Classification and Management of

Carpal Dislocations
DAVIDP. GREEN,M.D., AND EUGENE
T. O ' B R I E NM.D.
,

Although carpal dislocations have been a dislocation occurs at the midcarpal joint,
topic of interest for many years, some con- where the capitate is usually displaced
fusion still exists regarding their classifica- dorsal to the lunate. Much attention has
tion and management. The literature on this been directed to the unique anatomic posi-
subject is replete with inconsistencies and tion of the scaphoid, which bridges the 2
controversies, because many of the con- carpal rows and is in fact a part of both
clusions reached have been based on insuf- the proximal and distal rows.3"~32~sz~53~74 Be-
ficient clinical data and single case reports. cause of this relationship, when the capitate
Recognizing that these complex injuries are dislocates dorsal to the lunate, the scaphoid
still not fully understood, we have at- must either fracture or rotate, a concept
tempted in this article to put the historical probably first recognized by Destot in 192Y1
aspects of carpal dislocations into some and later emphasized by Cave13 and
sort of reasonable perspective, and have Wagner.*9-9"If no fracture occurs, the liga-
offered a classification and plan of manage- ments supporting the proximal pole of the
ment based upon the current state of our scaphoid are ruptured, allowing the proximal
knowledge. pole to rotate dorsally. This results in a
perpendicular orientation of the scaphoid
RELATIONSHIP BETWEEN to the long axis of the radius as seen in
PERILUNATE AND LUNATE the lateral view, and the injury is called a
DISLOCATION dorsal perilunate dislocation. On the other
hand, if the scaphoid is fractured through
Detailed descriptions of wrist anatomy
its waist, the distal pole dislocates dorsally
and mechanisms of injury are presented
with the capitate, and the proximal pole
elsewhere in this volume. Suffice it to say
remains attached to the lunate, resulting
here that most carpal dislocations are caused
in a dorsal transscaphoid perilunate dis-
by acute hyperextension (dorsiflexion) in-
location.
juries, often the result of violent trauma
The same mechanism that results in a
such as that sustained in falls from heights
dorsal perilunate dislocation may also prog-
or in motorcycle accidents. The primary
ress to volar dislocation of the lunate. In
the 1920s, a number of case reports and
From The Hand Surgery Services, University of
Texas Health Science Center at San Antonio, and articles describing series of patients with
Wilford Hall, USAF Medical Center, San Antonio, lunate dislocations were published in which
Texas. the discussion was focused only on the
Reprint requests to: Dr. David P. Green, 8042
Wurzbach, Suite 530, San Antonio, TX 78229. volar displacement of the lunate as an
Received: October 22. 1979. isolated injury.I .15,17,1R;20,37,4X,51,67,79 Although

0009-921X/80/0600/0055$01.40 0 J . B. Lippincott Co.

55
 Clinical Orthopaedics
56 Green a n d O’Brien and Related Research

TABLE 1 . Classification of Carpal has thus been our practice to consider

Dislocations perilunate and lunate dislocations as dif-
~

ferent stages or radiographic manifestations

I. Dorsal perilunateivolar h a t e dislocation” of the same injury. The key distinctions
11. Dorsal transscaphoid perilunate dislocation”
I1 1. Volar perilunateidorsal h a t e dislocation to be made in the initial evaluation are:
IV. Variants (1) whether the scaphoid is subluxated or
’4.Transradial styloid perilunate disloca- fractured; and (2) whether the displace-
tion* ment of the distal carpal row is dorsal or
B. Naviculocapitate syndrome volar. These distinctions allow us to classify
C. Transtriquetral fracture-dislocation
D. Miscellaneous carpal dislocations according to clinical
V . Isolated rotary scaphoid subluxation management of the various patterns of
A . Acute subluxation injury, a\ outlined in Table 1 . A brief
B. Recurrent subluxation discussion of each of these entities follows.
VI. Total dislocation of the scaphoid

i- The most common patterns of injury. DORSAL PERILUNATENOLAR

LUNATE DTSLOCATlON
these authors failed to recognize the dis- Recognition of dorsal perilunate disloca-
placement of other carpal bones in these tion is most easily made on the lateral
complex injuries, a careful review of the radiograph, which shows displacement of
illustrations in some of these and later the capitate dorsal to the h a t e and the
articles , 2 0 , 2 . ~ , ~ ~ i . ? X , J ~ . 5 X . i Yclearly shows dorsal proximal pole of scaphoid rotated dorsally
dislocation of the capitate (or os magnum (Fig. 1A). In the anteroposterior view, any
as it was called then). This relationship overlap density between the proximal and
began to be appreciated, and as early as distal rows of carpal bones (especially
1926,2i it was suggested that a h a t e dis- capitate and lunate) is suggestive of the
location is the end stage of a perilunate diagnosis (Fig. IB). The carpus may be
dislocation, i.p., the result of spontaneous foreshortened, and there may be a gap
reduction of a dorsal perilunate dislocation. between the scaphoid and lunate. In some
Many authors since then have agreed with cases, the forces of injury may have
this C O n c e p ~ , ~ ~ . ~ , 7 , ~ . l1,2~.~~1.17,~.2.73.1(3,X!~.!lO
l~.l
spontaneously reduced the capitate and
In the past, there has been an attempt
to consider perilunate and lunate disloca-
tions as separate and distinct entities. How-
ever, there may be considerable diagnostic
overlap between these 2 injuries. When a
patient is first seen, the original lateral
radiograph may show a “pure” lunate or
perilunate dislocation, or it may depict a
configuration of the carpal bones that lies
somewhere in between these 2 extremes,
i.r., with the lunate being displaced slightly
volarly from its normal position. As in all
ligamentous injuries, there is a spectrum of FIG.I A . Dorsal perilunate dislocation, lateral
view. The capitate is displaced dorsal to the
damage in carpal dislocations, ranging from lunate, which remains nestled in the concavity
partial tears to total disruption of the com- of t h e distal radius. The proximal pole of
plex ligamentous structure of the wrist. It scaphoid is rotated dorsally.
Number 149
June, 1980 Carpal Dislocations 57

