Perilunate Dislocations With Median Nerve Involvement: Importance of Early Diagnosis and Surgical Intervention‐A Case Series

ABSTRACT

Perilunate dislocation in the wrist is a rare injury yet challenging and is missed in 25% of cases on initial presentation. We present two cases of carpal injury. First case is a delayed presentation of perilunate dislocation with median nerve compression and ipsilateral fracture of shaft of radius. The second case is acute presentation of transcaphoid fracture, perilunate dislocation with median nerve compression. Both the patients underwent open reduction and internal fixation with percutaneous K‐wires with first case via solar approach and second via dorsal approach. Both patients demonstrated near‐normal wrist motion and satisfactory functional recovery by 3 months of follow‐up, with no early recurrence of dislocation. Early diagnosis and prompt intervention by surgery is crucial to prevent complications and poor outcome.

Key Clinical Message

Perilunate dislocation is a rare wrist injury yet challenging and is missed on initial presentation. Early recognition, diagnosis, and intervention by surgery is crucial to prevent complications such as avascular necrosis of lunate and scaphoid and secondary osteoarthritis.

1. Introduction

Perilunate dislocation and perilunate fracture dislocation are injuries that involve traumatic disruption of the radioscaphocapitate (RSC) ligament, the scapholunate interosseous (SLI) ligament, and the lunotriquetral interosseous (LTI) ligament. These injuries are rare and account for less than 10% of all wrist injuries [1]. Perilunate dislocation in particular, is missed in 25% of cases on initial presentation and suboptimally treated often due to its anatomical complexity and clinician inexperience [1, 2]. The unremarkable physical examination and subtle radiographic findings further contributes to these injuries being misdiagnosed.

The most common mechanism of injury is a high‐energy trauma on a hyperextended wrist [2]. Early recognition and intervention is crucial to prevent significant complications produced by missed or improperly treated injuries including median nerve injury, chronic carpal instability, avascular necrosis of the mal‐reduced lunate, complex regional pain syndrome, persistent functional impairment, and posttraumatic arthrosis requiring a secondary surgery [1, 3, 4]. Despite surgical intervention, 50%–100% of patients may develop radiocarpal and/or midcarpal osteoarthritis [1, 5]. Delayed surgical management becomes challenging due to progressive fibrosis, scarring and the inability to achieve an anatomic reduction in the carpal bone complex [4]. Initial management includes an attempted closed reduction, followed by timely surgical stabilization to avoid poor outcomes [4, 6, 7]. The objective of operative treatment is to restore carpal alignment, repair ligamentous disruption, and treat evolving median nerve compression [8, 9].

Although these wrist injuries are rare, there is a high risk of irreversible joint damage and disability, if under diagnosed and left untreated. This case series highlights two distinct presentations of perilunate injury associated with median nerve compression, one delayed and one acute. The novelty of this report lies in the comparative illustration of open carpal tunnel release via a volar approach in a delayed case versus indirect median nerve decompression through a dorsal approach in an acute case, particularly in a resource‐limited setting. By presenting these two contrasting yet related cases, we aim to emphasize the importance of individualized surgical decision‐making to optimize neurological recovery and functional outcomes.

2. Case 1

2.1. Case History and Examination

A 45‐year‐old male presented with complaints of left wrist and forearm pain along with paresthesia over the palmar aspect of left hand with history of fall onto an outstretched left hand 2 weeks earlier. Initially, he had visited a basic health center, where the injury was missed and then he presented at our facility, due to persistent pain, paresthesia, and functional impairment of the left hand.

On examination, there was no visible external wound, and there was tenderness over the carpal region and forearm and restricted range of motion of the wrist and the elbow. There was no distal vascular deficit. Sensation was reduced at the median nerve distribution of the palmar region of the hand.

2.2. Investigations and Diagnosis

The plain radiographs of left wrist joint (Figure 1) showed disrupted Gilula's lines, increased scapholunate interval and “piece of pie” sign of lunate in anteroposterior view [10, 11] with significant “Spilled teapot sign” [11] owing to volar displacement of lunate in the lateral view. The scapholunate angle was greater than 70 degrees. Additionally, radiographs of forearm revealed a nondisplaced fracture of shaft of the ipsilateral radial shaft.

FIGURE 1.

Preoperative radiographs of left wrist and forearm.

Based on clinical and radiographic findings, the diagnosis was Stage IV perilunate dislocation with median nerve compression and ipsilateral nondisplaced radial shaft fracture.

2.3. Surgical Management

The patient underwent open reduction and stabilization. A single volar approach was chosen in order to release the carpal tunnel and address the median nerve compression. The lunate was reduced and confirmed under fluoroscopic guidance (Figure 2) followed by stabilization with percutaneous K‐wires placed across the scapholunate and lunotriquetral joint (Figure 3).

FIGURE 2.

Intraoperative radiographs showing reduction of lunate.

FIGURE 3.

Intraoperative radiographs post stabilization of the lunate with scapholunate and lunotriquetral K‐wires.

The scapholunate ligament was repaired. The nondisplaced ipsilateral radial shaft fracture was managed conservatively with a long arm posterior splint extending to the metacarpophalangeal joint for wrist support.

