Ulnar-sided wrist pain: evaluation and treatment of triangular fibrocartilage complex tears, ulnocarpal impaction syndrome, and lunotriquetral ligament tears

Ulnar-sided wrist pain is a common cause of upper extremity disability. Presentation can vary from acute traumatic injuries to chronic degenerative conditions. Because of its overlapping anatomy, complex differential diagnosis, and varied treatment outcomes, the ulnar side of the wrist has been referred to as the "black box" of the wrist, and its pathology has been compared with low back pain. Common causes of ulnar-sided wrist pain include triangular fibrocartilaginous complex injuries, lunotriquetrial ligament injuries, and ulnar impaction syndrome.

Arthroscopically assisted repair of peripheral triangular fibrocartilage complex tears: factors affecting outcome

PURPOSE

The purpose of our study was to identify factors affecting the outcome after arthroscopically assisted repair of peripheral triangular fibrocartilage complex (TFCC) tears.

TYPE OF STUDY

Retrospective case series.

METHODS

Thirty-five patients who underwent arthroscopic repair of traumatic TFCC tears were enrolled in this study (mean age, 34 +/- 12 years; 22 female and 13 male patients; mean follow-up, 29 months; range, 6 to 82 months). Patients with TFCC tears associated with distal radius fractures, or significant wrist bone or neurovascular pathology were excluded from the study. The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire score was used as the primary variable during statistical analysis to identify factors determining outcome.

RESULTS

The DASH score in this study was 12 +/- 12 points. A significant correlation was found between the age of the patient and the DASH score, indicating that older age has a significant negative effect on functional outcome. Significant correlations were also found between the DASH score and (1) decreased percentage of grip strength compared with the healthy side, (2) decreased supination, and (3) positive postoperative ulnar variance.

CONCLUSIONS

Age-related degenerative changes in the wrist might contribute to poor outcome and a TFCC tear resulting from minor or repetitive trauma. Loss of wrist rotation, grip strength, and ulnar positive variance are factors that are correlated with poor outcome.

LEVEL OF EVIDENCE

Level IV.

Peripheral tear of the triangular fibrocartilage: depiction with MR arthrography of the distal radioulnar joint

OBJECTIVE

Although central tears of the triangular fibrocartilage are easily seen on imaging, peripheral tears of the ulnar attachment are frequently missed. The aim of this study was to evaluate the accuracy of MR arthrography of the distal radioulnar joint in depiction of peripheral tears of the triangular fibrocartilage.

MATERIALS AND METHODS

Forty-one patients (18 women, 23 men; mean age, 38 years; age range, 18-60 years) underwent MR arthrography and wrist arthroscopy. For MR arthrography, iopamidol (300 mg I/mL) and gadopentetate dimeglumine (4 mmol/L) were injected into the distal radioulnar joint. Consensus review of both MR arthrograms and conventional arthrograms was performed by two experienced musculoskeletal radiologists. Presence or absence of communicating and noncommunicating tears of the ulnar attachment of the triangular fibrocartilage was recorded. Arthroscopy was used as the standard of reference for determining sensitivity, specificity, and accuracy in detection of tears of the ulnar attachment.

RESULTS

At MR arthrography, communicating tear of the ulnar attachment was diagnosed in three patients, noncommunicating tear in 19 patients, and normal attachment in 19 patients. Arthroscopy revealed peripheral tear of the triangular fibrocartilage in all three patients with communicating tear, in 14 of 19 patients with noncommunicating tear, and in three of 19 patients with normal attachment. The sensitivity was 85% (17/20), specificity was 76% (16/21), and accuracy was 80% (33/41).

CONCLUSION

MR arthrography of the distal radioulnar joint is accurate in depiction of peripheral tears of the ulnar attachment of the triangular fibrocartilage. These tears often appear as noncommunicating tears extending from the distal radioulnar joint into the triangular fibrocartilage.