the rest of the distal row, displacing the

h a t e volarly, resulting in a so-called volar
lunate dislocation. The lateral radiograph
in this situation will show the capitate
partially articulating with the distal radius,
and the lunate displaced volar to the lip of
the radius, with tilting of its distal concavity,
causing the “spilled teacup” sign (Fig. 2 ) .
The diagnosis of volar lunate dislocation
can also be made on the anteroposterior
view by noting a triangular or wedge-
shaped configuration of the lunate, rather
than its normal trapezoidal shape (Fig. 2).
As mentioned above, the initial radio-
graphs may show an intermediate pattern
somewhere between “pure” dorsal peri-
lunate and volar lunate dislocation. In such
cases, the lateral view will show only slight
dorsal displacement of the capitate, and
partial volar tilting of the lunate. In the
anteroposterior view, capitate-lunate over-
lap, scaphoiunate gap, and a triangular-
shaped lunate can be seen. FIG.1B. Dorsal perilunate dislocation, antero-
The initial clinical evaluation of all carpal posterior view. Notice the overlap between
the proximal and distal carpal rows. Any dis-
dislocations must include careful assess- tortion of the normal anatomical alignment of
merit of the r~eurOvaScular status, since the carpal bones on the A P view should make
median nerve damage is a frequent con- one think of a carpal dislocation.

FIG. 2 . Volar lunate

dislocation, (Left) lateral
view. The capitate has
spontaneously reduced,
and now articulates with
the distal radius. The
lunate has been displaced
volarly and is rotated,
resulting in the “spilled
teacup” sign. (Right) An-
teroposterior view. A
triangular o r wedge-
shaped h a t e is a patho-
gnomonic sign of lunate
dislocation.
 Clinical Orthopaedics
58 Green a n d O'Brien and Related Research

cornitant injury,7 3 . 1 0 . 1 1 . ~ : j , ~ ~ , ~ i . : ~ ~ , 1.4ti.54

: j i . : ~,l;l),-
! ~ , ~
of the midcarpal joint (capitate-lunate re-
fi:3,li7,7:3,9"
If the patient is seen early, re- lationship), residual subluxation of the
duction of the midcarpal dislocation can scaphoid frequently persists. since it is
usually be achieved relatively easily by difficult to hold the scaphoid reduced ana-
closed manipulation. Satisfactory anesthesia tomically after its supporting structures
to provide complete muscle relaxation and have been torn. This residual scaphoid
sustained traction for 10-15 minutes are subluxation must be recognized and cor-
essential to an atraumatic closed reduction. rected.
Although many different types of reduction Although DestoP clearly illustrated scaph-
maneuvers have been oid subluxation in 1926, this concept did
the technique described by not appear in English medical literature
Watson-JonesY'.!''' seems to have prevailed until 1949, when Russell i s and Vaughan-
as the most frequently employed method. Jackson,xxin separate articles, pointed out
After the period of sustained traction, the typical radiographic appearance. Thomp-
anteroposterior and lateral radiographs son, Campbell and Arnold8" further em-
taken with the hand suspended in finger- phasized its importance. The key fea-
traps will often give better visualization of tures, as seen in Fig. 3 . are as follows:
the individual carpal bones than could be seen 1 . Widening of the space between the
in the initial films before reduction. Dorsi- scaphoid and lunate in the anteroposterior
flexion is then applied to the wrist, fol- projection. This is usually seen better with
lowed by gradual palmar flexion to reduce the hand in full supination (anteroposterior
the capitate back into the concavity of rather than posteroanterior view).xJor with
the lunate, maintaining longitudinal traction the wrist in radial deviation:" A scapho-
throughout the maneuver. Pronation of the h a t e gap greater than 2 mm is said to
hand on the forearm may be helpful as well.X3 be diagnostic of scapholunate dissocia-
If t h e lunate is dislocated volarly, the tion .Tr2 This typical radiographic pattern
operator's thumb stabilizes the h a t e as has also been called the "Terry Thomas
the capitate is brought over into palmar sign. ' ',3l
flexion. Often the initial stages of reduction 2 . A foreshortened appearance of the
of the h a t e will reproduce the dorsal scaphoid on the anteroposterior view.H:'.XH
perilunate stage. 3 . A cortical "ring" shadow seen in t h e
Anteroposterior and lateral radiographs anteroposterior view, which represents an
are then taken in plaster to assess critically axial projection of the abnormally oriented
the reduction with particular attention given scaphoid.I!'
to: (1) rotary subluxation of the scaphoid; 4. In the lateral view, the long axis of
(2) lunate (intercalary segment) instability. the scaphoid lies perpendicular to the long
Although these are essentially 2 com- axis of the radius, rather than at its usual
ponents of the same instability pattern, we angle of 45-60"."z~xx
discuss them separately to emphasize the Although Tanz8'$and Morawa rt (11.~~'' re-
importance of recognizing both. port that residual scaphoid subluxation is
inconsequential and does not require treat-
ROTARYS U B L U X A T I O N OF THE S C A P H O I D ment, most authors believe that non-treat-
I n a perilunate dislocation in which the ment will usually lead to a poor result. Some
scaphoid is not fractured, the ligaments reports have shown that degenerative arthri-
stabilizing the scaphoid are ruptured, re- tis of the wrist is a likely, if not inevitable,
sulting in so-called rotary scaphoid subluxa- result of untreated residual scaphoid sub-
tion. Following successful closed reduction luxation. 9.42.85
Number 149
June, 1980 Carpal Dislocations 59

