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DISLOCATION, WRIST LUNATE

Introduction

Lunate dislocations are relatively uncommon but are serious usually high energy injuries and are considered to be the last stage of the perilunate injury pattern.1, 2 Collectively with perilunate dislocations, lunate dislocations are the most frequently occurring carpal dislocations.3 Lunate dislocations typically occur in young adults secondary to high-energy trauma such as motor vehicle crashes, falls from a height, and industrial and sports accidents. The typical mechanism of injury is wrist hyperextension, often coupled with ulnar deviation. As the final stage of the perilunate dislocation injury pattern, these injuries involve the lunate dislocating out of its lunate fossa in the distal radius and rotating volarly, while the remainder of the carpus remains relatively aligned with the radius.4 At this stage, only the dorsal capsule and volar radiolunate ligaments hold the lunate in place, and failure of the multitude of ligaments may also lead to dislocation of other carpals.5, 6 The examination of a patient with a lunate dislocation will show a deformed wrist with limited wrist motion.  The fingers will be in a flexed posture and extension causes pain.  Frequently, there will be signs of acute carpal tunnel syndrome.19,20  Routine PA X-ray should be evaluated for loss of carpal height, carpal gaps and overlapping carpal bones,  disruption of Gilula's arcs and a triangular appearing lunate.  Although purely conservative methods were previously used to treat these injuries, most experts currently prefer a surgical approach that begins with closed reduction and traction X-rays followed by open reduction and internal fixation (ORIF) that includes ligamentous and bony repair/reconstruction.7, 8,19,20
 

Definitions

  • A lunate dislocation occurs when the articular surface of the lunate is displaced off the articular surface of the lunate fossa of the distal radius.

Hand Surgery Resource’s Dislocation Description and Characterization Acronym

D O C S

D – Direction of displacement

O – Open vs closed dislocation

C – Complex vs simple

S – Stability post reduction

D – Direction of displacement

  • The primary description and characterization of lunate dislocations are done by noting the direction of the displacement of the lunate relative to the distal radius. The three possible directions of displacement are dorsal, lateral, and volar.9 Most lunate dislocations are in the volar direction.4, 5
    • The rare dorsal lunate dislocation usually results from a high-energy flexion force to the carpus or a severe blow to the dorsum of the hand. The vast majority of these dislocations are also associated with concomitant fractures of other carpals or the distal radius.4, 5
  • The degree of displacement further characterizes lunate dislocations. In a true complete dislocation, the articular surface of the lunate is no longer in contact with the articular cartilage of the capitate or distal radius. If there is partial contact of the cartilaginous surfaces, then this is not a true dislocation but rather a joint subluxation.9

O – Open vs closed

  • The majority of lunate dislocations are closed; the skin is intact, and there is no route for bacteria to contaminate the joint space.
  • About 10% of lunate dislocations are open injuries, which is a result of the typical high-energy nature of the associated trauma. When present, these cases always require urgent irrigation, debridement, open reduction, and ligament repair.4, 8
  • Open lunate dislocations have a worse prognosis than closed injuries.8

C – Complex vs simple

  • Most lunate dislocations are simple, meaning that reduction is technically feasible under anesthetic block and sedation and is not blocked by soft tissue being interposed in the joint between the carpal and radial joint surfaces; however, closed reduction alone is associated with poor outcomes and is not typically advised for these injuries.
  • Complex (irreducible) lunate dislocations are rare but do occasionally occur, and may involve interposition of the dorsal joint capsule or some other soft tissue.4

S – Stability

  • A completely volarly dislocated lunate can usually be reduced into the lunate facet but will not stay anatomically aligned without internal fixation (K-wires or screws).

