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High-Pressure Injection Injuries

TFCC Injury

Authors: David Abbasi, Mark Vitale

Topic updated on 03/16/14 12:13pm

Introduction

Mechanism of TFCC injury
- Type 1 traumatic injury
  - mechanism
    - most common is fall on extended wrist with forearm pronation
    - traction injury to ulnar side of wrist
  - traction injury to ulnar wrist
- Type 2 degenerative injury
  - associated with positive ulnar variance
  - associated with ulnocarpal impaction

Anatomy

TFCC made up of
- dorsal and volar radioulnar ligaments
  - deep ligaments known as ligamentum subcruatum
- central articular disc
- meniscus homolog
- ulnar collateral ligament
- ECU subsheath
- origin of ulnolunate and ulnotriquetral ligaments
Blood supply
- periphery is well vascularized (10-40% of the periphery)
- central portion is avascular
Origin
- dorsal and volar radioulnar ligaments originate at the sigmoid notch of the radius
Insertion
- dorsal and volar radioulnar ligaments converge at the base of the ulnar styloid

Classification

Class 1 - Traumatic TFCC Injuries
1A	Central perforation or tear
1B	Ulnar avulsion (without ulnar styloid fx)
1C	Distal avulsion (origin of UL and UT ligaments)
1D	Radial avulsion
Class 2 - Degenerative TFCC Injuries
2A	TFCC wear and thinning
2B	Lunate and/or ulnar chondromalacia + 2A
2C	TFCC perforation + 2B
2D	Ligament disruption + 2C
2E	Ulnocarpal and DRUJ arthritis + 2D

Presentation

Symptoms
- wrist pain
- turning a door key often painful
Physical exam
- positive "fovea" sign
  - tenderness in the soft spot between the ulnar styloid and flexor carpi ulnaris tendon, between the volar surface of the ulnar head and the pisiform
  - 95% sensitivity and 87% specificity for foveal disruptions of TFCC or ulnotriquetral ligament injuries
- pain elicited with ulnar deviation (TFCC compression) or radial deviation (TFCC tension)

Imaging

Radiographs
- usually negative
- zero rotation PA view evaluates ulnar variance
- dynamic pronated PA grip view may show pathology
Arthography
- joint injection shows extravasation
MRI
- has largely replaced arthrography
- tear at ulnar part of lunate indicates ulnocarpal impaction
- sensitivity = 74-100%
Arthroscopy
- most accurate method of diagnosis
- indicated in symptomatic patients after failing several months of splinting and activity modification

Differential

Differential for ulnar sided wrist pain

Treatment

Nonoperative
- imobilization, NSAIDS, steroid injections
  - indications
    - all acute Type I injuries
    - first line of treatment for Type 2 injuries
Operative
- arthroscopic debridement
  - indications
    - type 1A
    - diagnostic gold standard
- arthroscopic repair
  - indications
    - type 1B, 1C, 1D
    - best for ulnar and dorsal/ulnar tears
    - generally acute, athletic injuries more amenable to repair than chronic injuries
  - outcomes
    - patient should expect to regain 80% of motion and grip strength when injuries are classified as acute (<3 months)
- ulnar diaphyseal shortening
  - indications
    - Type II with ulnar positive variance is > 2mm
    - advantage of effectively tightening the ulnocarpal ligaments and is favored when LT instability is present
- Wafer procedure
  - indications
    - Type II with ulnar positive variance is < 2mm
    - type 2A-C
- limited ulnar head resection
  - indications
    - type 2D
- Darrach procedure
  - indications
    - contraindicated due to problems with ulnar stump instability