FIG.3. Rotary subluxation of the scaphoid after closed reduction of a perilunate dislocation. (Left)
In the lateral view, the axis of the scaphoid is almost 90" to the long axis of the radius. (Right)
In the AP view, the scaphoid is foreshortened, there is a gap between the scaphoid and lunate. The
cortical ring sign appears in the scaphoid.

LUNATE
(INTERCALARYSEGMENT) Early recognition of scaphoid subluxation
INSTABILITY or lunate instability is an important step
in the proper management of these in-
In the normal wrist, the lunate is cen- juries, since accurate reduction and liga-
tered precisely in the lateral view, with its mentous healing are much more likely to
long axis colinear with the axes of the be successful in the acute injury than in
capitate and the radius, its concavity facing chronic subluxation.
directly distalward, with no volar or dorsal Several techniques for closed reduction
tilt. In 1943, Gilford et a1.32presented the of scaphoid subluxation have been de-
concept of the wrist as a ''link'' system, s ~ r i b e d * ~ . ~ ~ ~however,
~"."'; our cineradio-
with the middle link or intercalary segment graphic studies have demonstrated that no
(the proximal carpal row) being stabilized single position or maneuver will consistently
by the intact scaphoid. If this stability reduce the scaphoid without also possibly
is lost either by fracture or rotary sub- re-displacing the capitate and/or lunate. If
luxation of the scaphoid, a collapse de- anatomic reduction is achieved by closed
formity takes place within the carpus,so reduction, and if plaster immobilization
allowing the concavity of the h a t e to alone is used, weekly radiographs are
tilt dorsally. Fisk30 coined the term "con- absolutely essential, since loss of the re-
certina collapse": Linscheid et al.32called it duction is likely to occur.
"dorsiflexion instability. " More detailed Percutaneous pin fixation following closed
discussions of these instability patterns ap- reduction is occasionally possible, but is
pear elsewhere in this symposium; the much more difficult than in isolated rotary
important point to be made here is that subluxation of the scaphoid (discussed
they should be specifically looked for in below). The image intensifier is essential
the immediate postreduction and serial if closed pinning is attempted, and it is
follow-up radiographs in any patient with a imperative to secure anatomical position of
carpal dislocation. the scaphoid, lunate, and capitate.
 Clinical Orthopaedics
60 Green and O’Brien and Related Research

If an accurate reduction cannot be achieved complex can easily be accomplished by

