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Kim BS, Cho CH, Lee KJ, Lee SW, Byun SH. Pathomechanism of Triangular Fibrocartilage Complex Injuries in Patients with Distal-Radius Fractures: A Magnetic-Resonance Imaging Study. J Clin Med 2022; 11:jcm11206168. [PMID: 36294489 PMCID: PMC9604910 DOI: 10.3390/jcm11206168] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 10/12/2022] [Accepted: 10/18/2022] [Indexed: 11/16/2022] Open
Abstract
Injury to the triangular fibrocartilage complex (TFCC) is one of the most common complications following a fracture of the distal radius. In this study, an examination of TFCC injuries in patients with distal-radius fractures was conducted using magnetic-resonance imaging (MRI); the aim of the study was to analyze the prevalence of TFCC injury as well as to suggest acceptable radiologic parameters for use in prediction of the injury pattern. Fifty-eight patients with distal-radius fractures who underwent MRI prior to undergoing open-reduction surgery between April 2020 and July 2021 were included in this study. An analysis of various radiologic parameters, the fracture type, and the MRI classification of TFCC injuries was performed. Radiologic parameters were used in the evaluation of distal radioulnar joint (DRUJ), radial shortening, and the dorsal angularity of the fracture. All of the patients in this study had definite traumatic TFCC injuries. A statistical relationship was observed between the radial length gap between the intact wrist and the injured wrist, which represents relative radial shortening, and the pattern of TFCC injury. In conclusion, the shortening of the distal radius, causing peripheral soft tissue of the ulnar side to become tauter, is highly relevant with regard to the pattern of TFCC injury. However, because no data on the clinical outcome were utilized in this study, it is lacking in clinical perspective. The conduct of further studies on patients’ clinical outcome will be necessary.
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Xiao AX, Graf AR, Dawes A, Daley C, Wagner ER, Gottschalk MB. Management of Acute Distal Radioulnar Joint Instability Following a Distal Radius Fracture: A Systematic Review and Meta-Analysis. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2021; 3:133-138. [PMID: 35415552 PMCID: PMC8991773 DOI: 10.1016/j.jhsg.2021.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 02/23/2021] [Indexed: 11/19/2022] Open
Abstract
Purpose We sought to review the clinical outcomes of conservative and operative treatment options for acute distal radioulnar joint (DRUJ) instability associated with distal radius fractures in adult patients. Methods A systematic search of PubMed, MEDLINE, and EMBASE for articles published between 1990 and 2020 involving DRUJ instability associated with distal radius fractures was performed. The primary outcomes analyzed included clinical grip strength; range of motion; the disability of the arm, shoulder and hand (DASH) score; and the modified Mayo wrist score (MMWS). Results Of the 531 articles identified in the literature search, 8 met our defined criteria and were included in the final analysis. The cumulative sample size was 258 patients at a mean follow-up of 11.1 months (range, 3–16.9 months). Treatment groups included cast immobilization in supination, K-wire stabilization, and triangular fibrocartilage complex (TFCC) repair. Statistical analysis revealed no difference across groups in active flexion-extension or DASH scores. A significant decrease in grip strength was found in patients who underwent TFCC repair compared with that in those who underwent both cast immobilization (P = .04) and K-wire stabilization (P = .02). Furthermore, we found a significant decrease in active pronation-supination between patients who underwent TFCC repair and those who underwent cast immobilization (P = .03). Patients who underwent TFCC repair were also found to exhibit decreased MMWS as compared with those who underwent K-wire stabilization (P = .05). Overall, persistent DRUJ instability was only found in 4 patients (1.5%), without a significant difference between treatment groups. Conclusions This study suggests functional advantages of certain treatment modalities over others, with the range of motion being highest in patients who underwent cast immobilization and grip strength being highest in patients who underwent K-wire stabilization. However, the mean DASH scores showed no difference across all groups, calling into question the clinical need to pursue operative treatment via K-wire stabilization or TFCC repair over conservative treatment via cast immobilization. This study will hopefully serve as a foundation for future prospective studies to help improve and standardize treatment algorithms in patients with DRUJ instability and distal radius fractures. Type of study/level of evidence: Therapeutic II.