Arthroscopically assisted reattachment of avulsed triangular fibrocartilage complex to the fovea of the ulnar head

Triangular fibrocartilage complex (TFCC) insertion into the fovea of the distal ulna plays a crucial role in stabilizing the distal radioulnar joint. Consequently, surgical reattachment against avulsion of the foveal TFCC insertion is required to stabilize the distal radioulnar joint. However, because of technical difficulties, no arthroscopic procedure for such a lesion has currently been established. We present a new technique for arthroscopic reattachment of the avulsed TFCC into the fovea. An osseous tunnel 2.9 mm in diameter is created from the ulnar neck to the foveal surface. Under arthroscopic guidance, a nonabsorbable suture passed into a 21-gauge needle is placed into the TFCC through the osseous tunnel. The avulsed portion of the TFCC is anchored to the fovea by means of a repair suture passed through the TFCC. To achieve normal tension of the TFCC, the suture is tied onto the periosteum around the proximal entrance of the osseous tunnel. Our arthroscopic technique is relatively simple and has great advantages for progressive healing at the attachment site between the TFCC and the fovea.

Ulnar impaction

Ulnar impaction syndrome is a common source of ulnar-sided wrist pain. It is a degenerative condition that occurs secondary to excessive load across the ulnocarpal joint, resulting in a spectrum of pathologic changes and symptoms. It may occur in any wrist but is usually associated with positive ulnar variance, whether congenital or acquired. The diagnosis of ulnar impaction syndrome is made by clinical examination and is supported by radiographic studies. Surgery is indicated if nonoperative treatment fails. Although a number of alternatives exist, the 2 primary surgical options are ulnar-shortening osteotomy or partial resection of the distal dome of the ulna (wafer procedure). This article discusses the etiology of ulnar impaction syndrome, and its diagnosis and treatment.

Comparison between high-resolution MRI with a microscopy coil and arthroscopy in triangular fibrocartilage complex injury

PURPOSE

To determine whether high-resolution magnetic resonance imaging (MRI) could detect injuries to the triangular fibrocartilage complex (TFCC).

METHODS

Eleven patients who showed both a positive sign during the ulnocarpal stress test and tenderness at the distal end of the ulna had a high-resolution MRI using a 47-mm diameter microscopy coil. Six regions of the TFCC were investigated for injury: the radial attachment, disc, ulnar attachment of the triangular fibrocartilage (TFC), ulnotriquetral ligament, palmar radioulnar ligament (PRUL), and dorsal radioulnar ligament (DRUL). Arthroscopy was performed subsequently on each patient.

RESULTS

For injuries to the radial attachment or the disc of the TFC, a high-resolution MRI showed 100% sensitivity and 100% specificity compared with arthroscopy. In 3 cases in which injury to the ulnar attachment of the TFC was detected with MRI and examination showed a positive piano-key sign and distal radioulnar joint instability, only 1 injury was confirmed with arthrotomy. For MRI diagnosis of an ulnotriquetral ulnolunate attachment injury, the sensitivity was 100% and the specificity was 70%; however, 3 cases had false-positive results. Finally MRI had 100% sensitivity for detecting DRUL and PRUL injuries, although specificities were 75% and 83%, respectively. With MRI there were 2 false-positive DRUL injury diagnoses and 1 false-positive PRUL injury diagnosis.

CONCLUSIONS

High-resolution MRI using a microscopy surface coil allowed assessment of each TFCC component and showed a higher accuracy for diagnosing injuries to the radial attachment and the disc of the TFC compared with previous studies. High-resolution MRI, however, was not able to diagnose DRUL, PRUL, or ulnolunate ligament injuries accurately.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

Arthroscopic treatment of peripheral triangular fibrocartilage complex tears with the deep fibers intact

PURPOSE

We describe a variant of triangular fibrocartilage complex (TFCC) tears in which the superficial fibers attaching to the ulnar capsule are torn, with preservation of deep fibers inserting on the fovea. We present the clinical and magnetic resonance imaging findings and the results of arthroscopic repair in patients with this injury.

