This document describes a case report of a 33-year-old male who sustained a perilunate dislocation of the left wrist after falling on an outstretched hand. On examination, the patient had swelling and tenderness over the scaphoid and lunate bones. X-rays revealed a perilunate dislocation. The patient underwent closed reduction under anesthesia and was placed in a cast post-operatively. The document then reviews wrist anatomy, mechanisms of perilunate injuries, classification systems for these injuries, clinical presentation, imaging findings, and management strategies including closed or open reduction with possible ligament reconstruction or fixation.

1. PERILUNATE DISLOCATION
(A CASE REPORT)
Dr KISHORE VEMULA,
JUNIOR RESIDENT,
DEPT OF ORTHOPAEDICS,
SVMC,TPT.

2. CASE HISTORY
• 33 year old male sustained road traffic
accident,
• Fall on outstreched hand
• Pain and swelling of lt wrist
• Not able to do move wrist

3. On examination
• Diffuse swelling of wrist
• Point tenderness over scaphoid, distal to
listers tubercle
• Wrist movements are painful
• No associated neurovascular deficits

4. radiogaphy

5. management

7. • Post op patient is managed in above elbow
cast
• waiting for follow up and results………..

8. PERILUNATE DISLOCATIONS AND
FRACTURES

9. WRIST ANATOMY
 EXTRINSIC LIGAMENTS
RADIUS – CARPALS - METACARPALS
 INTRINSIC LIGAMENTS
CARPAL – CARPAL
• VOLAR LIGAMENTS
strong, more developed
• DORSAL LIGAMENTS

10. MAJOR VOLAR LIGAMENTS
• RADIO SCAPHO CAPITATE – entire scaphoid
kinematics
• RADIO SCAPHO LUNATE – not a true ligament, only
a tuft of vascular synovium ( ligament of testut)
• RADIO LUNO TRIQUETRAL
• SHORT RADIO LUNATE
• ULNO LUNATE
• ULNO TRIQUETRAL
• ULNO CAPITATE
• VENTRAL RADIO ULNAR

11. MAJOR DORSAL LIGAMENTS
• RADIO SCAPHOID
• RADIO LUNATE
• DORSAL RADIO TRIQUETRAL
• DORSAL INTER OSSEOUS

12. INTRINSIC LIGAMENTS
PROXIMAL ROW
• SCAPHO LUNATE
• LUNO TRIQUETRAL
DISTAL ROW
• TRAPEZIO TRAPEZOID
• TRAPEZIO CAPITATE
• CAPITO HAMATE
MID CARPAL LIGAMENTS
• SCAPHO CAPITATE
• SCAPHO TRAPEZOID
• TRIQUTRO HAMATE
• TRIQUTRO CAPITATE
NON DIS ASSOCIATIVE TYPE OF CARPAL INSTABILITY

13. RADIOGRAPHIC ANATOMY
• RADIAL INCLINATION - 22
• RADIAL LENGTH- 11MM
• VOLAR TILT- 11
• SCAPHO LUNATE ANGLE -44
• CAPITO LUNATE ANGLE – 0
clasically radius , lunate, capitate acts as a
central link in sagittal plane.
SPACE OF PORIER- non ligamentous area b/w
capitate, lunate.. Disappears on flexion. Prominent
on extension gives space for lunate to dislocate
GILULA LINES OF CARPALS

15. MECHANISM OF INJURY
• FALL ON OUTSRECHED HAND, WRIST EXTENSION,
ULNAR DEVIATION, INTERCARPAL SUPINATION
• GREATER ARC
Starts radially through
radial styloid/ scaphoid body/
Scapho lunate interval
• LESSER ARC
More curved path,
Only ligaments involved
Goes perilunate path

16. MAYFIELD PROGRESSION OF PERILUNATE
INJURY
STAGE 1;
TRANS SCAPHOID PERILUNATE.. Mc type.. DEQUERVAINS INJURY
TRANS STYLOID PERILUNATE
TRANS SCAPHO CAPITATE
R-S-L, S-L LIGAMENTS ARE DAMAGED
STAGE 2;
MID CARPAL LIGAMENTS INJURY
TO SPACE OF POIRIER
STAGE 3;
LUNO TRIQUETRAL DISASSOCIATION
STAGE 4;
DORSAL R-L-T INJURY
VOLAR DISPLACEMENT OF LUNATE

