Acute Triangular Fibrocartilage Complex Injuries: Treatment & Management
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Transcript of Acute Triangular Fibrocartilage Complex Injuries: Treatment & Management
Acute Triangular Fibrocartilage Complex InjuriesTreatment & Management
Ivan TamiCentro manoegomito
Clinica Ars Medica – GravesanoSwitzerland
anatomyatlases.org
Introduction
Introduction
Introduction
Anatomy of the DRUJ
- mobility (forearm pronosupination)
- stability (load and force trasmission)
Anatomy
• N-sigmoid notch• L-lunate art. surface• S-scaphoid art. surface
Anatomy
Anatomy
• DRUJ congruity
– 60% in neutral position
– 10% during maximal P/S
Anatomy
• DRUJ congruity
– 60% in neutral position
– 10% during maximal P/S
Arthroscopic Management of Ulnar Pain, F. del Piñal et al.
Anatomy
• The dorsal capsule– extended in P– folded in S
• The palmar capsule– extended in S– folded in P
Arthroscopic Management of Ulnar Pain, F. del Piñal et al.
Anatomy
• TFCComplex– triangular fibrocartilage– meniscus homologue– RU ligaments– UL and UT ligaments– sheat floor of ECU– ulnar joint capsule
Arthroscopic Management of Ulnar Pain, F. del Piñal et al.
Clinical Presentation
• Ulnar-sided– wrist pain– snapping– clunking
• grip strength• Impaired function
– P/S
Clinical Examination
• DRUJ instability– ulnar fovea sign
• DRUJ instability– ulnar fovea sign
Atzei A et al. Foveal TFCC Tear Classification and Treatment. Hand Clin 2011
Clinical Examination
• DRUJ instability– ulnar fovea sign
Arthroscopic Management of Ulnar Pain, F. del Piñal et al.
• DRUJ instability– ulnar fovea sign– distal ulna ballottment test
Clinical Examination
• DRUJ instability– ulnar fovea sign– distal ulna ballottment test
Functional Evaluation of the Distal Radioulnar Joint, N. Badur and M. Garcia-Elias
Clinical Examination
• DRUJ instability– ulnar foveal sign– distal ulna ballottment test– piano key sign
Functional Evaluation of the Distal Radioulnar Joint, N. Badur and M. Garcia-Elias
Imaging for TFCC
Imaging: MRI ”floating styloid”
Courtesy of F. Del Grande, EOC CH-Lugano
Imaging: MRI”complete TFCC tear”
Courtesy of F. Del Grande, EOC CH-Lugano
Imaging: MRI”non repairable TFCC tear”
Courtesy of F. Del Grande, EOC CH-Lugano
Diagnosis: arthroscopy
Gold standard
Diagnosis: arthroscopy
Diagnosis: arthroscopy
Diagnosis: arthroscopy
• Hook test– positive TFCC tear– negative No tear
Arthroscopic Management of Ulnar Pain. F. del Piñal et al.
Diagnosis: arthroscopy
• Hook test1, 2
– positive TFCC tear– negative No tear
1Atzei A et al. New trends in arthroscopic management of type 1-B TFCC injuries with DRUJ instability. JHS Eur 2009
2Atzei A et al. Foveal TFCC tear classification and treatment. Hand Clin 2011
Video: https://www.youtube.com/watch?v=EO8VR5XUF2g
Diagnosis: arthroscopy
Arthroscopic Management of Ulnar Pain. F. del Piñal et al.
