U will get Everything, necessary and related to it in this PPT.

1. LUNATE FRACTURE
AND
PERILUNATE DISLOCATION
DR. ARPAN KUMAR CHAUDHARY

7. MAXIMAL SPACE SEEN IN
DORSIFLEXION AND SPACE
ALMOST DISAPPEARS IN PALMAR
FLEXION OF WRIST.
This often clinical relavance in dorsal
dislocations, as it is throgh this area of
weakness that the lunate displaces intpo
the carpal canal.
SPACE FO PORIER:
Ligamet free area between RADIOSCAPHOLUNATE Ligament & RADIOLUNATE
LIGAMENT – at level of midcarpal joint. AN AREA OF POTENTIAL WEAKNESS.

8. Column concept:
•lateral (mobile) column:
•comprises scaphoid, trapezoid and trapezium.
•scaphoid is center of motion and function is mobile.
•central (flexion-extension) column:
•comprises lunate, capitate and hamate.
•luno-capitate articulation is center of motion.
•motion is flexion/extension.
•medial (rotation) column:
•comprises triquetrum and distal carpal row.
•motion is rotation.
Rows concept:
•comprises proximal and distal rows.
•scaphoid is a bridge between rows.
•motion occurs within and between rows.
Three biomechanic concepts have been proposed:
Link concept:
three links in a chain composed of radius, lunate and capitate
head of capitate acts as center of rotation
proximal row (lunate) acts as a unit and is an intercalated segment with no direct tendon
attachments.
distal row functions as unit

9. LUNATE FRACTURE
• Lunate is fourth most fractured carpal bon after
scaphoid,triquetrum & trapezium.
• The word lunate is derived from the Latin
word luna which means "crescent-shaped" or
("moon),The bone's shape resembles that of a
crescent moon.
• Lunate is the “CARPAL KEYSTONE’’ .
• It is situated in the center of the proximal row
carpal bones, between the lateral scaphoid bone
and medial triquetral bone.

11. Kienböck's disease is another name for avascular
necrosis[2] (death and fracture of bone tissue due to
interruption of blood supply) with fragmentation and
collapse of the lunate.

12. Mechanism of Injury:
fall onto an outstretched hand
 direct blow
 repetition injury
 secondary to Kienbock's disease
In extension lunate displaced on palmar aspect of lunate fossa and rotates dorsally.
Capitate pushes against th palmar aspect of lunate & at same time moves it in ULNAR
DIRECTION, which is countered by RadioScaphoLunate ligament.
When forearm pronated ,minimal ulnar minus variance ,so support by TFCC and ulnar
head redused leads to compression on lunate and proximal displacement of triquetrum
placing further tensile strees on lunate by Lunotriquetral ligament.
This all leads to transverse fracture of lunate,
Avulsion fracture of Dorsal pole is likely associated with ScaphoLunate Dissociation.
Avulsion fracture of ulnar pole of lunate are frequently associated with perilunate
dislocation and thus likely due to tension on LunoTriquetral Ligament.
IN ABOVE SITUATIONS STRESS MAY BE PLACED ON THE VASCULATURE OF LUNATE PRIOR
TO FRACTURE OCCURING,LEADING TO DEVELOPEMRNT OF ‘’KIENBOCK’S DISEASE.

13. The Teisen and Hjarbaek classification of lunate fracture.
One classification system uses the following 5 groups to categorize lunate fractures:
Group I: volar pole fractures
Group II: chip fractures
Group III: dorsal pole fractures
Group IV: sagittal fractures through the body
Group V: transverse fractures through the body
Osteochondral and transarticular body fractures of the lunate are also possible.

14. Associated Injuries
Complex dislocations of the carpus:
Lunate dislocation
Perilunate dislocation
Scapho-lunate dissociation.
Complications include:
Compartment syndrome.
Avascular necrosis (Kienböck's disease of the
lunate)
Non-union
Secondary degenerative arthritis.
Main is the compression of MEDIAN NERVE
when fracture-dislocation anteriorly.

15. Clinical Features:
There may be diffuse swelling of the wrist.
Bony point tenderness may be elicited over the lunate.
The lunate can be appreciated by palpation on the dorsum of the wrist just distal to
the radius (or more specifically - the radial or Lister's tubercule) in line with the third
(middle) metacarpal.
Note that in some cases patients may not even recall a specific injury event, but
simply present with chronic wrist pain due to avascular necrosis and/ or secondary
osteoarthritic changes.