Related anatomy4, 5

  • Extensor tendons
  • Flexor tendons
  • Radial collateral ligament
  • Radioscaphocapitate ligament
  • Radiolunate ligaments (short and long)
  • Radioscapholunate ligament
  • Radiolunotriquetral ligament
  • Radioscaphoid ligament
  • Lunatocapitate ligament
  • Lunotriquetral ligament
  • Scaphotrapeziotrapezoid ligament
  • Scaphocapitate ligament
  • Triquetrohamatecapitate ligament
  • Ulnocarpal ligamentous complex: ulnolunate, ulnotriquetral, and ulnocapitate ligaments
  • Dorsal radiocarpal ligament
  • Dorsal intercarpal ligament
  • Space of Poirer
  • Osteology of the carpals and distal radius
  • The scapholunate and lunotriquetral ligaments are the lunate’s two major intercarpal attachments, which maintain a state of balance between the opposing forces. When one of these ligaments is disrupted, the balance is lost and the lunate is dominated by the remaining intercarpal relationship.10

Overall incidence

  • Because lunate dislocations and perilunate dislocations are part of the same injury pattern, many statistics group the two entities together, and it may therefore be difficult to distinguish individual characteristics of each.
  • Lunate and perilunate dislocations account for 7-10% of all carpal injuries,11, 12 but they are collectively the most common carpal dislocations.3 Lunate dislocations are less common than perilunate dislocations but account for 10-23% of all carpal dislocations.1, 2
  • Between 16-25% of lunate and perilunate dislocations are not accurately diagnosed upon initial evaluation.3, 13
  • Up to 10% of lunate and perilunate injuries are open, 26% are associated with polytrauma, and 11% have ipsilateral concomitant upper extremity injuries.8

Related Injuries/Conditions

  • Axial carpal fracture-dislocations which disrupt the distal carpal row and the metacarpal arch can be associated with lunate and perilunate dislocations.20
  • Fractures of the scaphoid, lunate, capitate, and/or triquetrum
  • Fractures of the distal radius
  • Lunate fracture-dislocation
  • Perilunate dislocation and fracture-dislocation
  • Extrinsic ligament injuries
  • Intrinsic ligament injuries
  • Extensor tendon ruptures
  • Flexor tendon ruptures

 

NOTE: For additional information see also carpal fractures adult -  lunate fracture

ICD-10 Codes

  • DISLOCATION, WRIST LUNATE

    Diagnostic Guide Name

    DISLOCATION, WRIST LUNATE

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    DISLOCATION WRIST: MIDCARPAL (PERILUNATE, TRANSSCAPHOID, ETC) S63.035_S63.034_ 

    Instructions (ICD 10 CM 2020, U.S. Version)

    THE APPROPRIATE SEVENTH CHARACTER IS TO BE ADDED TO EACH CODE FROM CATEGORY S63, S64, S65 AND S69
    A - Initial Encounter
    D - Subsequent Routine Healing
    S - Sequela