METHODS

Twenty-nine wrists were treated arthroscopically for peripheral TFCC tears with outside-in suture repair of the TFCC to the ulnar capsule. A retrospective review of all cases was performed to assess the physical examination, magnetic resonance imaging, and intraoperative findings. Patients were evaluated at greater than 1 year with range of motion, grip strength, standard outcome measures, and a survey assessing return to work and sports.

RESULTS

Before surgery, all patients had complaints of ulnar-sided wrist pain with a stable distal radioulnar joint on examination. Twenty-six wrists (90%) were available for follow-up at a mean of 31 months. There was one repeat surgery, a re-tear that required revision TFCC repair. The preoperative visual analog scale and Disabilities of the Arm, Shoulder, and Hand scores improved from 5 and 38 to 1 and 9, respectively, at final follow-up. Side-to-side comparisons demonstrated no measurable loss in motion or grip strength. There were no cases of distal radioulnar joint instability at final follow-up. Of 11 high-level athletes in the total cohort, 7 (64%) were able to return to sports, including all of those in racquet sports; however, athletes who bore weight through their hands were unable to return to their sporting activity.

CONCLUSIONS

Tears of the TFCC superficial fibers with the deep fibers intact present with ulnar-sided wrist pain but without distal radioulnar joint instability. The results of outside-in repair of the articular disk back to the ulnar capsule demonstrated improvement in pain and function with no measurable objective losses. Return to sport was variable and appeared worse for those who bear weight through the hands.

Injury of the dorsal sensory branch of the ulnar nerve as a complication of arthroscopic repair of the triangular fibrocartilage

This report presents a case of direct injury to the dorsal sensory branch of the ulnar nerve caused by arthroscopic repair of the triangular fibrocartilage complex. The dorsal sensory branch of the ulnar nerve was strangulated by one of the three pull-out sutures of the joint capsule, just ulnar to the extensor carpi ulnaris tendon. Pain and dysaesthesia of the ulnar side of the wrist was completely relieved after excision of the injured nerve segment. This complication can be avoided by careful exploration of the dorsal sensory branch of the ulnar nerve prior to suturing or passage of instruments during arthroscopy.

Ulnar impaction syndrome

Although Palmer's classification of TFCC lesions differentiates post-traumatic central perforations (IA tears) from degenerative tears secondary to ulnocarpal impaction (IIC) [3], the distinction is not always clear clinically. In the final analysis, the literature suggests that as many as 25% of wrists with TFCC tears have residual symptoms following arthroscopic debridement alone [23], and it is likely that static or dynamic ul-nar positive variance plays a role [2,5,17,25]. The authors' results suggest that combined arthroscopic TFCC debridement and wafer resection are feasible and efficacious as treatment for all stages of ulnar impaction syndrome. When class II A and B changes are observed, that is, when a TFCC perforation has not yet developed, the authors have observed favorable results in most patients following arthroscopic TFCC central disc excision and wafer resection as an alternative to ulnar shortening osteotomy [33] or open wafer excision [10].

Pediatric distal radius fractures and triangular fibrocartilage complex injuries

Management of distal radius fractures is guided by the pattern and location of injury, degree of deformity, and expectations of bony remodeling based on the amount of remaining skeletal growth.Indications for surgical treatment include unstable or irreducible fractures, open fractures, floating elbow injuries, and neurovascular or soft-tissue compromise precluding cast immobilization. Patients and families should be counseled regarding the potential for post-traumatic distal radial growth arrest following physeal fractures. In these cases, epiphysiodeses, ulnar shortening osteotomies, or corrective radial osteotomies may be performed, depending on the pattern of arrest,degree of deformity, and remaining skeletal growth.TFCC tears may be the source of ulnar-sided wrist pain in children and adolescents, though symptoms and physical examination findings maybe subtle. Patients who have persistent pain and functional limitations despite activity modification and therapy are candidates for surgical treatment. Appropriate repair of peripheral TFCC tears with correction of concomitant wrist pathology restores normal wrist anatomy, alleviates pain, and allows for return to functional activities.

