Courtesy Dr Bo LIU, Dr Ashok Shyam, Ortho TV

Introduction

Perilunate injuries are uncommon but severe carpal injuries that can lead to significant functional impairment.

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Types of Perilunate Injuries

• Perilunate fracture-dislocations (commonly involving scaphoid fractures)
• Pure ligamentous injuries involving:
  • Scapholunate (SL) ligament
  • Lunotriquetral (LT) ligament

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Clinical Impact

• Severe carpal instability
• Long-term functional limitation if not treated appropriately

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Classification of Perilunate Injuries

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Mayfield Classification

Describes progressive ligamentous disruption:

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Conventional Management

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Emergency Management

• Immediate closed reduction
• Assessment for median nerve compression

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Definitive Surgical Treatment

Options

• Open reduction and internal fixation (ORIF)

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Surgical Approaches

• Dorsal approach
• Volar approach
• Combined approach

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Goals of Surgery

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

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Limitations of Open Surgery

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Clinical Outcomes

Even with proper treatment:

• Reduced range of motion
• Decreased grip strength
• Persistent stiffness

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Recovery Timeline

• Return to heavy activity: 6 months
• Full rehabilitation: up to 12 months

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Drawbacks

• Extensive soft tissue dissection
• Capsular and ligament damage
• Increased scar formation
• Potential compromise of vascularity (especially scaphoid)

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Importance of Preserving Wrist Motion

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High-Demand Patients

• Athletes
• Manual laborers
• Individuals requiring fine wrist function

 Require optimal motion preservation

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Arthroscopic Management

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Concept

• Arthroscopic-assisted reduction and fixation
• Minimally invasive approach
• Direct visualization of intra-articular structures

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Historical Development

• Introduced by Guillaume Herzberg (2008)
• Initially considered:
  • Technically demanding
  • Limited evidence

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Recent Evidence

• Increasing success reported
• Studies demonstrate:
  • Improved functional outcomes
  • Better recovery profiles

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Closed Reduction Strategy

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Recommended Approach

• Attempt one careful closed reduction

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Avoid

• Repeated forceful blind attempts

 Risk of:

• Cartilage damage
• Further ligament injury

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Arthroscopic-Assisted Reduction (AAR)

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Indication

• Failed closed reduction

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Technique

• Wrist traction tower
• Arthroscopic probe/elevator
• Controlled reduction under visualization

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Advantages

• Precise manipulation
• Reduced risk of cartilage injury
• Identification of obstacles to reduction

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Causes of Failed Closed Reduction

• Interposed carpal bones
• Displaced scaphoid fracture
• Capitate blocking reduction

 Arthroscopy allows direct identification and correction

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Arthroscopic Fixation of Scaphoid Fractures

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Limitations of Conventional Fixation

• Malreduction risk
• Persistent pain
• Nonunion or delayed union

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Advantages of Arthroscopy

• Direct visualization
• Anatomical reduction
• Accurate screw placement

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Management of Ligament Injuries

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Common Injuries

• Scapholunate ligament
• Lunotriquetral ligament

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Arthroscopic Benefits

• Direct visualization
• Accurate reduction
• Percutaneous K-wire stabilization

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Arthroscopic Ligament Augmentation

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Technique

• Use extended 3–4 portal
• Insert suture anchors into lunate
• Tie sutures over dorsal capsule

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Purpose

• Reinforce dorsal SL complex
• Improve stability

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Clinical Scenarios

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1. Trans-Scaphoid Perilunate Injury

Management

• Closed reduction
• Arthroscopic evaluation
• Percutaneous scaphoid fixation
• Ligament stabilization

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Outcome

• Union at ~3 months
• Good functional recovery
• Minimal scarring

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2. Pure Ligamentous Injury

Example

• Lunate dislocation without fracture

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Management

• Arthroscopic reduction
• Stabilization of:
  • SL interval
  • LT interval

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Advantages of Arthroscopic Treatment

• Minimal soft tissue trauma
• Preservation of vascularity
• Reduced stiffness
• Smaller scars
• Faster rehabilitation

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Clinical Outcomes

• Better range of motion
• Improved functional scores
• Faster return to activity

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Limitations

• Technically demanding
• Visualization challenges:
  • Bleeding
  • Hematoma
• Requires significant surgical expertise

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Current Evidence

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Short-Term Results

• Improved motion
• Good patient satisfaction
• Functional improvement

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Limitation

• Long-term outcomes still under evaluation

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Practical Recommendations

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Emergency Care

• Perform urgent closed reduction
• Assess median nerve

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Avoid

• Repeated blind reductions

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Definitive Options

• Open surgery
• Arthroscopic-assisted techniques

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Conclusion

Arthroscopic management of perilunate injuries is:

• Feasible and promising
• Provides:
  • Better motion
  • Faster recovery
  • Minimal tissue trauma