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Pathoanatomy Photos and Related Diagrams
Carpal diagrams, Normal X-rays and Alignment
  • Normal distal radius(R), capitate C), lunate(L), scaphoid(S) and metacarpals(M) alignment on “true” lateral x-ray of the wrist. A “true” lateral x-ray of the wrist must be taken in neutral forearm rotation and neutral wrist deviation.
    Normal distal radius(R), capitate C), lunate(L), scaphoid(S) and metacarpals(M) alignment on “true” lateral x-ray of the wrist. A “true” lateral x-ray of the wrist must be taken in neutral forearm rotation and neutral wrist deviation.
  • On a normal neutral rotation lateral, the horizontal axis of the radius, lunate, capitate, and metacarpals is a straight line (1). A line (2) the longitudinal axis of the scaphoid crosses line (1) at point (3). The average normal angle between these lines is 47° (range 30-60°). Angles outside this range suggest carpal instability (DISI >60°; VISI <30°).
    On a normal neutral rotation lateral, the horizontal axis of the radius, lunate, capitate, and metacarpals is a straight line (1). A line (2) the longitudinal axis of the scaphoid crosses line (1) at point (3). The average normal angle between these lines is 47° (range 30-60°). Angles outside this range suggest carpal instability (DISI >60°; VISI <30°).
  • Gilula’s lines (ref 4) superimposed on a neutral deviation PA wrist x-ray. Arc 1 is a smooth arcing line paralleling the proximal articular surfaces of the triquetrum, lunate, and scaphoid. Arc 2 parallels the distal concave surfaces of the triquetrum, lunate, and scaphoid. Arc 3 parallels the smooth curved surface of the proximal hamate and capitate. When these smooth curved lines are irregular, disrupted, or step off it is indicative of a carpal instability or dislocation. The insert shows the classi
    Gilula’s lines (ref 4) superimposed on a neutral deviation PA wrist x-ray. Arc 1 is a smooth arcing line paralleling the proximal articular surfaces of the triquetrum, lunate, and scaphoid. Arc 2 parallels the distal concave surfaces of the triquetrum, lunate, and scaphoid. Arc 3 parallels the smooth curved surface of the proximal hamate and capitate. When these smooth curved lines are irregular, disrupted, or step off it is indicative of a carpal instability or dislocation. The insert shows the classic deformities and disruptions (*) of Gilula’s lines 1 and 2 on the PA X-ray of a acute lunate dislunation.
  • The lesser arc injuries described by Mayfield (ref 21) that are associated with ligamentous injuries that lead to rotatory subluxation of the scaphoid, perilunate, and lunate dislocations. The arrow shows the path of the forces through first three stages. The insert shows the full four Mayfield lesser arc injury stages.
    The lesser arc injuries described by Mayfield (ref 21) that are associated with ligamentous injuries that lead to rotatory subluxation of the scaphoid, perilunate, and lunate dislocations. The arrow shows the path of the forces through first three stages. The insert shows the full four Mayfield lesser arc injury stages.
  • Greater arc carpal injuries are typically fracture/dislocations of radius, carpal bones, and ulnar styloid. Fracture possibilities include radial styloid fractures (1); S-scaphoid fractures (2) which are associated with transscaphoid perilunate fracture/dislocations; C-capitate fractures (3); L-lunate fractures (4); T-triquetral fractures (5) and/or ulnar styloid fractures (6).
    Greater arc carpal injuries are typically fracture/dislocations of radius, carpal bones, and ulnar styloid. Fracture possibilities include radial styloid fractures (1); S-scaphoid fractures (2) which are associated with transscaphoid perilunate fracture/dislocations; C-capitate fractures (3); L-lunate fractures (4); T-triquetral fractures (5) and/or ulnar styloid fractures (6).
  • Diagrammatic lateral x-ray of a lunate dislocation. R-radius; C-capitate, and L-lunate.
    Diagrammatic lateral x-ray of a lunate dislocation. R-radius; C-capitate, and L-lunate.
  • Axial carpal fracture and dislocation pathways (ref 20) superimposed on normal PA x-ray. Axial carpal fracture (Fx) and dislocation injuries usually disrupt the distal carpal row and metacarpal arch and can occasionally be associated with lunate dislocations.
    Axial carpal fracture and dislocation pathways (ref 20) superimposed on normal PA x-ray. Axial carpal fracture (Fx) and dislocation injuries usually disrupt the distal carpal row and metacarpal arch and can occasionally be associated with lunate dislocations.
Symptoms
History of high energy wrist trauma
Wrist pain, swelling and deformity
Limited wrist and finger range of motion
Numb fingers and paresthesia
Wrist pain with passive finger extension
Typical History