Repair of the triangular fibrocartilage complex after ulnar-shortening osteotomy: second-look arthroscopy

PURPOSE

Ulnar shortening is a widely used procedure for various conditions associated with ulnar wrist pain, including triangular fibrocartilage complex (TFCC) injury; however, few reports have examined the condition of the TFCC after osteotomy. The central avascular zone of the TFCC generally is considered to have no potential to heal. This study investigated whether the avascular zone of the TFCC has any potential for repair, and whether repair of the torn disc proper correlates with clinical findings.

METHODS

Between 1987 and 2005, we performed 75 second-look arthroscopies after an ulnar-shortening osteotomy for ulnar wrist disorders. Of these, 32 wrists with a TFCC (disc proper) tear on first arthroscopy were included in this study. Data from patient charts, radiography, and video images of arthroscopy were reviewed retrospectively. Tears of the disc proper were classified as radial, central, or ulnar tears, and as either linear or round tears.

RESULTS

Meticulous second-look arthroscopy showed repair of tears in 50% of studied wrists. Round tears tended to repair better than linear tears. Although the final clinical score was better in repaired wrists than in nonrepaired wrists, no marked differences were noted between groups in terms of age, gender, preoperative ulnar variance, follow-up period, or surgical procedures used.

CONCLUSIONS

The avascular zone of the TFCC possesses some potential for repair; however, factors promoting spontaneous repair of this tissue were not identified.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Accuracy of direct magnetic resonance arthrography in the diagnosis of triangular fibrocartilage complex tears of the wrist

The aim of this study was to assess the value of direct magnetic resonance (MR) arthrography of the wrist for detecting full-thickness tears of the triangular fibrocartilage complex (TFCC). Twenty-four consecutive patients who had ulnar-sided wrist pain and clinical suspicion of TFCC tear were included in the study. All patients underwent direct MR arthrography and then wrist arthroscopy, and the results of MR arthrography were compared with the arthroscopic findings. The positive predictive value of MR arthrography in detecting TFCC full-thickness tear was 0.95, and the negative predictive value was 0.50. The sensitivity of MR arthrography in detecting a TFCC full-thickness tear was 74% (15/19), and specificity was 80% (4/5). The overall accuracy of MR arthrography in detecting a full-thickness tear of the TFCC in our study was 79% (19/24). We believe that diagnosis of tears in the TFCC by direct MR arthrography is not entirely satisfactory, although MR arthrography has a high positive predictive value for detecting TFCC tears. Negative results of MR arthrography in patients with clinical suspicion of TFCC tear should be interpreted with caution.

Biomechanical study of the extensor carpi ulnaris as a dynamic wrist stabilizer

PURPOSE

To investigate the dynamic stabilizing effect of the extensor carpi ulnaris (ECU) on the distal radioulnar joint (DRUJ) and the ulnocarpal joint in a simulated model of triangular fibrocartilage complex (TFCC) injury.

METHODS

Using 8 fresh-frozen cadavers, we fixed the humerus and ulna at 90° of elbow flexion, and the radius and hand were allowed to rotate freely around the ulna. Passive mobility was tested by translating the radiocarpal unit relative to the ulna along dorsal-palmar directions. Unit displacement was measured by an electromagnetic tracking device in different forearm rotations and under varied loading to the wrist motor tendons. Magnitudes of displacement were compared between different loading patterns of the prime wrist movers in the TFCC-sectioned wrists. The effect of sectioning the ECU subsheath was analyzed.

RESULTS

When physiological loads were applied to all of the prime wrist movers, the magnitude of displacement during passive mobility testing decreased in supination and neutral rotation. After ECU tendon loading was released, mobility increased again in supination and neutral rotation. When the load was applied only to the ECU tendon, mobility decreased in supination and neutral rotation as compared with unloaded. Little change in the mobility was found in pronation regardless of the tendon loading pattern. After sectioning of the ECU subsheath, the stabilizing effect of the ECU decreased in neutral rotation.