17. SCAPHO LUNATE DISSOCIATION
• Mc signifigant ligamentous disruption of wrist
• Fall on outstreched hand, ulnar deviation,
intercarpal supination
• Damage
R-S-L ligament
S-L interosseous ligament

19. LUNO TRIQUETRAL DISSOCIATION
• Stage 3 lesser arc injury
• Fall on outstreched hand, radial deviation,
intercarpal pronation
• Damages
interosseous L-T
dorsal R-L-T ligament

20. VISI
Scaphoid--------lunate-------triquetrum

22. CLINICAL PRSENTATION
• h/o trauma
• Pain, swelling of wrist
• Decreased grip stength
• Most consistent sign to describe ligamentous
injuries is LOCALISED TENDERNESS
distal to listers tubercle…S-L
distal to ulnar head…L-T
Snuff box… scaphoid #

23. STESS TESTS
• WATSON TEST ….. S-L dissociation
• BALLOTMENT TEST…… L-T dissociation

24. Radiography
• AP
• LATERAL
• SCAPHOID VIEW
• ULNAR DEVIATION SUPINATED VIEW
• CLENCHED FIST SUPINATED VIEW
• `RADIAL DEVIATION VIEW

25. AP VIEW
• terry thomas sign
• cortical ring sign
• gilula arches disturbance
• wedge / triangular lunate
• assosiated fractures of carpals

27. Lateral view

28. MANAGEMENT
• PERILUNATE DISLOCATION
CLOSED REDUCTION UNDER ANASTHESIA
Longitudinal traction, wrist hyper extension with
volar pressure to lunate often successful
PINNING
lunate to radius, triquetrum to lunate, scaphoid to
lunate
maintained reduction in short arm cast for 4-6 weeks f/b
mobilisation

29. Trans scaphoid perilunate dislocation-
management
• Volar approach
• Reduction of lunate
• Scaphoid fixation
• Carpal tunnel release

30. Open reduction
• when closed reduction not possible or
unstable
• Combined volar, dorsal approach
• reduction ,Ligament reconstruction

31. complications
• Median nerve injury… emergency release
• Chronic carpal instability.. Inadequate
treatment… chronic pain in wrist
Salvage ….
Proximal row carpectomy/ radio carpal fusion
• Post traumatic arthritis

32. ULNO CARPAL DISSOCIATION

33. TRIANGULAR FIBRO CARTILAGE..
anatomy
Components
• Articular disc
• Meniscal homologue
• Dorsal radio ulnar ligament
• Ventral radio ulnar ligament
• Ulno lunate ligament
• Ulno triquetral ligament
• Ulnar collateral ligament
• Psudo sheath of ECU

35. • TFCC is a major stabiliser of ulnar carpus and
DRUJ
• It absorbs about 20 percent of axial load
across the wrist joint
• Injury to TFCC leads to ulno carpal , DRUJ
instability

36. Ulno carpal dissociation
• Avulsion or rupture of TFCC from ulnar styloid
results in loss of sling support for ulnar wrist
• Lunate and triquetrum fall away relative to
distal ulna
• Had a palmar flexed, semisupinated attitude
• Distal ulna subluxed dorsally

37. Ulno carpal dissociation
• Clinically
dorsal prominence of distal ulna
Volar displacement of ulnar carpus
tenderness distal to ulnar head, at ulnar
styloid
X ray
AP VIEW…. Avulsion of ulnar styloid
Lateral view…..dorsal displacement of ulna

38. management
• Dorsal approach
• b/w 5th , 6th extensor compartment
• large styloid fragment needs fixation
• Ligamentous reconstruction
• Ular neuropathy….
• Usually transient sensory sympts
• Sometimes requires exploration

39. •Thank u………..