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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?
ECU tendon rupture
Triangular fibrocartilaginous complex (TFCC) tear
Hook of hamate fracture
Scapholunate ligament injury
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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.
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.
Papapetropoulos PA, Ruch DS.
Hand Clin. 2009 Aug;25(3):389-94. PMID: 19643338 (Link to Abstract)
Clin Sports Med. 1998 Jul;17(3):533-52. PMID: 9700418 (Link to Abstract)
Sports Med. 1998 Feb;25(2):115-30. PMID: 9519400 (Link to Abstract)
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Which of the following structures is an anatomical component of the triangular fibrocartilage complex?
Extensor carpi ulnaris tendon sheath
Lunotriquetral interosseous ligament
Extensor digiti minimi tendon sheath
Flexor carpi ulnaris tendon sheath
The extensor carpi ulnaris tendon sheath is part of the triangular fibrocartilage complex (TFCC).
Palmer et al studied the anatomy and function of the 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.
Nakamura T, Takayama S, Horiuchi Y, Yabe Y
J Hand Surg Br. 2001 Oct;26(5):446-54. PMID: 11560427 (Link to Abstract)
Palmer AK, Werner FW.
J Hand Surg Am. 1981 Mar;6(2):153-62. PMID: 7229292 (Link to Abstract)
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