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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 post
    • 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 post
    • 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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