CONCLUSIONS

In a neutral wrist position with complete sectioning of the TFCC, the ECU dynamically stabilized the DRUJ and the ulnocarpal joint in supination and neutral forearm rotation. The ECU subsheath assisted ECU tendon stabilization on the ulnar side of the wrist, especially in the neutral rotation.

CLINICAL RELEVANCE

Maintaining the ECU and its subsheath may reduce DRUJ instability in patients with TFCC injuries.

Ulnar shortening after TFCC suture repair of Palmer type 1B lesions

PURPOSE

The objective of this study was to determine functional and subjective outcomes of an ulnar shortening procedure elected by patients who experienced persistent ulno-carpal symptoms following arthroscopic suture repair of a Palmer type 1B lesion. All patients had a dynamic ulna positive variance.

METHODS

Five patients (3 males and 2 females) with arthroscopic repair of Palmer type 1B tears who subsequently underwent ulnar shortening were reviewed. At the time of the arthroscopic repair the patients' average age was 37 +/- 13 years (range 16-52 years). Average time to follow-up was 14 +/- 6 months (range 10-23 months). The average age was 38 +/- 14 years (range 17-53 years) when the ulnar shortening was performed. The second follow-up took place 7 +/- 2 months (range 5-9 months) after ulnar shortening. During the follow-ups, range of motion, grip strength, pain, Modified Mayo Wrist Score, DASH Score, and ulnar length were evaluated. Citing persistent ulno-carpal symptoms, the patients elected ulnar shortening an average of 17 +/- 7months (range 13-29 months) following the arthroscopic repair. Prior to ulnar shortening the average static ulnar variance was 0.2 +/- 1.3 mm (range -1 to 2 mm), the average dynamic ulnar variance was 1.4 +/- 0.5 mm (range 1 to 2 mm).

RESULTS

Ulnar shortening brought about further reduction in pain after the arthroscopic repair of the triangular fibrocartilage complex (TFCC) had already reduced it. As measured by a visual analogue scale, the average value after ulnar shortening was 2.2 +/- 2.1 (range 0.7-5.0). The average static ulnar variance was -3.4 +/- 2 mm (range -5 to -1 mm). Patients were very satisfied with the results of the ulnar shortening and four out of five indicated that it had significantly improved their symptoms and they would elect ulnar shortening again. Postoperative range of motion as a percentage of the contralateral side averaged 90% for the extension/flexion arc, 80% for the radial/ulnar deviation arc, and 100% for the pronation/supination arc of motion. In addition, there was an improvement in grip strength. The Modified Mayo Wrist Score was rated excellent in three patients, and fair in two patients. The average DASH score was 22 +/- 22 (range 0-53).

CONCLUSIONS

Patients who have a dynamic ulna positive variance and experience persistent ulno-carpal symptoms following arthroscopic suture repair of a Palmer type 1B lesion, benefit from an ulnar shortening procedure. Shortening the ulna can improve these patients' symptoms of pain, range of motion, and grip strength.

Clinical, radiographic, and arthroscopic outcomes after ulnar shortening osteotomy: a long-term follow-up study

PURPOSE

Previous studies have investigated the long-term outcomes of ulnar shortening osteotomy (USO) in the treatment of ulnocarpal abutment syndrome (UCA), but none have used arthroscopic assessments. The purpose of this study was to investigate the long-term clinical outcomes of USO with patient-based, arthroscopic, and radiographic assessments.

