M u s c u l o s k e l e t a l I m a g i n g • R ev i ew

Scalcione et al.
Carpal Dislocations and Fracture-
Dislocations

Musculoskeletal Imaging
Review
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Spectrum of Carpal Dislocations

FOCUS ON:

and Fracture-Dislocations: Imaging

and Management
Luke R. Scalcione1 OBJECTIVE. The objectives of this article are to discuss the imaging of carpal disloca-
Lana H. Gimber 1 tions and fracture-dislocations and to review the ligamentous anatomy of the wrist, mecha-
Annette M. Ho1 nisms of injury, and routine management of these injuries.
Stephen S. Johnston1 CONCLUSION. Perilunate dislocations, perilunate fracture-dislocations (PLFDs), and
Joseph E. Sheppard2 lunate dislocations are high-energy wrist injuries that can and should be recognized on radio-
graphs. These injuries are a result of important sequential osseous and ligamentous injuries or
Mihra S. Taljanovic1
failures. Prompt and accurate radiographic diagnosis aids in the management of patients with
Scalcione LR, Gimber LH, Ho AM, Johnston SS, perilunate dislocations, PLFDs, and lunate dislocations while assisting orthopedic surgeons
Sheppard JE, Taljanovic MS with subsequent surgical planning. CT may better show the extent of the injury and help in treat-
ment planning particularly in cases of delayed treatment or chronic perilunate dislocation. A
CT examination with coronal, sagittal, and 3D reformatted images is ordered at our institution
in cases in which the extent of the carpal injuries is poorly shown on radiographic examination.

P
erilunate dislocations and perilu- “arcs of Gilula” [3] (Fig. 1). The first arc out-
nate fracture-dislocations (PLFDs) lines the proximal convexity of the scaph-
typically result from high-energy oid, lunate, and triquetrum. The second arc
injuries. These injuries are missed conforms to the distal concave surface of the
clinically and radiographically in up to 25% of scaphoid, lunate, and triquetrum. The third
cases [1]. Perilunate dislocations and PLFDs arc contours the proximal convex surface of
typically result from a fall on an outstretched the capitate and hamate [4].
hand in which an axial force is directed on the A lateral radiograph of the wrist should
Keywords: lunate dislocations, Mayfield classification, carpus with the wrist in hyperextension (dorsi- be obtained to assess the normal colinearity
perilunate dislocations, perilunate fracture-dislocations,
flexion), ulnar deviation, and intercarpal supi- of the distal radial articular surface, lunate,
transcapitate, transradial styloid, transscaphoid,
transtriquetral, transulnar styloid nation. Osseous and ligamentous failures occur capitate, and middle finger metacarpal base.
in a sequential manner as described by May- These structures should align on a lateral ra-
DOI:10.2214/AJR.13.11680 field et al. [2]. diograph. Scapholunate interosseous ligament
injuries are suggested when there is a scaph-
Received August 4, 2013; accepted after revision
January 14, 2014.
Normal Bony and Ligamentous olunate interosseous distance of more than 2
Anatomy of the Wrist and mm on a posteroanterior radiograph [5, 6]. A
Presented at the 2013 ARRS annual meeting, Radiographic Assessment scapholunate interosseous distance of up to
Washington, DC. Radiographic Evaluation 4 mm, however, may be a normal variant in
1 Posteroanterior, oblique, lateral, and pos- some individuals [7]. When the scapholunate
Department of Medical Imaging, The University of
Arizona Health Network, 1501 N Campbell Ave, PO Box teroanterior with ulnar deviation (i.e., scaph- interosseous distance exceeds 4 mm, it is al-
245067, Tucson, AZ 85724-5067. Address correspon- oid view) radiographs are obtained in the eval- most certainly abnormal [7]. When the scaph-
dence to L. R. Scalcione ([email protected]). uation of wrist injuries. Radiographs are the olunate interosseous ligament fails, the scaph-
2
initial examination, although CT may be per- oid tends to palmar flex whereas the lunate
Department of Orthopaedic Surgery, The University of
Arizona Health Network, Tucson, AZ.
formed for further characterization of fractures dorsiflexes. The relationship of the scaphoid
and of the orientation of fracture fragments in and lunate can be evaluated by assessing the
This article is available for credit. the setting of a perilunate dislocation or PLFD scapholunate angle; this angle is defined as
owing to its spatial resolution and ability to re- the angle taken from a line drawn along the
AJR 2014; 203:541–550
construct images in various planes. long axis of the scaphoid and a line drawn
0361–803X/14/2033–541 Posteroanterior radiographs with the pa- along the short axis of the lunate. A normal
tient’s wrist in the neutral position should be scapholunate angle measures between 30°
© American Roentgen Ray Society scrutinized to ensure the continuity of the and 60° [8] (Fig. 1). A scapholunate angle of

AJR:203, September 2014 541

 Scalcione et al.

