Surgical techniqueTreatment of Acute Lunate and Perilunate Dislocations
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Indications and Contraindications
Indications include the following:
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Closed reduction should be attempted emergently in all patients who present within a few days of injury. Early closed reduction relieves pressure on the median nerve and other soft tissues while the patient awaits definitive surgical management. After a few days, closed reduction will not be successful.1 If a successful closed reduction was performed, the located carpus may be splinted and surgically stabilized after 3 to 4 days, when the swelling has subsided.4
Surgical Anatomy
Perilunate dislocations occur when the lunate remains located in its fossa, but the remainder of the carpus is dorsally dislocated (Fig. 3A). The lunate remains anchored in its fossa by the strong short radiolunate ligament. The carpus may occasionally “rebound” volarly, displacing the lunate from its fossa and leading to a volar lunate dislocation; in these cases, the lunate rotates volarly on the short radiolunate ligament, and the remainder of the carpus remains relatively aligned with the
Closed reduction
Closed reduction is possible for only a few days after injury. Closed reduction will not be successful if soft tissue (such as the dorsal joint capsule) becomes interposed between the carpal rows or in the case of a completely dislocated lunate. Complete muscle relaxation is essential, either through general anesthesia, Bier block, or an axillary block.2 Local anesthetic will not provide enough pain relief or muscle relaxation to allow for a successful reduction. After appropriate anesthesia
Outcomes
Despite optimal management, the prognosis of this injury is relatively poor, and most patients experience a loss of grip strength and motion and also develop radiographic signs of arthritis and carpal collapse. However, these clinical measurements and radiographic changes do not correlate with patient satisfaction or the ability to return to work.2 The major poor prognostic indicators are a delay in treatment greater than 28 to 45 days, open injuries, and persistent carpal malalignment; some
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Perilunate injuriesRepair by dual dorsal and volar approaches
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Perilunate dislocations and fracture-dislocations: a multicenter study
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