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DISLOCATION, WRIST PERILUNATE

Introduction

Perilunate dislocations are severe and disabling injuries that are generally associated with poor outcomes.1,2 They account for 7-10% of all carpal injuries3,4 but are the most frequently seen carpal dislocation.5 In most cases, perilunate dislocations result from high-energy trauma such as a motor vehicle crash or fall from a height, and the typical mechanism of injury is wrist hyperextension, ulnar deviation, and intercarpal supination with an axial load.2 This force displaces the lunate from the carpus—starting with disruption of the scapholunate ligament—but the radiolunate articulation remains preserved. Perilunate dislocations and perilunate fracture-dislocations are part of the same injury pattern in which the final stage is a lunate dislocation, but purely ligamentous perilunate (lesser arc) dislocations are challenging injuries in their own right.6 The examination of a patient with a lunate dislocation will show a deformed wrist with limited wrist motion.  The fingers will be in a flexed posture and extension causes pain.  Frequently, there will be signs of acute carpal tunnel syndrome.16,17,18   Routine PA X-ray should be evaluated for loss of carpal height, carpal gaps and overlapping carpal bones, disruption of Gilula's arcs and a triangular appearing lunate. 
 

Although purely conservative methods were traditionally used to treat these injuries, most experts currently prefer a surgical approach that begins with closed reduction and is followed by open reduction and internal fixation (ORIF) that includes ligamentous and bony repair/reconstruction.2,7,16,17,18

Definitions

  • A perilunate dislocation occurs when the articular surface of the carpus is displaced off the articular surface of the lunate, which remains in normal alignment with the distal radius. The capitate will be displaced dorsally or palmarly.

Hand Surgery Resource’s Dislocation Description and Characterization Acronym

D O C S

D – Direction of displacement

O – Open vs closed dislocation

C – Complex vs simple

S – Stability post reduction

D – Direction of displacement

  • The primary description and characterization of perilunate dislocations are done by noting the direction of the displacement of the carpus relative to the lunate. The three possible directions of displacement are dorsal, lateral, and volar.8
    • The majority of perilunate dislocations are dorsal, while only ~3% are volar.7,9
  • The degree of displacement further characterizes perilunate dislocations. In a true complete dislocation, the articular surface of the carpus is no longer in contact with the articular cartilage of the lunate. If there is partial contact of the cartilaginous surfaces, then this is not a true dislocation but rather a joint subluxation.8

O – Open vs closed

  • The majority of perilunate dislocations are closed; the skin is intact, and there is no route for bacteria to contaminate the joint space.
  • Open perilunate dislocations are rare and only account for ~10% of these injuries. When present, these cases always require urgent irrigation, debridement, open reduction, and ligament repair.2
  • Open perilunate dislocations have a worse prognosis than closed injuries.2

C – Complex vs simple

  • Most perilunate dislocations are simple, meaning that reduction is technically feasible under anesthetic block and sedation and is not blocked by soft tissue being interposed in the joint between the carpal and radial joint surfaces; however, closed reduction alone is associated with poor outcomes and is not typically advised for these injuries.
  • Complex (irreducible) perilunate dislocations are rare but do occasionally occur and may involve interposition of the dorsal joint capsule or some other soft tissue.4

S – Stability

  • A completely dislocated perilunate can usually be reduced into the lunate facet but will not stay anatomically aligned without internal fixation (K-wires or screws).

Related anatomy2

  • Extensor tendons
  • Flexor tendons
  • Radial collateral ligament
  • Radioscaphocapitate ligament
  • Radiolunate ligament (short and long)
  • Radioscapholunate ligament
  • Radioscaphoid ligament
  • Ulnocapitate ligament
  • Ulnotriquetral ligament
  • Ulnolunate ligament
  • Scaphotrapeziotrapezoid ligament
  • Scaphocapitate ligament
  • Triquetrohamatecapitate ligament
  • Dorsal radiocarpal ligament
  • Dorsal intercarpal ligament
  • Space of Poirer
  • Osteology of the carpals
  • The scapholunate and lunotriquetral ligaments are the lunate’s two major intercarpal attachments, which maintain a state of balance between the opposing forces. When one of these ligaments is disrupted, the balance is lost and the lunate is dominated by the remaining intercarpal relationship.

