Perilunate Injuries

Courtesy Dr Bo LIU, Dr Ashok Shyam, Ortho TV

Introduction

• Perilunate injuries are uncommon but devastating carpal injuries.
• They may occur as:
  • Perilunate fracture-dislocations (most commonly involving the scaphoid fracture).
  • Pure ligamentous injuries involving disruption of:
    • Scapholunate (SL) ligament
    • Lunotriquetral (LT) ligament
• These injuries cause severe carpal instability and functional impairment.

 

Classification of Perilunate Injuries

Most surgeons use the Mayfield classification to describe the progressive ligamentous disruption.

Mayfield Stages

• Stage I: Scapholunate ligament injury
• Stage II: Capitolunate disruption
• Stage III: Lunotriquetral ligament injury
• Stage IV: Lunate dislocation

 

Current Standard Treatment

Initial Emergency Management

• Immediate closed reduction
• Assessment of median nerve compression

 

Definitive Surgical Treatment

Common approaches include:

• Open reduction and internal fixation
• Surgical approaches:
  • Dorsal approach
  • Volar approach
  • Combined dorsal and volar approach

Goals of surgery:

• Fix associated fractures (e.g., scaphoid fracture)
• Repair disrupted ligaments
• Restore carpal alignment

 

Limitations of Conventional Open Surgery

Even with appropriate treatment:

• Prognosis is often suboptimal
• Many patients experience:
  • Reduced range of motion
  • Decreased grip strength
  • Persistent wrist stiffness

Functional recovery:

• Return to heavy labor or sports may take ?6 months
• Full rehabilitation may require up to 12 months

 

Problems with Open Surgery

Open procedures may cause:

• Additional surgical trauma
• Damage to:
  • Capsule
  • Carpal ligaments
• Increased scar formation
• Joint stiffness

They may also affect the blood supply to carpal bones, particularly the scaphoid.

 

Importance of Wrist Motion

Preserving wrist motion is particularly important for:

• Athletes
• Individuals with manual occupations
• Patients involved in activities requiring fine wrist movements

 

Arthroscopic Management as an Alternative

Concept

• Arthroscopic-assisted reduction and fixation
• Minimally invasive technique
• Allows direct visualization of intra-articular structures

 

Early Development of Arthroscopic Treatment

• Guillaume Herzberg proposed arthroscopic treatment as a potential option.
• In a 2008 Journal of Hand Surgery publication, arthroscopy was suggested as:
  • A technically demanding procedure
  • But potentially beneficial in reducing stiffness

At that time:

• Clinical evidence was limited.

 

Recent Evidence

Recent studies have demonstrated:

• Increasing success of arthroscopic treatment for perilunate injuries
• Several authors (including Korean and European hand surgeons) have reported promising outcomes.

 

Arthroscopic Treatment Experience

Example series:

• 40 cases over 5 years
• Most patients had >1 year follow-up

Findings:

• Arthroscopic management can achieve good functional outcomes.

 

Closed Reduction Strategy

Recommended Approach

• Attempt one careful closed reduction in the emergency department.
• Avoid repeated forceful blind reductions.

Reason:

• Repeated attempts can cause:
  • Additional cartilage damage
  • Further injury to carpal structures.

 

Arthroscopic-Assisted Reduction (AAR)

If closed reduction fails:

• Proceed to arthroscopic-assisted reduction.

Technique:

• Use wrist traction tower
• Arthroscopic instruments (probe or elevator) assist reduction
• Allows controlled manipulation under visualization

Benefits:

• Avoids uncontrolled blind manipulation
• Reduces risk of cartilage damage

 

Mechanism Preventing Closed Reduction

Failure of closed reduction may occur due to:

• Interposed carpal bones
• Scaphoid fracture displacement
• Capitate blocking reduction

Arthroscopy allows:

• Identification of obstruction
• Controlled reduction of fragments.

 

Arthroscopic Fixation of Scaphoid Fractures

Traditional technique:

• Percutaneous screw fixation under fluoroscopy

Limitations:

• Malreduction may occur
• Some patients develop:
  • Persistent wrist pain
  • Delayed union or nonunion

 

Advantage of Arthroscopy

Arthroscopy provides:

• Direct visualization of fracture reduction
• Ability to achieve anatomic reduction
• Accurate percutaneous screw fixation

 

Treatment of Ligament Injuries

Perilunate injuries commonly include:

• Scapholunate ligament disruption
• Lunotriquetral ligament disruption

Arthroscopy allows:

• Direct visualization
• Reduction of ligament intervals
• Percutaneous K-wire stabilization

 

Arthroscopic Ligament Augmentation Technique

Technique example:

• Use extended 3-4 portal
• Insert suture anchors into the lunate
• Sutures tied over dorsal capsule

Purpose:

• Reinforce the dorsal scapholunate complex
• Improve stability of the scapholunate interval

 

Clinical Example

Case: Trans-Scaphoid Perilunate Injury

Treatment steps:

• Closed reduction
• Arthroscopic assessment
• Percutaneous fixation of scaphoid
• Stabilization of ligament intervals

Outcome:

• Fracture healed at 3 months
• Good wrist function
• Minimal surgical scar

 

Pure Ligamentous Perilunate Injury

Example:

• Lunate dislocation without scaphoid fracture

Management:

• Arthroscopic reduction
• Percutaneous fixation of:
  • Scapholunate interval
  • Lunotriquetral interval

 

Advantages of Arthroscopic Treatment

Compared with open surgery:

• Less soft tissue trauma
• Better preservation of ligament blood supply
• Less postoperative stiffness
• Smaller scars
• Faster rehabilitation

Clinical outcomes show:

• Slightly better range of motion
• Slightly better functional scores
• Faster recovery

 

Limitations of Arthroscopic Treatment

• Technically demanding
• Visualization can be difficult due to:
  • Bleeding
  • Hematoma
• Requires significant surgical expertise

 

Current Evidence

Short-term outcomes suggest:

• Improved wrist motion
• Better functional scores
• Good patient satisfaction

However:

• Long-term outcomes are still under evaluation.

 

Practical Recommendations

Emergency Management

• Perform urgent closed reduction
• Assess median nerve function

 

Avoid

• Repeated forceful blind reductions

 

Surgical Options

• Traditional open reduction
• Arthroscopic-assisted treatment

 

Conclusion

• Arthroscopic treatment of perilunate injuries is feasible and promising.
• Provides:
  • Better range of motion
  • Faster rehabilitation
  • Minimal surgical trauma
• However:
  • It remains technically demanding
  • Long-term results are still being studied.

Surgeons should consider arthroscopic techniques as a valuable option in the management of perilunate injuries.