Triangular Fibrocartilage Complex Lesions Research Articles

The Correlation of Fracture Patterns of Distal Radius Fractures and Triangular Fibrocartilage Complex Injures

Purpose: The aim of the study was to determine the correlation of patterns of distal radius fractures with the triangular fibrocartilage complex (TFCC) injures. Methods: Sixty adult patients (mean age, 43 years) with distal radius fractures were included. The patients were analyzed according to the fracture character at the time of injury and classified with an Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification system. Wrist arthroscopy was performed for all cases to identify and classify TFCC injuries according to Palmer’s classification system. Results: TFCC lesion of varying severity was present in 39 fractures. Statistical analysis yielded a correlation with any patterns of the distal radius fractures with the associated TFCC injuries. The comminution or dorsal angulation of the distal radius, ulnar styloid fracture, and AO classification system have no correlation with associated TFCC injuries. Conclusions: The patterns of a distal radius fracture do not predict a TFCC injury. TFCC injury should be considered with all distal radial fractures.

High-Resolution 3T MR Imaging of the Triangular Fibrocartilage Complex.

This study is intended as a review of 3Tesla (T) magnetic resonance (MR) imaging of the triangular fibrocartilage complex (TFCC). The recent advances in MR imaging, which includes high field strength magnets, multi-channel coils, and isotropic 3-dimensional (3D) sequences have enabled the visualization of precise TFCC anatomy with high spatial and contrast resolution. In addition to the routine wrist protocol, there are specific techniques used to optimize 3T imaging of the wrist; including driven equilibrium sequence (DRIVE), parallel imaging, and 3D imaging. The coil choice for 3T imaging of the wrist depends on a number of variables, and the proper coil design selection is critical for high-resolution wrist imaging with high signal and contrast-to-noise ratio. The TFCC is a complex structure and is composed of the articular disc (disc proper), the triangular ligament, the dorsal and volar radioulnar ligaments, the meniscus homologue, the ulnar collateral ligament (UCL), the extensor carpi ulnaris (ECU) tendon sheath, and the ulnolunate and ulnotriquetral ligaments. The Palmer classification categorizes TFCC lesions as traumatic (type 1) or degenerative (type 2). In this review article, we present clinical high-resolution MR images of normal TFCC anatomy and TFCC injuries with this classification system.

Effect of ulnar styloid fracture on outcomes after conservative treatment of distal radius fracture.

This study aims to investigate the effect of accompanying ulnar styloid fracture (USF) on clinical outcomes and hand-wrist muscle strength in conservatively treated active patients after displaced distal radius fracture (DRF). The retrospective study, which was conducted November 2012 and September 2016, included 56 patients (34 males, 22 females; mean age 28.8 years; range 20 to 40 years) with displaced DRF treated with closed reduction and casting. Patients were divided into three groups according to ulnar styloid status as group A (intact ulnar styloid), group B (USF non-union), and group C (healed USF). Grip strength, quick-disabilities of the arm, shoulder and hand (DASH) score, and joint range of motions were evaluated; the results were combined with measurements of isokinetic muscle strengths of hand-wrist region. Magnetic resonance imaging was performed to evaluate the accompaniment of distal radioulnar joint injury and triangular fibrocartilage complex (TFCC) lesion. There were no significant differences between the groups regarding joint range of motion, grip strength, and quick-DASH scores. However, the peak torque and total work of supination was better in group A compared to group B (p=0.008 and p=0.006, respectively). According to the magnetic resonance imaging findings, of the 10 patients with detected TFCC lesion, four were in group C, five in group B, and one was in group A. Results of this study suggest that USF should not be the focus of attention during initial treatment of DRF and surgical intervention might be considered in case of an accompanying TFCC lesion.