greater than 60° indicates dorsal tilt of the lu- bility pattern [14]. Normally, when the wrist Ligaments of the Wrist
nate and dorsal intercalated segment instabil- is in ulnar deviation, the scaphoid is maximal- The wrist ligaments are intracapsular and
ity (DISI), which typically occurs with tears ly profiled and there is slight widening of the are categorized into two main subdivisions:
of the scapholunate interosseous and extrinsic scapholunate interosseous distance [15]. As the intrinsic wrist ligaments, which have in-
dorsal intercarpal ligaments [9]. Conversely, a the patient moves the wrist so it is in radial terosseous attachments between carpal bones,
scapholunate angle of less than 30° indicates deviation, the distal pole of the scaphoid ro- and the extrinsic, or capsular, wrist ligaments,
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volar tilt of the lunate and volar intercalated tates into a palmar-flexed position. With the which extend beyond the carpal bones.
segment instability (VISI), which is typical- wrist in radial deviation, there is also slight Intrinsic wrist ligaments—The two most im-
ly associated with lunotriquetral interosse- widening of the lunotriquetral interosseous portant intrinsic wrist ligaments are the scaph-
ous and extrinsic dorsal radiocarpal ligament distance [15]. The hamate, capitate, and trap- olunate interosseous ligament and lunotriqu-
tears [10]. On lateral radiographs, perilunate ezoid move as a fixed unit in a “supple” cup etral interosseous ligament. The scapholunate
dislocations and PLFDs are characterized by formed by the scaphoid, lunate, and trique- interosseous ligament attaches the scaphoid and
loss of colinearity of the radius, lunate, and trum [15]. With the wrist in a clenched prone lunate bones as its name implies and has dorsal,
capitate. The volar tilt and dislocation of the position, as the patient moves the wrist from central (proximal), and volar bands. The dor-
lunate have been termed the “spilled-teacup” radial deviation to ulnar deviation, the scaph- sal band is more robust and more important for
sign on lateral radiographs and “piece-of-pie” oid may show abnormal tracking in the lat- wrist stability than the central and volar bands.
sign on posteroanterior radiographs. Although ter two thirds of the movement with transient The central band is triangular-shaped, and the
the spilled-teacup and piece-of-pie signs have widening of the scapholunate interosseous volar band is trapezoidal in shape.
been classically described in lunate disloca- distance and a sudden “lurch” of the scaph- The lunotriquetral interosseous ligament
tions, the morphology of the lunate in peri- oid as it assumes normal alignment when the is smaller than the scapholunate interosseous
lunate dislocations may be altered and there wrist moves into extreme ulnar deviation. ligament and maintains the alignment of the
may be a loss of the normal quadrangular ap- This altered scaphoid movement can be asso- lunate and triquetrum via its osseous attach-
pearance of the lunate on posteroanterior ra- ciated with an audible click [16]. ments. Similar to the scapholunate interos-
diographs. The capitolunate angle should also seous ligament, the lunotriquetral interosse-
be assessed when evaluating the colinearity Carpal Bones ous ligament has three bands (dorsal, central
of the wrist on the lateral view. The capitolu- The carpus is formed by the proximal or proximal, and volar), with the volar band
nate angle is measured by the angle created and distal carpal rows in addition to three being the most important for wrist stability.
by drawing a line along the short axis of the biomechanically organized columns. The The scapholunate and lunotriquetral inter-
lunate and a line drawn along the long axis proximal row consists of the scaphoid, lu- osseous ligaments maintain the stability of
of the capitate (Fig. 1). A normal capitolunate nate, and triquetrum and is more mobile the lunate and balance the net forces acting
angle measures less than 30° [8]. A capitolu- because it adapts to the motions of the dis- on the lunate. The scaphoid exerts a net volar
nate angle of greater than 30° can be seen in tal radius and ulna. The pisiform is a ses- force on the lunate, and the triquetrum exerts
the setting of DISI or VISI as the lunate dor- amoid within the flexor carpi ulnaris ten- a net dorsal force on the lunate. Thus, dis-
sally and volarly tilts, respectively. An ac- don and does not play a significant role in ruption of the scapholunate interosseous lig-
ceptable neutral lateral view is necessary for carpal instability owing to its confined lo- ament causes a relatively unopposed dorsal
evaluation of the capitolunate angle because cation. The distal row—consisting of the pull on the lunate from the triquetrum via an
off-lateral views may produce a relative pseu- trapezium, trapezoid, capitate, and ha- intact lunotriquetral interosseous ligament,
dodorsiflexion appearance of the lunate [11]. mate—is more rigid and conforms to the which results in DISI. In contradistinction,
motion of the metacarpal bases. The three disruption of the lunotriquetral interosseous
Fluoroscopic Evaluation of Instability columns of the carpus are divided accord- ligament causes a relatively unopposed volar
Fluoroscopy can be used in the diagnosis of ing to their biomechanical function in the pull on the lunate from the scaphoid via an
carpal instability when radiographs show nor- longitudinal plane and include the follow- intact scapholunate interosseous ligament,
mal findings and clinical examination is indeter- ing: the radioscaphoid column consisting of which results in VISI.
minate [12]. Taleisnik [13] introduced the con- the scaphoid, trapezium, and trapezoid; the Extrinsic wrist ligaments—The incon-
cept of dynamic carpal instability resulting from lunate column consisting of the lunate and sistency in the nomenclature of the extrin-
partial ligamentous injuries that cause wrist pain capitate; and the ulnotriquetral column con- sic wrist ligaments in the radiology and or-
without changes in carpal alignment on static ra- sisting of the triquetrum and hamate [17]. thopedics literature is often daunting when
diographs. Real-time evaluation of the wrist in a The radiocarpal joint is formed by the dis- learning these ligaments. We will address
pronated position is performed while the patient tal biconcave articular surface of the radi- each extrinsic wrist ligament with various
moves the wrist from extreme radial deviation us and the convex articular surfaces of the supernumerary names in parentheses for
to extreme ulnar deviation. The lateral position scaphoid and lunate bones. The distal articu- ease of referencing these ligaments. The ex-
of the wrist while the patient dorsiflexes and pal- lar surface of the radius has a volar tilt of ap- trinsic ligaments work in concert to oppose
mar flexes is also assessed. Longitudinal trac- proximately 10° and a radial inclination of the normal tendency of the carpus, which
tion and wrist palmar flexion may be used to ac- approximately 24° [18]. The midcarpal joint wants to rest in an ulnar and palmar position
centuate capitolunate instability [12, 14]. Dorsal is formed by the scaphotrapeziotrapezoid- owing to the radial inclination and a palmar
subluxation of the capitate with respect to the lu- triscaphe articulation, scaphocapitate articu- tilt of the distal radius [20].
nate will be evident on the lateral view after this lation, lunocapitate articulation, and trique- The palmar extrinsic ligaments are more
maneuver in patients with a capitolunate insta- tral-hamate articulation [19]. robust, thicker, and stronger than the dorsal

