Introduction: Perilunate injuries and dislocations are often caused by high impact trauma, and can result in acute compression of the median nerve requiring prompt bedside or operative intervention. Few studies describe operative treatment of these injuries, but to the best of our knowledge, no study describes epidemiology, injury mechanism, immediate treatment, and rate of need for carpal tunnel release (CTR). Methods: Perilunate injuries at a single Level-1-trauma-center were retrospectively reviewed from 1/1/2014-10/1/2023. Data on patient demographics, injury mechanism, initial management, and operative management were collected. Results:Forty cases were included in analysis, with an average age of 36.5 years. The most common injury mechanism was fall from a height(63%), followed by motor vehicle collision. Most cases in our cohort involved a perilunate dislocation (most frequently Mayfield 3) with some additional scaphoid fracture or injury(63%). Initial reduction of dislocation was unsuccessful in 38% of cases, requiring operative intervention. 75% of cases had median nerve paresthesias on initial exam, with most needing CTR. 63% of cases when to the OR within 24 hours, although 100% of cases eventually needing operative intervention. In the OR, 50% of cases had open reduction internal fixation, 25% closed reduction only, and 25% open reduction with percutaneous pinning. Conclusions:While overall uncommon, perilunate injuries still require prompt evaluation and treatment. If initial reduction is not successful, urgent operative intervention will be needed. However, there are some instances where delayed operative management is appropriate. There are multiple acceptable methods of operative fixation to realign the carpal bones.