The typical patient is a 25-year-old female who injured her wrist in a car accident. The woman was driving at a high speed of ~55 MPH when a car suddenly emerged into her lane. She was forced to swerve out of the way and subsequently crashed into a telephone pole. Upon impact, the woman was still holding onto the steering wheel, which hyperextended both of her wrists and resulted in a lunate dislocation of the right wrist. Unfortunately, because of more serious trauma to her head, neck, and chest, the lunate dislocation was initially overlooked in the ED to focus on her other injuries. Ten hours after admission a secondary survey by the Orthopaedic team revealed a tender, swollen and deformed right wrist.  The patient was still intubated so a sensory exam was impossible, but her fingers were in an abnormal flexed posture. A right wrist portable X-ray confirmed a volar lunate dislocation.  During the next twelve hours, the patient’s overall condition was stabilized. With the patient sedated, traction was applied.  The lunate dislocation was closed reduced, a traction X-ray was done, and splints applied.  Later in the patient’s hospitalization, she was brought to the operating room, given general anesthesia and a formal open reduction, pinning and ligament repairs and/or reconstructions were performed.  The patient recovered from her multiple injuries and was discharged. Eight weeks after the open reduction of the right wrist lunate dislocation, the buried K-wires were removed in an ambulatory surgery center.

Positive Tests, Exams or Signs
Work-up Options
Images (X-Ray, MRI, etc.)
Lunate Dislocations
  • Right lunate dislocation AP X-ray: 1- radial styloid fracture; 2- volarly displaced triangular lunate; 3- ulna fracture.
    Right lunate dislocation AP X-ray: 1- radial styloid fracture; 2- volarly displaced triangular lunate; 3- ulna fracture.
  • Right lunate dislocation lateral X-ray volarly displaced lunate (arrow)
    Right lunate dislocation lateral X-ray volarly displaced lunate (arrow)
  • Left lunate dislocation AP X-ray volarly displaced triangular lunate (arrow) with "piece of pie" sign and disrupted Gilula's lines
    Left lunate dislocation AP X-ray volarly displaced triangular lunate (arrow) with "piece of pie" sign and disrupted Gilula's lines
  • Left lunate dislocation lateral X-ray volarly displaced lunate (arrow) with a "spilled tea cup" sign.
    Left lunate dislocation lateral X-ray volarly displaced lunate (arrow) with a "spilled tea cup" sign.
  • Left Scapholunate ligament rupture with lunate dislocation
    Left Scapholunate ligament rupture with lunate dislocation
Treatment Options
Treatment Goals
  • Perform a temporary closed reduction as soon as the patient's overall condition will allow.
  • Analyze the stability of the lunate and all of its articulations after the closed reduction by examination and traction X-rays.
  • Once the patient is medically stable, a formal ORIF with repair/reconstruction of the damged ligaments should be performed.
  • Maintain normal hand and wrist function with hand therapy designed to regain range of motion and strength.
Conservative
  • Lunate dislocations were historically managed with closed reduction under local anesthesia with sedation and casting, and some clinicians continue to treat them conservatively today, but an anatomical reduction is difficult to obtain and hold, and these methods often result in unsatisfactory outcomes. This is why the current gold standard of treatment is closed reduction followed by ORIF that includes ligamentous and bony repair.4, 6-8, 16
  • The first step of treatment is immediate, gentle, closed reduction performed under general anesthesia, Bier block, or an axillary block.
    • The reduction consists of flexing the wrist and then reducing the lunate into its fossa, using thumb pressure applied to the volar lunate and hook of hamate, followed by wrist extension. The capitate is then reduced onto the lunate with traction and wrist flexion, maintaining volar pressure on the lunate to prevent its redislocation.
    • After reduction, the wrist is placed in a sugar tong splint in neutral alignment to allow full digital motion. Radiographs are then taken to confirm the reduction, and if it can be maintained in the splint and progressive median nerve dysfunction does not occur, ORIF may be delayed for 3-5 days.4
