Perilunate Dislocation Research Articles

Descriptive Epidemiology and Management of Perilunate Injuries.

Perilunate injuries and dislocations, typically caused by high-impact trauma, can lead to acute compression of the median nerve and subsequent complications if left untreated. This study examines the epidemiology, injury mechanisms, immediate treatment, and need for carpal tunnel release in such cases. Perilunate injuries at a single level 1 trauma center were retrospectively reviewed from 2014 to 2023. Data on patient demographics, injury mechanism, initial management, and operative management were collected. Thirty-three cases were analyzed, averaging 33.9 years in age. Injury mechanisms included falls (24% each from 0 to 10 feet and >10 feet, and motor vehicle accidents), bicycle-auto collisions or assaults (10%), pedestrian-auto collisions (5%), and 1 crush injury (3%). Most cases involved trans-scaphoid perilunate dislocation (predominantly Mayfield 3). Initial reduction in the emergency department succeeded in 60% of cases, with 48% showing median nerve paresthesias. Thirty-three percent underwent surgery within 24 hours, and 95% required operative intervention, including open reduction internal fixation (56%), open reduction with percutaneous pinning (30%), and closed reduction with percutaneous pinning (7%). Fifty-two percent needed carpal tunnel release. Prompt evaluation and treatment are crucial for perilunate injuries. If initial reduction fails, urgent operative intervention is warranted, although delayed management may be appropriate in some cases. Various operative fixation methods exist for realigning carpal bones, emphasizing the importance of tailored approaches to individual cases.

Revue à 18 ans de recul minimum, de 10 patients présentant une luxation périlunaire isolée du carpe

Objective: To evaluate, in long-term, the functional abilities and the occurrence of osteoarthritis in patients treated for a posterior perilunate carpal dislocation without bone lesion associated.Patients and method: This was a monocentric retrospective observational study on patients operated on at the University Hospital of Guadeloupe for a posterior perilunate dislocation without bone lesion associated with a minimum of 18 years of follow-up. Ten patients were included with a mean follow-up of 22.8 years. The evaluation criteria were clinical (PRWE, QuickDASH, pain, grip strength, wrist joint mobility, Watson and Reagan tests, Cooney functional score) and radiographic (Gilula curves, carpal height, carpal ulnar translation, scapholunate and radiolunar angles, scapholunate and triquetro-lunar interlines in statics and dynamics, Herzberg’s classification of complications).Results: The average Cooney score was 67.5/100. Mean PRWE and QuickDASH scores were 33.9 and 24.8 respectively. The mean flexion-extension arc on the injured side was 71.5° (66,7% compared to the healthy side). Mean grip strength was 27kg (72,8% compared to the healthy side). The prevalence of osteoarthritis was 60%, with three A types, two A1 types, one B type and four B1 types according to Herzberg.Conclusion: The factors influencing the long-term prognosis are the initial displacement of the lunate, the quality of the reduction and the presence of chronic carpal instability, particularly scapholunate. The high prevalence of osteoarthritis in our series (60%) is apparently not correlated with the functional capacities of patients over the long term.

Treatment and Outcomes of Missed Perilunate Dislocations: A Case Series

Treatment and Outcomes of Missed Perilunate Dislocations: A Case Series

Perilunate Fracture-Dislocation: Results at Mean Follow-Up of 7 Years after ORIF.

Background: Perilunate fracture-dislocations are frequently associated with a high risk of developing post-traumatic arthritis. Current studies indicate that during mid-term follow-ups, radiological signs of arthritis do not appear to correspond with functional score. The aim of this study was to assess the occurrence of posttraumatic arthritis and the wrist function after perilunate dislocations (PLD) and fracture dislocations at a mid-term follow-up of 7 years. Methods: We report the clinical and radiological outcomes of 17 wrists treated for PLD or fracture-dislocation by open reduction and internal fixation through a dorsal approach with dorsal ligament repair. Functional outcomes were evaluated using the short version of the Quick Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH), the Patient-Rated Wrist Evaluation questionnaire (PRWE) and the Mayo Wrist Score (MWS). Results of radiographs were assessed using the Herzberg Radiological Scoring Chart. Results: The MWS showed five excellent, five good, five fair and two poor results with an average score of 81%. Radiological analysis using the Herzberg classification revealed midcarpal and/or radiocarpal arthritis in 65% of cases, lunate collapse in 59% and an increase in the mean ulnar translocation ratio in 53% of the cases. Complications included one case of lunate osteonecrosis and one case of stage 3 scapholunate advanced collapse that required revision surgery. Conclusions: Although the clinical and functional outcomes are favourable at mid-term follow-up, radiological evaluation shows a progression towards osteoarthritis (OA). Further research is warranted to refine treatment strategies and investigate factors influencing the development of OA. Level of Evidence: Level IV (Therapeutic).

