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INJURIES TO THE TRIANGULAR FIBROCARTILAGE COMPLEX (TFCC) OF THE WRIST

WHY ARTHROSCOPIC RE-INSERTION?

 

– Written by Jonny K Andersson, Qatar

 

INTRODUCTION 

Triangular fibrocartilage complex (TFCC) injuries of the wrist are common among athletes as:

·      Golfers – do not duff!!

·      Racket sports (Tennis, Table tennis)

·      Ice Hockey (dorsal ulnotriquetral (UT) ligament injury = “Hockey wrist”)

·      Football – goalkeepers

But isolated TFCC injuries can be seen in all sports if the athlete - even in terms of children and adolescents1 - has suffered from a torque trauma or as a concomitant injury together with distal radius fracture. TFCC injury should be suspected if the dorsal angulation of the fractured radius exceeds 32 dgr2 (Figure 1).

Concomitant wrist ligament injuries are not seldom seen together with intraarticular or displaced distal radius fractures among younger non-osteoporotic patients (Figure 2).

 

ANATOMY

Several anatomical structures stabilize the distal radio-ulnar joint (DRUJ), of which the TFCC and especially its foveal insertion is the most important, according to Haugstvedt et al8. Those stabilizing structures include: the floor of extensor carpi ulnaris (ECU) sheath, the ulnocarpal (UC) ligaments, TFCC – especially its foveal insertion, the interosseous membrane – especially the distal oblique band (IOM), the skeleton and  joint congruency, as well as the dynamic muscle stabilizers (ECU, flexor carpi ulnaris – FCU, and pronator quadratus -  PQ). These stabilizing factors are shown in Figure 3 and 4, and they have to be evaluated in every patient with DRUJ instability by the physiotherapist and the physician, in accordance treating the correct deficits.

Acute TFCC injuries type 1 B (Figure 5a) and 1D (Figure 5b) – according to Palmer9 and Atzei10, are those types of injuries that come with concomitant DRUJ instability and most often need surgical re-insertion.

 

MEDICAL HISTORY AND CLINICAL EXAMINATION

Dorso-ulnar wrist pain, problems with forced pronation, as well as weak torque and instability are common symptoms, among patients with TFCC injuries. But other conditions such as synovitis, ganglion cysts, lunotriguetral ligament injury, ulnar impaction and other degenerative conditions, have to be rolled out, when the patient complains about dorso-ulnar wrist pain. This area of the wrist is called the “black-box”, as many diagnoses display similar local symptoms.

The foveal sign and DRUJ stability test (Figure 6 a and b), performed during comparison with the non-injured side, are the - among other several tests - the easiest and most consistent. But practice in assessing these patients is necessary as some patients, i.e. the Arabic population and young female athletes, often show habitual laxity, which can confuse the physiotherapist and physician in terms of the diagnostics.

 

DIAGNOSTICS

Plain x-rays can sometimes display a widening in the DRUJ on frontal view or a dorsal sub-dislocation of the ulnar head on the lateral view.

Unfortunately, MRI is not sensitive and specific enough to rule out a significant injury to the TFCC11. Wrist arthroscopy is still the gold standard in diagnostics of TFCC injury and the only tool existing to evaluate the grade of instability and the healing capacity.

Tools measuring the torque force (Figure 7) is valuable in the diagnostics and surgical follow-up of TFCC injury with concomitant DRUJ instability. It has been shown that a reduction of 30% of the peak torque force is present in 1B injuries and that the patients gain 16 % after a successful surgery with re-insertion of the TFCC12-14.

 

NON-SURGICAL TREATMENT

I recommend surgery directly, if global DRUJ instability at initial presentation or if sub-dislocation of the ulnar head is present. High demand patients, as athletes, also often need an early surgical intervention. 

Otherwise, I prefer to start with 6-8 weeks of physiotherapy including proprioceptive training (neuro-muscular training of the dynamic stabilizing muscles; pronator quadratus, extensor/flexor carpi ulnaris), especially isolated activation of the dynamic DRUJ-stabilizer; FCU (Figure 8)15.

 

SURGICAL TREATMENT

A systematic review in 201813 showed that there are comparable results between open and arthroscopic repair of the TFCC, in terms of DRUJ re-instability incidence and functional outcome scores. The re-instability incidence is approximately 15 % after re-insertion of the TFCC - probably because there are so many DRUJ-stabilizing factors that have to be addressed in terms of this complicated joint. As the arthroscopic technique in my hands is easier, more clarifying in terms of evaluating the healing capacity, grade of instability and possible differential diagnoses, as well as it gives slightly less problems with stiffness and postoperative neuroma of the dorsal sensory nerve branch of the ulnar nerve, I prefer the arthroscopic ulnar tunnel technique, described in Figures 9. But still the method used in re-insertion of the TFCC, is still the surgeon´s choice. If initial global instability or re-instability after re-insertion surgery, I prefer to perform the Adams procedure16, described in Figure 10 or a ulnar shortening osteotomy, if ulnar variance is positive (> +2 mm) with persistent instability in neutral position.

