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DISLOCATION, WRIST TRANSSCAPHOID PERILUNATE

Introduction

Perilunate dislocations are severe, disabling injuries generally associated with poor outcomes.1,2 They only account for 7-10% of all carpal injuries,3,4 but are the most common of all carpal dislocations.5 The majority of these injuries involve a scaphoid fracture, with transscaphoid perilunate dislocations, accounting for 61-65% of all perilunate dislocations and fracture-dislocations.5-7 A high-energy force—such as from a motor vehicle collision or fall from a height—is required to produce this insult, and the scaphoid fractures frequently owing to this severe trauma.8 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.29,30  Routine PA X-ray should be evaluated for loss of carpal height, carpal gaps and overlapping carpal bones,  disruption of Gilula's arcs and unusual shape of the proximal scaphoid fracture fragment.  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.29,30,31  The typical mechanism of injury is wrist hyperextension, ulnar deviation, and intercarpal supination with an axial load, which displaces the lunate from the capitate—starting with disruption of the scapholunate ligament—while the radiolunate articulation remains preserved.2 Transscaphoid perilunate dislocations are considered greater arc injuries in the perilunate dislocation injury pattern because they include a fracture, which is the initial destabilizing factor of the carpus, with the final stage being the lunate dislocation.9 Although purely conservative methods were traditionally used to treat transscaphoid perilunate dislocations, most experts currently prefer a surgical approach beginning with closed reduction, followed by open reduction and internal fixation (ORIF) that includes repair of the scaphoid and any damaged ligament(s).2,10,29,30,31
 

Definitions

  • A transscaphoid perilunate dislocation occurs when the articular surface of the capitate is displaced off the articular surface of the lunate—which remains in normal alignment with the distal radius—and the scaphoid is also fractured.

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 transscaphoid perilunate dislocations are done by noting the direction of the displacement of the capitate relative to the lunate. The three possible directions of displacement are dorsal, lateral, and volar.11
    • The majority of transscaphoid perilunate dislocations are dorsal, while only ~3% are volar.10,12
  • The degree of displacement further characterizes transscaphoid perilunate dislocations. In a true complete dislocation, the articular surface of the capitate 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.11

O – Open vs closed

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

C – Complex vs simple

  • Most transscaphoid perilunate dislocations are simple, meaning that reduction is easily achieved under digital anesthetic block and is not blocked by soft tissue being interposed in the joint between the capitate and lunate joint surfaces.
  • Complex (irreducible) transscaphoid perilunate dislocations are extremely rare, but do occur on some occasions.

S – Stability

  • A trans-scaphoid perilunate dislocation can usually be reduced into the lunate facet but will not stay anatomically aligned without internal fixation (K-wires or screws of the scaphoid fracture and L-T joint).
  • Trans-scaphoid perilunate dislocations are often more stable than pure perilunate dislocations if the waist fracture is transverse, the scapholunate ligament remains intact and the L-T ligament is repaired.

Related anatomy13,14

  • 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
  • Transscaphoid perilunate dislocations are often associated with a significant amount of additional wrist trauma, including ruptures of the radioscaphocapitate, scapholunate interosseus, and/or lunotriquetral ligaments.15

Overall incidence

  • Perilunate dislocations and fracture-dislocations account for 7-10% of all carpal injuries,3,4and they are the most common of all carpal dislocations.5
  • The incidence of perilunate fracture-dislocations alone has not yet been defined, but it is clearly known that the scaphoid is involved more than any other bone.15,16
    • Transscaphoid perilunate dislocations account for 61-65% of all perilunate dislocations and fracture-dislocations5-7—with most of these injuries being in the dorsal direction—and constitute ~3% of all carpal injuries.17
  • 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

  • Fractures of the capitate, lunate, and/or triquetrum
  • Fractures of the distal radius
  • Lunate dislocation and fracture-dislocation
  • Extrinsic ligament injuries
  • Intrinsic ligament injuries
  • Extensor tendon ruptures
  • Flexor tendon ruptures
  • Acute carpal tunnel syndrome
ICD-10 Codes

