axis of the radius, lunate, and
capitate (Figure 2).9 This longitudinal
axis may be interrupted by displacement
of the capitate in relation to the radius,
indicating a perilunate dislocation of the
same direction.8 Posteroanterior radio-
graphs should also be assessed for any
patterns of instability. The 3 arcs of Gi-
lula’s lines, smooth and continuous carpal
lines on the anteroposterior/posteroanteri-
or radiograph, consist of the borders of the
radiocarpal row, the midcarpal row, and
the proximal surface of the distal carpal
row (Figure 3).12 Any disruption of these
arcs suggests a lunate, perilunate, and car-
pal dislocation or fracture, respectively.7,12
Advanced imaging is rarely indicated in
the initial evaluation of ligamentous peri-
lunate dislocations; however, a computed
tomography scan may aid the diagnosis of
and better define some carpal bone frac-
tures.
Perilunate injuries are most commonly
classified using the system of Mayfield et
al6 (Figure 1, Table 1). In a stage I injury
(disruption of the scapholunate ligament
or transscaphoid fracture), radiographs
may reveal a widening of the scapholu-
nate space. The images should also be
carefully inspected for a scaphoid or other
carpal bone fracture.
A stage II injury (lunocapitate articu-
lation disruption) often presents with the
capitate dislocated dorsally, in addition to
stage I findings. A posteroanterior view
of a perilunate dislocation may reveal an
overlap of the distal and proximal carpal
rows with possible scaphoid fracture and
subluxation.7 An overlap of the triquetrum
on the lunate suggests a stage III perilu-
nate injury (disruption of the lunotriqu-
etral interosseous ligaments), and an as-
sociated volar fracture of the triquetrum
may be exhibited.7
Copyright © SLACK Incorporated

With a stage IV injury, a lunate disloca-
tion, rotation of the lunate in the volar di-
rection presents as a triangular appearance
known as the “piece of pie” sign (Figure
4) on a posteroanterior view. This rotation
in the lateral view yields the “spilled tea-
cup” sign, in which the lunate resembles a
teacup tipped in the volar direction.7
Alternatively, perilunate dissociation
injuries may be described using the arc
methodology: the loading mechanism re-
sults in fracture through the greater arc,
ligamentous disruption through the lesser
arc, and/or fracture through the translunate/
interlunate arc13 (Figure 5). Greater arc in-
jury results in fracture of the respective car-
pal bone or radial styloid, whereas lesser
arc injury is associated with ligamentous
disruption.6 Mayfield et al6 showed that
higher velocity axial loads result in pure-
ly ligamentous injury of the lesser arc,
whereas lower velocity axial loads tend to
result in fractures within the greater arc. As
described by Mayfield et al,6 the greater
arc begins at the scaphoid, traverses the
capitate, and ends at the triquetrum (Fig-
ure 5). Perilunate or lunate dislocations
that only involve greater arc fractures are
described by the fractures involved.1,6 For
example, an associated scaphoid fracture
is described as a transscaphoid perilunate
dislocation, a scaphoid fracture with a
capitate fracture is termed a transscaphoid,
transcapitate perilunate dislocation, and
so on. Each of these fracture fragments is
associated with its respective ligament of
the lesser arc. The intact scapholunate and
lunotriquetral ligaments remain in continu-
ity to the scaphoid, capitate, and triquetral
fracture fragments.1,2,6
The lesser arc represents the ligamen-
tous injuries that may occur.6 As with
greater arc injuries, the force pattern pro-
gresses from radial to ulnar. The lesser arc
begins at the scapholunate ligament, tra-
verses the lunocapitate joint and lunotri-
quetral ligament, and ends at the short ra-
diolunate ligament (Figure 5).6 The fourth
stage (short radiolunate ligament disrup-
tion) results in a lunate dislocation.2
JANUARY/FEBRUARY 2019 | Volume 42 • Number 1
Figure 2: Lateral radiograph with normal findings
revealing a collinear axis of the radius (red), lunate
(yellow), and capitate (green).
In 2008, the translunate arc concept was
described by Bain et al11 (Figure 5). Ap-
proximately 34 cases have been reported in
the literature since 1976.10 This arc may be
more easily understood as fracture of the
lunate associated with ligament disruption
on the opposite end of the greater arc.10 All
injuries can occur in isolation or in combi-
nation with another type (Figure 6).