542 AJR:203, September 2014

 Carpal Dislocations and Fracture-Dislocations

extrinsic wrist ligaments and are important in The palmar scaphotriquetral ligament ex- extrinsic wrist ligaments become taut and lock
wrist stabilization [21, 22]. The palmar ex- tends between the scaphoid and triquetrum the lunate to the radius at the lunate fossa with
trinsic ligaments include the radioscapho- superficial to the radioscaphocapitate and ul- subsequent tightening of the palmar ligaments
capitate (also known as radiocapitate), long nocapitate ligaments. The radioscaphocapi- locking the distal carpal row to the proximal
radiolunate (also known as radiolunotriqu- tate, lunocapitate, and palmar scaphotrique- carpal row.
etral, radiotriquetral, and lunotriquetral), ra- tral ligaments form the arcuate ligament [25].
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dioscapholunate (also known as the ligament The dorsal extrinsic ligaments are less ro- Mechanism of Injury
of Testut and Kuenz), short radiolunate (also bust than the palmar extrinsic ligaments and Perilunate dislocations, PLFDs, and lu-
known as radiolunate), ulnocapitate (also are biomechanically less important [21]. The nate dislocations occur from a fall on an out-
known as ulnotriquetrocapitate), palmar ulno- dorsal extrinsic ligaments include the dor- stretched hand that involves a summation of
lunate, palmar ulnotriquetral, and palmar sca- sal radiocarpal (also known as radiotriquetral forces. The carpus is hyperextended and su-
photriquetral (also known as triquetrocapito- and radiolunotriquetral), dorsal intercarpal pinates on a fixed pronated forearm.
scaphoidal and triquetroscaphoidal) (Fig. 2). (also known as triquetroscaphoidal and tri- The term “zone of vulnerability” describes
The radioscaphocapitate ligament origi- quetrotrapezoidotrapezial), and dorsal ulnotri- a mechanism of wrist injuries that follow a se-
nates from the volar radial aspect of the radi- quetral (also referred to as “capsular thicken- quential pattern around the carpus [29]. The
al styloid, courses about the scaphoid waist, ing”) ligaments (Fig. 2). The dorsal extrinsic zone of vulnerability outlines the direction of
and inserts onto the palmar aspect of the cap- ligaments contribute to stabilization of the the major volar wrist ligaments in the region
itate [23, 24]. The radioscaphocapitate liga- proximal carpal row. The dorsal radiocar- of the greater carpal arc and is a more simplis-
ment is a major stabilizer of the scaphoid and pal ligament in conjunction with the lunotri- tic approach than the more complex Mayfield
has been likened to a seat belt around the quetral interosseous ligament are responsible classification [2]. Failure can involve ligamen-
scaphoid waist that maintains the anatomic for maintaining lunate stability, and failure tous or osseous structures (or both) around the
position of the scaphoid [21]. of these ligaments results in VISI. The dor- carpus (Fig. 3). Starting at the radial aspect of
The long radiolunate ligament is the longest sal intercarpal ligament in conjunction with the wrist, failure may occur at the radial styloid,
palmar extrinsic wrist ligament; it originates the scapholunate interosseous ligament are re- scaphoid waist, proximal pole of the scaph-
just ulnar to the radioscaphocapitate ligament sponsible for maintaining lunate stability; the oid, or scapholunate joint. Failure at the capi-
from the radial styloid and courses obliquely failure of these ligaments results in DISI. tate, which may manifest as a fracture of the
along the palmar aspect of the lunate to insert The collateral extrinsic, or capsular, wrist capitate body or disruption of the capitolunate
onto the triquetrum [23, 24]. The long radio- ligaments include the radial collateral and ul- joint, occurs next. Then, the base of the hamate,
lunate ligament may be interrupted along its nar collateral ligaments at the radial and ul- the triquetrum, or the lunotriquetral joint fails.
course, typically around the lunate [21]. nar aspects of the wrist, respectively, and do Last, a fracture of the ulnar styloid may occur
The radioscapholunate ligament is a not a not contribute significantly to carpal stabili- (Fig. 3). Mayfield et al. [2] reported that a rapid
true ligament and does not contain ligamen- ty. The radial collateral ligament extends be- application of forces (axial loading with dorsi-
tous fibers; instead, it is a synovial fold with tween the radial styloid and scaphoid bones, flexion, ulnar deviation, and supination of the
an associated neurovascular bundle and may and the ulnar collateral ligament extends be- carpus) produced purely ligamentous injuries
represent an embryologic remnant of vas- tween the ulnar styloid and triquetrum. involving the so-called “lesser arc,” which out-
cular ingrowth [20, 21]. The deep fibers of lines the radial, distal, and ulnar aspects of the
the radioscapholunate ligament are intimate Normal Wrist Kinematics lunate. A slower application of forces results in
with the palmar aspect of the scapholunate A complete discussion of the nuances of mixed osseous and ligamentous failures caus-
interosseous ligament. wrist kinematics is beyond the scope of this ar- ing PLFDs involving the “greater arc” of the
The short radiolunate ligament represents ticle and there is much debate in the literature carpus (Fig. 3).
the capsular thickening that stabilizes the lu- about the precise wrist kinematics and intra- Perilunate dislocations are primarily liga-
nate. The short radiolunate ligament origi- carpal motions. We will focus our discussion mentous injuries and involve the lesser arc of
nates from the volar aspect of the distal radius on the kinematics of ulnar and radial devia- the carpus (Fig. 3). Mayfield et al. [2, 26, 30]
and spans the entire lunate fossa and attaches tions as well as dorsiflexion and palmar flex- classified perilunate injuries in cadaveric spec-
to the radial half of the lunate [23, 24]. ion as they relate to perilunate dislocations and imens and showed the sequential failures (pro-
The palmar ulnolunate and palmar ul- PLFDs. In ulnar deviation, the proximal carpal gressive perilunate instability) of the intrinsic
notriquetral ligaments originate from the row slides toward the radius, whereas in radi- and extrinsic ligaments around the carpus and
volar radioulnar ligament [22]. These lig- al deviation, the proximal carpal row slides to- resulting dislocation of the carpus (Table 1).
aments help stabilize the lunate. Superfi- ward the ulna [2, 26]. The distal carpal row in- The pattern of failure begins at the radius and
cial to the palmar ulnolunate and palmar cluding the trapezium, trapezoid, capitate, and traverses the lesser arc of the carpus (Fig. 3).
ulnotriquetral ligaments is the ulnocapi- hamate form a stable platform for the metacar- As the radial-sided force moves in an ulnar
tate ligament; the ulnocapitate ligament pals with very little motion occurring at these direction, the first stage of failure (stage I) in-
originates from the ulnar head and cours- bones [27]. Dorsiflexion is primarily a function volves the scapholunate joint with failure of the
es obliquely distally over the volar aspect of the midcarpal joint with the radiocarpal joint scapholunate interosseous ligament and the ra-
of the interosseous lunotriquetral ligament, contributing slight movement [2]. Palmar flex- dioscaphocapitate ligament (Fig. 4A, solid yel-
extends into the midcarpal joint space, and ion occurs primarily at the radiocarpal joint. A low line). Disruption of the scapholunate inter-
then extends toward the radius to attach to screw-vice phenomenon occurs as the wrist is osseous ligament allows rotary subluxation of
the capitate body. fully extended (dorsiflexed) [28]. The palmar the scaphoid. Alternatively, the force may tra-