2.4. Outcome and Follow‐up

The postoperative radiograph was satisfactory (Figure 4).

FIGURE 4.

Postoperative radiographs showing satisfactory reduction and alignment of the carpals and the radial shaft fracture.

Immediate postoperative follow‐up and review at the orthopedic ward was uneventful. The patient reported immediate relief of carpal tunnel syndrome symptom.

At 5 weeks of follow‐up, no adverse events was noted and the radiograph showed satisfactory alignment of the carpal bones and evidence of healing of the radial shaft fracture (Figure 5).

FIGURE 5.

5 week postoperative radiographs showing maintained reduction and alignment of the carpals.

The splint and the K‐wires were removed (Figure 6), and the patient was started on physiotherapy sessions to regain range of motion of the wrist and the elbow.

FIGURE 6.

Radiograph post removal of splint and K‐wire.

By 3 months, the patient was able to achieve near normal range of motion of the wrist and elbow joint with adequate strength in his left upper limb, he was able to return to work as a cook without any complications.

3. Case 2

3.1. Case History and Examination

A 43‐year‐old male presented with complaints of right wrist with swelling and paresthesia over the palmar aspect of right hand with history of fall onto an outstretched right hand 2 days earlier. Initially, he ignored the injury and then he presented at our facility, due to persistent pain, swelling, paresthesia, and functional impairment of the right hand.

On examination, there was no visible external wound at the site of injury except for the swelling of the affected hand. There was tenderness over the carpal region and forearm and restricted range of motion of the wrist and the elbow. There was no distal vascular deficit. Sensation was reduced at the median nerve distribution of the palmar region of the hand.

3.2. Investigations and Diagnosis

The plain radiographs of left wrist joint (Figure 7) and CT scan (Figure 8) showed disrupted Gilula's lines, increased scapholunate interval and “piece of pie” sign of lunate in anteroposterior view with significant “Spilled teapot sign” owing to volar displacement of lunate in the lateral view. There was fracture of the scaphoid.

FIGURE 7.

Preoperative x‐ray images of left wrist.

FIGURE 8.

Preoperative CT scan images of left wrist.

Based on clinical and radiographic findings, diagnosis was transcaphoid fracture, perilunate dislocation with median nerve compression.

3.3. Surgical Management

The patient underwent open reduction and percutaneous pinning under peripheral nerve block. A single dorsal approach was chosen through which the carpal bones were reduced and indirect release of the carpal tunnel was addressed for the median nerve decompression. The lunate was reduced and confirmed under fluoroscopic guidance, scaphoid fracture was reduced followed by stabilization with percutaneous K‐wires placed across the scapholunate, Capitolunate, and scaphocapitate. (Figure 9).

FIGURE 9.

Intraoperative radiographs showing reduction and stabilization of lunate and scaphoid with K‐wires.

The surgical site was immobilized with short arm volar splint for support.

3.4. Outcome and Follow‐up

The postoperative radiograph showed satisfactory alignment of the carpal bones and reduction and fixation of transchaphoid fracture, perilunate dislocation (Figure 10).

FIGURE 10.

Postoperative radiographs showing satisfactory reduction and alignment of the carpals.

Immediate postoperative follow‐up was uneventful. The patient reported relief of median nerve compression symptoms.

At 5 weeks of follow‐up, no adverse events was noted and the radiograph showed satisfactory alignment of the carpal bones (Figure 11). The wound has healed well, and there was no pin site infection (Figure 12).

FIGURE 11.

Five‐week postoperative radiographs showing maintained reduction and alignment of the carpals.

FIGURE 12.

Clinical picture of surgical site with good wound healing.

The splint and the K‐wires were removed, and the patient was started on hand physiotherapy sessions to regain range of motion of the left wrist and hand.

4. Discussion

Perilunate dislocations are rare with diagnostic delay reported in 20%–30% of cases [1]. Failure to recognize and treat a perilunate dislocation can lead to long‐term complications, including chronic pain, instability, and loss of function [12]. This case report supports the Green and O'Brien theory of mechanism of injury by falling onto a hyperextended wrist.

According to classification by Mayfield et al. [13] in the first stage of carpal instability injury, the scapho‐lunate articulation is disrupted. The second stage involves disruption of the capito‐lunate joint in addition to the scapho‐lunate injury. The third stage involves second stage and perilunate dislocation where the luno‐triquetral joint is also disrupted. The fourth stage involves the lunate dislocation, where the radio‐lunate joint is disrupted and the lunate is dislocated volarly from the lunate fossa which results in median nerve compression [14]. In our cases, the radiographic findings were consistent with stage IV perilunate dislocation.

CT imaging was not obtained due to temporary unavailability of the CT machine at our facility. The diagnostic decision‐making therefore relied on clinical examination and plain radiographs, which is common in resource‐constrained settings like ours.

