• The differential diagnosis of ulnar-sided wrist pain is lengthy. A careful examination of the ulnar side of the wrist will frequently rule in other causes of patient's symptoms.
• The dorsal branch of the ulnar nerve crosses from volar to dorsal in the region of ulnar (6U) wrist arthroscopy portals. Careful dissection and protection of this nerve is mandatory to prevent complications.
Anteroposterior, lateral, and oblique radiographs of the wrist were obtained (Fig. 66-1).
Ulnar styloid nonunion TFCC tear Ulnocarpal abutment DRUJ incongruity Distal radius malunion ECU tendinitis
Triangular Fibrocartilage Complex (TFCC) Tear
Ulnar-sided wrist pain is a common complaint. The patient's age, hand dominance, avocations, and occupation are important historical factors, and the nature and date of injury should be sought. Patterns of injury have been associated with particular recreational activities (e.g., hook of the hamate fractures with sports involving a bat or club). Neurologic complaints are common and should be sought. The differential diagnosis above is limited to the diagnoses likely after a distal radius fracture.
Examination of the TFCC is performed in conjunction with a thorough exam of the wrist, elbow, and hand, including neurovascular structures. Direct palpation of the bony and soft tissue structures of the ulnar side to localize point tenderness is the most helpful examination maneuver. Tenderness radial or ulnar to the ECU tendon with the wrist in neutral rotation may be consistent with a TFCC lesion. The DRUJ is examined with the patient's elbow on a table in front of the examiner. The DRUJ is stressed with one of the examiner's hands grasping the distal ulna and the other grasping the radius. Volar and dorsal translation is assessed in neutral, pronation, and supination. A TFCC grind test is performed with the wrist in ulnar deviation and dorsiflexion with an axial load applied to the hand by the examiner as the carpus is rotated on the fixed forearm. Radiographs aid in establishing the diagnosis of a malunion of the distal radius or a nonunion of the ulnar styloid. Fractures at the base of the ulnar styloid are more likely to be associated with a TFCC injury that will produce persistent symptoms if untreated. Ulnocarpal abutment is more likely in patients with ulnar positive or ulnar neutral variance.
The term triangular fibrocartilage complex was originally used by Palmer and Werner for the group of structures that stabilize the carpus and distal radius to the fixed distal ulna. This complex includes the volar and dorsal radioulnar ligaments, the ulnar collateral and ulnocarpal ligaments, and the articular disk. The articular
Table 66—1 Classification of Triangular Fibrocartilage Complex Lesion Main Category Subcategories
Type 1: Traumatic A: Horizontal tear adjacent to the radius
B: Peripheral detachment from the ulna C: Tear of the ulnocarpal ligaments D: Avulsion from sigmoid notch Type 2: Degenerative A: Partial-thickness thinning of the articular disk
B: A + chondromalacia of lunate and/or ulnar head C: B + full-thickness tear of the articular disk D: C + partial tear of the lunotriquetral ligament E: D + pull tear of the lunotriquetral ligament and arthrosis disk separates the carpal bones from the distal radioulnar articulation. The complex is central to three biomechanical functions of the wrist: (1) stability of the DRUJ, (2) axial load transmission from the carpus to the ulna, and (3) ulnar-sided carpal stability.
TFCC lesions were classified by Palmer in the Journal of Hand Surgery in 1989. There are two main categories: traumatic and degenerative (Table 66—1).
Recommended initial management of traumatic TFCC injuries based on history and physical examination is 4 weeks of immobilization. The intimate relationship of the articular disk and the DRUJ typically requires the use of an above-elbow cast. At 4 weeks, patients are begun on range-of-motion and strengthening exercises and progress as tolerated. Surgical management is indicated for failure of conservative treatment.
Degenerative lesions are more common in patients with ulnar positive variance. Recommended initial treatment includes activity modification, splinting, and non-steroidal medications. The author's experience has been that patients with negative or neutral ulnar variance are more likely to respond to conservative treatment. Surgical intervention is indicated for failure of conservative treatment.
Surgical treatment of lesions of the TFCC continues to evolve. Traumatic lesions are typically classified at the time of diagnostic arthroscopy. Wrist arthroscopy is performed with the wrist in 10 pounds of traction to facilitate visualization of the TFCC. The portals for visualization and manipulation of the TFCC include 3-4, 4-5, and 6R. Type 1A or central lesions are the most common traumatic injury seen. Arthroscopic debridement of the unstable edges of the tear is typically recommended. Cadaveric studies have demonstrated that excising the central two thirds of the articular disk does not alter the biomechanical functions of the TFCC. Post-operatively, patients are encouraged in immediate mobilization. Return to work or athletics usually is within 6 to 12 weeks. Diagnostic arthroscopy of this case demonstrated a type 1B lesion.
The finding of a peripheral detachment of the TFCC is not always as obvious at arthroscopy as one might anticipate. A helpful diagnostic maneuver is the trampoline sign that is elicited with a probe in the 4-5 portal and the arthroscope in the
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