Transradial Trans-Scaphoid Transcapitate Transtriquetral Perilunate Dislocation of the Wrist

Abstract Perilunate dislocation is a severe complex injury associated with carpal bone fracture. The most common pattern is trans-scaphoid perilunate dislocation. A transradial, trans-scaphoid, transcapitate, and transtriquetral perilunate dislocation pattern, an extremely rare complex injury of the wrist joint, may be the first reported case of a combination of three carpal bone fractures and radial styloid fracture associated with perilunate dislocation.

Modified volar approach for proximal row carpectomy

ObjectivesProximal row carpectomy is a well-accepted surgical procedure for the management of traumatic and degenerative wrist pathologies. It is routinely performed through a dorsal approach; a volar surgical access was presented in order to enable concomitant carpal tunnel release and avoid flexion limitation or disabilities caused by adhesions of the dorsal capsule and extensor tendons. We propose a modification to the volar approach, with detailed description of skin incision (reproducing the standard palmar access to the scaphoid), capsular section (beginning with a longitudinal cut radial to flexor carpi radialis tendon and prolonged transversally along the radio-lunate joint) and sequence of carpal bone removal (starting with the scaphoid rather than the lunate). Materials and methodsThe patients who underwent surgical treatment with modified volar proximal row carpectomy between 1992 and 2015 were enrolled in a retrospective analysis. ResultsWe report postoperative improvement in both the Mayo Wrist score and total active range of motion in 38 patients, in line with the outcomes of dorsal proximal row carpectomy. ConclusionsThe modified volar approach is highly recommended when better visualization and access to proximal carpal bones are needed (particularly useful for inveterate perilunate dislocations), moreover if concomitant carpal tunnel syndrome or extensor tendon pathologies are present.

Outcomes of Perilunate Dislocation and Perilunate Fracture Dislocation After a Minimum 1-Year Follow-Up Following Open Reduction and Internal Fixation Via the Dorsal Approach: A Retrospective Study

Outcomes of Perilunate Dislocation and Perilunate Fracture Dislocation After a Minimum 1-Year Follow-Up Following Open Reduction and Internal Fixation Via the Dorsal Approach: A Retrospective Study

A deep learning-based algorithm for automatic detection of perilunate dislocation in frontal wrist radiographs

This study proposes a Deep Learning algorithm to automatically detect perilunate dislocation in anteroposterior wrist radiographs. A total of 374 annotated radiographs, 345 normal and 29 pathological, of skeletally mature adolescents and adults aged ≥16 years were used to train, validate and test two YOLOv8 deep neural models. The training set included 245 normal and 15 pathological radiographs; the pathological training set was supplemented by 240 radiographs obtained by data augmentation. The test set comprised 30 normal and 10 pathological radiographs. The first model was used for detecting the carpal region, and the second for segmenting a region between Gilula’s 2nd and 3rd arcs. The output of the segmentation model, trained multiple times with varying random initial parameter values and augmentations, was then assigned a probability of being normal or pathological through ensemble averaging. In the study dataset, the algorithm achieved an overall F1-score of 0.880: 0.928 in the normal subgroup, with 1.0 precision, and 0.833 in the pathological subgroup, with 1.0 recall (or sensitivity), demonstrating that diagnosis of perilunate dislocation can be improved by automatic analysis of anteroposterior radiographs. Level of evidence: III.