Emergency surgical treatment is the gold standard treatment [8, 9]. An emergency primary closed reduction minimizes the risks of median nerve compression, but if a nonreducible dislocation of a carpal bone occurs as in our case with median nerve compression, an open reduction is necessary. The management of median nerve compression in perilunate dislocations remains controversial. Several authors report that acute median nerve symptoms may resolve following prompt reduction without the need for formal carpal tunnel release. However, persistent neurological symptoms, delayed presentation, and anticipated fibrosis favor direct decompression. Our first case, was delayed presentation with ongoing paresthesia, suggesting prolonged compression and possible fibrotic changes. Therefore, open carpal tunnel release via a volar approach was performed, allowing direct visualization, decompression of the median nerve, and management of associated soft tissue pathology. In contrast, the second case presented acutely within 48 h, and median nerve symptoms resolved following reduction and stabilization through a dorsal approach. In this scenario, indirect decompression was deemed sufficient, avoiding unnecessary volar dissection. These cases underscore the importance of tailoring the surgical approach based on symptom duration, timing of intervention, and intraoperative findings.

Management of acute injuries involves closed reduction and percutaneous fixation for pure dislocations or open reduction and internal fixation for dislocations involving fractures [15]. The timing for surgery is as soon as possible if there is dislocation with median nerve compression symptoms. However, the recommendation is to wait for 3 to 5 days before performing the surgery to allow edema to subside. It is also mentioned that patients treated in the first week after the trauma had a significant better functional outcome than those operated after 1 week [1, 9]. Conservative management with closed reduction and cast immobilization showed recurrence of dislocation in 59% of patients [9, 14]. Open reduction and internal fixation or a salvage procedure like proximal row carpectomy or wrist arthrodesis is performed in case of delayed and chronic cases (7–45 days or > 45 days) [14]. For our first case with delayed presentation an attempt of closed reduction was unsuccessful. Hence, the patient underwent open reduction and stabilization with percutaneous K‐wire and carpal tunnel release. Open reduction allowed for a more direct approach to realign the bones properly. And releasing the carpal tunnel was a prudent decision therefore a single volar approach was chosen for the surgical procedure. This procedure would help reduce the dislocation, relieve pressure on the nerve, remove the adhesions and fibrosis, and prevent further complications. However, for the second case we did an emergency surgery via approaching through a dorsal incision to reduce dislocation and fracture and fix the fragments with indirect decompression of the carpal tunnel.

The duration of immobilization and mode of hand therapy further contributes to the healing process and to avoid complications. Postoperative immobilization ranges between 3 to 10 weeks depending on the injury and the surgery. In our cases, postoperative care was typically done by immobilization in a splint for 5 weeks, followed by the removal of K‐wires and initiation of physiotherapy. Early rehabilitation exercises were initiated to restore function and prevent stiffness following immobilization.

Despite timely and optimum treatment most patients develop posttraumatic osteoarthritis. Worse outcomes and prognosis are associated with delay in treatment, open injuries, persistent carpal malalignment, and fracture dislocations. Other complications include persistent pain, median nerve dysfunction, reduced strength, complex regional pain syndrome (CRPS), tendon ruptures, residual carpal instability, and avascular necrosis of the lunate [12, 16]. In our cases, no adverse events were noted during the subsequent follow‐up. The patients underwent rigorous hand therapy and rehabilitation, to regain strength and resume their work after 3 months.

This report has several limitations. Functional outcomes were primarily assessed clinically and reported qualitatively, as standardized objective outcome measures such as DASH or PRWE scores, formal range‐of‐motion measurements, and grip strength assessment using a dynamometer were not routinely recorded. This was partly due to the retrospective nature of the cases and limited availability of validated assessment tools in our clinical setting. Future studies incorporating these measures would provide more robust comparisons and strengthen outcome evaluation. Another limitation of this report is the short follow‐up duration of up to 3 months, which is not sufficient to identify long‐term complications such as post‐traumatic osteoarthritis, residual carpal instability, or avascular necrosis. Therefore, conclusions regarding long‐term outcomes should be interpreted cautiously, and extended follow‐up is necessary to fully assess durability of functional recovery.

5. Conclusion

Perilunate dislocation and fractures is a rare and frequently missed wrist injury associated with significant morbidity if diagnosis or treatment is delayed. Timely recognition and appropriate surgical intervention are essential to relieve median nerve compression, restore carpal alignment, and optimize early functional recovery.

Author Contributions

Nomina Pradhan: conceptualization, data curation, investigation, methodology, resources, visualization, writing – original draft, writing – review and editing. Ujal Pradhan: conceptualization, data curation, resources, validation, writing – review and editing.

Funding

This study received no specific grant from any funding agency in the public, commercial, or not‐for‐profit sectors.

Ethics Statement

Institutional review board has exempted the ethics review via letter Ref.No.IRB/Waiver‐Exempt/PN‐2024‐017/1237.

Consent

Written informed consent was obtained from the patient for anonymized patient information to be published in this article.

Conflicts of Interest

The authors declare no conflicts of interest.

Pradhan N. and Pradhan U., “Perilunate Dislocations With Median Nerve Involvement: Importance of Early Diagnosis and Surgical Intervention‐A Case Series,” Clinical Case Reports 14, no. 2 (2026): e72043, 10.1002/ccr3.72043.

Data Availability Statement

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.