AJR:203, September 2014 543

 Scalcione et al.

TABLE 1:  Classification of Perilunate Injuries According to Mayfield et al. [2] hand (Fig. 6). Intense strain is placed on the ra-
dial aspect of the carpus. Radial styloid body
Classification Joint Failure Ligament Failure Alternate Osseous Failure
fractures occur secondary to an avulsive injury
Stage I Scapholunate joint or Scapholunate interosseous Radial styloid of the radioscaphocapitate ligament (stage I in-
triscaphe joint ligament or radioscaphocapitate
jury) [2]. An avulsive injury of the radial col-
ligament
lateral ligament (stage II injuries), however, re-
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Stage II Capitolunate joint Radial collateral ligament Capitate sults in a fracture of the radial styloid tip [2].
Stage III Lunotriquetral or Lunotriquetral interosseous Triquetrum
triquetrohamate joint ligament, long radiolunate Transscaphoid Perilunate Fracture-Dislocations
ligament, or palmar ulnotriquetral
Transscaphoid fracture-dislocations are the
ligament
most common greater arc injuries associated
Stage IV Dorsal radiocarpal ligament with PLFDs (Fig. 7). They account for approx-
imately 95% of PLFDs [1]. Most transscaphoid
fractures involve the middle portion of the scaph-
verse the triscaphe joint (scaphotrapeziotrap- triquetral, transulnar styloid) (Fig. 4). These oid and scaphoid waist [1]. The proximal pole of
ezoid joint) [1] (Fig. 4A, dashed yellow line) subcategories of PLFDs represent a number the scaphoid typically maintains its alignment
for which the radiographic findings are not of variants and can be seen in combinations. with the lunate. The distal fracture fragment dis-
described in the literature to date. Stage II in- If one adheres to the Mayfield et al. [2] pro- locates dorsally with the capitate [33].
juries disrupt the capitolunate joint with fail- gression of ligamentous injuries from a wrist
ure of the radial collateral ligament (Fig. 4A, sprain or a partial scapholunate ligament inju- Transcapitate Perilunate Fracture-Dislocations
orange line). The third stage of failure (stage ry to an isolated complete scapholunate disrup- During hyperextension of the wrist (dorsi-
III) is disruption of the lunotriquetral joint by tion followed by perilunate dislocation and sub- flexion), as the lunate rotates dorsally, the dor-
means of tearing the lunotriquetral interosse- sequent volar lunate dislocation, one can easily sal lip of the lunate impinges on the body of
ous ligament, long radiolunate ligament, and imagine an injury that results in a near progres- the capitate, which can result in a transcapitate
palmar ulnotriquetral ligament (Fig. 4A, solid sion from stage II (isolated scapholunate liga- PLFD. Some authors believe that the dorsal lip
red line). The entire carpus with the exception ment disruption) to stage III (perilunate dislo- of the radius causes the transcapitate PLFD
of the lunate is now mobilized and dislocates cation), which might result in an incomplete [34]. A transcapitate fracture is typically trans-
dorsally with respect to the long axis of the ra- transition that returns to an isolated injury of versely oriented with respect to the long axis
dius and lunate. Although exceedingly rare, the the scapholunate ligament if the force either of the capitate [35] (Fig. 8). Transcapitate frac-
carpus can dislocate volarly. Alternatively, the terminates or dissipates through a fracture else- tures have a high incidence of nonunion and
force may disrupt the triquetrohamate joint and where. Herzberg [31] reported that spontaneous osteonecrosis because, like the scaphoid, the
spare the lunotriquetral joint (Fig. 4A, dashed reduction can occur with any perilunate dislo- capitate has a tenuous blood supply.
red line) [31]. The final stage, stage IV, involves cation or PLFD. This spontaneous reduction
failure of the dorsal radiocarpal ligament with might result in a radiographic malalignment of Transtriquetral Perilunate
resultant palmar dislocation of the lunate (Fig. the carpus that underestimates the full extent of Fracture-Dislocations
4A, blue line; Fig. 5). The short radiolunate lig- the original injury. The radiographs obtained Avulsion fractures of the long radiolunate
ament, which maintains a vascular supply to after any injury represent only the manifesta- ligament or palmar ulnotriquetral ligament
the lunate and allows closed reduction, is usu- tions of the extent of the injury after the dissipa- result in transtriquetral PLFDs. These frac-
ally intact [31]. After the sequential ligamen- tion or termination of forces and not the extent tures occur in stage III injuries. Triquetral
tous disruption described, the lunate traverses of the radiographic abnormalities during the in- fractures associated with perilunate disloca-
the “space of Poirier,” which is a relatively weak jury. This likely could be said about many trau- tions more often involve the triquetral body
zone in the central palmar aspect of the carpus matic radiographic abnormalities. rather than the more common isolated triqu-
in which no ligamentous structures reside. The We believe that the utility of the Mayfield etral fracture of the dorsal ridge [35] (Fig. 9).
space of Poirier is between the lesser and great- classification system [2] may be more from
er carpal arcs between the capitate and lunate. an academic rather than a clinical standpoint. Transulnar Styloid Perilunate
The lunate may dislocate into the carpal tunnel The specifics of each stage are not as impor- Fracture-Dislocations
and may potentially cause injury of the medi- tant as an understanding of the propagation Transulnar styloid PLFDs occur as an accom-
an nerve; reported rates of median nerve injury of forces and of the mechanism of injury that panying fracture in PLFDs [1] (Figs. 3 and 6).
range from 24% to 45% [32]. aids radiologists in heightening their aware-
PLFDs involve both ligamentous and os- ness to potential radiographic findings given Midcarpal or Central Carpal Dislocations
seous failure. PLFDs fail in a similar se- the stage the propagating force has reached. Midcarpal or central carpal dislocations
quence as purely ligamentous perilunate are a variation of stage III perilunate dislo-
dislocations. Unlike the purely ligamentous Transradial Styloid Perilunate cations and PLFDs. Midcarpal dislocations
perilunate dislocations that involve the lesser Fracture-Dislocations are characterized by dorsal perilunate sub-
arc of the carpus, PLFDs involve the great- Transradial styloid PLFDs may occur in luxation of the capitate with slight volar sub-
er arc of the carpus. Greater arc injuries are stage I or II injuries. Transradial styloid PLFDs luxation and tilt of the lunate (Fig. 10). There
designated by the prefix “trans-” (transradial are sequelae of the ulnar deviation forces acting is loss of the normal colinearity of the radius
styloid, transscaphoid, transcapitate, trans- on the wrist during a fall on the outstretched and lunate as well as of the lunate and capi-