by closed manipulation or if follow-up suturing the transverse rent. On the dorsal
radiographs show loss of reduction, then side, the entire ligamentous complex gen-
open reduction is indicated. erally has been stripped completely from the
carpal bones, and repair of these rela-
tively weak structures is difficult and some-
OPENREDUCTION
what unsatisfying. The paucity of solid
Most aUthorS4,2fi,41,R9,DO have advocated a ligamentous tissue available for repair and
dorsal approach, although Dobyns and the tendency for rotary subluxation of the
S w a n ~ o n stated
* ~ that a combination of dorsal scaphoid to recur after removal of the
and volar approaches should probably be Kirschner wires suggest that some type of
done to allow the surgeon to assess and re- reinforcement may be desirable, although
pair ligamentous as well as bony structures we have not used any of the techniques
about both surfaces of the wrist. One of described by Dobyns et a1.22or Taleisnikx2
us (DPG) now routinely employs both for reinforcement of these ligaments in any
approaches in open reduction of dorsal of our acute cases.
perilunate or volar h a t e dislocations. The Osteochondral fractures of the carpal
other (ETO) prefers the dorsal approach, bones, especially the capitate and lunate,
adding the volar exposure only if h a t e are frequent concomitant injuries in these
dislocation or instability:jfi can be dem- patient^.^^,"".^ Often the damage to articular
onstrated. surfaces is rather extensive, and attempts
Recent anatomic studies by Taleisnikx’%82 should be made to remove small fragments
and Mayfield et have more clearly and reattach larger ones if possible (oc-
identified the ligamentous anatomy of the casionally they are avulsed by intercarpal
wrist, demonstrating several important points: ligaments).
( 1 ) the major ligaments of the wrist are It is essential to stabilize the restored
intracapsular, making them difficult to vis- anatomic relationships of the scaphoid,
ualize at the time of operation, since they capitate, and lunate, and we generally do
are covered by the capsule; ( 2 ) the volar this with 0.045-inch Kirschner wires. It has
ligaments are much more substantial (and been advised that the pins be removed
thus apparently more important) than the at times varying from 6 to 12 week^.^,'^
dorsal ligaments; ( 3 ) the general configura- Recurrence of scaphoid subluxation follow-
tion of the volar ligaments is a double ing pin removal 6 weeks postoperatively
V-shaped structure, with an area of po- has been and we now routinely
tential weakness between them (the space leave the pins in place for 8 weeks. Be-
of Poirier) lying directly over the capitate- cause the wires traverse the mid- and
liinate articulation. intercarpal joints, it is necessary to im-
The findings at operation have been fairly mobilize the wrist in plaster until the pins
consistent in the perilunate and lunate dis- are removed. We generally use a removable
locations which we have explored acutely. volar splint for an additional 4 weeks after
On the volar side, there has been a very pin removal.
typical transverse rent in the capsule and Our planned operative sequence is thus
ligaments whether or not the h a t e is dis- as follows: ( 1 ) expose the carpus through
placed volarly into the carpal canal. Al- both volar and dorsal approaches: (2)reduce
though it is virtually impossible to identify the lunate and repair the volar capsule and
and repair the individual ligaments de- ligaments; (3) reduce the capitate and
scribed by Taleisnik and Mayfield, an scaphoid from the dorsal side and secure
adequate repair of the volar ligamentous the position of all 3 bones with Kirschner
Number 149
June, 1980 Carpal Dislocations 61

wires; (4) repair the dorsal ligaments; (5)

carefully assess the adequacy of reduction
and the position of the pins with antero-
posterior, lateral and oblique radiographs.

DORSAL TRANSSCAPHOID
PERILUNATE DISLOCATION
In this injury, the midcarpal dislocation
is accompanied by a fracture through the
waist of the scaphoid, and the distal pole
of the scaphoid displaces dorsally with the
capitate, leaving the proximal pole attached
to the lunate (Figs. 4A and B). As in the
perilunate dislocation without fracture of
the scaphoid previously discussed, the
forces of injury may result in volar dis-
location of the lunate. In this situation,
however, the proximal pole of the scaphoid
is usually displaced with the lunate (Fig. 5 ) .
The initial clinical assessment and closed
reduction techniques are identical to those
described previously for dorsal perilunate
dislocation without fracture. Often the extent
of damage can be visualized better after
the closed reduction while the hand is still
suspended in finger-trap traction. Again, FIG. 4B. Transscaphoid perilunate disloca-
tion, anteroposterior view. The fracture through
reduction of the midcarpal dislocation the waist of the scaphoid is clearly seen, with
(capitate-lunate relationship) is usually easy the proximal pole still attached to the lunate.
to accomplish in acute injuries, but critical
analysis of the scaphoid must be made
spica cast is applied with the wrist in
after the closed reduction.
neutral or slight flexion, and new films are
If the radiographs in traction show good
taken in plaster. It may be difficult to
reduction of the midcarpal joint and ana-
visualize the scaphoid reduction adequately
tomic reduction of the scaphoid, a thumb
in plaster, but we believe it is imperative
to take enough different views to be ab-
solutely certain there is no displacement
of the fracture. If anatomic reduction is
obtained and maintained in plaster, satis-
factory healing of the fracture and a good
result can be achieved (Fig. 6). However,
serial follow-up radiographs are necessary,
since loss of reduction of the scaphoid
will very likely lead to nonunion of the
fracture and/or late posttraumatic dorsiflex-
FIG.4A. Transscaphoid perilunate dislocation,
lateral view. Dorsal displacement of the capitate
ion instability (Figs. 7A and B).
can be seen, but notice that the scaphoid is It has long been recognized that failure
not rotated. to reduce the fracture anatomically will
 Clinical Orthopaedtcs
62 Green and O'Brien and Related Research

FIG.5A. A transscaphoid perilunate disloca-

tion which has progressed to volar lunate dis-
location. Notice that the scaphoid remains
attached to the h a t e and is also dislocated
volarly. This type of injury has a poor prog- F:c. 6A. Not all tranascaphoid perilunate
nosis. dislocations demand open reduction. A 25-year-
old man had a typical transscaphoid perilunate
dislocation which was treated by closed reduc-
yield a poor result,!" but the problem of tion (Jw Fig. 68).
the unreduced scaphoid fracture has been a
subject of considerable controversy. Earlier advised primary arthrodesis of the wrist in
authors recommended excision of the prox- all cases of transscaphoid perilunate dis-
imal fragment or proximal row carpec- location in which anatomical reduction of
t~my:~~.':(WagnerY"reported such uniformly the scaphoid could not be achieved by
poor results with open reduction that he closed reduction. Few authors share that
extreme degree of pessimism, and since
publication of the excellent article by
Campbell et u l . , in 1965," several au-
thors5,11 ,36,3!J.97 have recommended open