  • If the lunate is subluxated out of its fossa but remains partially reduced and rotated <90°, closed reduction is often successful. Less commonly, the lunate dislocates completely out of its fossa and rotates >90°. In these cases, closed reduction is ineffective and should not be attempted. Prompt ORIF is indicated instead.4
  • In most cases closed reduction is only possible for a few days after the injury.4,19-21
Operative
  • If an adequate closed temporary reduction cannot be maintained in a splint following the removal of traction or in a polytrauma setting, percutaneous K-wires or external fixation may be used to temporarily maintain the reduction until a formal reconstruction ca be carried out.4
  • The surgical portion of treatment, which consists of open reduction, ligament and bone repair, and supplemental fixation, is typically performed within 3-5 days after the temporary closed reduction and initial swelling subsides. The optimal surgical approach—dorsal, volar, or combined—however, remains controversial.4, 6-8
    • The dorsal approach provides the best exposure for anatomical alignment and interosseous ligament repair.6
    • Adding a volar incision allows decompression of the carpal tunnel and direct repair of the volar capsule and ligament tear, but increases the surgical time and dissection.6 However, the combined volar and dorsal approach maybe needed to adequately reduce the lunate.
    • In general, it appears that a combined or volar approach is usually advised, especially if a carpal tunnel release is also to be performed.4, 6, 10
  • Carpal tunnel release
    • Necessary for patients with any evidence of median nerve compression.4
  • Closed reduction and percutaneous pinning (CRPP) can be performed but most surgeons favor ORIF and ligament repair which is associated with superior outcomes.4
  • Proximal row carpectomy
    • A salvage procedure for chronic lunate dislocations.
    • Should be avoided if there is loss of articular surface in the lunate fossa or proximal capitate.10
  • Total wrist arthrodesis and total wrist arthroplasty are rarely indicated for primary surgical treatment of a lunate dislocation but maybe occasionally be needed in severe complicated cases.
  • Arthroscopy assisted ORIF is another surgical option for lunate dislocations.
Treatment Photos and Diagrams
Open Reduction Lunate Dislocation
  • Open reduction of volar lunate dislocation (insert) with carpal tunnel release. Note 1- volar capsular ligament tear; 2- lunate in carpal tunnel; 3- retracted flexor tendons and median nerve.
    Open reduction of volar lunate dislocation (insert) with carpal tunnel release. Note 1- volar capsular ligament tear; 2- lunate in carpal tunnel; 3- retracted flexor tendons and median nerve.
Hand Therapy
  • Some patients with closed lunate dislocations that are close reduced early will need to exercise their fingers on their own or with the assistance of a hand therapist before their definitive reconstructive surgery to help reduce swelling and improve range of motion and strength.
  • Surgically repaired lunate dislocations, repaired ligaments, and unstable lunate dislocations will definitely need hand therapy, custom splinting, and possibly dynamic extension splints.
    • Postoperative management typically consists of immobilization in a thumb spica splint, followed by a short-arm thumb spica cast. Initial rehabilitation focuses on active movement of the shoulder, elbow, and fingers to prevent stiffness.7, 8
    • The cast is removed after 8 weeks and pins removed. Next active and passive range of motion and strengthening exercises for the wrist, forearm, and thumb can begin.7
Complications
  • Stiffness
  • Pain
  • Infection
  • Residual deformity
  • Weakened grip
  • Impaired ROM
  • Nerve injuries
  • Vascular injuries
  • Carpal tunnel syndrome
  • Chronic carpal instability
  • Complex regional pain syndrome
  • Lunate deformation and collapse
  • Posttraumatic osteoarthritis
  • Avascular necrosis is a rare complication after lunate dislocations.6
Outcomes
  • In general, the available evidence on lunate dislocations supports a surgical approach over a conservative one, as multiple studies have demonstrated superior outcomes in patients who undergo ORIF compared to those treated with closed reduction alone or CRPP.4, 6, 8, 11, 17
