| 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
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| Anatomy |
- TFCC made up of
- dorsal and volar radioulnar ligaments
- deep ligaments known as ligamentum subcruentum
- 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
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| Classification |
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Class 1 - Traumatic TFCC Injuries
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| 1A |
Central perforation or tear |
| 1B |
Ulnar avulsion (without ulnar styloid fx) |
| 1C |
Distal avulsion (origin of UL and UT ligaments) |
| 1D |
Radial avulsion |
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Class 2 - Degenerative TFCC Injuries
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| 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 |
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| 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)
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| 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
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| Differential |
 Differential for ulnar sided wrist pain
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| Treatment |
- Nonoperative
- immobilization, NSAIDS, steroid injections
- indications
- all acute Type I injuries
- first line of treatment for Type 2 injuries
- Operative
- arthroscopic debridement
- 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
- Darrach procedure
- indications
- contraindicated due to problems with ulnar stump instability
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| 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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