Perilunate injuries often result from high-energy trauma to the carpus. Despite the severity of these injuries, they are often missed initially because of their subtle radiographic and physical examination findings. Early anatomic reduction of any carpal malalignment is paramount to a successful outcome. Even with optimal treatment, complications, such as generalized wrist stiffness, diminished grip strength, and posttraumatic arthritis, commonly develop; however, recent studies suggest these issues are often well tolerated. In this article, the basic presentation and treatment of perilunate injuries are discussed.