F I G . 6B. Two years after closed reduction

treatment of dislocation, radiographs show com-
plete healing of the scaphoid fracture and es-
sentially normal carpal architecture. The pa-
FIG.SB. Another view of the transscaphoid tient's active range of wrist motion was 75% of
perilunate dislocation (.Tee Fig. 5 A ) . normal (.w~ Fig. 6 A ) .
Nu rnber 149
June, 1980 Carpal Dislocations 63

reduction and internal fixation if anatomical

reduction of the scaphoid fracture cannot
be achieved and maintained in plaster. Cave
actually advocated this principle in 1941.13
Several pertinent points. however, remain
disputed: (1) the timing of operative inter-
vention; (2) the surgical approach; ( 3 ) the
type of fixation; (4) whether or not bone
grafting is indicated at the time of open
reduction; ( 5 ) the incidence of avascular
necrosis of the proximal fragment.

TIMING
OF OPERATIVE
INTERVENTION
Specific details concerning operative treat- FIG. 7B. At 5 months, not only was there
ment of the displaced scaphoid fracture delayed union of the fracture, but dorsiflexion
are skimpy in the many articles on carpal instability as well (see Fig. 7 A ) .
dislocations. What little mention is given to
the timing of open reduction of the scaphoid order to allow the intercarpal ligaments to
is at wide variance. Cave'" said that open heal. We advise open reduction as soon
reduction must be done "within a few after injury as is practical, but preferably
days," believing that later it may be im- within 2 weeks.36 We believe that this en-
possible to realign the fragments satis- hances potential for healing and revas-
factorily. Worland and Dick9' also favored cularization of the proximal pole. Also,
immediate operative intervention, but H i I P anatomic reduction of the scaphoid, even
preferred to defer open reduction until under direct vision, becomes more difficult
after 3 to 4 weeks of immobilization, in after 2 or 3 weeks.

TYPEOF FIXATION
AND
OPERATIVE
APPROACH
The type of internal fixation favored
by most authors has been Kirschner
wires, 10,36,3X,63,97 although CaveI3 reported
the successful use of dowel grafts taken
from the tibia. Cave's approach was a
curved radial incision exposing the scaphoid
just anterior to the tendons of the first
dorsal compartment. Worland and Dickg7
advocated a dorsal approach for primary
open reduction, since this necessitates no
further dissection of the soft-tissue structures
FIG. 7A. Radiographs of a transscaphoid because they are usually completely stripped
perilunate dislocation in 22-year-old man dem- off as a result of the perilunate c isloca-
onstrate what is likely to happen if reduction tion. They reserved the volar (Russe typeT2)
of the scaphoid fracture is lost in plaster. approach for later bone grafting if indicated.
Radiograph in plaster at 6 days reveals what
was thought to represent acceptable reduction. Keeping in mind that the primary ob-
However, there was gradual loss of reduction jective of open reduction in these patients
( s e e Fig. 7B). is to stabilize the scaphoid and prevent
 Clinical Orthopaedics
64 Green and O'Brien and Related Research

subsequent collapse deformity, we fre- imal pole following transscaphoid perilunate

quently expose only the scaphoid through a dislocation. Campbell et al.'" said that it is
limited Russe approach," which allows not common, but they did not report any
direct visualization of the fracture site dur- figures regarding its incidence in their large
ing insertion of the Kirschner wires. How- series. Morawa and his associates'j3 had only
ever, at the time of open reduction, it is 2 cases among their 21 patients. Wagners9
extremely important to assess critically the said, however, that the incidence was 50%
reduction of the lunate as well. If fixation with accurate reduction of the scaphoid
of the scaphoid adequately stabilizes the and 100% without anatomic reduction, al-
midcarpal joint, no further fixation is re- though h e did not support this statement
q:.,ired. Midcarpal stability must be assessed with clinical data. Hawkins and Torkelson3*
radiographically after fixation of the scaph- reported 100% avascular necrosis in their
oid, since the lunate-capitate relationship 16 patients, although all of the 8 patients
is not well visualized through the relatively treated with open reduction had union of
small Russe-type incision. If the midcarpal the fracture. Avascular necrosis of the
joint is not anatomically reduced, additional proximal pole developed in 8 of Worland
Kirschner wires should be inserted to and Dick'sY79 cases, and 13 of Russell's73
stabilize the lunate and capitate. Failure to 27 patients.
d o this may result in late dorsiflexion The mere presence of avascular necrosis
instability. of the proximal pole is, in itself, not an
We have not used screw fixation of the indication for bone grafting. We have
scaphoid"l in these acute cases, primarily seen several patients with transient radio-
because of the technical difficulties involved graphic changes suggestive of this, who
in the screw's precise insertion and place- nonetheless went on to successful healing
ment. However, if the surgeon is familiar of the fracture. If the fracture appears to
with the use of this device, certainly ade- be healing, we will continue immobilization
quate fixation can be achieved with it rather for 6 to 12 months until radiographic
than with Kirschner wires. union is seen. If serial radiographs show
no progression toward healing, we consider
BONEGRAFT bone grafting as early as 4 months after
The need for bone graft at the time of injury. If grafting is necessary, we use
open reduction has seldom been men- the volar approach and technique described
tioned. Cave"'" used his bone graft as the by R u s s ~ . ~ ~
sole means of internal fixation, and H i I P Our worst results with carpal dislocations
reported that bone graft should be used in have been in those patients with trans-
con.junction with internal fixation. As noted scaphoid perilunate dislocations in which
above, Worland and Dickg7preferred to de- the lunate and proximal pole of scaphoid
lay bone grafting for 6 weeks, using it only have been dislocated volarly into the carpal
if there were signs of avascular necrosis tunnel.:36 These are frequently open in-
o r early nonunion. Although we have used juries, with severe concomitant soft-tissue
supplemental bone graft in some of our injury, and despite early open reduction,
open reductions, it is probably not neces- the prognosis in these cases is poor.
sary, since we have had several successful
unions using only internal fixation without VOLAR PERILUNATEiDORSAL
bone graft :"li LUNATE DISLOCATION