METHODS

We retrospectively reviewed 30 patients with UCA after a minimum follow-up of 5 years, with arthroscopic evaluations at the time of both USO and plate removal. We confirmed the initial diagnosis of UCA by radiography and arthroscopy. Mean age at the time of index surgery was 37 years. Mean duration of follow-up was 11 years (range, 5-19 y). We obtained Disabilities of the Arm, Shoulder, and Hand and Hand20 self-assessments postoperatively for all patients. Bony spur formation was evaluated postoperatively from plain radiographs.

RESULTS

We detected triangular fibrocartilage complex (TFCC) disc tear in 13 wrists arthroscopically at the time of USO. Of these, 10 showed no evidence of TFCC disc tear at second-look arthroscopy. The remaining 17 cases showed no TFCC disc tear at either first- or second-look arthroscopy. Follow-up radiography revealed that bony spurs at the distal radioulnar joint had progressed in 13 wrists. Disabilities of the Shoulder, Arm, and Hand and Hand20 scores did not significantly correlate with the presence of bony spurs or TFCC disc tears. Range of motion decreased significantly with age only. Lower grip strength correlated with bony spur and lower radial inclination. Triangular fibrocartilage complex tear, male sex, and advanced age were associated with lower Disabilities of the Shoulder, Arm, and Hand and Hand20 scores.

CONCLUSIONS

Ulnar shortening osteotomy achieved excellent long-term results in most cases. Most TFCC disc tears identified at the initial surgery had healed by long-term arthroscopic follow-up. We suggest that UCA with a TFCC disc tear is a good indication for USO.

Distal ulna fractures

In isolation, distal ulna fractures are rare. They are often found in conjunction with distal radius fractures, and the complexity of the interaction of the distal ulna with the radioulnar joint and triangular fibrocartilage complex makes understanding and treatment of distal ulna fractures challenging. Fixation of distal ulna fractures can be problematic owing to comminution making reduction challenging. A thin soft tissue can lead to hardware prominence and necessitate implant removal. In this Current Concepts article, we review the anatomy, pathology, and treatment of distal ulna fractures as well as potential complications and salvage procedures.

Arthroscopic and open repair of the TFCC

Injury to the triangular fibrocartilage complex is the most common cause of ulnar-sided wrist pain. This functionally related complex of anatomic structures can be a source of pain secondary to acute injury or chronic degeneration. Strategies for the treatment of these injuries involve determining the anatomic location of the tear, the presence of associated distal radioulnar joint instability, and the presence of associated degenerative changes. Surgical management with open and arthroscopic techniques have been described, both with successful results.

Advantages of open repair of a foveal tear of the triangular fibrocartilage complex via a palmar surgical approach

Foveal tears of the triangular fibrocartilage complex (TFCC) can be repaired via a palmar surgical approach. Unlike the dorsal approach, in this method the floor of the extensor carpi ulnaris tendon subsheath and the dorsal superficial limb of the radioulnar ligament do not hinder the view of the fovea. Patients with a fresh or chronic TFCC foveal tear and a positive ulnar fovea sign with its dorsal styloid insertion remaining intact are candidates for this procedure. During operation, the shoulder is positioned at 90 degrees of abduction, and the elbow is flexed at 90 degrees on an arm board. A 4 cm curved skin incision along the flexor carpi ulnaris tendon is made on the anterior aspect of the ulnar fovea. The ulnar fovea is exposed through a transverse capsulotomy of the distal radioulnar joint. The ulnocarpal joint distal to the TFCC is also exposed between the extensor carpi ulnaris tendon subsheath and the ulnotriquetrum ligament. After curettage of the scar tissues at the fovea, the lifted TFCC is sutured onto the fovea using a suture anchor technique.

MR Imaging of Ligaments and Triangular Fibrocartilage Complex of the Wrist

Imaging of the wrist with MR imaging can be difficult because of the small size of this joint, its complex anatomy, and its sometimes poorly understood pathologic lesions. A recent study by Hobby and coworkers of 98 patients revealed that MR imaging of the wrist influences clinicians' diagnoses and management plans in most patients. This article summarizes the current diagnostic criteria that can be useful in interpreting abnormalities of the wrist ligaments and triangular fibrocartilage complex (TFCC) of the wrist in this difficult topic in joint MR imaging.