Overall incidence

  • Because lunate dislocations and perilunate dislocations are part of the same injury pattern, many statistics group the two entities together, and it may therefore be difficult to distinguish individual characteristics of each.
  • Perilunate dislocations account for 7-10% of all carpal injuries,3,4 but they are the most frequently occurring carpal dislocation.5
  • Between 16-25% of perilunate dislocations are not accurately diagnosed upon initial evaluation.5,10
  • Up to 10% of perilunate injuries are open, 26% are associated with polytrauma, and 11% have ipsilateral concomitant upper extremity injuries.2

Related Injuries/Conditions

  • Axial carpal fracture-dislocations which disrupt the distal carpal row and the metacarpal arch can be associated with lunate and perilunate dislocations
  • Fractures of the scaphoid, lunate, and/or triquetrum
  • Fractures of the distal radius
  • Perilunate fracture-dislocation
  • Lunate dislocation and fracture-dislocation
  • Extrinsic ligament injuries
  • Intrinsic ligament injuries
  • Extensor tendon ruptures
  • Flexor tendon ruptures

 

NOTE: For additional information see also carpal fractures adult -  lunate fracture

ICD-10 Codes

  • DISLOCATION, WRIST PERILUNATE

    Diagnostic Guide Name

    DISLOCATION, WRIST PERILUNATE

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    DISLOCATION WRIST: MIDCARPAL (PERILUNATE, TRANSSCAPHOID, ETC) S63.035_S63.034_ 

    Instructions (ICD 10 CM 2020, U.S. Version)

    THE APPROPRIATE SEVENTH CHARACTER IS TO BE ADDED TO EACH CODE FROM CATEGORY S63, S64, S65 AND S69
    A - Initial Encounter
    D - Subsequent Routine Healing
    S - Sequela

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Pathoanatomy Photos and Related Diagrams
Carpal diagrams, Normal X-rays and Alignment
  • Normal distal radius(R), capitate C), lunate(L), scaphoid(S) and metacarpals(M) alignment on “true” lateral x-ray of the wrist. A “true” lateral x-ray of the wrist must be taken in neutral forearm rotation and neutral wrist deviation.
    Normal distal radius(R), capitate C), lunate(L), scaphoid(S) and metacarpals(M) alignment on “true” lateral x-ray of the wrist. A “true” lateral x-ray of the wrist must be taken in neutral forearm rotation and neutral wrist deviation.
  • On a normal neutral rotation lateral, the horizontal axis of the radius, lunate, capitate, and metacarpals is a straight line (1). A line (2) the longitudinal axis of the scaphoid crosses line (1) at point (3). The average normal angle between these lines is 47° (range 30-60°). Angles outside this range suggest carpal instability (DISI >60°; VISI <30°).
    On a normal neutral rotation lateral, the horizontal axis of the radius, lunate, capitate, and metacarpals is a straight line (1). A line (2) the longitudinal axis of the scaphoid crosses line (1) at point (3). The average normal angle between these lines is 47° (range 30-60°). Angles outside this range suggest carpal instability (DISI >60°; VISI <30°).
  • Gilula’s lines (ref 5) superimposed on a neutral deviation PA wrist x-ray. Arc 1 is a smooth arcing line paralleling the proximal articular surfaces of the triquetrum, lunate, and scaphoid. Arc 2 parallels the distal concave surfaces of the triquetrum, lunate, and scaphoid. Arc 3 parallels the smooth curved surface of the proximal hamate and capitate. When these smooth curved lines are irregular, disrupted, or step off it is indicative of a carpal instability or dislocation. The insert shows the classic dis
    Gilula’s lines (ref 5) superimposed on a neutral deviation PA wrist x-ray. Arc 1 is a smooth arcing line paralleling the proximal articular surfaces of the triquetrum, lunate, and scaphoid. Arc 2 parallels the distal concave surfaces of the triquetrum, lunate, and scaphoid. Arc 3 parallels the smooth curved surface of the proximal hamate and capitate. When these smooth curved lines are irregular, disrupted, or step off it is indicative of a carpal instability or dislocation. The insert shows the classic dis
  • The lesser arc injuries described by Mayfield (ref 18) that are associated with ligamentous injuries that lead to rotatory subluxation of the scaphoid, perilunate, and lunate dislocations. The arrow shows the path of the forces through first three stages. The insert shows the full four Mayfield lesser arc injury stages.
    The lesser arc injuries described by Mayfield (ref 18) that are associated with ligamentous injuries that lead to rotatory subluxation of the scaphoid, perilunate, and lunate dislocations. The arrow shows the path of the forces through first three stages. The insert shows the full four Mayfield lesser arc injury stages.
  • Greater arc carpal injuries are typically fracture/dislocations of radius, carpal bones, and ulnar styloid. Fracture possibilities include radial styloid fractures (1); S-scaphoid fractures (2) which are associated with transscaphoid perilunate fracture/dislocations; C-capitate fractures (3); L-lunate fractures (4); T-triquetral fractures (5) and/or ulnar styloid fractures (6).
    Greater arc carpal injuries are typically fracture/dislocations of radius, carpal bones, and ulnar styloid. Fracture possibilities include radial styloid fractures (1); S-scaphoid fractures (2) which are associated with transscaphoid perilunate fracture/dislocations; C-capitate fractures (3); L-lunate fractures (4); T-triquetral fractures (5) and/or ulnar styloid fractures (6).
  • Diagrammatic lateral x-ray of a perilunate dorsal dislocation. R-radius; L-lunate which is still seated in the lunate facet of the distal radius; C-capitate which is displaced dorsally.
    Diagrammatic lateral x-ray of a perilunate dorsal dislocation. R-radius; L-lunate which is still seated in the lunate facet of the distal radius; C-capitate which is displaced dorsally.
  • Axial carpal fracture and dislocation pathways (ref 17) superimposed on normal PA x-ray. Axial carpal fracture (Fx) and dislocation injuries usually disrupt the distal carpal row and metacarpal arch and can occasionally be associated with perilunate dislocations.
    Axial carpal fracture and dislocation pathways (ref 17) superimposed on normal PA x-ray. Axial carpal fracture (Fx) and dislocation injuries usually disrupt the distal carpal row and metacarpal arch and can occasionally be associated with perilunate dislocations.
Symptoms
History of high energy wrist trauma
Wrist pain, swelling and deformity
Limited wrist and finger range of motion
Numbness and tingling in the fingers
Wrist pain with passive finger extension
Typical History