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Affiliation(s)
| | - Alexander R. Graf
- Department of Orthopedic Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Alexander Dawes
- Department of Orthopedic Surgery, Emory University, Atlanta, GA
| | - Charles Daley
- Department of Orthopedic Surgery, Emory University, Atlanta, GA
| | - Eric R. Wagner
- Department of Orthopedic Surgery, Emory University, Atlanta, GA
| | - Michael B. Gottschalk
- Department of Orthopedic Surgery, Emory University, Atlanta, GA
- Corresponding author: Michael B. Gottschalk, MD, Department of Orthopedic Surgery, Emory University, 59 S Executive Park NW, Atlanta, GA 30329
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Tomori Y, Nanno M, Takai S. The Presence and the Location of an Ulnar Styloid Fracture Associated With Distal Radius Fracture Predict the Presence of Triangular Fibrocartilage Complex 1B Injury. Arthroscopy 2020; 36:2674-2680. [PMID: 32502711 DOI: 10.1016/j.arthro.2020.05.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 05/13/2020] [Accepted: 05/13/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To investigate the correlation between ulnar styloid fracture (USF) associated with distal radius fracture (DRF) and triangular fibrocartilage complex (TFCC) injuries and to elucidate whether the presence or location of an USF in a patient with DRF predicts the presence of traumatic TFCC injuries. METHODS From 2005 to 2018, an arthroscopic evaluation was performed to detect TFCC injuries associated with DRF. The presence and location of USFs were evaluated using computed tomography. TFCC injuries were classified in accordance with Palmer's classification. All wrists were divided into group A (DRF without USF) and group B (DRF with USF). The incidence of TFCC injuries in the 2 groups was compared. group B was then divided into 2 subgroups in accordance with the USF location: the tip or middle fracture subgroup and the base fracture subgroup. Data were analyzed with significance set at P < .05. RESULTS One hundred thirty-eight patients were enrolled in this study. Group A included 42 wrists in 42 patients, whereas group B included 96 wrists in 96 patients. There were significant differences between the 2 groups regarding the incidence of traumatic TFCC injuries (P = .036) and TFCC 1B injury (P = .002), although there were no differences between the 2 groups regarding age, sex, injured side, direction of displacement, and type of DRF. Within group B, the tip and middle fracture subgroup included 37 wrists in 37 patients, whereas the base fracture group included 59 wrists in 59 patients; a significant difference was observed between the two subgroups regarding the incidences of TFCC 1B injuries (P = .044). CONCLUSIONS The presence of USF associated with DRF predicted the presence of frequently occurring traumatic TFCC injury and TFCC 1B injury. Moreover, the location of USFs was a predictive factor for TFCC 1B injury in adults with DRF. On the other hand, traumatic TFCC injury had occurred in adults with DRF, regardless of the presence of USF. LEVEL OF EVIDENCE Level IV, Case series.
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Affiliation(s)
- Yuji Tomori
- Department of Orthopaedic Surgery, Nippon Medical School Hospital, Tokyo, Japan.
| | - Mitsuhiko Nanno
- Department of Orthopaedic Surgery, Nippon Medical School Hospital, Tokyo, Japan
| | - Shinro Takai
- Department of Orthopaedic Surgery, Nippon Medical School Hospital, Tokyo, Japan
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McNamara CT, Colakoglu S, Iorio ML. A Systematic Review and Analysis of Palmer Type I Triangular Fibrocartilage Complex Injuries: Outcomes of Treatment. J Hand Microsurg 2020; 12:116-122. [PMID: 32788827 DOI: 10.1055/s-0040-1713580] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Triangular fibrocartilage complex (TFCC) injuries can present incidentally as an asymptomatic lesion or can cause acute and chronic pain. This study compared different treatment approaches for symptomatic Palmer Type 1 TFCC injuries and rates of improvement using a systematic review of the literature. Two hundred thirty-one articles were identified, 43 met criteria and were included. Two of these articles indicated conservative therapy may be adequate. Patients who underwent debridement for any Type 1 Palmer class returned to work at a rate of 92% ( n = 182), but only 44% ( n = 38) were free of pain. For 1B lesions that underwent repair, 68.3% ( n = 226) were able to return to work and 41% ( n = 52) had persistent pain. 1D lesions were treated with both repair and debridement with similar results. Data for Types 1A and 1C were limited as no authors solely addressed these lesions. For 1A lesions, those treated with traditional treatment of debridement still had high rates of being unable to return to work. The literature remains insufficient, making comparison between studies and techniques difficult. For asymptomatic injuries, there is no need for treatment. For patients with recalcitrant symptoms, surgery improves pain, grip strength, and increases return to work and activity. The level of evidence is IV.