Triangular fibrocartilage complex tears associated with symptomatic ulnar styloid nonunions

PURPOSE

Tear of the triangular fibrocartilage complex (TFCC) and nonunion of the ulnar styloid are common lesions resulting from upper extremity injuries such as distal radius fractures. Whereas ulnar styloid fractures are a common feature of the distal radius fracture pattern, symptomatic nonunions of the ulnar styloid are found in a minority of these injuries. The purposes of this study were to confirm the association of symptomatic ulnar styloid nonunions and TFCC tears, and to report intra-articular findings and clinical outcomes for the concurrent arthroscopic management of TFCC tears and open excision of ulnar styloid nonunions in a consecutive series of patients.

METHODS

We retrospectively reviewed the medical records of 8 consecutive patients who underwent open excision of an ipsilateral ulnar styloid nonunion fragment and concurrent diagnostic arthroscopy. The diagnosis of TFCC tear was made by magnetic resonance imaging preoperatively in only 5 of 8 patients. We assessed outcomes with the Disabilities of the Arm, Shoulder, and Hand questionnaire and the visual analog scale.

RESULTS

Arthroscopic findings demonstrated full-thickness chondral injury on the dorsum of the triquetrum with a tear of the dorsal radiolunotriquetral ligament and avulsion of the ulnar margin of the TFCC from the extensor carpi ulnaris subsheath. The clinical outcome scores showed statistically significant improvement (p<.05) from the preoperative baseline, with a mean Disabilities of the Arm, Shoulder, and Hand score of 3.69 (SD, 9.68) and a mean visual analog scale pain score of 1.0 (SD, 0.83) postoperatively.

CONCLUSIONS

Symptomatic ulnar styloid nonunions can be associated with TFCC tears, and diagnostic arthroscopy should be considered in all patients who are candidates for open excision of an ulnar styloid nonunion. Concurrent arthroscopic TFCC repair and open excision of the ulnar styloid fragment is an effective surgical approach for this combined injury pattern.

FUNCTIONAL RESULTS POST-TRIANGULAR FIBROCARTILAGE COMPLEX RECONSTRUCTION WITH EXTENSOR CARPI ULNARIS WITH OR WITHOUT ULNAR SHORTENING IN CHRONIC DISTAL RADIOULNAR JOINT INSTABILITY

From September 1996 to September 2001, 37 adult patients were diagnosed with chronic triangular fibrocartilage complex (TFCC) tears with distal radioulnar joint (DRUJ) instability in our clinic. They had all received the procedure of TFCC reconstruction with partial extensor carpi ulnaris (ECU) combined with or without ulnar shortening. There were 36 males and one female in the study with a mean age of 22.4 years. The follow-up period ranged from 25 to 48 months with a mean of 36.2 months. All patients received the rehabilitation programme and were re-examined at our outpatient department. The results were graded according to the Mayo Modified Wrist Score. Eleven of the 37 patients rated their wrists "excellent", 22 rated "good", and four rated "fair". Overall, a total of 33 patients (89%) rated satisfactorily and returned to work or sport activities. Therefore, TFCC reconstruction with partial ECU tendon combined with or without ulnar shortening procedure is an effective method for post-traumatic chronic TFCC tears with DRUJ instability suggested by this study.