16. Investigations:
Plain radiography
Standard views include:
● A-P : widening of the scapho-lunate space as a clue to possible
occult lunate injury.
● Lateral
● Oblique
As for all fractures of the carpal bones, lunate fractures are
frequently difficult to diagnose on plain radiography.
When clinical suspicion for injury remains high, despite a normal
plain radiograph, then CT scan or MRI scan should be done.
Patients with late presentations may have radiographs showing
evidence of osteonecrosis with a relatively mottled and radiodense
area of the lunate.

18. CT scan
In cases where plain radiographs have not provided a clear
diagnosis and clinical suspicion remains.
Will provide details about fracture and osteonecrotic changes
that is primary fracture or secondary fracture associated with
fregmentation.
MRI Scan
This is the best imaging modality.
Detect early vascular compromise within carpal bones.
 It is a sensitive tool in the follow-up of avascular necrosis and
fracture healing (resolution of oedema).
Arthroscopy can be used.

19. Treatment:
NON-OPERATIVE:
Managemement in cast approximately 4 weeks is sutable for more isolated
Lunate Fractre.
OPERATIVE;
When displaced fracture and associated carpal instability.
If there is evidence of sepration of lunate fragement. Fixation of LUNATE by K-
WIRE,SCREWS and Ligamnts.Distraction with EXTERNAL FIXATOR may facilate
reduction of LUNATE fragements.
If ( KIENCBOCKS DISEASE ) THAN SHOUD GO FOR
-RADIAL SHORTENING (MORE GOOD PROCEDURE).
-ULNAR LENGTHENING.
-CORE DECOMPRESSION.
-CARPAL ARTHRODESIS IF CONDITION ADVANCED.
-REPLACEMENT LUNATE PROSTHESIS.

20. PERILUNATE DISLOCATION & FRACTURE
DISLOCATION:
DEFINITION:
INTRODUCTION:
Most common form of wrist dislocation.
Spectrum of injury which includes both Ligamentos
and Osseous.
Prefix ‘Trans’ refers – to associatd fracture.
Prefix ‘Peri’ refers - to dislocation.
Commoly missed in 25% initial presentation.

21. Dislocation can occur by:
GREATER ARC INJURY:
Ligamentous injury associated with fracture of one
or more bone around the Lunate
Injury in this known as PERILUNATE FRACTURE
DISLOCATION.
LESSER ARC INJURY:
Purely Ligamentous injury so leads to dislocation
only
Known as PERILUNATE DISLOCATION.
Disruption of Capsular and Ligamentous structure of
Lunate to adjacent carpal bones
SLD and LTD often persist even after relocation
leads to recurrence of instability and late carpal
collpse.

22. TWO CATEGORIES OF DISLOCATIONS:
 PERILUNATE DISLOCATION:
 LUNATE STAYS IN POSITION WHILE CARPUS DISLOCATES.
 4 TYPES:
1. TRANSCAPHOID PERILUNATE(M/C)
2. PERILUNATE
3. TRANSRADIAL STYLOID
4. TRANSCAPHOID-TRANSCAPITATE-PERILUNAR
 LUNATE DISLOCATION:
 LUNATE FORCED VOLAR OR DORSAL WHILE CARPAL REMAIN
ALIGNED

23. Can leads to MEDIAN NERVE compression.
NOTE – LUNATE DISLOCATION IS THE END STAGE OF
PROGRESSIVE PERILUNATE DISLOCATION.

28. CLINICAL FEATURES
Often young male,high energy trauma.
H/O Hyprextnsion injury.
Wrist pain,swelling and deformity.
Signs: tendreness distal to the Lister”s tubercle.
: marked prominence of entire carpus distally.
: compression test- palpable,audible snap,click or clunk.
MIDCARPAL SHIFT TEST:
Pressure applied over dorsum of capitate,wrist moving from radial to ulnar
deviation.
If POSITIVE – clunk present as the LUNATE reduces from the palmar flexed
position.
16% presents with MEDIAN NERVE compression signs and symptoms, M/C in
Mayfield stage 4,wher LUNATE dislocates in carpal tunnel.