Adjunctive Dorsal Spanning Plate Fixation in the Stabilization of Perilunate Dislocations

To compare the biomechanical properties of adjunctive dorsal spanning plate (DSP) fixation with traditional K-wire fixation of perilunate dislocations in a cadaveric model. Fourteen fresh-frozen cadaveric wrists underwent simulated perilunate injury. The specimens were randomly allocated to either K-wire fixation versus K-wire and DSP fixation. Scapholunate (SL) ligament repair was performed in all specimens. The constructs were tested using a robot cyclically and to failure. Fluoroscopic images were obtained of the specimens prior to simulated injury, after fixation, after 10 and 100 loading cycles, and at construct failure. Differences in carpal alignment parameters (SL interval, SL angle, lunotriquetral interval, and capitolunate angle) and load to failure were recorded. There were no statistically significant differences between the two group's carpal alignment parameters after fixation. Specimens fixated with K-wires and DSP required significantly higher loads to achieve construct failure. The only significant difference between the two groups' carpal alignment parameters was SL interval change at failure. Compared with K-wire fixation alone, adjunctive DSP fixation resulted in significantly increased loads to failure and decreased change in SL interval at the time of failure. Adjunctive DSP may be a useful technique in the polytraumatized patient in whom providing back a weight-bearing extremity may be advantageous in the rehabilitation process.

Evaluation of chronic perilunate dislocations: A comparative study of single-stage, two-stage ORIF, and salvage procedures

ObjectiveThis study aims to evaluate the outcomes of open reduction and internal fixation (ORIF) for chronic perilunate dislocations using single-stage, two-stage, and salvage procedures. The study also compares these approaches with each other and with results from existing literature. MethodsA total of 15 patients with chronic perilunate injuries from 2013 to 2019 were included in the study. Pre-operative and post-operative assessments were conducted using plain radiographs, with CT scans performed selectively for detailed morphology and fracture pattern analysis. Among the patients, 13 underwent ORIF, while 2 underwent salvage procedures. Among the ORIF cases, single-stage procedures were performed in 4 patients, and two-stage procedures in 9 patients. External fixators, including unilateral uniplanar external fixators (UUEF) and bilateral uniplanar external fixators (BUEF), were applied in 5 and 4 patients, respectively. Our methodology of treating chronic perilunate injuries has evolved over the years. We started with single stage ORIF then graduated to a two staged procedure initially using a external fixator as a carpal distractor applied only on the radial side and finally settling down with bilateral carpal distraction using external fixators both on the radial and ulnar sides. ResultsAmong the 15 patients, 3 were lost to follow-up. Of these, one underwent four-corner fusion, while the remaining two had UUEF. The mean time interval between injury and surgery was 3.60 months. The post-operative mean scapholunate angle measured 52.46°, with a negative radio-lunate angle (indicating flexion) observed in two patients, while others showed a positive angle (indicating extension). Two cases exhibited nonunion and avascular necrosis (AVN) of the scaphoid, while one case presented with lunate AVN. Mid-carpal and radio-carpal arthritis was observed in 4 and 2 patients, respectively. Functional outcomes were evaluated using Mayo's wrist score categorized as good for two-stage BUEF cases and satisfactory for UUEF and single-stage procedures. ConclusionStaged reduction utilizing the BUEF followed by open reduction has demonstrated superior outcomes when compared to UUEF, single-stage open reduction and salvage procedures. Level of evidence: 4

Surgical management and functional outcomes of perilunate dislocations and fracture dislocations through the dorsal approach.

Perilunate dislocations and perilunate fracture dislocations (PLD/PLFDs) are rare injuries of the wrist, with surgical management leading to acceptable functional results. The purpose of this study was to assess the functional outcomes of the patients of our department who were treated with surgical management of PLDs/PLFDs through dorsal approach, as well as to report any complications on their follow-up. In this retrospective study, 52 patients with PLD/PLFD, fulfilling the inclusion and exclusion criteria of the study, underwent surgical management of their injury. All patients were followed up at 6weeks, 12weeks, 6months, 1year postoperatively with radiographic imaging as well as functional scores measured with the modified mayo wrist score and the QuickDASH questionnaire. The mean postoperative modified Mayo score was 76.8 ± 8.8 and the mean QuickDASH score was 1.52 ± 2.18. Of the 52 cases, 20% had excellent results, 42% had good results, 29% had fair results and 9% had poor results as per the modified Mayo wrist score. No patient signed any symptoms of median nerve neuropathy. In conclusion, open reduction and internal fixation through dorsal approach is a reliable technique to manage perilunate injuries in spite of radiological evidence of wrist arthritis, as it also provides consistently good results in terms of functional outcomes. Retrospective case series study.