I N C I D E N C E O F AVASCULAR
NECROSIS VOLARPERILUNATE
DISLOCATION
Broad disagreement exists as to the Only a few isolated cases of volar
incidence of avascular necrosis of the prox- perilunate dislocation have appeared in
Number 149
June, 1980 Carpal Dislocations 65

the l i t e r a t ~ r e . ~This
* ~ ~rare
. ~ ~injury, like its
more common dorsal counterpart, requires
either a fracture or dorsal subluxation of
the scaphoid. The lunate is palmar-flexed
and the capitate is displaced volarly. Be-
cause of the rarity of the injury, the proper
diagnosis is liable to be missed. One of our
cases was not diagnosed for 5 months.
Forced hyperflexion from a fall on the
back of the hand has been proposed as the
mechanism of injury by Aitken and Nale-
buff.3 Two of our patients, however, were
quite certain that they fell with the wrist in
dorsiflexion. One of our patients died of
other injuries 2 weeks after his volar
perilunate dislocation. Manipulation of the
dissected hand showed that the midcarpal
displacement could be recreated by supina-
tion of the proximal segment on the extended
distal segment, rotation occurring around
the triquetrum. A fall on the hyperextended
wrist with supination of the forearm and
proximal row on the fixed hand and distal
row appears to be the likely mechanism
for this injury.
In acute injuries, closed reduction utiliz-
ing finger-trap traction supplemented with
supination of the hand and distal row on
the fixed forearm and proximal row is some-
times successful. Correction of residual
scaphoid subluxation should be performed
through a dorsal approach. Kirschner-wire
fixation must be maintained at least 8 weeks.

VOLARTRANSSCAPHOID
PERILUNATE
DISLOCATION
Volar transscaphoid perilunate disloca-
tion3..”6is apt to be widely displaced and FIGS.8A and B . Volar transscaphoid peri-
may be more unstable than the more com- lunate dislocation. (A, upper; B, lower) A 25-
year-old man fell on his outstretched right
mon dorsal variety. Open reduction to cor- hand. There was an abrasion over the distal
rect any residual displacement between the palm, suggesting a dorsiflexion injury.
scaphoid fragments is best accomplished
through a volar Russe-type incision (Figs. VARIANTS
8A-F).
DORSALL U N A T E DISLOCATION STYLOID
TRANSRADIAL
PERILUNATE
DISLOCATION
Dorsal lunate dislocation is even more
uncommon than volar perilunate disloca- A significant number of perilunateilunate
tion. The mechanism of injury is unknown. dislocations have accompanying radial sty-
 ClinlLal OtThOpdedicb
66 Green a n d O'Brien and Related Research

of the scaphoid. These injuries occur to-

gether sufficiently often that one should be
on the alert when evaluating a patient with
a radial styloid fracture. Although isolated
radial styloid fractures do occur, con-
comitant carpal bone injury must be spe-
cifically ruled out when evaluating these
patients clinically and radiographically. Fig-
ure 9A shows a patient who was treated
for what was thought to be an isolated
radial styloid fracture, but follow-up films
one month later (Fig. 9B) revealed rotary

FIGS.8C and D. (C, upper; D, lower) Closed

reduction with finger-trap traction reduced the
perilunate displacement, but residual displace-
ment of the scaphoid fracture necessitated
open reduction and Kirschner-wire fixation
through a volar Russe approach. The pins were
left in place for 8 weeks and plaster immo-
bilization was continued for a total of 12 weeks.

