Info

3—4 portal. The elasticity of the articular disk is tested with the probe, and a positive test is loss of the normal tissue tautness (Fig. 66—1).

Peripheral tears are through the vascular zone of the TFCC and are typically repaired. A variety of techniques have been described including open, arthroscopi-cally assisted, and arthroscopic. A small incision is made just ulnar to the ECU tendon, and blunt dissection is performed to isolate and protect the dorsal branch of the ulnar nerve. Two Tuohy needles are used to penetrate the wrist capsule and the articular disk in the appropriate location, and a horizontal mattress suture is used with 2—0 nonabsorbable suture in an outside-to-in technique.

Two or three sutures are placed and tied over the capsule (Fig. 66—2). Postoperatively the patient is immobilized for 4 to 6 weeks in a Munster cast to eliminate rotation of the forearm, and an additional 2 to 4 weeks in a wrist splint. Return to full activity is allowed at 3 months.

Controversial point: Treatment of type 1C and 1DTFCC injuries has not received as much attention as the more common injury patterns. Classically it was believed that radial detachments would not heal and were debrided to stable edges, if there was not a bony fragment attached to the articular disk. Recently, open and arthro-scopically assisted repair of avulsion of the TFCC from the sigmoid notch (1D lesions) has been described but outcome data are limited. Distal avulsions (1C) are the least common injury pattern described in most series. Whether debridement or repair of 1C or 1D lesions is superior is unclear at present.

Treatment of degenerative lesions of the TFCC depends on the Palmer classification stage. Lesions classified as 2A or 2B are typically treated nonoperatively with antiinflammatories, splinting, and activity modification. An extraarticular ulnar shortening or an intraarticular "wafer" procedure (with removal of 2 to 4 mm of distal ulna) can be considered in the unusual case of symptoms refractory to these measures. If the lesion has progressed to stage 2C, a TFCC debridement is performed. If the patient is ulnar positive, this may be combined with a "wafer" procedure. Treatment of stage 2D lesions includes an ulnar shortening and treatment of the wrist instability if it is substantial. Stage 2E lesions may present with substantial degeneration of the ulnar carpus and typically require a salvage procedure.

Palmer Tfcc Classification

placed through the second needle to complete the outside-in mat-

A 2—0 nonabsorbable suture is used and a 3—0 Prolene is

Figure 66—2. Peripheral TFCC

repair using two 18-gauge spinal needles or Tuohy needles.

placed through the second needle to complete the outside-in mat-

A 2—0 nonabsorbable suture is used and a 3—0 Prolene is

Figure 66—2. Peripheral TFCC

repair using two 18-gauge spinal needles or Tuohy needles.

tress suture.

Suggested Readings

Botte MJ, Cooney WP, Linscheid RL. Arthroscopy of the wrist: anatomy and technique. J Hand Surg [Am] 1989;l4A:313-316.

Fulcher SM, Poehling GG. The role of operative arthroscopy for the diagnosis and treatment of lesions about the distal ulna. Hand Clin 1998;14:285-296.

Graham TJ, ed. Problems about the distal end of the ulna. Hand Clin 1998.

Kleinman WB, Graham TJ. Distal ulnar injury and dysfunction. In: Peimer C, ed. Surgery of the Hand and Upper Extremity. New York: McGraw-Hill; 1996.

Palmer AK. Triangular fibrocartilage complex lesions: A classification. J Hand Surg [Am] 1989;14A:594-605.

Palmer AK, Werner FW. The triangular fibrocartilage complex of the wrist—anatomy and function. J Hand Surg [Am] 1981;6A:151-162.

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Section XI

Essentials of Human Physiology

Essentials of Human Physiology

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