The typical patient is a 19-year-old right-handed male college student. While intoxicated one night, he was challenged to climb a 10 ft. lamppost, which he attempted and succeeded in doing. Once at the top of the lamppost, however, he lost his balance and fell forward, landing on his two outstretched hands. This force led to a left wrist hyperextension, ulnar deviation, and intercarpal supination, and resulted in a perilunate dislocation in his left wrist, which was accompanied by severe pain, swelling, and tenderness in that area. When the patient arrived in the emergency room his fingers and wrist were in an abnormal flexed posture. His left index and thumb were numb and tingling.  A left wrist portable X-ray confirmed a volar lunate dislocation.  During the emergency room visit, the patient was sedated, and traction was applied.  The perilunate dislocation was closed reduced, a traction X-ray was done, and splints applied.  The patient was admitted to hospital and the following day he was brought to the operating room, given general anesthesia and a formal open reduction, pinning and ligament repairs and/or reconstructions were performed.  The patient recovered from anesthesia and was discharged. Eight weeks after the open reduction of the left wrist lunate dislocation, the buried K-wires were removed in an ambulatory surgery center.

Positive Tests, Exams or Signs
Work-up Options
Images (X-Ray, MRI, etc.)
Perilunate Dislocation X-rays
  • Left dorsal perilunate dislocation lateral X-ray. Note capitate (C) and lunate (L).
    Left dorsal perilunate dislocation lateral X-ray. Note capitate (C) and lunate (L).
  • Left dorsal perilunate dislocation AP X-ray. Note triangular lunate (arrow) with the "piece of pie" sign and disruption of Gilula's lines.
    Left dorsal perilunate dislocation AP X-ray. Note triangular lunate (arrow) with the "piece of pie" sign and disruption of Gilula's lines.
  • Note right scapholunate acute rupture (arrow) with vertical scaphoid (wrist signet ring sign) and no perilunate dislocation
    Note right scapholunate acute rupture (arrow) with vertical scaphoid (wrist signet ring sign) and no perilunate dislocation
  • Right volar perilunate dislocation X-ray. Note capitate(C) and lunate(L).
    Right volar perilunate dislocation X-ray. Note capitate(C) and lunate(L).
  • Volar perilunate dislocation MRI. Note capitate(C), lunate(L) and radius (R.)
    Volar perilunate dislocation MRI. Note capitate(C), lunate(L) and radius (R.)
Treatment Options
Treatment Goals
  • Perform a temporary closed reduction as soon as the patient's overall condition will allow.
  • Analyze the stability of the lunate and all of its articulations after the closed reduction by examination and traction X-rays.
  • Once the patient is medically stable, a formal ORIF with repair/reconstruction of the damaged ligaments should be performed.
  • Maintain normal hand and wrist function with hand therapy designed to regain range of motion and strength.
Conservative
  • Perilunate dislocations were historically managed with closed reduction and casting, and some clinicians continue to treat them conservatively today, but these methods have been found to result in unsatisfactory outcomes. This is why the current standard of treatment is closed reduction followed by ORIF that includes ligamentous and bony repair/reconstruction.2,6,7
  • The first treatment step consists of an urgent nonemergent, gentle, closed reduction intended to decrease pressures on critical neurovascular structures and cartilage.  This reduction should always be done with traction.
    • Reduction under local anesthesia with sedation is performed with the elbow flexed to 90°, the hand placed in finger traps and a counter weight at the elbow. The wrist is brought progressively into flexion while maintaining a dorsally directed force on the lunate until the capitate is reduced over the lunate.
    • A closed reduction is typically achieved, with reported maintenance of reduction in >90% of cases, and significant muscle relaxation improves the chances for a successful closed reduction.
    • After reduction, the wrist is splinted in a neutral position with the metacarpophalangeal (MP) joints free to allow elevation and full ROM of the fingers.2,7