loid fractures.""."~.'"These appear to be less

FIGS. 8E and F. ( E , upper: F, lower) Two
w i t h the transscaphoid type Of and one-half years after injury, the patient had
injury, but are relatively common with 90% of normal wrist motion and only a 2043
perilunate dislocations or rotary subluxation diminution of grip strength.
Number 149
June, 1980 Carpal Dislocations 67

subluxation of the scaphoid, which had not

been recognized at the time of injury.
If the carpal dislocation requires open
reduction, the associated radial styloid
fracture should be reduced anatomically
and held with additional Kirschner wires
at the same time. In some patients the
radial styloid is severely comminuted, and
in these cases, the most expeditious treat-
ment may appear to be excision of the
fragments. However, since this creates a
potentially unstable situation by removing
important bony and ligamentous support of
the scaphoid, it is probably preferable to FIG. 9B. One month later, scapholunate
dissociation is clearly visible. This case also
mold the fragments back into place as nearly demonstrates that the AP (palm up) view is more
anatomically as possible. helpful than the PA (palm down) in delineating
scaphoid subluxation (see Fig. YA).
SYNDROME
NAVICULOCAPITATE
the most logical mechanism of injury, i . e . ,
The naviculocapitate syndrome is a rela- direct compression of the capitate by the
tively uncommon variation of midcarpal dorsal lip of the radius with the wrist in
dislocation in which the capitate is frac- acute hyperextension, a theory also sup-
tured, with the proximal pole rotating 90 or ported by Monahan and Galasko.62
180”.The first reported case was by Nichol- Since radiographic interpretation of this
in 1940. F e n t ~ n ~coined
* , ~ ~ the term injury may be confusing, it is helpful to
“naviculocapitate syndrome” in 1956, pos- obtain films with the hand suspended in
tulating that the fracture resulted from a finger-trap traction. The squared-off end of
force transmitted from the radial styloid the proximal capitate is easily seen on this
through the waist of the scaphoid. Stein view (Fig. 10).
and Seige17spresented what appears to be FentonZH advocated excision of the proxi-
mal pole as primary treatment because he
believed avascular necrosis and nonunion
were inevitable. Although Jones4yand Adler
and Shaftan2have described cases in which
the fragment healed in its malrotated posi-
tion, Marsh and lam pro^^^ subsequently
demonstrated that the fragment may un-
dergo necrosis if left unreduced. However,
Meyers et al.61described a case in which
union was accomplished by open reduction
and internal fixation with Kirschner wires.
Weseley and WarenfeldS5achieved success-
ful healing in their single case with pri-
mary bone grafting after open reduction
of the capitate. Adler and Shaftan,2 in
FIG.9A. Always look for a carpal dislocation their comprehensive article on capitate
in any patient with a radial styloid fracture.
This patient was thought to have an isolated fractures, made the important point that
radial styhid fracture and was treated in a treatment of the displaced capitate fracture
short arm cast ( . W P Fig. YB). should be determined on the basis of other
 Clinical Orthopaedics
68 Green and O'Brien and Related Research

displace with the capitate. This can occur

with the standard type of perilunate dis-
location, or, as in the case reported by
Weseley and Warenfeld,Y*5 be part of trans-
scaphoid, transcapitate perilunate disloca-
tion (naviculocapitate syndrome). We have
encountered this variant in several patients,
noting that occasionally the triquetral frac-
ture may be severely comminuted. We
have directed no special attention to this
particular aspect of the injury, except for
removing nonviable free fragments of bone
from the triquetrum. Generally, the tri-
quetral fracture is restored into an acceptable
position with reduction of the midcarpal
joint.

MISCEL
LANEOUS

Several case reports of unusual variants

of carpal dislocations have appeared over
the years. They are mentioned here only
for the sake of completeness. A dorsal
perilunate dislocation was reported by
McGoeySYin a patient with a congenital
coalition of the triquetrum and lunate. The
FIG. 10. Naviculocapitate syndrome. The dislocation was managed satisfactorily with
squared-off end of the proximal capitate is seen closed reduction. Gordon?' reported a case
best on a distraction view.
in which both the scaphoid and the lunate

associated carpal injuries. Agreeing with

this basic concept, we believe that per-
sistent displacement of a capitate fracture
after closed reduction is an indication for
open reduction. We try to achieve exact
anatomic reduction of both the scaphoid
and capitate through a dorsal approach.
Transient avascular changes in the proximal
poles of both bones are common, but heal-
ing usually occurs.

TRANSI
RIQUETRAL
FRACTURE-DISLOCATION
In some carpal dislocations, the line of
cleavage separating the midcarpal joint may
FIG. I 1 . Transtriquetral transscaphoid peri-
extend through the triquetrum (Fig. I l ) , h a t e dislocation. Notice that the fracture lines
leaving its proximal pole attached to the in both the scaphoid and triquetrum (arrows)
lunate and allowing the distal fragment to are directly in line with the midcarpal joint.
Number 149
June, 1980 Carpal Dislocations 69

