TFCC Injury - Hand - Orthobullets

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 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

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
- immobilization, 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