544 AJR:203, September 2014

 Carpal Dislocations and Fracture-Dislocations

tate. It is conceivable that partially reduced TABLE 2:  Classification of Perilunate and Lunate Dislocations According to
lunate dislocation or perilunate dislocation Herzberg et al. [1]
could have an appearance of a midcarpal dis- Classification Descriptiona
location, although no additional supporting
information is in the literature to date. Stage I Mayfield stages I–III
Stage II Mayfield stage IV
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Lunate Dislocations Stage IIA Mayfield stage IV and lunate is volarly dislocated and rotated < 90°
Lunate dislocations occur in stage IV peri-
Stage IIB Mayfield stage IV and lunate is volarly dislocated and rotated > 90°
lunate dislocations and PLFDs. In order for the
aMayfield stages are from Mayfield et al. [2] and are defined in Table 1.
lunate to dislocate volarly, the dorsal restraints
of the lunate must be injured. Failure of the
dorsal radiocarpal ligament in stage IV injuries not advocate closed reduction for stage IIB lu- Conclusion
disrupts the dorsal restraint of the lunate and nate dislocations owing to the risk of injuring Perilunate dislocations, PLFDs, and lu-
leaves the lunate entirely without ligamentous the short radiolunate ligament and compromis- nate dislocations are high-energy wrist in-
attachment, thus allowing the lunate to dislo- ing its vascular contribution [1, 32]. juries that can and should be recognized on
cate volarly (Fig. 10). Herzberg et al. [1] classi- Historically, closed reductions have been radiographs. These injuries are a result of se-
fied perilunate and lunate dislocations into two the definitive treatment of perilunate and lu- quential osseous and ligamentous injuries or
stages (Table 2): Stage I injuries included peri- nate dislocations and fracture-dislocations failures. Prompt and accurate radiographic
lunate dislocations and fracture-dislocations [37]. The current practice, however, entails diagnosis aids in the management of patients
(Mayfield stages I–III), and stage II injuries in- operative management of these injuries be- with perilunate dislocations, PLFDs, and lu-
cluded lunate dislocations (Mayfield stage IV). cause the complex intercarpal relationship nate dislocations and assists orthopedic sur-
Lunate dislocations, stage II injuries, were fur- is difficult to maintain with closed reduc- geons with surgical planning. CT examina-
ther subdivided into two substages: Stage IIA tion and immobilization alone. Inadequate tion may better show the extent of injury and
lunate dislocations occur when the lunate is realignment of the carpus can result in car- help in treatment planning particularly in
volarly dislocated and rotated less than 90° [1]. pal instability, posttraumatic osteoarthritis, cases of delayed treatment or chronic peri-
Stage IIB injuries are characterized by a lunate scapholunate advanced collapse, and loss of lunate dislocation [1]. CT examination with
that has dislocated volarly and has rotated more range of motion [36]. Intraoperative volar, coronal, sagittal, and 3D reformed images is
than 90° [1] (Table 2). A lunate that is rotat- dorsal, or combined volar-dorsal surgical ap- ordered at our institution in cases in which
ed greater than 90° has a higher probability of proaches can be used for repair after closed the extent of the carpal injuries is poorly
soft-tissue interposition, which could preclude reduction by 3–5 days to allow the swelling shown on radiographic examinations.
closed reduction [1]. around the carpus to subside.
Successful open reduction involves re- References
Treatment alignment of the scaphoid and lunate and 1. Herzberg G, Comtet JJ, Linscheid RL, et al. Perilu-
When acute perilunate dislocations, PLFDs, correcting the intercalated segment insta- nate dislocations and fracture-dislocations: a multi-
and lunate dislocations are identified radio- bility. The remaining carpus (lunotriquetral center study. J Hand Surg Am 1993; 18:768–779
graphically, immediate closed reduction is at- alignment and midcarpal alignment) typi- 2. Mayfield JK, Johnson RP, Kilcoyne RK. Carpal
tempted with the patient under IV sedation. cally falls into alignment with correction dislocations: pathomechanics and progressive
Longitudinal traction is applied to the hand of lunate dorsiflexion and scaphoid palmar perilunar instability. J Hand Surg Am 1980;
with the wrist in dorsiflexion for perilunate flexion. Ligamentous repair, particularly 5:226–241
dislocations and PLFDs. The wrist is slowly scapholunate interosseous ligament repair, 3. Peh WC, Gilula LA. Normal disruption of carpal
brought into flexion (palmar flexion), thus al- is important for maintaining carpal stability. arcs. J Hand Surg Am 1996; 21:561–566
lowing the carpus to return to anatomic align- Some authors will repair the lunotriquetral 4. Gilula LA. Carpal injuries: analytic approach and
ment, typically with an audible clunk. Stage interosseous ligament and the dorsal radio- case exercises. AJR 1979; 133:503–517
IIA lunate dislocations are reduced with the carpal ligament [32]. Percutaneous fixation 5. Taljanovic MS, Sheppard JE, Jones MD, et al. So-
patient’s wrist in flexion initially to loosen ten- with Kirschner wire maintains alignment nography and sonoarthrography of the scapholunate
sion on the palmar extrinsic ligaments. The cli- of the scaphoid and capitate (preventing and lunotriquetral ligaments and triangular fibrocar-
nician’s thumb applies a dorsally directed force scaphoid palmar flexion), scaphoid and lu- tilage disk. J Ultrasound Med 2008; 27:179–191
to the lunate in an attempt to reduce the lunate nate (maintaining the scapholunate interos- 6. Jacobson JA, Oh E, Propeck T, Jebson PJ, Jamadar
into the lunate fossa. Longitudinal traction is seous distance), and lunate and triquetrum DA, Hayes CW. Sonography of the scapholunate liga-
applied to the hand and the wrist is extended (maintaining the lunotriquetral interosseous ment in four cadaveric wrists: correlation with MR
(dorsiflexed). The clinician maintains a volar distance) [36]. Most authors support carpal arthrography and anatomy. AJR 2002; 179:523–527
buttress around the lunate with his or her fin- tunnel release in patients with median nerve 7. Griffith JF, Chan DP, Ho PC, et al. Sonography of
ger and the wrist is slowly brought into flex- neurapraxia. Greater arc bony injuries are the normal scapholunate ligament and scapholunate
ion (palmar flexion), allowing the capitate to transfixed with headless screws (scaphoid joint space. J Clin Ultrasound 2001; 29:223–229
realign with the lunate. A displaced volar cap- and capitate). Missed or chronic injuries are 8. Walsh JJ, Berger RA, Cononey WP. Current sta-
sule or palmar extrinsic ligaments adjacent to often treated with proximal row carpectomy tus of scapholunate interosseous ligament inju-
the radiocarpal joint and lunate fossa may pre- or scaphoidectomy and “four-corner fusion” ries. J Am Acad Orthop Surg 2002; 10:32–42
clude a closed reduction [36]. Some authors do (“lunotriquetrocapitohamate fusion”). 9. Mitsuyasu H, Patterson RM, Shah MA, et al. The