Classification and MR imaging of triangular fibrocartilage complex lesions

To explore the MRI characteristics of injuries of triangular fibrocartilage complex (TFCC), and provide imaging basis for the early diagnosis and treatment of the injuries. A total of 10 healthy volunteers without wrist injuries and 200 patients from Beijing Jishuitan Hospital who complained ulnar-sided wrist pain and were highly suspected as the injury of TFCC underwent the wrist magnetic resonance examination. All subjects were in a prone position and underwent examination on coronal T1WI scan and PD-FS on 3 planes respectively. Then the MRI characteristics of 3 healthy volunteers and 67 patients with TFCC injuries that confirmed by operation were analyzed. According to the comparative analysis of normal anatomy and Palmer classification, the injuries were classified and MRI features of different types of injuries were analyzed. At last, imaging findings were compared with surgical results. Three healthy volunteers without injuries showed mainly in low signal intensity on T1WI and PD-FS images. According to Palmer classification, there were 52 traumatic injuries (ⅠA 9, ⅠB 25, ⅠC 3, ⅠD 13, In addition, 1 has central perforation and ulnar avulsion and 1 has ulnar and radial injuries simultaneously) and 15 degenerative injuries (ⅡA 5, ⅡB 1, ⅡC 2 , ⅡD 1 , ⅡE 6) among 67 patients. The central perforation mainly demonstrated as linear high signal perpendicular to the disk, and run in a sagittal line. The ulnar, distal, and radial avulsion mainly showed the injuries were irregular, the structures were ambiguous, and there was high signal intensity in the injured structures on PD-FS. Degenerative injuries demonstrated the irregularity of TFC and heterogeneous signals on PD-FS. There were mixed intermediate-high signals and changes in the articular cartilage of lunate and ulna, high signal in the lunotriquetral ligament and ulnocarpal or radioulnar arthritis. MRI can demonstrate the anatomy of TFCC accurately, evaluate and make the general classification of injuries. It is of significance for the early diagnosis and treatment protocols of the TFCC injuries.

Preventable Repeat Wrist Arthroscopies: Analysis of the Indications for 133 Cases.

Background Frequently, patients undergo repeated wrist arthroscopies for single wrist problems. Purpose The purposes of this study were to assess the indications for repeat wrist arthroscopies and to identify potentially preventable procedures. Methods For this retrospective, two-center study, the electronic patient records were examined for patients, who underwent repeat wrist arthroscopy in a 5-year period. The cases were sorted by the underlying pathologies and the causes that necessitated repeat arthroscopies. Results Ulnar-sided wrist pain accounted for 100 (77%) of all 133 revision arthroscopies: 67 of which due to suspected ulnar triangular fibrocartilage complex (TFCC) avulsions, 33 due to ulnar impaction syndromes. Cartilage was reassessed in 22 (17%) wrists. Thereby, insufficient preoperative diagnostics necessitated pure diagnostic before therapeutic arthroscopy in 49 (37%) wrists: 48 of which for TFCC pathologies, one for a scapholunate (SL) ligament lesion. The uncertainty of diagnosis despite previous arthroscopy necessitated 18 (14%) revision arthroscopies: 15 for ulnar TFCC avulsions, 1 for a central TFCC lesion, 2 to reevaluate the SL ligament. Inadequate photo or video documentation of the cartilage necessitated arthroscopic reassessment in 16 (12%) wrists. Conclusion In this series, two out of three revision arthroscopies could potentially have been prevented. Inadequate preoperative diagnostics with the lack of reliable preoperative diagnoses necessitated pure diagnostic arthroscopies for ulnar-sided wrist pain. However, even arthroscopically, the diagnosis of ulnar TFCC avulsions or SL ligament lesions is not trivial. Surgical skills and experience are necessary to detect such lesions. Finally, adequate photo or video documentation may prevent repeated arthroscopic diagnostic procedures. Level of Evidence Level IV.

The correlation of initial radiographic characteristics of distal radius fractures and injuries of the triangular fibrocartilage complex.

