Carpal Instability-Perilunate Dislocations and Fracture Dislocations

Perilunate Dislocations and Fracture Dislocations

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Perilunate dislocations and fracture dislocations are high-energy injuries that can result in pain, stiffness, weakness, or disability if inappropriately treated. Prompt recognition and surgical treatment with anatomic reduction of carpal malalignment improve the likelihood of optimal, long-term clinical success and patient satisfaction. The progressive development of radiographic evidence of arthrosis is common but has not been shown to consistently correlate with worse patient function and outcomes. Ligament injury most commonly progresses from radial to ulnar with disruption of the scapholunate ligament, disruption of the lunocapitate articulation, lunotriquetral ligament injury accompanied by dissociation of the carpus from the lunate, and finally, dislocation of the lunate from its fossa into the carpal tunnel. Ligament-only injuries, or perilunate dislocations (PLDs), are referred to as lesser arc injuries, whereas dislocations with associated fractures are referred to as greater arc injuries, or perilunate fracture dislocations (PLFDs). Perilunate dislocations and PLFDs manifest with both intercarpal and intracarpal patterns of instability (carpal instability complex). They are high-energy injuries caused by falls, sports, or motor vehicle accidents. Nonoperative management of these injuries has been shown to produce inferior results. Early treatment with open reduction and internal fixation is recommended both to assess the osteochondral and ligamentous disruption and to achieve anatomic reduction of the carpus. Prompt surgical treatment depends on early recognition and diagnosis. Radiographic evidence of perilunate injury can be subtle. Given the high incidence of concomitant injuries associated with perilunate dislocations, advanced imaging such as computed tomography may be beneficial in detecting fractures that are not readily apparent on plain radiographs and assessing their displacement. Magnetic resonance imaging is useful in evaluating wrist intrinsic and extrinsic ligament injuries, and imaging with 3 T magnetic resonance imaging may improve diagnostic accuracy compared with 1.5 T imaging. Surgical treatment should facilitate adequate visualization and repair of ligamentous disruption. The ligamentous repair can be protected with temporary screw fixation. Screw fixation of associated fractures results in excellent rates of bony union. Despite radiographic progression of arthrosis over time, satisfactory long-term clinical outcomes can be achieved with prompt recognition, timely surgical treatment, and careful anatomic reduction with robust fixation.

Keywords

Perilunate dislocations

fracture dislocations

high-energy injuries

surgical treatment

anatomic reduction

carpal malalignment

ligament injury

carpal instability complex

advanced imaging

long-term outcomes