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role of the dorsal intercarpal ligament in dynamic 19. Moritomo H, Apergis E, Herzberg G, et al. 2007 27. Stanley JK, Trail IA. Carpal instability. J Bone
and static scapholunate instability. J Hand Surg IFSSH Committee report of wrist biomechanics Joint Surg Br 1994; 76:691–700
Am 2004; 29:279–288 committee: biomechanics of the so-called dart- 28. Macconaill MA. The mechanical anatomy of the
10. Viegas SF, Patterson RM, Peterson PD, et al. Ulnar- throwing motion of the wrist. J Hand Surg Am carpus and its bearing on some surgical problems.
sided perilunate instability: an anatomic and biome- 2007; 32:1447–1453 J Anat 1941; 75:166–175
chanic study. J Hand Surg Am 1990; 15:268–278 20. Theumann NH, Pfirrmann CWA, Antonio GE, et 29. Johnson RP. The acutely injured wrist and its re-
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11. Yang Z, Mann FA, Gilula LA, Haerr C, Larsen al. Extrinsic carpal ligaments: normal MR arthro- siduals. Clin Orthop Relat Res 1980; 149:33–44
CF. Scaphopisocapitate alignment: criterion to graphic appearance in cadavers. Radiology 2003; 30. Mayfield JK, Johnson RP, Kilcoyne RF. The liga-
establish a neutral lateral view of the wrist. Radi- 226:171–179 ments of the human wrist and their functional sig-
ology 1997; 205:865–869 21. Shahabpour M, Demaeseneer M, Pouders C, et al. nificance. Anat Rec 1976; 186:417–428
12. Braunstein EM, Louis DS, Greene TL, Hankin MR imaging of normal extrinsic wrist ligaments 31. Herzberg G. Perilunate and axial carpal disloca-
FM. Fluoroscopic and arthrographic evaluation of using thick slices with clinical and surgical cor- tions and fracture-dislocations. J Hand Surg Am
carpal instability. AJR 1985; 144:1259–1262 relation. Eur J Radiol 2011; 77:196–201 2008; 33:1659–1668
13. Taleisnik J. The wrist. New York, NY: Churchill 22. Taljanovic MS, Malan JJ, Sheppard JE. Normal 32. Stanbury SJ, Elfar JC. Perilunate dislocation and
Livingstone, 1985:13–38 anatomy of the extrinsic capsular wrist ligaments perilunate fracture-dislocation. J Am Acad Or-
14. White SJ, Louis DS, Braunstein EM, Hankin FM, by 3-T MRI and high-resolution ultrasonography. thop Surg 2011; 19:554–562
Greene TL. Capitate-lunate instability: recogni- Semin Musculoskelet Radiol 2012; 16:104–114 33. Yeager BA, Dalinka MK. Radiology of trauma to the
tion by manipulation under fluoroscopy. AJR 23. Berger RA. The ligaments of the wrist: a current wrist: dislocations, fracture-dislocations, and insta-
1984; 143:361–364 overview of anatomy with considerations of their bility patterns. Skeletal Radiol 1985; 13:120–130
15. Arkless A. Cineradiography in normal and abnor- potential functions. Hand Clin 1997; 13:63–82 34. E1-Khoury GY, Usta HY, Blair WF. Naviculocapi-
mal wrists. Am J Roentgenol Radium Ther Nucl 24. Berger RA. The anatomy of the ligaments of the tate fracture-dislocation. AJR 1982; 139:385–386
Med 1966; 96:837–844 wrist and distal radioulnar joints. Clin Orthop 35. Kaewlai R, Avery LL, Asrani AV, et al. Multide-
16. Protas JM, Jackson WT. Evaluating carpal insta- Relat Res 2001; 383:32–40 tector CT of carpal injuries: anatomy, fractures,
bilities with fluoroscopy. AJR 1980; 135:137–140 25. Taljanovic MS, Goldberg MR, Sheppard JE, Rog- and fracture-dislocations. RadioGraphics 2008;
17. Craigen MA, Stanley JK. Wrist kinematics: row, ers LF. US of the intrinsic and extrinsic wrist liga- 28:1771–1784
column or both? J Hand Surg Br 1995; 20:165–170 ments and triangular fibrocartilage complex: 36. Najarian R, Nourbakhsh A, Capo J, et al. Perilu-
18. Schuind FA, Linscheid RL, An KN, Chao EY. A normal anatomy and imaging technique. Radio- nate injuries. Hand (N Y) 2011; 6:1–7
normal database of posteroanterior roentgeno- Graphics 2011; 31:e44 37. Adkison JW, Chapman MW. Treatment of acute
graphic measurements of the wrist. J Bone Joint 26. Mayfield JK. Mechanism of carpal injuries. Clin lunate and perilunate dislocations. Clin Orthop
Surg Am 1992; 74:1418–1429 Orthop Relat Res 1980; 149:45–54 Relat Res 1982; 164:199–207