Our purpose was to determine the correlation of initial radiographic parameters of a distal radius fracture with an injury of the triangular fibrocartilage complex. In a prospective study, 85 patients with surgically treated distal radius fractures were included. Wrist arthroscopy was used to identify and classify triangular fibrocartilage complex lesions. The initial radial length and angulation, dorsal angulation, ulnar variance and distal radioulnar distance were measured. Wrist arthroscopy identified a triangular fibrocartilage complex lesion in 45 patients. Statistical analysis did not identify a correlation with any single radiographic parameter of the distal radius fractures with the associated triangular fibrocartilage complex injuries. The initial radiograph of a distal radius fracture does not predict a triangular fibrocartilage complex injury. III.

Análisis artroscópico de las lesiones asociadas a las fracturas de escafoides carpiano

ObjectiveArthroscopy has enabled wrist fractures and the injuries associated with them to be diagnosed and treated. There are injuries associated with scaphoid fractures, which may influence the success of treatment and can lead to an unsatisfactory result and delay in the functional recovery. Material and methodA prospective study was conducted on 17 cases with acute scaphoid body fractures treated by arthroscopic reduction and placement of a cannulated scaphoid screw. Systematic arthroscopy evaluation (radiocarpal and midcarpal) was performed, recording the presence or absence of associated lesions in each case. Treatment outcome was measured using the Mayo Wrist Score, and the fracture consolidation evaluated with plain x-rays. ResultsAssociated soft tissues injuries and/or chondral/osteochondral injuries were diagnosed in 14 (82%) cases. The most frequently found lesions were scapholunate ligament injuries (53%) in different degrees, triangular fibrocartilage complex (TFCC) lesions (35.3%), and osteochondral lesions (35.3%). Functional outcomes (Mayo Wrist Score) were excellent or good in 13 patients (76.5%), and in 3 cases (17.5%) the results were fair, and only 1 case (5.9%) had a poor outcome. ConclusionsWrist arthroscopy is a valuable tool for the diagnosis and treatment of wrist injuries. There are associated injuries in acute scaphoid body fractures that could influence treatment outcomes.

Results after Arthroscopically Assisted Management of Intra-Articular Distal Radius Fractures

Background/Goal: An arthroscopically assisted management of intra-articular distal radius fractures may improve the quality of reduction. Furthermore, concomitant ligament and triangular fibrocartilage complex injuries can be identified and treated. However, this approach increases the duration of surgery. If severe soft tissue lesions, such as SL-ligament disruptions are treated simultaneously, a longer post-operative immobilisation will be required. The aim of this study was to measure the clinical outcome one year after arthroscopically assisted treatment of intra-articular distal radius fractures. In a retrospective study from 2011 to 2013 we identified 27 patients with intra-articular distal radius fractures who were treated with volar fixed angle plates in an arthroscopically assisted fashion. The amount of associated injuries, the duration of surgery and the time of immobilisation were documented. One year postoperatively we evaluated 23 of these patients using several scores. Patient satisfaction, range of motion, visual analogue scale and grip strength were assessed using a standardised questionnaire. The mean surgery time was 111 min (60-190 min). On average, we found 1.4 (0-3) associated injuries per patient. Seventy percent (19) of all patients had a triangular fibrocartilage complex lesion, 67% (16) had some degree of scapholunate ligament lesion. The mean number of interventions in addition to the plate fixation was 1.1 per patient (0-3). Among these were debridements of the triangular fibrocartilage complex in 11 cases (41%) and scapholunate ligament repairs in 4 cases (15%). The mean immobilisation time was 22 (0-42) days. At one year after surgery, the mean Mayo wrist score was 79 (65-95) and the DASH score was 12 (0-49). The arthroscopically assisted management of intra-articular distal radius fractures helps to identify and treat associated injuries. However, it results in extended surgery and immobilisation time, especially if concomitant intra-articular lesions are treated. In our group of patients, the clinical outcome after one year was nonetheless very good.

Mini dorsal incision to the triangular fibrocartilage complex: a new surgical approach.

The purpose of this paper is to describe a mini dorsal approach to the triangular fibrocartilage complex (TFCC). We describe a mini incision approach which aims to preserve the structure and proprioception of the primary and secondary stabilisers of the wrist joint. This approach requires less dissection and provides adequate exposure to the distal aspect of the TFCC and allows visualisation of the distal radial ulna joint (DRUJ) with complete TFCC lesions.

