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The Wrist Injury X-Rays That Often Mistakenly Get Read As Normal
A perilunate dislocation is a severe wrist injury in which the wrist bones dislocate AROUND the lunate. A lunate dislocation is the later stage, where the lunate itself is pushed out of place. It needs the emergency department the same day, and surgery, ideally within the first week. Expect 8 to 12 weeks in a cast or splint, 6 to 12 months of recovery, and a wrist that ends up stiffer than before.
Around a quarter of these are missed at the first hospital visit, because the front-on X-ray can look almost normal and the injury only declares itself on the side view.
This is the one wrist injury on this site where the delay is measured in hours, not weeks.
Here’s how it usually goes. A hard fall, a swollen wrist, an X-ray, “it’s a bad sprain”, a cast or a splint, see you in two weeks.
Get that wrong and the price isn’t just a slow recovery. Past 6 to 8 weeks the torn ligaments have scarred and shortened, repair stops being reliable, and the conversation moves to salvage surgery: partial fusion or removing a row of wrist bones.
If you’re reading this because a wrist “sprain” from a big fall still isn’t right, keep going.
What is a perilunate dislocation?
Your wrist has two rows of small bones. The lunate sits in the middle of the first row, right in line with the radius (the main forearm bone) and the capitate (the big bone of the second row).
High energy, a fall from height, a motorcycle crash, a heavy fall onto an outstretched wrist, drives force around the lunate in a predictable arc, tearing ligaments as it goes.
- Stage 1: the scapholunate ligament fails. See scapholunate ligament tear.
- Stage 2: the capitate dislocates behind the lunate.
- Stage 3: the lunotriquetral ligament fails.
- Stage 4: the lunate itself is squeezed forward out of position. That’s a lunate dislocation.
Often a bone breaks on the way through, most commonly the scaphoid. That variant is called a trans-scaphoid perilunate fracture-dislocation, and it is the most common version. See scaphoid fracture.
The lunate ends up sitting in the carpal tunnel. Which is why acute median nerve symptoms, numbness in the thumb, index and middle fingers appearing straight after the injury, are part of the presentation and not a coincidence.
What are the symptoms?
- Severe pain and fast swelling after a big fall or impact. Not the kind of wrist you “walk off”.
- Can’t move the wrist, or movement is tiny and very painful.
- A thickened or odd-looking wrist, sometimes with a bump on the palm side. Swelling can hide the shape.
- Numbness or tingling in the thumb, index and middle fingers straight after the injury. That’s the median nerve being squeezed, and it makes this more urgent, not less. See carpal tunnel syndrome for what that nerve does.
- Fingers held slightly bent and painful to straighten.
Why does it get missed on X-ray?
On the front-on (PA) film, the carpal bones stay roughly in a row. What’s abnormal is the loss of the three smooth arcs the wrist bones normally form. Subtle unless you’re looking for it.
On the side (LATERAL) film it is obvious: the normal stack of radius, lunate, capitate is broken. The lunate tips forward into what radiologists call the spilled teacup sign. (Lovely name for a wrist that’s come apart.)
If a high-energy wrist injury was assessed without a proper lateral X-ray, it was not assessed.
The other reason it’s missed: swelling and severe pain get put down to a bad sprain, and the wrist goes into a cast. See sprained wrist or something worse.
How is it diagnosed?
- X-rays, front and a TRUE side view. The side view does most of the work.
- CT scan to map fractures (scaphoid, radial styloid, capitate) before surgery.
- A nerve check: feeling in the thumb, index and middle fingertips, recorded before and after the bones are put back.
If you had a high-energy wrist injury and you’re not sure a side view was taken, ask. It’s a fair question.
What’s the treatment?
This one is short. Emergency department, same day.
Reduction, putting the bones back, is usually done urgently to take pressure off the median nerve, but it is a holding measure, not the treatment.
Definitive treatment is surgical, ideally within the first week:
- Open reduction and ligament repair, with wires or screws holding the bones in line. See K-wire pin care and removal.