Perilunate Dislocations: Cadaveric Model K-Wire Versus Compression Staple Fixation

Repair of perilunate dislocations requires stabilization of the carpal bones, although there is limited research on the preferred method(s) of stabilization. We compared the biomechanical characteristics of K-wire versus staple fixation of scapholunate (SL) and lunotriquetral (LT) intervals in the wrist. After creating a grade IV instability model, 20 cadaver wrists were randomized into 2 stabilization model groups using K-wires or surgical staples across the SL and LT intervals. For each ligament, two K-wires or one surgical staple was used to stabilize the proximal carpal row. Each wrist was loaded with 15 N of force and cycled 5,000 times at an angular velocity of 10 rpm. Displacement between bones was measured at different cycles (10, 100, 500, 1,000, 2,000, 3,000, 4,000, and 5,000). A t test was used for comparisons. For the LT K-wire group, the average displacement at 10 cycles was 0.08 mm, and at 5,000 cycles, 0.163 mm. For the SL K-wire group, the average displacement at 10 cycles was 0.025 mm, and at 5,000 cycles, 0.129 mm. For the LT and SL staple fixation models, the average shifts at 10 cycles were 0.029 and 0.063 mm, and at 5,000 cycles, 0.098 and 0.176 mm, respectively. No significant difference between the fixation models was found at any interval. Notably, in each group, a similar number of small outliers with higher amounts of displacement was observed. Either K-wire or surgical staple stabilization is suitable for perilunate dislocations. The surgical method should be selected based on patient-specific circumstances and the provider's judgment. Therapeutic III.

WITHDRAWN: Concurrent palmar lunate dislocation and posterior elbow dislocation with a distal radius fracture: A rare case report

We present an unusual case involving the simultaneous dislocation of the trans scapho retro lunate in the right wrist and a posterio-lateral dislocation in the right elbow joint in a 23-year-old male. These injuries occurred when he fell onto his outstretched right hand. The elbow dislocation was successfully treated using a closed reduction method. External manipulation was employed to reduce the transscaphoid perilunate dislocation, which was subsequently stabilized through percutaneous screw fixation of the scaphoid using a triquetrum-lunate pin. Additionally, a styloid pin was utilized to address and manage a distal radius fracture, followed by the implementation of a radiometacarpal external fixator. After one year and three months, the patient reported no pain in his elbow and minimal wrist discomfort during heavy lifting.

Clinical Features and Classification of Proximal Carpal Fracture Dislocation Through the Radiocarpal Joint.

Background: The most common types of wrist dislocation are trans-scaphoid lunate dislocation (TLD) and trans-scaphoid perilunate dislocation, in which the lunate and proximal scaphoid are dislocated through the midcarpal joint. There is another rare type of dislocation in which the proximal carpi are dislocated through the radiocarpal joint. The purpose of this study is to examine the clinical features of this type of dislocation. Methods: Six cases of the proximal carpal fracture dislocation via the radiocarpal joint were retrospectively reviewed. All patients underwent open reduction and internal fixation with the ligament reconstruction. A Mayo wrist score was assigned to each patient based on the assessment of pain, functional status, range of motion and grip strength at the last follow-up. Clinical subjective evaluation of function and pain was assessed using the patient-rated wrist evaluation (PRWE) method. Results: All patients were male and injured with a median age of 33.5 years. The median follow-up period was 10 months. There were three types of dislocations: Scaphoid fracture dislocation, TLD and scaphoid-lunate dislocation. All patients had satisfactory results with an average PRWE of 7.2 ± 4.7. The preoperative VAS was 6.7 ± 1.0 and the postoperative VAS was 0.7 ± 0.7 (p < 0.01). Postoperative grip strength accounted for 89.2% ± 9.8% of the contralateral side; the Mayo wrist score averaged 90.0 ± 6.5, with four patients obtaining excellent and two good results. Conclusions: Fracture dislocation of the proximal carpal bones through the radiocarpal joint is an independent type of wrist dislocation that tends to occur in young men with high-energy impact. The wrist is most often injured in a pronation hyperextension position. If treatment is timely and appropriate, the prognosis is quite good. Level of Evidence: Level IV (Therapeutic).