Current and Evolving Concepts in Wrist Arthroscopy

Arthroscopy of the wrist and the small joints of the hand is an established surgical technique in the diagnosis and treatment of hand and wrist pathology. The purpose of this review is to highlight recent advances as well as future directions of its use in hand surgery. Current indications include carpal interosseous ligament and triangular fibrocartilage complex lesions, arthritis and selected fractures. As experience with small joint arthroscopy grows, new indications and refined surgical techniques are introduced that address wrist pathology at earlier stages, thus minimizing the need for salvage procedures in hand surgery.

Arthroscopy for Galeazzi fractures, a way to demonstrate TFCC damage in extra-articular radius fracture: A series of 7 cases

Galeazzi fracture is a trauma associating diaphysal radius fracture and dislocation or subluxation of the distal radio-ulnar joint (DRUJ). Despite an anatomic reduction of the radius, DRUJ impairment, especially injury of triangular fibrocartilage complex (TFCC) may lead to partial instability with secondary pain and stiffness. This prospective case series proposes to perform wrist arthroscopy for Galeazzi fractures in order to diagnose ligamentous injuries and to enable their reparations. Over a period of 18 months, 7 recent Galeazzi closed fractures were operated on with wrist arthroscopy. We used a locking compression plate, a 1.9 mm arthroscope with 3 radio-carpal portals: 3-4, 4-5 and 6U. A dorsal forearm splint was kept for 3 weeks followed by an active/passive physiotherapy. Physical examination and X-ray were performed after 3, 6 and 12 weeks. Analysis criteria were: – perioperative: ligament impairment, duration of surgery; – postoperative: pain, wrist motion (flexion/extension; prono/suppination), grasp strength, time off work and sports, X-ray analysis (reduction, consolidation, secondary displacement). All patients were reviewed 3 times. The triangular ligament was injured in all cases, 3 cases in the radial part, 3 cases in the ulnar part and one both side. All ulnar injuries were repaired systematically. The radial TFCC injuries were only repaired when DRUJ instability persisted despite good reduction of the radius. After osteosynthesis of the radius, DRUJ remained instable in 3 cases, one ulnar lesion, one radial and one both side. The reparation of the triangular ligament improved stability of the DRUJ in 2 cases, one case remained instable despite TFCC reparation. About strength and mobility: – after 3 weeks: F/E: 50/60°, P/S 45°/45°, grasp 20%; – after 6 weeks: F/E: 80/80°, P/S 70°/60°, grasp 45%; – after 12 weeks: F/E: 85/80°, P/S 80°/75°, grasp 80%. We noticed 7 anatomic radius reductions and no secondary displacement. A dorsal DRUJ subluxation was noticed despite the ulnar TFCC repair; none nonunion was reported. Time off work was 7 weeks (4–10). Functional mobility was regained after 6 weeks, accompanied by good strength. TFCC reparation participate in DRUJ stabilization but was not always sufficient to fully stabilize the DRUJ. A next study with DRUJ MRI and prono-supination strength measurement should participate to demonstrate further benefits of TFCC reparation in Galeazzi fractures. A lesion of the TFCC was noticed in all cases suggesting that TFCC lesion could occur in some other extra-articular distal radius fractures.

Arthroscopy of the distal radioulnar joint.

Wrist arthroscopy is now widely indicated for diagnosis and treatment of acute or chronic wrist pain, especially for triangular fibrocartilage complex (TFCC) lesions, as a gold standard. In most cases radiocarpal and midcarpal arthroscopy was performed, while DRUJ arthroscopy has been rarely performed because of its difficulties. Recent anatomic and biomechanical studies demonstrated that the radioulnar ligament (RUL), which is the proximal component of the TFCC facing to the DRUJ, is the primary stabilizer of the distal radioulnar joint (DRUJ). Rupture of the radioulnar ligament (RUL) at the fovea area, where it is the main attaching portion to the ulna and is the isometric point during forearm rotation as the rotation axis passes, is responsible for DRUJ instability. Although physical examination and imaging diagnosis may indicate a foveal detachment of the TFCC, DRUJ arthroscopy is potential for visualizing the RUL at the fovea. Role of DRUJ arthroscopy should be more important not only for diagnosis of rupture of the RUL but also for decision making of treatment option for RUL tear. DRUJ arthroscopy also demonstrates the joint surface of both the sigmoid notch and ulnar head, and the proximal surface of the TFCC.