  • Closed reduction after 6 weeks—at which point the perilunate dislocation becomes chronic—is not wise and usually unsuccessful.1
Operative
  • After a temporary closed reduction the surgical portion of treatment, which consists of open reduction, ligament repair/reconstruction, and internal fixation for fractures and to maintain carpal alignment.  This is typically performed within 3-5 days after the initial reduction, once swelling subsides. The optimal surgical approach, however, remains debated.2,7
    • The volar approach allows for direct repair of the volar aspect of the lunotriquetral and radioscaphocapitate ligaments, which can be included in the capsular repair.
    • The dorsal approach allows for direct visualization of intercarpal and radiocarpal joints, and for thorough irrigation and removal of loose osteochondral fragments, assessments of osteochondral lesions, and full assessment of the ligamentous injuries. Direct visualization of the lunate through this approach also assists with reduction and stabilization of the scapholunate and lunotriquetral interval.2
    • A combined approach offers the benefits of improved exposure, ease of reduction, access to distal scaphoid fractures, the ability to repair volar ligaments, and carpal tunnel decompression.7
    • Fixation typically involves temporary intracarpal pinning, although some authors have reported comparable results with intracarpal screws.11
  • Carpal tunnel release
    • Necessary for patients with any evidence of median nerve compression.2
  • Closed reduction and percutaneous pinning (CRPP) for some perilunate dislocations but usually ORIF is the preferred treatment.7
  • Arthroscopy assisted reduction is another option for perilunate dislocations.  This treatment method is technically difficult because of severe derangement of the midcarpal and radiocarpal arcs.1
  • Proximal row carpectomy is a salvage procedure for chronic perilunate dislocations.11
  • Total wrist arthrodesis is another salvage procedure which is usually indicated after an ORIF is complicated by post-traumatic arthritis.
Treatment Photos and Diagrams
Perilunate Dislocation Treatment
  • Right dorsal perilunate dislocation (insert) reduction, pinning and ligament repairs.
    Right dorsal perilunate dislocation (insert) reduction, pinning and ligament repairs.
  • Volar perilunate dislocation AP X-ray (insert) reduction, pinning and ligament repairs.
    Volar perilunate dislocation AP X-ray (insert) reduction, pinning and ligament repairs.
  • Volar perilunate dislocation lateral X-ray (insert) reduction, pinning and ligament repairs.
    Volar perilunate dislocation lateral X-ray (insert) reduction, pinning and ligament repairs.
Hand Therapy
  • Some patients with closed lunate dislocations that are close reduced early will need to exercise their fingers on their own or with the assistance of a hand therapist before their definitive reconstructive surgery to help reduce swelling and improve range of motion and strength.
  • Surgically repaired lunate dislocations, repaired ligaments, and unstable lunate dislocations will definitely need hand therapy, custom splinting, and possibly dynamic extension splints.
    • Postoperative management typically consists of immobilization in a thumb spica splint, followed by a short-arm thumb spica cast. Initial rehabilitation focuses on active movement of the shoulder, elbow, and fingers to prevent stiffness.2, 7
    • The cast is removed after 8 weeks and pins removed. Next active and passive range of motion and strengthing exercises for the wrist, forearm, and thumb can begin.7
Complications
  • Stiffness
  • Pain
  • Infection
  • Residual deformity
  • Weakened grip
  • Impaired ROM
  • Nerve injuries 
  • Vascular injuries
  • Carpal tunnel syndrome
  • Chronic carpal instability
  • Complex regional pain syndrome
  • Hand or wrist weakness
  • Posttraumatic osteoarthritis
    • Even when treated surgically, 50-100% of patients will develop radiocarpal and/or midcarpal osteoarthritis.11
Outcomes
  • In general, the available evidence supports a surgical approach over a purely conservative one for perilunate dislocations, as multiple studies have demonstrated superior outcomes in patients who undergo ORIF compared to those treated with closed reduction alone or CRPP.2,3,12,13
     