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Affiliation(s)
- Colin T McNamara
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Center, Aurora, Colorado, United States
| | - Salih Colakoglu
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Center, Aurora, Colorado, United States
| | - Matthew L Iorio
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Center, Aurora, Colorado, United States
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Affiliation(s)
- David M Brogan
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Richard A Berger
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Sanjeev Kakar
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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Kootstra TJ, van Leeuwen WF, Chen N, Ring D. Variation in Repair of the Triangular Fibrocartilage Complex. J Wrist Surg 2018; 7:243-246. [PMID: 29922502 PMCID: PMC6005778 DOI: 10.1055/s-0038-1625953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 12/26/2017] [Indexed: 10/18/2022]
Abstract
Background There is controversy regarding the value of repair of the triangular fibrocartilage complex (TFCC). Given that an acute tear of the TFCC associated with a displaced distal radius fracture uncommonly benefits from repair, the role of repair in other settings is uncertain. Our impression is that TFCC repair is highly variable from surgeon-to-surgeon. Purpose The purpose of this study is to determine the rate of TFCC repair in patients who had a magnetic resonance imaging (MRI) scan of the wrist obtained for ulnar-sided wrist pain, and that showed signal changes in the TFCC. We tested the primary null hypothesis that there are no demographic or surgeon factors associated with repair of the TFCC. Patients and Methods Three hundred and ninety-four patients with ulnar-sided wrist pain and an MRI scan showing changes in the TFCC were included in this retrospective study. No patients had instability of the distal radioulnar joint (DRUJ) recorded in the medical record. Surgical repair of TFCC tears was used as the primary outcome during statistical analysis to identify factors associated with repair. Results Out of 394 (6%), 25 patients underwent TFCC repair. We found that 10% of the treating surgeons (4 out of 41) performed 80% of the procedures (20 out of 25). Patients who discerned a trauma prior to their symptoms and patients whose MRI showed signal changes primarily in the ulnar portion of the TFCC were more likely to have surgical repair. Conclusion We found that the rate of TFCC repair varies substantially from surgeon-to-surgeon. The observation that repair is more likely to happen when patients perceive themselves as injured suggests that perception of injury affects how patients and surgeons consider treatment options. To help avoid surgeries based on surgeon bias or patient misperception, we suggest studying the effect of tools that provide simple, balanced, dispassionate, and empowering information (e.g., decision aids) that can limit surgeon-to-surgeon variation. Level of Evidence Level IV.
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Affiliation(s)
- Thomas J.M. Kootstra
- Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Wouter F. van Leeuwen
- Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Neal Chen
- Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - David Ring
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, Texas
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Why do we use arthroscopy for distal radius fractures? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2018; 28:1505-1514. [DOI: 10.1007/s00590-018-2263-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Accepted: 05/30/2018] [Indexed: 01/12/2023]
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Boer BC, Vestering M, van Raak SM, van Kooten EO, Huis In 't Veld R, Vochteloo AJH. MR arthrography is slightly more accurate than conventional MRI in detecting TFCC lesions of the wrist. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2018; 28:1549-1553. [PMID: 29700613 PMCID: PMC6244851 DOI: 10.1007/s00590-018-2215-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 04/17/2018] [Indexed: 11/29/2022]
Abstract
Introduction In case of clinical suspicion of triangular fibrocartilage complex (TFCC) injury, different imaging techniques are used. The aim of this study was to determine whether MRA is superior to MRI and whether 3.0 T is better than 1.5 T (expresses in sensitivity, specificity and accuracy) in detecting TFCC injury, using arthroscopy as the gold standard. Materials and methods The arthroscopic and MR findings of 150 patients who underwent arthroscopy for ulnar-sided wrist pain between January 2009 and November 2016 were retrospectively reviewed. Results MRA was slightly more accurate compared to conventional MRI, and 1.5 T was slightly more accurate than 3.0 T. 1.5 T wrist MRA had a sensitivity of 80%, a specificity of 100% and accuracy of 90%; 3.0 T wrist MRA 73, 100 and 86%, resp. Conventional 1.5 T wrist MRI had a sensitivity of 71%, a specificity of 75% and accuracy of 73%. For 3.0 T conventional MRI, this was 73, 67 and 70%, resp. Conclusions MRA seems slightly superior to conventional MRI, but one could question whether this difference in diagnostic accuracy outweighs the burden and risks of an invasive procedure for patients with its additional costs. Furthermore, we could not confirm the superiority of 3 T compared to 1.5 T.
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Affiliation(s)
- B C Boer
- Hand and Wrist Unit, Centre for Orthopaedic Surgery OCON, PO Box 546, 7550 AM, Hengelo, The Netherlands
| | - M Vestering
- Department of Radiology, Ziekenhuisgroep Twente, PO Box 546, 7550 AM, Hengelo, The Netherlands.,Department of Radiology, Medisch Spectrum Twente, Postbus 50 000, 7500 KA, Enschede, The Netherlands
| | - S M van Raak
- Department of Radiology, Ziekenhuisgroep Twente, PO Box 546, 7550 AM, Hengelo, The Netherlands
| | - E O van Kooten
- Department of Plastic Surgery, Medisch Spectrum Twente, Postbus 50 000, 7500 KA, Enschede, The Netherlands
| | - R Huis In 't Veld
- Hand and Wrist Unit, Centre for Orthopaedic Surgery OCON, PO Box 546, 7550 AM, Hengelo, The Netherlands
| | - A J H Vochteloo
- Hand and Wrist Unit, Centre for Orthopaedic Surgery OCON, PO Box 546, 7550 AM, Hengelo, The Netherlands.
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Gay AM, Samson P, Legré R. Fractures articulaires complètes de l’extrémité distale du radius chez le sujet jeune actif. HAND SURGERY & REHABILITATION 2016; 35S:S51-S54. [DOI: 10.1016/j.hansur.2016.09.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 04/23/2016] [Accepted: 09/15/2016] [Indexed: 11/16/2022]
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Conservative Treatment Is Sufficient for Acute Distal Radioulnar Joint Instability With Distal Radius Fracture. Ann Plast Surg 2016; 77:297-304. [DOI: 10.1097/sap.0000000000000663] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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