A B C
Fig. 1—Radiographic assessment of normal wrists in 36-year-old-man.
A, Posteroanterior radiograph of wrist of shows three “Gilula’s arcs.” First arc (1, solid white line) outlines proximal convexity of scaphoid, lunate, and triquetrum. Second
arc (2, dashed white line) conforms to distal concave surface of scaphoid, lunate, and triquetrum. Third arc (3, black line) contours proximal convex surface of capitate
and hamate.
B, Lateral radiograph of wrist of shows normal scapholunate angle (black arc) of 30–60° measured from line drawn along long axis of scaphoid (white line) and line drawn
along short axis of lunate (black line). NL = normal.
C, Lateral radiograph of wrist of shows normal capitolunate angle (black arc) that measures less than 30°. Angle is measured from line along short axis of lunate (black
line) and line drawn along long axis of capitate (white line). NL = normal

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 Carpal Dislocations and Fracture-Dislocations
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A B
Fig. 2—Extrinsic wrist ligaments in healthy 36-year-old male (same patient as in Fig. 1). Fig. 3—Zone of vulnerability and greater and lesser
A, Drawing of palmar extrinsic wrist ligaments superimposed on posteroanterior radiograph of normal wrist. arcs. Drawing of zone of vulnerability and greater
1 = radioscaphocapitate (also known as radiocapitate), 2 = long radiolunate (also known as radiolunotriquetral, and lesser arcs superimposed on posteroanterior
radiotriquetral, and lunotriquetral), 3 = radioscapholunate (also known as ligament of Testut and Kuenz), 4 = radiograph of normal wrist of 36-year-old healthy man
short radiolunate (also known as radiolunate), 5 = palmar ulnolunate, 6 = palmar ulnotriquetral, 7 = lunocapitate (same patient as in Fig. 1). Greater arc (dashed black
(also known as ulnotriquetrocapitate), 8 = palmar scaphotriquetral (also known as triquetrocapitoscaphoidal line) outlines osseous failure in perilunate fracture-
and triquetroscaphoidal). dislocations. Lesser arc (dashed white line) outlines
B, Drawing of dorsal extrinsic wrist ligaments superimposed on posteroanterior radiograph of normal wrist. lunate and represents purely ligamentous failure in
1 = dorsal radiocarpal (also known as radiotriquetral and radiolunotriquetral), 2 = dorsal intercarpal (also known perilunate dislocations or lunate dislocations. 1 =
as triquetroscaphoidal and triquetrotrapezoidotrapezial), 3 = ulnar collateral, 4 = radial collateral, 5 = dorsal fracture of radial styloid, scaphoid waist, or proximal
ulnotriquetral (also referred to as “capsular thickening”). pole and failure of scapholunate joint (scapholunate
interosseous ligament); 2 = fracture of capitate
body or failure of capitolunate joint; 3 = fracture of
base of hamate, fracture of triquetrum, or failure
of lunotriquetral joint (lunotriquetral interosseous
ligament); 4 = fracture of ulnar styloid.