  • DISLOCATION, WRIST TRANSSCAPHOID PERILUNATE

    Diagnostic Guide Name

    DISLOCATION, WRIST TRANSSCAPHOID 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 2) 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.
    Gilula’s lines (ref 2) 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 lesser arc injuries described by Mayfield (ref 32) 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 32) 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). The white arrow shows the pathway of forces during a classic transscaphoid perilunate fracture dislocation.
    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). The white arrow shows the pathway of forces during a classic transscaphoid perilunate fracture dislocation.
Symptoms
History of high energy wrist trauma
Wrist pain, swelling and deformity
Numbness and tingling in the fingers
Limited wrist and finger range of motion
Wrist pain with passive finger extension
Typical History

The typical patient is a 24-year-old male painter who injured himself on the job. While standing on a ladder to paint the second story of a house, a bee flew into the man’s eye and caused him to lose his balance. He subsequently fell sideways off the ladder and landed in the driveway with his hands outstretched, which hyperextended both wrists and resulted in a right transscaphoid perilunate dislocation. The injury was evinced by severe pain, swelling, and tenderness in the right wrist, and the man was taken to go to the ED for treatment. When the patient arrived in the emergency room his fingers and wrist were in an abnormal flexed posture. His right index and long finger were numb and tingling.  A right wrist portable X-ray confirmed a volar lunate dislocation.  During the emergency room visit, the patient was sedated, and traction was applied.  The trans-scaphoid 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 and scaphoid OEIF was performed. Carpal pinning and ligament repairs and/or reconstructions were also performed.  The patient recovered from anesthesia and was discharged. Eight weeks after the open reduction of the right wrist 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.)
Trans-Scaphoid Perilunate Fracture Dislocations
  • Trans-Scaphoid perilunate fracture dislocation. Note the scaphoid fracture (arrow), disrupted Gilula's lines and excessive scaphoid capitate overlap.
    Trans-Scaphoid perilunate fracture dislocation. Note the scaphoid fracture (arrow), disrupted Gilula's lines and excessive scaphoid capitate overlap.
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 of the scaphoid fracture with repair/reconstruction of the damaged L-T ligament should be performed.
  • Maintain normal hand and wrist function with hand therapy designed to regain range of motion and strength.
Conservative
  • Perilunate trans-scaphoid dislocations were historically managed with closed reduction and casting, and some clinicians continue to use conservative interventions 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 repair of the scaphoid and any damaged ligament(s).2,9,10,13
  • The first step consists of immediate, gentle, closed reduction, which is a temporizing treatment intended to decrease pressures on critical neurovascular structures and cartilage and prevent the progression of median nerve neuropathy.
    • Reduction is performed with the elbow flexed to 90° and the hand placed in finger traps. The wrist is brought progressively into flexion while maintaining a dorsally directed force on the lunate until the capitate is reduced over the lunate.
    • Stable 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.2,10,19
  • Closed reduction after 6 weeks—at which point the trans-scaphoid perilunate dislocation becomes chronic—is generally considered impossible, and immediate surgical intervention is required.1
Operative
  • The surgical portion of treatment, which consists of open reduction, ligament and scaphoid repair, and supplemental fixation, is typically performed within 3-5 days after the closed reduction, once swelling subsides. Some surgeons prefer to perform ORIF immediately after closed reduction.2,10,20,29,30,31
  • The optimal surgical approach for transscaphoid perilunate dislocations remains debated.
    • 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.2,29,30,31
    • 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.10
  • Scaphoid fractures are typically fixed using cannulated headless screw systems, while comminuted fractures can be treated with K-wire fixation and autologous bone grafting from the distal radius.10,29,30,31
  • Carpal tunnel release
    • Necessary for patients with any evidence of median nerve compression.2
  • Closed reduction and percutaneous pinning (CRPP)
    • An alternative for some transscaphoid perilunate dislocations, but generally associated with high rates of posttraumatic osteoarthritis and poor outcomes.10,20
  • Arthroscopy
    • Another option for chronic trans-scaphoid perilunate dislocations that 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
  • Total wrist arthrodesis is another salvage procedures for some chronic trans-scaphoid perilunate dislocations.13
Treatment Photos and Diagrams
Trans-Scaphoid Perilunate Fracture Dislocations Treatment
  • Trans-Scaphoid Perilunate Fracture /Dislocations ORIF with a screw.
    Trans-Scaphoid Perilunate Fracture /Dislocations ORIF with a screw.
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, 10
    • The cast is removed after 8 weeks and pins removed. Next active and passive range of motion and strengthening exercises for the wrist, forearm, and thumb can begin.2,10
Complications