Techniques

Arthroscopic debridement
- approach
  - arthroscopic approach to the wrist
    - performed through combination of 3-4 and 6R portal
- technique
  - maintain 2 mm rim peripherally otherwise joint can become unstable
- pros & cons
  - not effective if patient has ulnar positive variance
  - 80% of patients obtain good relief of pain
Arthroscopic repair
- approach
  - arthroscopic approach to the wrist
- technique
  - many techniques exist such as outside-in and inside-out
  - generally suture based repair
- pros & cons
  - only works for peripheral tears where blood supply is present
  - patient immobilized for 6 weeks
- complications
  - ECU tendonitis from suture knot
  - dorsal sensory nerve injury
Ulnar diaphyseal shortening
- approach
  - dorsal approach to the forearm
- technique
  - osteotomy of the diaphysis or metaphysis followed by plate fixation
- pros & cons
  - can address > 2 mm ulnar variance
  - requires immobilization and time for fracture healing
  - can help tension the ulnocarpal ligaments
- complications
  - nonunion
  - hardware irritation necessitating removal
Wafer procedure
- approach
  - dorsal approach to the forearm
- technique
  - ulnar cortex is not disrupted
  - do not extend bone removal into the DRUJ
- pros & cons
  - intrinsic stability of ECU, TFCC, and ulnar periosteum obviate need for plate fixation
Limited ulnar head resection
- approach
  - arthroscopic approach to the wrist
- technique
  - removal of approximately 2-4 mm of bone under the TFCC
  - distal ulnar burred through central TFCC defect
- pros & cons
  - can be technically difficult to obtain level shortening through TFCC window
  - only applicable when patient has < 2mm of ulnar variance
Darrach procedure
- approach
  - dorsal approach to the forearm
- technique
  - resection of the distal 1-2cm of the distal ulna
  - TFCC should be approximated to the wrist capsule
- pros & cons
  - salvage procedure for pain relief only
  - distal joint is unstable
- complications
  - ECU tendon can sublux over remaining ulna causing pain

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Qbank (2 Questions)

TAG

(SBQ07.3) A 19-year-old football player suffers a fall onto a pronated, extended wrist. He has pain with resisted ulnar deviation and is tender to palpation just distal to the ulnar styloid. He has no tenderness over the extensor carpi ulnaris (ECU) tendon. Current radiographs are shown in in Figures A and B and and MRI of the wrist is shown in FIgure C. Which of the following is the most likely diagnosis? Topic

Review Topic

FIGURES: A

1. ECU tendon rupture

2. Triangular fibrocartilaginous complex (TFCC) tear

3. Hook of hamate fracture

4. Scapholunate ligament injury

5. Perilunate dislocation

PREFERRED RESPONSE ▶

DISCUSSION: Fall from standing onto an extended and pronated wrist is a risk factor for injuries to the soft tissues of the wrist. The structures at risk include the triangular fibrocartilaginous complex (TFCC), the lunotriquetral ligament, ulnolunate ligament, hook of hamate, ulnar styloid, and the extensor carpi ulnaris (ECU) tendon sheath. Pain with resisted ulnar deviation and ulnar catching are all concerning for injury to the TFCC. MRI is useful for diagnosing TFCC tears ( Illustration A shows another example).

Papapetropoulos et al in their review article discuss the evaluation and arthroscopic treatment of TFCC injuries. Specifically they discuss that most tears in athletes are acute and amenable to repair by repair of the dorsal tear to the ECU tendon sheath.

Cohen in his review of injuries in athletes discusses scapholunate ligament, lunotriquetral ligament, and midcarpal injuries. Of note he divides scapholunate and lunotriquetral ligament injuries into dissociative lesions (abnormal motion within proximal carpal bones) vs. midcarpal lesions which are generally considered nondissociative (abnormal motion between proximal and distal carpal bones).

Rettig in his review of sports injuries of the extremities discusses the Palmer classification of TFCC tears. Specifically he notes that central tears are more associated with repetitive activities in patients with positive ulnar variance.

Incorrect Answers:
Answer 1: The patient is not tender in the region of the ECU tendon sheath.
Answer 3: The carpal tunnel view radiograph shows no hook of hamate fracture.
Answer 4 and 5: Wrist radiographs shows no scapholunate widening or perilunate dislocation. Physical exam in this case is more consistent with a TFCC injury.