- Carpal tunnel release where there are nerve symptoms.
- Fixation of the scaphoid fracture if present.
Perilunate dislocation recovery time, phase by phase
This is the Closing Window Method in its clearest form: name the window, find where you are in it, act while it’s open. The first week is the window for the best repair. The first 12 months are the window for getting the most out of it.
Your surgeon’s dates win over these. These are typical.
- Weeks 0 to 8 (sometimes 12): cast or splint, wires in. The wrist doesn’t move. The fingers, elbow and shoulder DO. Tendon glides, 10 reps of each position, 4 to 5 times a day, and full fists and full straightening every hour you’re awake. Hand above heart for swelling.
- Weeks 8 to 12: wires out, motion begins. Gentle active wrist bending and straightening, side to side, and forearm turning palm up and palm down. 10 reps each, 3 to 4 times a day, within comfort. A removable splint between sessions.
- Months 3 to 6: strength. Putty, light grip, wrist curls with a small weight, progressing as the surgeon allows. Push-ups and weight-bearing on the extended wrist come LAST.
- Months 6 to 12: final level. Movement and grip keep creeping up. Most of what you’ll have, you have by 12 months.
Fingers that stiffen in the cast are a second problem stacked on the first. Keep them moving. See stiff hand after a cast or surgery.
Will my wrist be normal again?
Honestly, usually not fully.
Even with prompt, well-executed surgery, the typical outcome is around 60 to 70 percent of normal wrist motion and grip. Plenty of people live and work well inside that range, but it’s not the wrist you had.
Post-traumatic arthritis develops in a substantial proportion within 5 to 10 years. Heavy manual workers frequently do not return to the same job. See wrist arthritis and SLAC wrist.
Missed or treated late, the outcomes are markedly worse, and salvage procedures, partial fusion or proximal row carpectomy, become the realistic options rather than repair. See wrist fusion recovery.
When can I work, drive and play sport?
- Desk work: in my experience, often 2 to 6 weeks after surgery, one-handed, in the cast.
- Light manual work: about 3 to 4 months.
- Heavy manual work: 6 months or more, and not always back to the same job.
- Driving: not in a cast. After it’s off, once you can grip and turn the wheel firmly enough for an emergency stop. Often around 3 months.
- Gym, contact sport, push-ups, yoga on the hands: 6 months at the earliest, cleared by your surgeon.
The window
- First hours: reduce it, protect the nerve. Window OPEN.
- First week: definitive repair, best results.
- Beyond 6 to 8 weeks: ligaments have scarred and shortened; anatomic repair becomes unreliable. Window CLOSING.
- Chronic: salvage surgery only. Window SHUT for repair. The goal changes to a stable, less painful wrist.
This is not a wrist sprain that went badly. It is one of the highest-energy injuries the wrist sustains, and the whole prognosis turns on whether somebody looked at the side view on day one.
Go to the ER today if
- A fall from height, a motorcycle crash or a heavy fall onto the hand left a wrist that is badly swollen and won’t move.
- Numbness or tingling in the thumb, index or middle fingers started right after the injury.
- The wrist looks deformed, or there’s a hard bump on the palm side.
- You were told it was a sprain but no side-view X-ray was taken, and the pain is severe.
Call your surgeon today if
After surgery:
- Numbness in the fingers is getting worse, not better.
- The cast feels too tight, the fingers are pale, blue or cold, or pain keeps climbing.
- Redness, discharge or pain around the wire sites, or a fever.
Get it checked if
- A wrist “sprain” from a big fall still can’t take weight or turn a key after 2 weeks.
- A clunk or giving-way in the wrist months after the injury.
- Fingers stiffening in the cast despite exercises.
A sprain gets better with time. This injury gets worse with time. The side-view X-ray tells you which one you’ve got.
Written by Nigel Chua, hand occupational therapist in practice since 2005. Thousands of hands, wrists and elbows assessed and treated. My credentials are here. This article explains; it doesn’t examine. A high-energy wrist injury deserves a proper X-ray series today, not a reassuring guess.