TRIANGULAR FIBROCARTILAGE COMPLEX, TFCC INJURY , DR ARJUN ,

TRIANGULAR FIBROCARTILAGE COMPLEX, TFCC INJURY , MENISCAL HOMOLOGUE, ATICULAR DISC , LIGAMENTS OF DRUJ , DRUJ INJURY

1. TFCC INJURIES Arjun Das Resident of Department of Orthopedics Kathmandu University of School of Medical Sciences

2. Importance TFCC Injury – m/c ligament injury >40 % of displaced distal radial fractures associated with instability of DRUJ In 1981, Palmer and Werner introduced term TFCC

3. Osteology Stabilise during pronation and supination Sigmoid notch of the radius

4. Origin Concave sigmoid notch medial to the distal end of radius from its hyaline cartilage Insertion Fovea Base of ulnar styloid ECU subsheath Ulnocarpal ligaments

5. TFCC components Dorsal and Volar radioulnar ligaments(Superficial ) D eep ligaments known as ligamentum subcruentum C entral fibro-cartilaginous disc Meniscal homologue U lnar collateral ligament ECU Tendon subsheath U lnolunate and U lnotriquetral ligaments

6. Central Disc Occupies 80 % of area Composed of fibrocartilage Type I collagen bundles with interspersed chondrocytes Avascular Poor healing potential Attaches to hyaline cartilage of sigmoid notch Peripheral Disc Outer 20 % of area Vascular connective tissue along with fibroblasts Good healing potential

7. Blood supply Periphery portion : branch from ulnar artery and also from Ant . and P ost . i nterosseous arteries Central portion :nourished by synovial fluid

8. Biomechanics

9. Biomechanics

10. Symptoms of TFCC Injury Ulnar sided wrist pain Popping/clicking with pronation and supination Decreased rotational movements Decreased grip strength Instability of DRUJ

11. Diagnosis of TFCC Injuries Physical examination of the TFCC Palpable tenderness over the TFCC Combined ulnar deviation and pronation /supination may cause pain and popping/clicking sounds Ulnar impingement sign TFCC Stress Test “Press Test”: has been shown to have 100 % sensitivity for TFCC tears

12. Physical Examination Ulnar impaction test W rist hyperextension and ulnar deviation with axial compression Press Test Seated patient is asked to lift himself/herself out of chair while bearing weight on extended wrists

13. Piano key test Shuck test Radial aspect of wrist stabilized Anteroposterior stress is applied to the ulnar side of wrist Fovea sign

14. Radiology X-ray Ulnar variance is calculated in neutral position (+) is associated with TFCC Tears MRI Radioulnar ligaments , ulnocarpal ligaments and the TFCC with its foveal attachment to ulna can be visualized S ensitivity and specificity for TFCC tears (100%)

15. Arthroscopic Evaluation Trampoline test Hook test

16. Differential Diagnosis

17. Non –operative Immobilisation ,NSAIDS ,Steroid Injections All acute T ype I injuries First line of treatment for Type 2 injuries

18. Surgical repair For patients with isolated or associated injuries yielding significant DRUJ instability Often does not itself restore stability of the joint Careful patient selection

19. Traumatic Lesion of TFCC (Palmer Class 1A): Traumatic central tears of the TFCC with no instability Initial treatment non-operative for 4 weeks . Persistent pain relieved by Arthroscopic debridement of the flap portion of tear No more than two thirds of the central disc should be excised 2mm of the TFCC peripheral rim should be preserved

20. Lesions of TFCC ( Palmer Class 1B): Traumatic detachment of TFCC from ulna with or without ulnar styloid fracture Initially conservative A/w ulnar styloid fracture ORIF or Excision of small fragment –usual T/T Open repair of TFCC A/w injury to ECU sheath A rthroscopic repair of TFCC O pen ECU sheath reconstruction

21. Class 1C Lesions Disruptions of ulnocarpal ligaments A/w injuries include lunotriquetral and class 1B tears D ifficult to diagnose Usually conservative management Operative treatment Late open or arthroscopic repair

22. Class 1D Lesions Tear of TFCC from the radius at the distal end of sigmoid notch Oriented in AP direction May involve radioulnar ligaments Frequently a/w distal radius fractures S atisfactory reduction of radial fracture-healing with stable DRUJ I f instability after fracture reduction A rthrocopic /Open repair

23. Arthroscopic Repair of Class 1D Injury

24. Open Repair of Class 1D Injuries

25. Chronic Instability of DRUJ After unsuccessful attempts to repair the TFCC Failed primary TFCC repair Other causes After isolated trauma to the DRUJ After fracture of distal radius and ulna Inflammatory arthritis

26. Procedures to stabilize DRUJ Soft tissue procedures TFCC Repair TFCC Reconstruction Malunited distal radius fracture D istal radial osteotomy and bone grafting Ununited displaced ulnar styloid fracture O pen reduction and internal fixation

27. Anatomical reconstruction of distal radio ulnar ligaments( A dam and B erger)

28. Ulnar impaction and DRUJ arthritis Non operative Operative Without DRUJ arthritis Arthroscopic joint debridement Open/arthroscopic distal ulnar resection Ulnar shortening osteotomy With DRUJ Arthritis Excisional or interposition arthroplasty Modified arthrodesis

29. Ulnar shortening osteotomy

30. Limited Ulnar Head Excision : Hemiresection Interposition Arthroplasty Indications Unreconstructable fractures of ulnar head U lnocarpal impingement syndrome with incongruity of the DRUJ Rheumatoid arthritis involving the DRUJ P osttraumatic arthritis and osteoarthritis of the DRUJ C hronic painful triangular fibrocartilage tear Contraindications N o reconstructable TFCC

31. Hemiresection arthroplasty

32. “WAFER” distal ulna resection Symptomatic tear of TFCC or ulnar impaction syndrome or both Preserves ulnar styloid process and attached liagments Not indicated for DRUJ instability Distal radioulnar degenerative arthritis Carpal instability

33. “WAFER” D istal U lna R esection

34. Sauve-Kapandji procedure Used to salvage painful wrist caused by previous surgery , traumatic arthritis and RA

35. Modified Sauve - Kapandji procedure

36. Darrach resection

37. Procedure to stabilize unstable proximal ulnar segment after distal ulnar excision V olar , distally based capsular flap attached to the ulna proximally S lip of the ECU tendon , based proximally or distally, passed through drill holes in the ulna or wrapped around ulna PQ as a combination interposition-stabilizer Slip of FCU tendon , usually distally based and passed through drill holes in ulna C ombination of ECU tenodesis and dorsal transfer of PQ

38. Tenodesis of ECU and Pronator Q transfer

39. Combination Tenodesis of ECU & FCU

40. 44/M

41. Take Home Message TFCC injury is most common Multiple causes of ulnar sided wrist pain Conservative treatment is mainstay of treatment Persistent pain and instability only requires o perative treatment

42. References Campbell’s Operative Orthopaedics ,14 th Edition Hand and Wrist Surgery ,Operative Techniques ,13 th edition IFSSH Scientific Committee on Anatomy and Biomechanics ,2013 Anatomy of the Triangular Fibrocartilage Complex (TFCC) ,ISSHACADEMICS

43. THANK YOU