Approximately 60% of perilunate inju-
ries present with transscaphoid fractures,
72% of which are transverse fractures
through the middle third.14 In a retrospective
multicenter study of 166 perilunate disloca-
tions, perilunate fracture-dislocations were
more common than ligamentous perilunate
dislocations, occurring at a ratio of 2 to 1.3
In the same series, dorsal transscaphoid
perilunate fracture-dislocations accounted
for 96% of perilunate fracture dislocations
and 61% of the entire series.3 The direction
n Review Article
Figure 3: Anteroposterior radiograph of the right
wrist with normal findings showing Gilula’s 3 car-
pal arcs.
of displacement was predominantly dorsal
(97%) compared with volar (3%).3
Management
Closed Reduction and Immobilization
Carpal dislocations require urgent hand
surgery consultation. Studies comparing
nonsurgical with surgical intervention
have consistently shown better outcomes
for the latter.9 Because of the disruption of
structurally crucial ligaments, closed re-
duction and immobilization alone is inad-
equate to provide necessary architectural
support.
Closed reduction and splinting is more
effective with perilunate dislocations and
less so with lunate dislocations because
of the extent of ligamentous damage.7
Initial management of lunate dislocations
involves a closed reduction and immobili-
zation using a sugar-tong splint.9 Patients
are discouraged from applying any axial
load to the injured wrist.
Under intravenous sedation (either a
benzodiazepine such as diazepam or seda-
tives such as propofol), the patient’s arm
is held in longitudinal traction prior to
(or during) the reduction attempt. Hang-
ing the hand in finger traps with weight
hanging from the biceps may be a useful
adjunct, as countertraction is mandatory
to achieve sufficient distraction for reduc-
tion. The classic teaching at the authors’
institution is 10-10-10: 10 mg of diaze-
pam, hanging in 10 pounds of traction, for
e3
n Review Article
Figure 4: A stage IV lunate dislocation. Note the “piece of pie” sign on the anteroposterior (A) and oblique
(B) radiographs and the “spilled teacup” sign on the lateral (C) radiograph.
Figure 6: Anteroposterior (A), oblique (B), and lateral (C) radiographs of a left wrist showing a transscaph-
oid, transtriquetral perilunate fracture-dislocation associated with a distal radius fracture.
10 minutes before attempting reduction.
The precise reduction maneuver depends
on the patient’s injury; however, for the
most common dorsal perilunate disloca-
tions, the patient’s wrist is held in longi-
tudinal traction and the surgeon’s thumb
is placed on the volar aspect of the lunate
and used to apply a dorsal-directed force
while the wrist is slowly brought into
flexion, guiding the lunate back into the
radiolunate fossa and lunocapitate articu-
lation.9,15 Described as the “paradox of re-
duction,” restoration of the scapholunate
relation by means of radial deviation re-
sults in a widening of the torn palmar liga-
ments and the inability to restore scaphoid
flexion, which would, conversely, require
ulnar deviation for correction.6,9
e4
Surgical Management
A variety of surgical options have been
proposed for treatment: closed reduction
with percutaneous pinning (Figure 7),
open reduction and internal fixation, ar-
throscopic repair, external fixation, and
acute proximal row carpectomy. Regard-
less of fixation method, patients should be
managed acutely—within 6 weeks of in-
jury—as late treatment may impact surgi-
cal outcomes because of fibrosis, soft tis-
sue scarring, and avascular necrosis.9,16,17
Herzberg et al3 reported that perilunate
dislocations/fracture dislocations treated
6 weeks after injury or those with open
injuries had significantly worse clinical
outcome scores (P<.05) than those treated
within 6 weeks. Certain injury patterns
Figure 5: Anteroposterior radiograph of a left wrist
showing the greater arc (A), lesser arc (B), and
translunate arc (C). Injury to the greater arc results
in transscaphoid, transcapitate, and/or transtri-
quetral fracture. The lesser arc injuries result in
scapholunate, lunocapitate, and/or lunotriquetral
ligament injury. Injury to the translunate arc results
in lunate fracture. All injury arc patterns may occur
in isolation or in combination.