• Trampoline test– positive TFCC tear– negative No tear
Diagnosis: arthroscopy
• Trampoline test1
– positive TFCC tear– negative No tear
1Hermansdorfer JD et al. Management of chronic peripheral tears of the TFCC. JHS Am 1991
Video: https://www.youtube.com/watch?v=u2zC5DgFUFA
Palmer Classification of TFCC Lesions1
• I Traumatic injury– A: central perforation– B: ulnar avulsion– C: distal avulsion– D: radial avulsion
• II Degenerative injury
1Palmer AK. Triangular fibrocartilage complex lesions: a classification. JHS Am 1989
Central perforation
Oneson SR., Chamoy L. et al. MR Interpretation of the Palmer Classification of TFCC Lesions. RadioGraphic 1996
• Palmer Class IA Lesions– perforation of TFC proper– sagittally oriented– avascular portion– debridement
Nakamura T. et al. Repair of foveal detachment of the triangular fibrocartilage complex: open and arthroscopic transosseous techniques. Hand Clin 2011
Surgical Treatment: debridement
Video: https://www.youtube.com/watch?v=Or4rw_tTUP0
Distal (Volar) avulsions
• Palmer Class IC Lesions– avulsion volar attachments– sagittally oriented– ulnocarpal instability– surgical repair
– debridement– ulnar shortening
Oneson SR., Chamoy L. et al. MR Interpretation of the Palmer Classification of TFCC Lesions. RadioGraphic 1996
Radial avulsions
• Palmer Class ID Lesions– radial avulsion– less common than IA/B– by distal radius fractures– avascular– surgical repair
– debridement
Oneson SR., Chamoy L. et al. MR Interpretation of the Palmer Classification of TFCC Lesions. RadioGraphic 1996
Radial avulsions
Radial avulsions
Video: https://www.youtube.com/watch?v=jJNLUiYwxJM
Radial avulsions
Ulnar avulsions
• Palmer Class IB Lesions– well-vascularized – ulnar lesions
– capsule tear– foveal tear
– surgical repair by instability
Oneson SR., Chamoy L. et al. MR Interpretation of the Palmer Classification of TFCC Lesions. RadioGraphic 1996
Ulnar avulsions
• Palmer Class IB Lesions– well-vascularized – ulnar lesions
– capsule or distal tear– foveal or proximal tear– complete tear
– surgical repair by instability
Nakamura T. et al. Functional anatomy of the triangular fibrocartilage complex. JHS Br 1996
Ulnar avulsions
• Palmer Class IB Lesions– well-vascularized – ulnar lesions
– capsule or distal tear– foveal or proximal tear– complete tear
– surgical repair by instability
Nakamura T. et al. Functional anatomy of the triangular fibrocartilage complex. JHS Br 1996
Atzei-EWAS Classification of TFCC1
1Atzei A. New Trends in arthroscopic management of 1-B TFCC injuries with DRUJ instability. JHS Eur 2009
Atzei-EWAS Classification of TFCC1
Palmer Class IB
1Atzei A. New Trends in arthroscopic management of 1-B TFCC injuries with DRUJ instability. JHS Eur 2009
Atzei-EWAS Classification of TFCC1
Palmer Class II
1Atzei A. New Trends in arthroscopic management of 1-B TFCC injuries with DRUJ instability. JHS Eur 2009
Atzei-EWAS Classification of TFCC
Acute injuries
Atzei-EWAS Classification of TFCC
Acute injuries
Atzei Class I:suture ligament-to-capsule
Surgical Treatment: suture (ligament-to-capsule)
• Repair: suture ligament-to-capsule
Surgical Treatment: suture (ligament-to-capsule)
Video: https://www.youtube.com/watch?v=kBJcpmQNZMs
Atzei-EWAS Classification of TFCC
Atzei Class II and III:foveal refixation
Surgical Treatment: foveal refixation
• Repair: foveal refixation
Nakamura T. et al. Repair of foveal detachment of the triangular fibrocartilage complex: open and arthroscopic transosseous techniques. Hand Clin 2011
Surgical Treatment: foveal refixation
Video: https://www.youtube.com/watch?v=1gWL0JvBTic
Open versus Arthroscopic Repair
Marc Garcia-EliasInstitut Kaplan, Barcelona
Open versus Arthroscopic Repair
Lucchetti R. Comparison between open and arthroscopic-assisted foveal triangular fibrocartilage complex repair for post-traumatic distal radio-ulnar joint instability. JHS Eur 2014
Rehabilitation• 1-3° weeks
– long-arm cast– neutral rotation– elbow F/E
• 4-6° weeks– short cast– start wrist F/E– assisted forearm rotation
• 7-10° weeks– short cast at night– resume daily activities
Sport and heavy works tasks > 3 months
• 1-3° weeks– short cast– start wrist F/E– assisted forearm rotation
• 4-6° weeks– wrist widget during the day– short cast at night– active E/F and P/S
• 7-10° weeks– resume daily activities– progressive forceful loading
Partial lesion: treatment
The author declares that the research for and communication of this independent body of work does not constitute any financial or other conflict of interest.
Take home message
• Clinical assessment
• MRI +/- arthrography
• Arthroscopic repair
• 3-6 months rehabilitation
Thank you for your attention!
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