A Comparison of Outcomes in Acute Perilunate Injuries: Systematic Review and Meta-Analysis of Treatment Approaches.

Perilunate dislocations (PLD) and fracture-dislocations (PLFD) comprise a spectrum of high-energy wrist injuries. The purpose of this review was to review operative strategies for perilunate injuries based on approach and compare outcomes. A systematic review of literature on PLD and fracture-dislocations was carried out according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). PubMed and EMBASE databases were queried for literature. Inclusion criteria included English studies reporting clinical or functional outcomes of acute PLD and PLFD. Twenty-nine full-text articles (604 PLD and PLFD injuries) were included. The most common method of PLD and PLFD fixation is through an open approach with combined volar and dorsal exposure. There were no differences between approaches with regard to total arc range of motion, grip strength, Mayo Wrist Score, or mean scapholunate angle. Similarly, there was no difference between approaches and postoperative radiographic arthritis or complications. Most patients were able to return to their prior level of function and work. The incidence of postoperative complications ranged from 0% to 22.5%. Current evidence shows no difference in postoperative total wrist arc range of motion, grip strength (as compared to contralateral), or Mayo Wrist Score with regard to surgical approach. The most common method of PLD and PLFD fixation in the literature is through an open approach with combined volar and dorsal exposure. There is a large difference in reported rates of radiographic arthritis, although this finding does not appear to correlate with postoperative pain or disability. I, Systematic Review.

Open Reduction and Transosseous Plasty of the Dorsal Scapholunate Ligament in a Patient with Mayfield type IV Chronic Lunate Dislocation, Case Report, Literature Review and Description of Surgical Technique

Introduction Perilunate dislocations represent 3% of carpal injuries. They begin in a radial direction, destabilizing the scapholunate interval, and as the injury continues, there is a progressive sequence of instability, altering the anatomy of the carpus, causing significant functional deterioration. The acute diagnosis goes unnoticed, evolving into its chronic form. There are few reports of treatment in its chronic phase with a limited number of patients and follow-up evaluation is often limited. Objective We present a case of late diagnosis of chronic lunate dislocation that was managed surgically and review of the existing literature for diagnosis and treatment, as well as the surgical technique for its resolution. Clinical case 66-year-old male, fall from the plane of support, hyperextension mechanism of the right wrist, 2 months of evolution causing pain, progressive increase in volume, functional limitation. Treated with non-steroidal anti-inflammatory drugs for four weeks without improvement. Radiographically, loss of lunate joint congruity - capitate. Magnetic resonance images of avascular necrosis of the lunate. Diagnosing chronic semilunar dislocation of the right hand. Preoperative Quick-Dash 70.4 pts. A double dorsal and volar approach is performed to release the carpal tunnel, place a transosseous cerclage, and three 1.6 mm Kirschner pins in the scapholunate interval; semilunopyramidal and scaphocapitate. Immobilization with antebrachipalmar splint, removal of Kirschner pins at 7 weeks and referral to physical rehabilitation. 20 postoperative weeks, range of motion with flexion of 35° and extension of 30°, without visible sequelae to mobilization, and with Quick-Dash 20.4. Conclusion Early diagnosis and treatment are necessary to prevent the potential risk of avascular necrosis of the lunate and scaphoid, and secondary osteoarthritis. Reconstruction of the chronic pathology of lunate dislocation and scapholunate ligament (SL) remains a major challenge. There are unresolved issues regarding when to perform reconstruction rather than repair and therefore treatment remains controversial.

Single-Stage Reduction of Neglected Perilunate Dislocation: A Case Report

Abstract Neglected perilunate dislocations are rare and challenging injuries. We report a 59 days old perilunate dislocation in a 55 year old right-handed male. X-ray and CT imaging revealed a dorsal perilunate dislocation with no additional fractures and no increased density or microarchitectural collapse of the lunate or scaphoid. A single-stage open reduction and internal K-wire fixation procedure through a dorsal and volar approach was done. Eighteen months after the procedure, the patient was pain free during movement and had a ROM of 70%. His grip strength was 80.8% the opposite side and the Mayo wrist score was calculated 75. Full range of finger movement was achieved and he carried out his routine without any other complication.