are not amenable to early definitive open
reduction and internal fixation. Associated
comminuted distal radius fractures, severe
soft tissue injuries, and severe ligament
disruption may require spanning external
fixation for additional stabilization and
result in further complications.9 The use
of external fixation with percutaneous K-
wire fixation has shown acceptable return
to work and satisfactory functional and
radiographic outcomes in most patients at
3 years.18
Open reduction and internal fixation
and closed reduction with percutaneous
pinning have been shown to have better
long-term outcomes than closed reduc-
tion and casting.3,19,20 Open reduction
can be performed through volar or dorsal
surgical approaches or through a com-
bination of the 2. The volar approach is
favorable when the lunate has dislocated
volarly, as beginning with the side of dis-
location allows primary reduction of the
lunate and provides easy access to release
the transverse carpal ligament. The volar
approach also allows for direct repair of
the volar capsule’s space of Poirier, be-
tween the volar radiocapitate and the
volar radiotriquetral ligaments, through
which the lunate typically dislocates. It
also allows repair of the volar lunotriqu-
Copyright © SLACK Incorporated

etral ligament and removal of any osteo-
chondral fragments.9
Alternatively, the dorsal approach pro-
vides direct access to the carpus, which
is optimal for realignment. The scaph-
oid and other fractured carpal bones, as
well as the scapholunate interosseous
ligament, are accessible for direct re-
pair. The volar lunotriquetral and dorsal
scapholunate interosseous ligaments are
the strongest portions of their respective
ligaments. Proper exposure and restora-
tion of the scapholunate interosseous liga-
ment is believed to play a significant role
in a successful long-term outcome.9 The
combined dorsal–volar approach offers
the advantages of both approaches and al-
lows the surgeon complete visualization
and dual access to all structures requiring
repair.9 The complexity of the intercarpal
relationship disruptions involved in lunate
dislocations often requires the combined
dorsal–volar approach.21
Other techniques have been described
with mid-term outcomes comparable to
those of open reduction and internal fixa-
tion. Kim et al22, showed that arthroscopic
reduction and percutaneous fixation with
K-wires and headless compression screws
allows for minimal incisions and blood
loss, with a lower rate of posttraumatic
arthritis on radiographs at an average
follow-up of 31 months. Muller et al23
reported that acute proximal row carpec-
tomy can be used to manage perilunate
dislocations, with outcomes similar to
those of open reduction and internal fixa-
tion at approximately 3-year follow-up.
The proximal row carpectomy group also
benefited from a single surgical incision,
a shorter operative time, and a shorter im-
mobilization period.23
Neglected perilunate injuries may be
managed using various salvage proce-
dures, including proximal row carpec-
tomy, wrist arthrodesis, and lunate ex-
cision. However, given that there is no
consensus regarding the most appropriate
salvage procedure or the appropriate time
window, management remains controver-
JANUARY/FEBRUARY 2019 | Volume 42 • Number 1
A B
Figure 7: Anteroposterior (A) and lateral (B) radiographs of the wrist following closed reduction and
percutaneous pinning of a lesser arc perilunate dislocation.
sial.9 Even with these options, inappro-
priate (or no) initial treatment risks poor
outcomes.
Complications
Despite predictable injury patterns, lu-
nate and perilunate dislocations are often
misdiagnosed, leading to serious compli-
cations and a poor clinical prognosis. For
various reasons, up to 25% of perilunate
dislocations are undiagnosed or misdiag-
nosed in the acute setting.7 Carpal inju-
ries can often be overshadowed by more
severe, life-threatening injuries sustained
in the high-energy trauma. Furthermore,
radiographic images may be inadequately
assessed or what they reveal may go un-
recognized by a physician unfamiliar with
perilunate or lunate dislocations.21
Delayed treatment may result in re-
duced functionality and range of motion,
carpal instability, pain, and carpal tunnel
syndrome from the palmar lunate dis-
locating into the carpal tunnel and com-
pressing the median nerve.7 Studies have
reported that patients who underwent sur-
gical treatment exhibited signs of perma-
nent damage at only 2 months after initial
injury, including progressive degenerative
changes of the radiocapitate and midcar-
pal joints.24 Chronic carpal instability will
ultimately progress to end-stage scaph-
olunate advanced collapse deformity of
the wrist.
n Review Article
Conclusion
Perilunate and lunate dislocations are
severe injuries that warrant vigilance in
patients with a concerning mechanism of
injury. After a radiographic and clinical
workup, the dislocation must be addressed
with prompt reduction and splinting, often
followed by surgery. All operative tech-
niques have similar mid- to long-term-
functional and radiographic outcomes,
so the authors recommend that surgeons
choose the method with which they are
most comfortable and that is most suited
for the particular injury pattern.3,18,20,22,23
However, even the most effective treat-
ment usually falls short of restoring nor-
mal function in these severe injuries, but
early treatment can reduce the rates of
pain, instability, and nerve damage and
improve functionality.
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