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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