29. INVESTIGATIONS
X-RAY:
PA VIEW: NORMALLY AXIS OF FOREARM WILL PASS FROM
-HEAD AND BASE OD 3RD METACARPAL
-CAPITATE
-RADIaL ASPECT OF LUNATE,
-CENTRE OF LUNATE FOSSA OF RADIUS - LOSS OF ALIGMENT WILL BE SEEN.
LATERAL VIEW: LINE PASS FROM - INDEX FINGER METACARPAL,
- CAPITAT
- LUNATE
- RADIUS WITH SCAPHOID ON AXIS OF 45 DEGREE
NORMAL JOINT SPACE:
<2MM - NORMAL
>3MM - SUSPECTED LIGSMENT DISRUPTION
>5MM - DIAGNOSTIC

30. Perilunate Dislocation
Lateral view
Capitate displaced dorsal to lunate
PA view
Capitolunate joint space is obliterated as
the bones overlap one another
Lunate Dislocation
Lateral view
Lunate is pushed off the radius into the
palm ("spilled teacup" sign)
PA view
Lunate has triangular shape ("piece-of-pie
sign")

32. SCAPHOLUNATE ANGLE :
 NORMAL : 30-60 DEGREE
 >60 DEGREE : DISI
 <30 DEGREE : VISI
 >80 DEGREE : DIAGNOSTIC OF CARPAL
(SCAPHOLUNATE) INSTABILITY.
OTHER:
CAPITOLUNATE ANGLE(<15 normal): >15 to
20 suggest instability.
RADIOLUNATE(<15 normal): >15 to 20
suggest instability.
CARPAL HEIGHT RATIO:
CARPAL HEIGHT/LENGTH OF THIRD METACARPAL
NORMAL RATIO IS 0.5
<0.45 INDICATES CARPAL COLLPSE.

33. CT SCAN AND MRI : TO DETERMINE THE EXTENT OF LESION.

35. TREATEMENT :
NON-OPERATIVE :
 CLOSED REDUCTION AND CASTING.
INDICATION – NO INDICATIONS WHEN USED AS DEFINITIVE MANAGEMENT.
POOR FUNCTIONAL OUTCOME WITH NON-OPERATIVE.
RECURRENT DISLOCATION IS COMMON.

38. LIGAMENT RAPAIR:
 TALEISNIK SUGGESTED USING FLAP OF DORSAL RADIO ARTICULAR MARGIN,DORSAL
RAIOCARPAL LIGAMENT MEDIALLY AND DORSAL INTERCARPAL LIGAMENT DISTALLY –
REDUCTION OF SCPHOLUNATE DISRUPTION AND FIX WITH THREE (1.16 MM) K-WIRES
DIRECTED FROM SCAPHOID INTO LUNATE & CAPITATE.
POST-OP: AFTER 6 WEEKS REMOVAL OF LONG ARM CAST AND AND SHORT CAST FOR
ANOTHER 4 WEEKS & 8-10 WEEKS REMOVE K-WIRES.
TALEISNIK

39. REPAIR OF SCPHOLUNATE DISSOCIATION BY PALMAR,DOBYNS.

40. FOUR – BONE LIGAMENTOUS REPAIR:
USING EXTENSOR CARPI RADIALIS BREVIS OR LONGUS, HOLES MADE
FROM DORSAL TO PALMAR ON NON-ARTICULAR SURFACE OF
CAPITATE,LUNATE,SCAPHOID AND RADIUS.
SCPHOLUNATE DISSOCIATION REDUCED BY 22 GAUGE WIRE LOOP.

41. 3) CAPSULODESIS:
Taleisnik suggeested tenodesis with capsulodesis for lunate stabilisation in patient
with triquetro-lunate stability.
Use FCU for volar intercalated instability.
Use FCR for dorsal intercalated instability.
FCU
FCR

42. Reduce the scaphoid
with pressure by thumb
on its tubercle,bring
wrist in ulnar
deviation,
 k-wire fix from dorsal
pole of scaphoid to
capitate and into 3rd
metacarpal.
Make notch in
scaphoid nonarticular
surface with osteotome.
Pass
capsuloligamentous flap
from it and tie it,and tie
to outside skin by botton
using 4.0 stainless still
pull-out wire suture.
DORSAL CAPSULODESIS:

44. ARTHRODESIS:
FUSION SURGERIES
SCPHOLUNATE TRAPEZOID FUSION.
SCAPHOCAPITATE FUSION.
SCAPHOLUNATE FUSION.
LUNOTRIQUTRAL FUSION.