 

POSTOPERATIVE TREATMENT

After arthroscopic re-insertion of the TFCC, the postoperative treatment is as follows:

·      3 weeks of above elbow cast in approximately 90° of flexion and 20° of supination, followed by

·      2 weeks of custom made high TFCC-brace (Figure 11), allowing 20° of supination and pronation, and

·      2 weeks of low TFCC-brace.

After 4 months we allow full strength, but in terms of contact sports, the athlete has to wait to attend competition events for approximately 6 months in total.

 

WHY ARTHROSCOPIC RE-INSERTION?

The arthroscopic technique in my hands is easier compared with the open re-insertion techniques. The arthroscopic technique is more clarifying in terms of assessing the healing capacity of the TFCC, the grade of instability and possible differential diagnoses as well as gives slightly less problems with stiffness and postoperative neuroma of the dorsal sensory nerve branch of the ulnar nerve. The small scars are also preferable. The results are comparable with the open techniques.

 

 

 

 

Jonny K Andersson M.D., Ph.D.

Senior Consultant Hand Surgery 

Aspetar Orthopaedic and Sports Medicine Hospital

Doha, Qatar

 

contact: kent.andersson@aspetar.com

 

 

 

References 

1.     Andersson JK, Lindau T, Karlsson J, Fridén J. Distal radio-ulnar joint instability in children and adolescents after wrist trauma. J Hand Surg Eur. 2014, 39: 653-61.

2.     Scheer JH, Hammerby S, Adolfsson LE. Radioulnar ratio in detection of distal radioulnar joint instability associated with acute distal radius fractures. J Hand Surg Eur. 2010, 35: 730-4. 

3.     Fontes D, Lenoble E, de Somer B, Be- noit J. Lesions of the ligaments associated with distal fractures of the radius. 58 intraoperative arthrographies. Ann Chir Main Memb Super. 1992, 11: 119- 25. 

4.     Geissler WB, Freeland AE, Savoie FH, McIntyre LW, Whipple TL. Intracarpal soft-tissue lesions associated with an intra-articular fracture of the distal end of the radius. J Bone Joint Surg Am. 1996, 78: 357-65. 

5.     Lindau T, Arner M, Hagberg L. Chondral and ligamentous wrist le- sions in young adults with distal ra- dius fractures. A descriptive, arthros- copic study in 50 patients. J Hand Surg Br. 1997, 22: 638-43. 

6.     Richards RS, Bennett JD, Roth JH, Mil- ne K Jr. Arthroscopic diagnosis of in- tra-articular soft tissue injuries associ- ated with distal radial fractures. J Hand Surg Am. 1997, 22: 772-6. 

7.     Araf M, Mattar Junior R. Arthroscopic study of injuries in articular fractures of distal radius extremity. Acta Ortop Bras. 2014, 22:144-50. 

8.     Haugstvedt JR, Berger RA, Nakamura T, Neale P, Berglund L, An KN. Relative contributions of the ulnar attachments of the triangular fibrocartilage com- plex to the dynamic stability of the dis- tal radioulnar joint. J Hand Surg Am. 2006, 31: 445-51. 

9.     Palmer AK. Triangular fibrocartilage disorders: injury patterns and treat- ment. Arthroscopy. 1990, 6: 125–32. 

10.  Atzei A, Luchetti R. Foveal TFCC tear classification and treatment. Hand Clin. 2011, 27: 263–72. 

11.  Andersson JK, Andernord D, Karlsson J, Fridén J. Efficacy of magnetic resonance imaging and clinical tests in diagnostics of wrist ligament injuries: a systematic review. Arthroscopy 2015;31:2014-2020. 

12.  Andersson JK, Axelsson P, Strömberg J, Karlsson J, Fridén J. Patients with triangular fibrocartilage complex injuries and distal radioulnar joint instability have reduced rotational torque in the forearm. J Hand Surg Eur. 2016, 41: 732-8.

13.  Andersson JK, Hagert EM, Fridén J. Patients with triangular fibrocartilage complex injuries and distal radioulnar joint instability gain improved forearm peak pronation and supination torque after reinsertion. Hand (N Y). Hand (N Y). 2020, 15: 281-286.

14.  Rosvall F, Jedeskog, U, Andersson JK, Söderberg T, Hagert E. Reliability test of the ISOmetric Power device – a new instrument for assessment of force in all directions of wrist motion. J Hand Ther. 2020; S0894-1130(20)30012-0.doi:10.1016/j.jht.2019.12.013. Online ahead of print.

15.  Salva-Coll G, Garcia-Elias M, Hagert E. Scapholunate instability: proprioception and neuromuscular control. J Wrist Surg. 2013, 2: 136-40.

16.  Andersson JK, Åhlén M, Andernord D. Open versus arthroscopic repair of the triangular fibrocartilage complex: a systematic review. J Exp Orthop. 2018 Mar 13;5(1):6. doi: 10.1186/s40634-018-0120-1. 

17.  Adams BD. Anatomic reconstruction of the distal radioulnar ligaments for DRUJ instability. Tech Hand Up Ex- trem Surg. 2000, 4: 154–60.

 

 

 

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Sports Surgery

Volume 9
Targeted Topic - Wrist and Hand Injuries
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