  ↵

  • Stiffness
  • Pain
  • Scaphoid nonunion 
  • Intercarpal collapse
  • Chronic carpal instability 
  • Infection
  • Residual deformity
  • Weakened grip
  • Impaired ROM
  • Nerve injuries 
  • Vascular injuries
  • Carpal tunnel syndrome
  • 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.15,21
Outcomes
  • In general, the available evidence supports a surgical approach over a purely conservative one for trans-scaphoid perilunate dislocations, as multiple studies have demonstrated superior outcomes in patients who undergo ORIF compared to those treated with closed reduction alone or CRPP.2,3,15,22,23
  • Poor prognostic indicators for trans-scaphoid perilunate dislocations include open injury, delay of diagnosis of >4 weeks, persistent carpal malalignment, and large osteochondral defects.2,24
  • Some studies have shown that the rate for dislocation recurrence in patients treated conservatively is 59%.21
  • The scaphoid fracture can take 4-5 months to heal completely.31
  • In one retrospective study, 28 patients with 29 trans-scaphoid perilunate dislocations were treated with early open reduction, ligamentous repair, and cast immobilization.
    • At the follow-up, 28 fractures united, with 4 excellent, 15 good, 8 fair, and 2 poor results. Significantly better wrist ROM was obtained in patients immobilized for 4 weeks compared to those immobilized for >5 weeks.25
  • 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.26
  • In another 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 transscaphoid perilunate dislocations are relatively poor.27
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.8
    • On lateral radiographs, the hallmark sign of a trans-scaphoid perilunate dislocation is a loss of colinearity of the radius, lunate, capitate and the scaphoid fracture.10
  • Special X-ray views
    • A scaphoid series will also help to determine if a scaphoid fracture is present.15
  • CT scan
    • May be needed if there is any doubt and in order to avoid a delayed diagnosis.12
    • Can determine the type of fracture(s), the amount of displacement, degree of comminution, if there are any associated ligament injuries, and to identify occult fractures.10
  • Surgery for trans-scaphoid 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 trans-scaphoid perilunate dislocation, a salvage procedure is likely the only surgical option.2
  • Most authors agree that the key to a good clinical result in transscaphoid perilunate dislocations is the anatomic union of the scaphoid and restoration of proper carpal alignment.28
  • Approximately 16-25% of perilunate dislocations are not accurately diagnosed upon initial evaluation. This highlights the need for high clinical suspicion after any significant wrist trauma to reduce the chances of delayed diagnosis.5,18
  • 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.29-31
  • 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.
  • 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.29-31
  • 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.
  • There is no consensus regarding the best surgical approach for reduction and reconstruction of a lunate dislocation but if the lunate remains is in the carpal tunnel after an attempted closed reduction then a volar or combined volar/dorsal approach is usually needed.29-31
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. Herzberg, G and Forissier, D. Acute dorsal trans-scaphoid perilunate fracture-dislocations: medium-term results. J Hand Surg Br 2002;27(6):498-502. PMID: 12475503
  7. Blazar, PE and Murray, P. Treatment of perilunate dislocations by combined dorsal and palmar approaches. Tech Hand Up Extrem Surg 2001;5(1):2-7. PMID: 16520643