  • Por prognostic indicators for perilunate dislocations include open injury, delay of diagnosis of greater than 4-6 weeks, persistent carpal malalignment, and large osteochondral defects.2
  • A comparison trial of 28 patients with perilunate dislocation or fracture-dislocation found that 12 of 20 wrists managed with ORIF had good or excellent results, while the 8 treated with closed reduction and casting had fair or poor outcomes.14
  • Some studies have shown that the rate for dislocation recurrence in patients treated conservatively is 59%.11
  • In one study, 23 patients with perilunate dislocations and fracture-dislocations were treated surgically with a combined approach. Three years later, all had radiographic arthritic changes, diminished ROM, and grip strength at ~73% of the contralateral side. This and other studies suggest that even with optimal management, outcomes for perilunate dislocations are relatively poor.15
Key Educational Points
  • Open and complex perilunate dislocations require urgent surgical treatment.
  • Routine radiographs
    • Posteroanterior (PA) and lateral radiographs are most useful: the PA view should be scrutinized for uneven gapping in the carpal bones, and the 3 smooth carpal arcs of Gilula should be free of discontinuity.
    • On lateral radiographs, the hallmark sign of perilunate dislocation is a loss of colinearity of the radius, lunate, and capitate.7
  • MRI and CT Scan may be needed if there is any doubt and in order to avoid a delay in diagnosis.9
  • Surgery for perilunate dislocations should be undertaken within the first week after injury. After this time, it becomes more technically challenging if the reduction has not been properly maintained in the splint, and after 2 months it may not be possible to reduce. By 4 months after a perilunate dislocation, a salvage procedure is likely the only surgical option.2
  • Close reduction of a carpal lunate dislocation alone fails because of a paradox of this reduction, where there is no position of the wrist that optimizes the healing of all the damaged ligamentous structures.  Placing the wrist in extension after a close reduction approximates the scapholunate ligament and dorsal capsule but it separates the torn palmar ligaments. If the wrist is placed in palmar flexion after reduction this approximates the palmar ligaments but causes dorsal subluxation of the proximal pole scaphoid and separation of the scapholunate ligament.16-18
  • Wrist arthrosis and decreased range of motion is a frequent late complication of carpal dislocations even when the initial treatment is optimal
  • When patients present with carpal tunnel symptoms, even if they are mild, and they have palmar hand and wrist abrasions, the surgeon should consider early carpal tunnel release before these minor palmar wounds become colonized with increased skin bacterial flora.
  • Traction x-ray views done with the fingers in finger traps and a counterweight at the elbow are very useful diagnostically. These traction views frequently show carpal gaps and other carpal malalignments that are not seen on routine x-rays.16-18
  • The mechanism injury for a perilunate or lunate carpal dislocation is extension, ulnar deviation and intercarpal supination. Thus, the reduction maneuver for reducing a lunate dislocation is a reverse mechanism. During reduction, the surgeon applies traction, ulnar deviation which is followed by intercarpal pronation, palmar flexion and radial deviation while the surgeons pushes the lunate dorsally with his thumb.16-18
  • Scaphoid lunate ligament repair and lunotriquetral ligament repair at the time of open reduction and internal fixation improves the treatment outcome for a carpal lunate dislocation.
References

