TFCC.WRIST.INJURY.pptx tfcc wrist injuries

TFCC (Triangular Fibrocartilage Complex) injury is a tear or damage to the cartilage structure on the little-finger side of the wrist. These injuries can result from trauma, such as a fall on an outstretched hand or a forceful, repetitive wrist movement in sports, or can be degenerative over time. Symptoms include pain on the ulnar side of the wrist, clicking or popping sounds, weakness, and a reduced range of motion. Treatment ranges from conservative methods like rest, bracing, and physical therapy to surgical options for more severe tears.

1. Triangular fibrocartilage complex injuries

2. Moderators Dr.S.Lakshminarayana Sir (Unit Chief and Prof) Dr.B.Kiran Kumar Sir ( Associate Prof) Dr.K.Ravikanth Sir (Assistant Professor) Dr.Sai Charan Reddy Sir ( Assistant Professor)

3. Anatomy The structures causing pain on the ulnar side of the wrist include Triangular fibrocartilage complex or TFCC of Werner and Palmer. DRUJ Distal ulnocarpal joint

4. TFCC The TFCC includes the dorsal and volar radioulnar ligaments, ulnar collateral ligament, meniscal homologue, articular disc, ulnolunate ligaments, ulnotriquetral ligaments, and extensor carpi ulnaris sheath

5. The deep and superficial fibers of the TFCC begin on the ulnar side of the lunate fossa of the radius. The deep fibers of the TFCC then attach ulnarly at the head of the ulna called the “fovea,” and The superficial fibers of the TFCC attach to the ulnar styloid tip where it joins with the ulnar collateral ligaments

6. Articular surface contact in the shallow sigmoid notch accounts for about 20% of DRUJ stability and allows dorsopalmar translation of about 1 cm with the forearm in neutral position.

7. TFCC: Function Absorbs 20% of an axial load on the wrist joint
Cushions/supports carpal bones
Stabilizes radius and ulna during pronation, supination, and grasping motions

8. The thickness of the articular disc has an inverse relationship to the amount of ulnar variance. DRUJ conditions have been categorized as acute and chronic problems Acute conditions include fractures of the ulnar head, styloid, radius, and carpal bones and dislocations or subluxations involving the DRUJ, carpal bones, and the TFCC and extensor carpi ulnaris subluxation.

9. Chronic conditions include bony nonunions and malunions and incongruities of the wrist joint, including subluxation and dislocation of the DRUJ, the ulnocarpal region, the various carpal bones, and the TFCC, and localized arthritis of the pisotriquetral , lunotriquetral , and radioulnar joints and extensor carpi ulnaris subluxation related to arthritis.

10. Procedures helpful in managing these problems include arthroscopic debridement and repair, limited ulnar head excision, ulnar shortening, and ulnar pseudarthrosis with distal radioulnar arthrodesis and distal ulnar excision ( Darrach ).

11. High-demand athletes, such as tennis players or gymnasts, also are at risk of TFCC injuries Patients with a TFCC injury usually report a fall or some other trauma to the wrist that resulted in ulnar-sided wrist pain and mechanical symptoms (e.g., clicking) that improve with rest and worsen with activity, as well as weakness of grasp.

12. Physical examination may find painful grinding or clicking of the wrist with a range of motion Ulnar deviation of the wrist with the forearm in neutral produces ulnar wrist pain and occasional clicking A painful click may be elicited by having the patient clench and ulnarly deviate the wrist and then repeatedly pronate and supinate the wrist.

13. In contrast, patients with scapholunate instability usually have pain and clicking when the clenched fist is moved from ulnar to radial deviation The ulnar impaction test—wrist hyperextension and ulnar deviation with axial compression—also will elicit pain. The “press test” is another useful provocative test, this is not highly specific and may indicate DRUJ instability or ulnar impaction

14. With the wrist in pronation, an unstable distal ulna may translate dorsally and can be manually reduced with dorsal thumb pressure (“piano key test) Tenderness and pain identified when external pressure is applied to the area of the fovea (fovea sign) is indicative of an ulnocarpal ligament lesion.