  8. Kloss, BT, Patierno, SR and Sullivan, AM. Transscaphoid perilunate dislocation. Int J Emerg Med 2010;3(4):501-2. PMID: 21373343
  9. 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
  10. Stanbury, SJ and Elfar, JC. Perilunate dislocation and perilunate fracture-dislocation. J Am Acad Orthop Surg 2011;19(9):554-62. PMID: 21885701
  11. 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.
  12. 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
  13. Lal, H, Jangira, V, Kakran, R, et al. Two stage procedure for neglected transscaphoid perilunate dislocation. Indian J Orthop 2012;46(3):351-5. PMID: 22719125
  14. Chou, YC, Hsu, YH, Cheng, CY, et al. Percutaneous screw and axial Kirschner wire fixation for acute transscaphoid perilunate fracture dislocation. J Hand Surg Am 2012;37(4):715-20. PMID: 22386559
  15. Cowell, GW, Ng, CY, Tiemessen, CH, et al. Transscaphoid perilunate dislocation--a tale of two carpals? BMJ Case Rep 2011;2011. PMID: 22678943
  16. Viegas, SF, Bean, JW and Schram, RA. Transscaphoid fracture/dislocations treated with open reduction and Herbert screw internal fixation. J Hand Surg Am 1987;12(6):992-9.PMID: 3693856
  17. Inoue, G, Tanaka, Y and Nakamura, R. Treatment of trans-scaphoid perilunate dislocations by internal fixation with the Herbert screw. J Hand Surg Br 1990;15(4):449-54.PMID: 2269835
  18. 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
  19. Yildirim, C, Unuvar, F, Keklikci, K, et al. Bilateral dorsal trans-scaphoid perilunate fracture-dislocation: A case report.Int J Surg Case Rep 2014;5(5):226-30.PMID: 24705189
  20. Aslani, H, Bazavar, MR, Sadighi, A, et al. Trans-Scaphoid Perilunate Fracture Dislocation; A Technical Note. Bull Emerg Trauma 2016;4(2):110-2. PMID: 27331069
  21. 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
  22. Budoff, JE. Treatment of acute lunate and perilunate dislocations. J Hand Surg Am 2008;33(8):1424-32.PMID: 18929215
  23. 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
  24. Garg, B, Goyal, T and Kotwal, PP. Staged reduction of neglected transscaphoid perilunate fracture dislocation: a report of 16 cases. J Orthop Surg Res 2012;7:19.PMID: 22607705
  25. Inoue, G and Imaeda, T. Management of trans-scaphoid perilunate dislocations. Herbert screw fixation, ligamentous repair and early wrist mobilization. Arch Orthop Trauma Surg 1997;116(6-7):338-40. PMID: 9266036
  26. 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
  27. 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
  28. Lam, P and Baddeley, S. Dorsal transscaphoid perilunate dislocation through an isolated scaphoid non-union. Aust N Z J Surg 1995;65(1):60-2. PMID: 7818427
  29. Vitale MA, Seethharaman M, Ruchelsman DE. Perilunate dislocations. J Hand Surg AM. 2015; 40:358 - 362.
  30. Herzberg G. Perilunate and axial carpal dislocations and fracture-dislocations. J Hand Surg AM. 2008; 33A: 1659 - 1668.
  31. Knoll VD, Allan C, Trumble TE. Trans-scaphoid perilunate fracture dislocations: results of screw fixation of the scaphoid and lunotriquetral repair with dorsal approach. J Hand Surg AM. 2005; 30A(6): 1145.e1-1145.e11.
  32. Mayfield JK, Johnson RP, Kilcoyne RK. Carpal dislocations: pathomechanics and progressive instability. J Hand Surg AM. 1980; 5(3): 226 – 241.

Review

  1. Stanbury, SJ and Elfar, JC. Perilunate dislocation and perilunate fracture-dislocation. J Am Acad Orthop Surg 2011;19(9):554-62. PMID: 21885701

Classic

  1. Woodward AH, Neviaser RJ and Nisenfeld F. Radial and volar perilunate transscaphoid fracture dislocation. South Med J1975;68(7):926-8. PMID: 1154080
  2. Gilula LA: Carpal Injuries: Analytic Approach and Case Exercises.  Am J Roentgenology 133:513, 1979
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