New and Cited Articles

  1. Bhatia, DN. Arthroscopic Reduction and Stabilization of Chronic Perilunate Wrist Dislocations. Arthrosc Tech 2016;5(2):e281-90. PMID: 27354948
  2. Montero Lopez, NM and Paksima, N. Perilunate Injuries and Dislocations Etiology, Diagnosis, and Management. Bull Hosp Jt Dis (2013) 2018;76(1):33-37.PMID: 29537955
  3. Muppavarapu, RC and Capo, JT. Perilunate Dislocations and Fracture Dislocations. Hand Clin 2015;31(3):399-408. PMID: 26205701
  4. Inoue, G and Shionoya, K. Late treatment of unreduced perilunate dislocations. J Hand Surg Br 1999;24(2):221-5. PMID: 10372780
  5. Grabow, RJ and Catalano, L, 3rd. Carpal dislocations. Hand Clin 2006;22(4):485-500.PMID: 17097469
  6. Virani, SR, Wajekar, S, Mohan, H, et al. A unique case of bilateral trans-scaphoid perilunate dislocation with dislocation of lunate into the forearm. J Clin Orthop Trauma 2016;7(Suppl 1):110-114. PMID: 28018087
  7. Stanbury, SJ and Elfar, JC. Perilunate dislocation and perilunate fracture-dislocation. J Am Acad Orthop Surg 2011;19(9):554-62. PMID: 21885701
  8. Merrell G, Slade JF. Dislocations and ligament injuries in the digits. In: Wolfe, SW, Hotchkiss RN, Pederson WC, Kozin SH (eds): Green’s Operative Hand Surgery.  Philadelphia 2011: Elsevier Churchill Livingstone, pp. 291-332.
  9. Mahjoub, S, Dunet, B, Thoreux, P, et al. Transverse translunate fracture-dislocation: A rare injury. Hand Surg Rehabil 2016;35(3):220-224. PMID: 27740466
  10. Herzberg, G, Comtet, JJ, Linscheid, RL, et al. Perilunate dislocations and fracture-dislocations: a multicenter study. J Hand Surg Am 1993;18(5):768-79. PMID: 8228045
  11. Muller, T, Hidalgo Diaz, JJ, Pire, E, et al. Treatment of acute perilunate dislocations: ORIF versus proximal row carpectomy. Orthop Traumatol Surg Res 2017;103(1):95-99.PMID: 27923762
  12. Budoff, JE. Treatment of acute lunate and perilunate dislocations. J Hand Surg Am 2008;33(8):1424-32.PMID: 18929215
  13. Herzberg, G. Acute Dorsal Trans-scaphoid Perilunate Dislocations: Open Reduction and Internal Fixation. Tech Hand Up Extrem Surg 2000;4(1):2-13.PMID: 16609406
  14. Apergis, E, Maris, J, Theodoratos, G, et al. Perilunate dislocations and fracture-dislocations. Closed and early open reduction compared in 28 cases. Acta Orthop Scand Suppl 1997;275(55-9. PMID: 9385268
  15. Hildebrand, KA, Ross, DC, Patterson, SD, et al. Dorsal perilunate dislocations and fracture-dislocations: questionnaire, clinical, and radiographic evaluation. J Hand Surg Am 2000;25(6):1069-79. PMID: 11119665
  16. Vitale MA, Seethharaman M, Ruchelsman DE. Perilunate dislocations. J Hand Surg AM. 2015; 40:358 - 362.
  17. Herzberg G. Perilunate and axial carpal dislocations and fracture-dislocations. J Hand Surg AM. 2008; 33A: 1659 - 1668.
  18. Mayfield JK, Johnson RP, Kilcoyne RK. Carpal dislocations: pathomechanics and progressive instability. J Hand Surg AM. 1980; 5(3): 226 – 241. 

Reviews

  1. Stanbury, SJ and Elfar, JC. Perilunate dislocation and perilunate fracture-dislocation. J Am Acad Orthop Surg 2011;19(9):554-62. PMID: 21885701
  2. Montero Lopez, NM and Paksima, N. Perilunate Injuries and Dislocations Etiology, Diagnosis, and Management. Bull Hosp Jt Dis (2013) 2018;76(1):33-37.PMID: 29537955

Classics

  1. Spar I. Bilateral perilunate dislocations: case report with review of literature and anatomic study. J Trauma1978;18(1):64-5. PMID: 621767
  2. Galasko C. Transradial dorsal perilunate fracture dislocation: an unusual fracture dislocation of the wrist joint. Postgrad Med J1967;43(506):787-8. 
  3. Green DP, O’Brien ET. Open reduction of carpal dislocations: indications and operative techiques. J Hand Surg AM.1978; 3(3): 250 – 265.
  4. Mayfield JK, Johnson RP, Kilcoyne RK. Carpal dislocations: pathomechanics and progressive instability. J Hand Surg AM. 1980; 5(3): 226 – 241.
  5. Gilula LA: Carpal Injuries: Analytic Approach and Case Exercises.  Am J Roentgenology 133:513, 1979.
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