An Extraordinary case report: Bilateral pure perilunate dislocation

Introduction: Perilunate dislocation of the carpus is an unusual injury, requiring high-energy trauma. The simultaneous bilateral form is so rare that is worthy of report, with only a few cases mentioned in the literature. We present the case of a patient with an open volar dislocation of the right wrist associated with a closed dorsal dislocation of the left wrist and distal radioulnar subluxation. Case report: A 30-year-old, right hand dominant male, suffered injuries to both wrists after being involved in a high-speed car accident. Examination of the patient revealed diffuse swelling and tenderness to both wrists with a lacerated wound over the dorsum of right wrist. Anteroposterior and lateral X-rays of both wrists were obtained, which showed bilateral perilunate pure dislocations: volar in the right side and dorsal the left side combined with a dorsal subluxation of the distal radioulnar joint. Discussion: Perilunate dislocations are relatively rare injuries involving approximately only 7% of all injuries of the carpus. It is often overlooked in primary evaluations, approximately 25% of perilunate injuries were missed. A better comprehension of the injury's mechanism and its full extent has led to better management strategies. It is recommended in the literature, that the best treatment of these injuries is open reduction, restoration of carpal bones relationship, repair of the ligaments and a proper rehabilitation and physiotherapy program.

Volar Lunate Dislocation: A Case Report

Introduction: Perilunate dislocations are rare high-energy injuries which may often have the potential to cause lifelong disability of the wrist if not addressed optimally. Hence, early recognition, diagnosis, and intervention are of paramount importance in the restoring function and prevention of morbidity. Lunate dislocations are the fourth and last stage of perilunate dislocations being extremely rare, with volar dislocations representing &lt;3% of perilunate dislocations. Case Report: A 24-year-old man suffered from an alleged history of fall from a bike on an outstretched hand following which he developed complaints of pain and swelling in the right wrist. On examination, the patient has relative sensory loss over the lateral half of the palm with no vascular deficit. An accurate range of motion could not be documented due to severe pain. Standard digital X-rays revealed lunate displaced and angulated volarly with a typical “spilled teacup” appearance along with radial and ulnar styloid fractures. Management: The patient was initially given an attempt of closed reduction which was not successful and was followed with open reduction and internal fixation with both volar and dorsal approach with Kirschner wires. The patient’s wrist was immobilized for 6 weeks with below elbow cast with the removal of k wires at 8 weeks after which wrist ROM exercises were started. Results: The patient was followed up for 6 months and now has a functional range of motion of the wrist with no sensory deficit and is able to continue with his profession as a car mechanic. Conclusion: Mayfield progression Stage 4 perilunate dislocations are uncommon with a poor prognosis if not addressed timely. Hence, these injuries need to be identified early and optimally managed with surgical intervention for a favorable outcome. Keywords: Perilunate dislocation, carpal bones, avascular necrosis of lunate, wrist trauma, carpal instability

Reverse or Ulnar-Sided, Greater Arc Perilunate Injury: Case Report and Systematic Review of Literature.

Perilunate injuries of carpal bones are uncommon, high-energy injuries that necessitate early diagnosis and appropriate management to prevent progressive carpal instability and posttraumatic osteoarthritis. A much more uncommon mechanism that starts from the lunotriquetral ligament and proceeds radially in an opposite direction than the classic mechanism may cause a reverse or ulnar-sided perilunate dislocation (PLD). The purposes were: (1) to present an uncommon case of greater arc reverse (ulnar-sided) perilunate fracture-dislocation (REPLFD); and (2) to conduct a systematic review (SR) to evaluate the current evidence on reverse perilunate injuries (REPLIs). A novel pattern of injury of REPLFD with fractures of the ulnar styloid, triquetrum, and capitate is presented. A SR was conducted with primary outcome measures of the type of injury (pathoanatomy of lesions) and pathomechanics. Secondary outcome measures were choice of surgery and outcome on follow-up. The Murad's tool and modified Coleman Methodology Score revealed poor methodological quality of the available literature on REPLI. Evidence is lacking in the mechanism of injury and treatment of REPLI, especially regarding REPLFD. The SR revealed poor methodological quality of the available literature and exposes that not all PLDs can be explained by the current existing pathomechanical injury classifications. However, following the management principles of perilunate injuries, REPLI tends to have good functional results with no major complications. Level V.