Illustrations: A

REFERENCES:

1. Papapetropoulos PA, Ruch DS. Repair of arthroscopic triangular fibrocartilage complex tears in athletes. Hand Clin. 2009 Aug;25(3):389-94. PMID:19643338 (Link to Abstract)

2. Cohen MS: Ligamentous injuries of the wrist in the athlete. Clin Sports Med 1998;17:533-552. PMID:9700418 (Link to Abstract)

3. Rettig AC: Elbow, forearm and wrist injuries in the athlete. Sports Med 1998;25:115-130. PMID:9519400 (Link to Abstract)

Question Authors:

Anay Patel MD, Mark Vitale MD, Michael Hughes MD,

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TAG

(OBQ05.273) Which of the following structures is an anatomical component of the triangular fibrocartilage complex? Topic

Review Topic

1. Extensor carpi ulnaris tendon sheath

2. Lunotriquetral interosseous ligament

3. Extensor digiti minimi tendon sheath

4. Radioscaphocapitate ligament

5. Flexor carpi ulnaris tendon sheath

PREFERRED RESPONSE ▶

DISCUSSION: Palmer et al studied the anatomy and function of the triangular fibrocartilage complex (TFCC) through anatomical dissections and biomechanical testing. The TFCC was found to be composed of the sheath of the extensor carpi ulnaris (ECU), an articular disc, the dorsal and volar radioulnar ligaments, the meniscus homologue, and the ulnar collateral ligament. Biomechanically, they determined that the TFCC functions as a cushion at the ulnocarpal interface, and is a major stabilizer of the DRUJ. Nakamura et al histologically examined the origins and insertions of the TFCC in fresh-frozen cadaver wrists. They found that the floor of the ECU sheath originated from the dorsal side of the fovea of the ulna, through an arrangement of Sharpey's fibers. Illustration A shows the anatomy of the TFCC.

Illustrations: A

REFERENCES:

1. Nakamura T, Takayama S, Horiuchi Y, Yabe Y. Origins and insertions of the triangular fibrocartilage complex: a histological study. J Hand Surg Br. 2001 Oct;26(5):446-54. PMID:11560427 (Link to Abstract)

2. Palmer AK, Werner FW. The triangular fibrocartilage complex of the wrist--anatomy and function. J Hand Surg Am. 1981 Mar;6(2):153-62. PMID:7229292 (Link to Abstract)

Question Authors:

Joshua Blomberg MD, John Badylak MD,

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Videos

	Ulnar head excision (Darrach procedure) Hand - Surgical Techniques - TFCC Injury An open Darrach procedure to treat painful degeneration of the distal radioulnar...	10/20/2012 573 views 5
	Arthroscopic TFCC Tear Surgery - Dr. John Walker Hand - Surgical Techniques - TFCC Injury In this video Dr. John Walker performed an arthroscopic debridement of a central...	10/18/2012 627 views 0

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Evidence & References Show References

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Nakamura T, Takayama S, Horiuchi Y, Yabe Y. Origins and insertions of the triangular fibrocartilage complex: a histological study. J Hand Surg Br. 2001 Oct;26(5):446-54. PMID:11560427 (Link to Abstract)
Palmer AK, Werner FW. The triangular fibrocartilage complex of the wrist--anatomy and function. J Hand Surg Am. 1981 Mar;6(2):153-62. PMID:7229292 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

Undefined

Cohen MS: Ligamentous injuries of the wrist in the athlete. Clin Sports Med 1998;17:533-552. PMID:9700418 (Link to Abstract)
Papapetropoulos PA, Ruch DS. Repair of arthroscopic triangular fibrocartilage complex tears in athletes. Hand Clin. 2009 Aug;25(3):389-94. PMID:19643338 (Link to Abstract)
Rettig AC: Elbow, forearm and wrist injuries in the athlete. Sports Med 1998;25:115-130. PMID:9519400 (Link to Abstract)

TFCC Injury

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