A B
Fig. 4—Ligamentous and osseous failures seen in perilunate fracture-dislocations (PLFDs) and lunate fracture-
dislocations. Images obtained in healthy 36-year-old man (same patient as in Fig. 1).
A, Drawing shows pathways of ligamentous failures in perilunate dislocations according to Mayfield
classification [2] superimposed on posteroanterior radiograph of normal wrist. Stage I injuries involve
disruption of scapholunate joint (solid yellow line) with failure of scapholunate interosseous ligament and
radioscaphocapitate ligament or failure at triscaphe joint (dashed yellow line). Stage II injuries disrupt
capitolunate joint (orange line). Stage III injuries disrupt lunotriquetral joint (solid red line) with failure of
lunotriquetral interosseous ligament, long radiolunate ligament, and palmar ulnotriquetral ligament or disrupt
triquetrohamate joint (dashed red line). Finally, stage IV injuries completely mobilize lunate with failure of short
radiolunate ligament and dorsal radiocarpal ligament (blue line and arrow).
B, Drawing shows alternate osseous pathways involved in PLFDs involving greater arc injuries of carpus
superimposed on posteroanterior radiograph of normal wrist. Stage I injuries can take transscaphoid or
transradial styloid course from avulsive injuries of radioscaphocapitate ligament or radial collateral ligament
(dashed yellow lines). Stage II injuries follow transcapitate course (dashed orange line). Stage III injuries
follow transtriquetral course (dashed red line) with failure of ulnotriquetral ligament or long radiolunate
ligament. Finally, ulnar styloid fractures (dashed white line) can occur in conjunction with PLFD. Solid yellow
line = scapholunate interosseous ligament, solid orange line = capitolunate, solid red line = lunotriquetral
interosseous ligament, blue line and arrow = dorsal radiocarpal ligament.

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 Scalcione et al.

Fig. 5—Perilunate and lunate dislocations overview. Drawings show lateral view
of wrist. Normal wrist maintains colinearity (dashed lines) of radius, lunate (Lun),
capitate (Cap), and third metacarpal and middle finger (3). Perilunate dislocations
maintain colinearity of radius and lunate while capitate and middle finger
metacarpal are dorsally dislocated. Midcarpal dislocations disrupt colinearity
of radius and lunate with volar tilt and volar subluxation of lunate and dorsal
subluxation of capitate and middle finger metacarpal. Late lunate dislocations
will show loss of colinearity of lunate and radius with lunate volarly tilted and
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dislocated, but colinearity of radius, capitate, and middle finger metacarpal is

maintained.

A B C
Fig. 6—Perilunate fracture-dislocations (PLFDs).
A, Transradial styloid, transscaphoid transulnar styloid,
dorsal perilunate fracture-dislocation (PLFD) in 50-year-
old woman who fell. Posteroanterior radiograph of wrist
shows mildly displaced fracture of radial styloid (solid
arrow), minimally displaced fracture of proximal pole
of scaphoid (arrowhead), and mildly displaced fracture
of ulnar styloid (dashed arrow). There is disruption of
scapholunate and lunotriquetral joints characterized by
loss of Gilula’s first and second arcs.
B, Lateral radiograph of same patient shown in A shows
dorsal dislocation of triquetrum (Trq) and capitate (Cap)
(arrow). Sc = scaphoid, Lun = lunate.
C–E, Transradial styloid, transulnar styloid PLFD in
40-year-old man who sustained acute right wrist injury.
Coronal CT images (C and D) and 3D surface-rendered
reconstructed image viewed dorsally (E) show there
are minimally displaced fractures of radial styloid (solid
white arrow) and ulnar styloid (dashed white arrow, D
and E). There is disruption of scapholunate joint with
avulsed fracture fragment from scaphoid at attachment
of scapholunate interosseous ligament (dashed black
arrow, C). Small avulsed fracture fragment is seen about
dorsal aspect of capitate that is likely from avulsive injury
of dorsal intercarpal ligament (solid black arrow, E). All
these findings are consistent with transradial styloid,
transulnar styloid PLFD.
D E

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 Carpal Dislocations and Fracture-Dislocations

Fig. 7—Transscaphoid dorsal perilunate fracture-

dislocation.
A, Coronal reformatted CT image shows distal pole of
scaphoid (dashed arrow) and rotated proximal scaphoid
pole (solid arrow) fragments after scaphoid waist
fracture. Lunate remains aligned with distal radius.
B, Sagittal reformatted CT image shows dorsally
dislocated capitate (arrow) with respect to distal
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radius.

A B

Fig. 8—Transscaphoid transcapitate volar perilunate

fracture-dislocation (PLFD) in 23-year-old woman.
A, Posteroanterior radiograph of wrist shows mildly
displaced transversely oriented fracture of distal
pole of scaphoid (solid arrow). There is transversely
oriented fracture of capitate (dashed arrow).
B, Lateral radiograph shows capitate fracture
fragments (dashed lines). Lunate remains aligned
with distal radius and fractured capitate is volarly
dislocated.
A B

AJR:203, September 2014 549

 Fig. 9—Transtriquetral perilunate fracture-
dislocation (PLFD). Scalcione et al.
A, Posteroanterior radiograph of wrist shows
fracture of triquetral body (arrow) with disruption of
Gilula’s arcs.
B, Lateral radiograph shows dorsal dislocation of
carpus (arrow) with preserved colinearity of lunate
and distal radius.
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A B

A B

Fig. 10—Midcarpal and lunate dislocations.

A, Posteroanterior view of wrist shows abnormal
configuration of lunate (dashed lines), which is
referred to as “piece-of-pie” sign.
B, Lateral radiograph of wrist shows loss of
colinearity of radius, lunate, and capitate (dashed
line). Lunate (solid arrow) is volarly tilted and
volarly subluxed. Capitate (dotted arrow) is dorsally
subluxed. All these findings are consistent with
midcarpal and central carpal dislocation.
C, Lunate dislocation. Posteroanterior view of wrist
shows abnormal configuration of lunate (dashed
lines) known as piece-of-pie sign.
D, Lateral radiograph of wrist in same patient as C
shows loss of colinearity of radius and lunate and
preserved colinearity of radius and capitate. Lunate
(arrow) is volarly dislocated and rotated less than
90°; these findings are consistent with Herzberg
stage IIA injury [1].
C D

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550 AJR:203, September 2014