Anatomic foveal reconstruction of the triangular fibrocartilage complex with a tendon graft

An acute injury to the triangular fibrocartilage complex (TFCC) with avulsion of the foveal attachment can produce distal radioulnar joint (DRUJ) instability. The avulsed TFCC is translated distally so the footprint will be bathed in synovial fluid from the DRUJ and will become covered in synovitis. If the TFCC fails to heal to the footprint, then persistent instability can occur. The authors describe a surgical technique indicated for the treatment of persistent instability of the DRUJ due to foveal detachment of the TFCC. The procedure utilizes a loop of palmaris longus tendon graft passed through the ulnar aspect of the TFCC and into an osseous tunnel in the distal ulna to reconstruct the foveal attachment. This technique provides stability of the distal ulna to the radius and carpus. We recommend this procedure for chronic instability of the DRUJ due to TFCC avulsion, but recommend that suture repair remain the treatment of choice for acute instability. An arthroscopic assessment includes the trampoline test, hook test, and reverse hook test. DRUJ ballottement under arthroscopic vision details the direction of instability, the functional tear pattern, and unmasks concealed tears. If the reverse hook test demonstrates a functional instability between the TFCC and the radius, then a foveal reconstruction is contraindicated, and a reconstruction that stabilizes the radial and ulnar aspects of the TFCC is required. The foveal reconstruction technique has the advantage of providing a robust anatomically based reconstruction of the TFCC to the fovea, which stabilizes the DRUJ and the ulnocarpal sag.

Arthroscopic all-inside repair of Palmer type 1B triangular fibrocartilage complex tears: a technical note

Arthroscopic repair of peripheral dorso-ulnar triangular fibrocartilage complex (TFCC) lesions is now a preferred method. Both outside-in and inside-out techniques are commonly performed for repairing Palmer type 1B TFCC tear. But these techniques have disadvantages of making an additional skin incision to tie knots subcutaneously over the capsule. We performed an arthroscopic all-inside repair technique of Palmer type 1B TFCC tears, which is a modified method of the outside-in technique using a spinal needle. This all-inside technique is as simple as previously described arthroscopic techniques and also has advantages of vertical mattress suture and no additional incision. We recommend this technique as a useful alternative to the others for repairing Palmer type 1B TFCC tear.

Arthroscopic Management of Triangular Fibrocartilage Complex Peripheral Injury

Patients suffering from ulnar-sided wrist pain after trauma may develop tenderness, clicking, a positive fovea sign, or instability of the distal radioulnar joint. If the pain is persistent, conservative treatment does not help, and the patient agrees to surgery, arthroscopy may reveal a triangular fibrocartilage complex (TFCC) injury with capsular detachment, foveal avulsion, or a combination thereof. Capsular reattachment is possible using an arthroscopic assisted technique. The reattachment can be performed with an inside-out, outside-in, or all-inside technique, providing good to excellent results, which tend to persist over time, in 60% to 90% of cases.

The incidence of dorsal radiocarpal ligament tears in patients having diagnostic wrist arthroscopy for wrist pain

PURPOSE

The goal of this study was to examine the incidence of dorsal radiocarpal ligament (DRCL) tears in patients having diagnostic arthroscopy for chronic wrist pain.

METHODS

A chart review was performed of 64 patients who had diagnostic wrist arthroscopy for chronic wrist pain that was refractory to conservative measures. For each case, interosseous ligament instability/tears were graded according to the Geissler classification. Tears of the triangular fibrocartilage complex and the presence or absence of a DRCL tear were noted.

RESULTS

There were 35 of 64 wrists (in 64 patients) with DRCL tears. The average duration of wrist pain prior to treatment was 20 months. Only 10 patients could recall a specific injury. Five patients had an isolated DRCL tear. A scapholunate interosseous ligament injury was identified in 13 patients, of whom 7 had a concomitant DRCL tear. A lunotriquetral interosseous ligament injury was present in 7 patients, of whom 2 had a concomitant DRCL tear. Two patients had a capitohamate ligament tear: 1 of these patients had a DRCL tear. There were 7 patients with a solitary triangular fibrocartilage complex tear: 6 of 7 were in association with a DRCL tear. One patient had a chronic ulnar styloid nonunion and a DRCL tear. Two or more lesions were present in 23 patients; DRCL tears were present in 12.

CONCLUSIONS

DRCL tears are commonly seen with injuries to the primary wrist stabilizers. Recognition of this condition and further research into treatment methods are needed.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic IV.