15. TFCC instability also is suggested by excessive motion with the “shuck test”—with the radial aspect of the wrist stabilized, anteroposterior stress is applied to the ulnar side of the wrist

16. Anteroposterior and lateral views of the wrist and a pronated grip view should be obtained to determine ulnar variance. MRI has a sensitivity and specificity for TFCC tears approaching 100%, CT arthrography is highly sensitive for detecting central TFCC tears but is not accurate for detecting peripheral tears.

17. With the arthroscope in the standard 3-4 portal (see Fig. 69.15), a probe inserted through the 6R (or 4-5) portal is used to test the resilience of the TFCC by applying a compressive load (trampoline test)

18. The hook test is performed with a probe inserted through the 6R portal into the prestyloid recess and used to attempt to pull the TFCC in multiple directions

19. According to Atzei and Luchetti , with an isolated distal TFCC tear, the trampoline test is positive and the hook test is negative. With proximal tears or complete tears, both tests are positive.

20. Palmer classification

21. Management of class 1A TFCC (central perforation) lesions includes nonoperative measures initially If significant symptoms persist, arthroscopic debridement may provide relief. With an ulnar-positive wrist, the possible presence of degenerative changes in the ulnocarpal joint should be considered; these can be treated with arthroscopic “wafer” resection of the ulnar head or ulnar shortening osteotomy

22. Conservative Management • Rest and ice application. • Protective bracing/immobilization for 3 to 6 weeks.
• Activity modification to remove the force of injury.
• Progressive strengthening exercise program, when able, targeted at wrist, forearm and grip strength.
• Heat and/or electrotherapy modalities for pain

23. For class 1B lesions (avulsion from the ulna, with or without ulnar styloid fracture), immobilization for 6 weeks followed by rehabilitation may be sufficient If the ulnar styloid is fractured, open reduction and internal fixation of the fracture or excision of a small fragment is the usual treatment. Open repair of the TFCC injury is done at the time of ulnar styloid fixation. .

24. If Extensor carpi ulnaris tendon subluxation occur with traumatic TFCC injuries arthroscopic repair of the triangular fibrocartilage and open extensor carpi ulnaris sheath reconstruction may be necessary.

25. Class 1C lesions represent disruptions of the ulnocarpal ligaments in the substance of the ligaments or from the distal lunate and triquetral insertions. Associated injuries include lunotriquetral and class 1B tears. Class 1C injuries can be difficult to diagnose, may heal satisfactorily, and usually are treated without surgery unless significant instability develops. Carpal supination with a “sagging” of the ulnar side of the carpus is a helpful sign of instability.

26. Class 1D lesions (avulsions of the TFCC from the radius, with or without sigmoid notch fracture) may occur with fractures of the distal radius and ulna. If the ligament injury is unstable after reduction of the associated fracture, or if the notch fracture requires further treatment, detachment of the ligament from the radius can be repaired with open or arthroscopic techniques.

27. The dorsal DRUL can be reconstructed using a tendon graft, the ends of which were anchored in the bone of the radius and ulna. This technique has been shown to correct dynamic DRUJ instability (by scheker )

28. Methods of ulnar shortening. A) Wafer procedure; B) Subcapital osteotomy-fixation with a locking plate; C) Distal osteotomy with screw fixation; D) Diaphyiseal transverse osteotomy; E) Diaphyseal oblique osteotomy; F) Diaphyseal step-cut osteotomy; G) Darrach procedure; H) Sauvé- Kapandji procedure; I) Hemiresection-interpositional arthroplasty.

29. Kleinman -Greenberg procedure for treating distal ulna instabilityresulting from a failed Darrach resection. The ECU tenodesis retardsradioulnar impingement, and the pronator quadratus transfer limitsdorsal translation. Temporary percutaneous pinning of the ulna to theradius adds additional stability.

30. Wrist arthrodesis Fusion of the wrist is done most often for ununited or malunited fractures of the carpal scaphoid with associated radiocarpal traumatic arthritis and for severely comminuted fractures of the distal end of the radius. It also is useful for rheumatoid arthritis This usually is 10 to 20 degrees of extension, with the long axis of the third metacarpal shaft aligned with the long axis of the radial shaft.

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