Working Diagnosis:
Closed perilunate dislocation (Mayfield classification stage III) and closed proximal pole scaphoid fracture.

Treatment:
The hand surgeon proceeded with an ORIF on the same day of clinic arrival. The procedure was well tolerated with good alignment of the carpal bones. K-wires were used to fix the lunate to the triquetrum, sutures to repair the scaphoid lunate ligament, and a screw to repair the proximal pole of the scaphoid in place. He was placed into a post-op splint.

Outcome:
After the procedure, the patient was placed into a post-op splint.
On follow-up, sutures were removed. Exam demonstrated full ROM of his thumb, but with moderate dorsal discomfort with movement. He had good pronation and supination of his hand and was found to be neurovascularly intact. X-rays confirmed good alignment of hardware, scaphoid fracture and carpal bones. Case Photo #3 Case Photo #4
8 weeks after initial presentation, his K-wires were removed and hand therapy initiated.
12 weeks after initial presentation Case Photo #5 Case Photo #6 , his post-op thumb spica cast was discontinued and therapy was advanced with a progressive strengthening plan for an additional 6 weeks.
18 weeks after initial presentation, he successfully demonstrated left wrist strength of 105 lbs with 65 degrees extension and 55 degrees flexion. He was released to full activities including football.

Author's Comments:
A perilunate dislocation is an uncommon injury. It occurs after a high energy trauma that forcefully hyperextends the wrist with ulnar deviation and intercarpal supination. Treatment is emergent surgical correction. The diagnosis is missed at initial evaluation 14% to 25% of the time, especially among inexperienced physicians. Delay in surgical correction can lead to complications at surgery, poor functional outcomes, mid-carpal arthritis, recurrent dislocations, median-nerve damage and avascular necrosis of the lunate. Return of full function is generally not expected; however, early intervention typically yields the best outcomes. Common sequelae include decreased grip strength and stiffness

Editor's Comments:
As mentioned, although rare, one must consider perilunate dislocations for an acute, traumatic wrist injury sustained from a fall onto an outstretched hand FOOSH. The history will not be very helpful in making the diagnosis, however it will be important when carefully reviewing the radiographs. The injury was addressed appropriately and expeditiously following review of the radiographs to minimize risk of sequelae from this injury.

With greater experience as a practicing provider, one gains confidence in interpreting imaging. It is a good practice to always review the radiology you have ordered and discuss with radiology or orthopedic surgery if you are unsure. This case illustrates the key radiographic findings in perilunate dislocations, namely the disruption of Guila’s arcs was addressed. Additionally, observing the rough edge of the scaphoid provided clues to a secondary complication.

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