  • Despite optimal management, the prognosis for lunate dislocations is relatively poor, and most patients experience a loss of grip strength/ROM and develop radiographic signs of osteoarthritis and carpal collapse. However, these clinical measurements and radiographic changes do not correlate with patient satisfaction or the ability to return to work.4
    • Poor prognostic indicators for lunate dislocations include open injury, delay of diagnosis of greater than 4-6 weeks, persistent carpal malalignment, and large osteochondral defects.4, 6
    • There is no significant difference in the prognosis between perilunate and lunate dislocations.4
  • No differences in outcomes have been identified when comparing dorsal and volar surgical approaches for lunate dislocations.18
Key Educational Points
  • Remember the volar lunate dislocation represents the end-stage of a perilunate dislocation.20
  • Wrist arthrosis and decreased range of motion is a frequent late complication of carpal dislocations even when the initial treatment is optimal.19,20,21
  • Open and complex lunate dislocations require urgent surgical treatment.
  • Carpal tunnel syndrome is present in at least 25% of patients with lunate dislocations.4
  • When patients present with carpal tunnel symptoms, even if they are mild, and they have palmar hand and wrist abrasions, the surgeon should consider early carpal tunnel release before these minor palmar wounds become colonized with increased skin bacterial flora.
  • Routine radiographs
    • Posteroanterior (PA) and lateral radiographs are most useful: the PA view should be scrutinized for uneven gapping in the carpal bones.7
    • The primary radiographic signs of a lunate dislocation are:
    • The “spilled teacup sign”, showing dislocation of the lunate from the fossa into the space of Poirier with loss of colinearity of the radius, lunate, and capitate
    • Interruption of Gilula’s lines
    • The “piece of pie sign,” representing the lunate on a true AP view
    • Lunate and capitate overlap
    • An abnormal scapholunate angle of >70° or <30°14
    • CT scan - May be needed if there is any doubt and in order to avoid a delay in diagnosis.15
  • Traction x-ray views done with the fingers in finger traps and a counterweight at the elbow are very useful diagnostically. These traction views frequently show carpal gaps and other carpal malalignments that are not seen on routine x-rays.19,20
  • The mechanism injury for a perilunate or lunate carpal dislocation is extension, ulnar deviation and intercarpal supination. Thus, the reduction maneuver for reducing a lunate dislocation is a reverse mechanism. During reduction, the surgeon applies traction, ulnar deviation which is followed by intercarpal pronation, palmar flexion and radial deviation while the surgeons pushes the lunate dorsally with his thumb.21
  • Although a considerable delay between the injury and its treatment worsens the prognosis, acceptable outcomes are possible even if surgical treatment is delayed up to 45 days. However, after 4 months, a salvage procedure such as proximal row carpectomy may be required.4
  • Close reduction of a carpal lunate dislocation alone fails because of a paradox of this reduction, where there is no position of the wrist that optimizes the healing of all the damaged ligamentous structures.  Placing the wrist in extension after a close reduction approximates the scapholunate ligament and dorsal capsule but it separates the torn palmar ligaments. If the wrist is placed in palmar flexion after reduction this approximates the palmar ligaments but causes dorsal subluxation of the proximal pole scaphoid and separation of the scapholunate ligament.21
  • Scaphoid lunate ligament repair and lunotriquetral ligament repair at the time of open reduction and internal fixation improves the treatment outcome for a carpal lunate dislocation.
  • There is no consensus regarding the best surgical approach for reduction and reconstruction of a lunate dislocation but if the lunate remains is in the carpal tunnel after an attempted closed reduction then a volar or combined volar/dorsal approach is usually needed.19
References