were dislocated volarly. Weiss et additional views may be n e c e s ~ a r yThese

.~~
reported a very unusual irreducible trans- include the 6-view "motion study" sug-
scaphoid perilunate dislocation in which gested by Dobyns et a1.22(neutral antero-
the proximal pole of the scaphoid was posterior, neutral lateral, lateral in flexion,
dislocated volarly and rotated 180". Open lateral in extension, anteroposterior in radial
reduction was required. This case report is deviation, and anteroposterior in ulnar
significant because it demonstrates that deviation), and an anteroposterior view
there can be simultaneous fracture of the with clenched fist, which provides longi-
scaphoid and rupture of the scapholunate tudinal compression and may widen the
ligaments. scapholunate gap.
One of the most unusual carpal fracture- If the diagnosis is made early, the proper
dislocations was reported by Noble and treatment for isolated rotary subluxation
Lamb,66 in which the fracture line ran of the scaphoid would appear to be the same
across the radial styloid, scaphoid and as for residual scaphoid subluxation asso-
lunate. Although not a true dislocation in ciated with a perilunate dislocation, i.e.,
the strictest sense, it is of related interest. either closed reduction and percutaneous
This patient also required open reduction. pinning or open reduction, internal fixation
and ligamentous repair. Closed reduction
and pinning,71 which we prefer for this
ISOLATED ROTARY SCAPHOID
entity, may be successful as late as 6 to 8
SUBLUXATION
weeks following injury. The image intensifier
is essential in achieving accurate reduction
ACUTESUBLUXATION
and pin placement.
Although rotary scaphoid subluxation is Unfortunately, the literature reflects the
seen most commonly in combination with a fact that delay in diagnosis is common.
perilunate dislocation, several reports sup- In late cases, our experience has been
port the concept that primary (isolated) that closed reduction is impossible and
scaphoid subluxation can open reduction is difficult. At operation,
Presumably, this results from
41342*697859x6,91 one finds considerable scar tissue between
more limited ligamentous damage than that the scaphoid and lunate, and extensive
required to produce a perilunate dislocation. dissection and soft-tissue stripping is gen-
Both Taleisnikg2and Mayfield et al.57 have erally required to effect reduction. Even
noted that the key ligament associated then, anatomic restoration of the scaphoid
with rotary subluxation of the scaphoid is may be impossible. Some type of ligamen-
the volar radioscaphoid ligament, a short tous reconstruction is generally necessary
broad structure arising from the volar lip as well. Although Howard et have
of the radius and inserting into the scaphoid reported good results using the recon-
(and probably the lunate also). Although structive techniques described by Dobyns
rupture of the scapholunate ligaments is also e l al.,'' our experiences have not been
necessary to produce rotary subluxation, particularly rewarding. For operative de-
both authors reported that this will not occur tails of these procedures, the reader is re-
unless the radioscaphoid ligament is torn ferred to articles that deal with the specific
as well. They suggest that rotary scaphoid p r o c e d u r e ~ , ~as~ well
~ ~ " as
~ ~to~ ~other
~~
subluxation may be the first stage of a chapters in this symposium.
perilunate dislocation. Other authors have resorted to inter-
Early diagnosis is essential for success- carpal arthrodesis as treatment for the
ful treatment. Since the radiographic find- late rotary s~bluxation,~' although failure
ings in these patients may be more subtle, of fusion is not ~ n c o m m o n . ~ , ~ ~
 Clinical Orthopaedics
70 Green and O'Brien and Related Research
__ ____
RKURRFNTSUBLUXATION stages of the same injury and are there-
fore managed identically; displacement may
It is our opinion that so-called recurrent
be either dorsal or volar; anatomic restora-
subluxation probably represents unrecog-
tion of the 3 key elements (scaphoid,
nized rotary subluxation of the scaphoid,
lunate, and capitate) is essential. Follow-
even though there may be no specific
ing initial closed reduction, rotary sub-
history of injury recalled by the patient.
luxation of the scaphoid and intercalary
Vance r t 01.~' reported a patient with
segment instability must be specifically
bilateral asymptomatic scapholunate dis-
looked for and corrected in the patient
sociation, in whom they suggested gen-
with perilunate or h a t e dislocation with-
eralized ligamentous laxity as a possible
out fracture of the scaphoid. In trans-
etiologic factor. They emphasized the value
scaphoid perilunate dislocation, anatomic
of bilateral radiographic evaluation in pa-
reduction of the scaphoid fracture and main-
tients with this condition.
tenance of that reduction is necessary to
Some of these patients are relatively
prevent nonunion of the fracture andlor
asymptomtic and require no treatment. If
late dorsiflexion instability of the carpus. As
symptoms warrant intervention, either liga-
with all ligamentous injuries, early diagnosis
mentous reconstruction or intercarpal fusion
and treatment are essential. Failure to ob-
as noted above are recommended, keeping
tain or maintain anatomic position by
in mind that the results from these pro-
closed methods is an indication for open
cedures may be unpredictable.
reduction and internal fixation. Combined
dorsal and volar approaches are recom-
DISLOCATION OF T H E SCAPHOID
mended for perilunate and lunate disloca-
Isolated total dislocation of the scaphoid tions. In some cases of transscaphoid
without associated injuries to other carpal perilunate dislocations, a limited Russe ap-
bones is an exceedingly rare injury, but proach to stabilize the scaphoid fracture
such cases have been documented. Too may be sufficient. Frequent concomitant
few cases have been reported to make injuries include median nerve damage,
any specific comments, but different types osteochondral fractures of the carpal bones,
have been noted. Walker"' reported a dis- and fracture of the radial styloid. Isolated
location in which the scaphoid had rotated rotary subluxation of the scaphoid without
180" in the coronal plane, with the waist of perilunate dislocation is a more subtle
the scaphoid lying horizontally between the injury which may require special radio-
radial styloid and the trapezium. In Thomas' graphic views, and also demands early
case,X' the entire scaphoid was dislocated diagnosis and treatment.
volar to the carpus, and reduction was
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June, 1980 Carpal Dislocations 71

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