New and Cited Articles

  1. Adkison, JW and Chapman, MW. Treatment of acute lunate and perilunate dislocations. Clin Orthop Relat Res 1982;(164):199-207. PMID: 7067286
  2. Green, DP and O'Brien, ET. Open reduction of carpal dislocations: indications and operative techniques. J Hand Surg Am 1978;3(3):250-65. PMID: 350947
  3. Grabow, RJ and Catalano, L, 3rd. Carpal dislocations. Hand Clin 2006;22(4):485-500. PMID: 17097469
  4. Budoff, JE. Treatment of acute lunate and perilunate dislocations. J Hand Surg Am 2008;33(8):1424-32. PMID: 18929215
  5. Siddiqui, N and Sarkar, S. Isolated dorsal dislocation of the lunate. Open Orthop J 2012;6:531-4. PMID: 23248723
  6. Dimitriou, CG, Chalidis, B and Pournaras, J. Bilateral volar lunate dislocation. J Hand Surg Eur Vol 2007;32(4):447-9. PMID: 17321647
  7. Stanbury, SJ and Elfar, JC. Perilunate dislocation and perilunate fracture-dislocation. J Am Acad Orthop Surg 2011;19(9):554-62. PMID: 21885701
  8. Montero Lopez, NM and Paksima, N. Perilunate Injuries and Dislocations Etiology, Diagnosis, and Management. Bull Hosp Jt Dis (2013) 2018;76(1):33-37. PMID: 29537955
  9. Merrell G, Slade JF. Dislocations and ligament injuries in the digits. In: Wolfe, SW, Hotchkiss RN, Pederson WC, Kozin SH (eds): Green’s Operative Hand Surgery.  Philadelphia 2011: Elsevier Churchill Livingstone, pp. 291-332.
  10. Wingelaar, M, Newbury, P, Adams, NS, et al. Lunate Dislocation and Basic Wrist Kinematics. Eplasty 2016;16:ic37. PMID: 27610210
  11. Muppavarapu, RC and Capo, JT. Perilunate Dislocations and Fracture Dislocations. Hand Clin 2015;31(3):399-408. PMID: 26205701
  12. Inoue, G and Shionoya, K. Late treatment of unreduced perilunate dislocations. J Hand Surg Br 1999;24(2):221-5. PMID: 10372780
  13. Herzberg, G, Comtet, JJ, Linscheid, RL, et al. Perilunate dislocations and fracture-dislocations: a multicenter study. J Hand Surg Am 1993;18(5):768-79. PMID: 8228045
  14. Tucker, A, Marley, W and Ruiz, A. Radiological signs of a true lunate dislocation. BMJ Case Rep 2013;2013. PMID: 23616330
  15. Filippitzi, F, Dallaudiere, B, Omoumi, P, et al. Lunate dislocation. JBR-BTR 2014;97(5):318. PMID: 25597222
  16. Virani, SR, Wajekar, S, Mohan, H, et al. A unique case of bilateral trans-scaphoid perilunate dislocation with dislocation of lunate into the forearm. J Clin Orthop Trauma 2016;7(Suppl 1):110-114. PMID: 28018087
  17. Herzberg, G. Acute Dorsal Trans-scaphoid Perilunate Dislocations: Open Reduction and Internal Fixation. Tech Hand Up Extrem Surg 2000;4(1):2-13. PMID: 16609406
  18. Melone, CP, Jr., Murphy, MS and Raskin, KB. Perilunate injuries. Repair by dual dorsal and volar approaches. Hand Clin 2000;16(3):439-48. PMID: 10955217
  19. Vitale MA, Seethharaman M, Ruchelsman DE. Perilunate dislocations. J Hand Surg AM. 2015; 40:358 - 362.
  20. Herzberg G. Perilunate and axial carpal dislocations and fracture-dislocations. J Hand Surg AM. 2008; 33A: 1659 - 1668.
  21. Mayfield JK, Johnson RP, Kilcoyne RK. Carpal dislocations: pathomechanics and progressive instability. J Hand Surg AM. 1980; 5(3): 226 – 241.

Review

  1. Budoff, JE. Treatment of acute lunate and perilunate dislocations. J Hand Surg Am 2008;33(8):1424-32. PMID: 18929215

Classic

  1. Campbell RD Jr, Lance EM, Yeoh CB. LUNATE AND PERILUNAR DISLOCATIONS. J Bone Joint Surg Br 1964;46:55-72. PMID:
  2. Green DP, O’Brien ET. Open reduction of carpal dislocations: indications and operative techiques. J Hand Surg AM.1978; 3(3): 250 – 265.
  3. Mayfield JK, Johnson RP, Kilcoyne RK. Carpal dislocations: pathomechanics and progressive instability. J Hand Surg AM. 1980; 5(3): 226 – 241.
  4. Gilula LA: Carpal Injuries: Analytic Approach and Case Exercises.  Am J Roentgenology 133:513, 1979.
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