CORR Insights: Prevalence of triangular fibrocartilage complex abnormalities regardless of symptoms rise with age: systematic review and pooled analysis.

C han and colleagues have attempted to ask a relevant clinical question regarding the evaluation of triangular fibrocartilage complex lesions (TFCC) of the wrist: What relationships exist between TFCC tears, age, and pain? All too often we have patients who have been referred to us for wrist pain and have been diagnosed as having a ‘‘tear’’ involving the TFCC. Moreover, patients may or may not have a history of a traumatic event precipitating the pain. Unfortunately, our diagnostic evaluation of ulnar-sided wrist pain has not changed substantially for several decades now. We know from our experience in other orthopaedic clinical problems that the simple presence of a radiographic finding does not necessarily mean that the finding is generating the pain. Patients with low-back pain often have radiographic findings that are not clinically relevant. SLAP lesions of the shoulder, likewise, often are asymptomatic, coincidental findings were noted on MRIs in the workup of shoulder pain.

The Role of MRI and MR Arthrography in Evaluation of Wrist Pain

Objectives: The aim of this work is to show the value of MRI and MRA in evaluation of patients suffering from wrist pain. Background: Wrist pain is a common clinical complaint. The most common causes of wrist pain are traumatic & non traumatic abnormalities involving avascular necrosis, ganglia, and TFC lesions. MRI serves as a problem solving technique to assess the cause of wrist pain. It also plays an important prognostic role. MRA is an excellent tool in assessing TFC and wrist ligaments injury. Methods: This study was conducted on 60 patients complaining of chronic wrist pain. The patients were referred to the radiology department from the outpatient clinics and the orthopedics department of Menoufia University Hospital. All patients were examined by x-ray and conventional MRI. 15 patients with suspected triangular fibrocartilage complex (TFC) and/or ligament injury underwent MRA as well. Data of soft tissue and osseous lesions were collected and analyzed. Results: There were thirty four males and twenty six females, their ages ranged between 17 & 59 years (mean age, 38 years). Joint effusion, kienbock disease and ganglion cysts were the most common findings in conventional MRI . TFC injury was the most common finding in MRA. Conclusion: MRI has a dramatic impact on the diagnosis and assessment of variety of wrist disorders. It is non invasive and ideal modality to demonstrate the complex anatomy and pathological conditions of the wrist. MRA is an excellent tool in assessing TFC and ligaments injury.

Arthroscopy During Ulnar Shortening for Idiopathic Ulnar Impaction Syndrome

Arthroscopy during ulnar shortening osteotomy for ulnar impaction syndrome is subject to debate regarding its clinical usefulness. The purposes of this study were to analyze the arthroscopic findings in patients who underwent ulnar shortening osteotomy and to assess the role of arthroscopic evaluation during osteotomy. Medical records and arthroscopic findings of 50 consecutive patients who had been diagnosed with idiopathic ulnar impaction syndrome were retrospectively evaluated. Pathologic changes of the articular disk of the triangular fibrocartilage complex (TFCC), chondromalacia of the lunate and triquetrum, and tears of the lunotriquetral interosseous ligament (LTIL) were evaluated during arthroscopy. Palmer’s classification was used to classify the TFCC lesions. Perforation of the TFCC was observed in 20 patients, and central tears were observed in 10. Thirty-eight patients exhibited chondromalacia of the lunate, including 4 unstable cartilage flaps. Partial tears of the LTIL were detected in 24 patients, including 9 unstable flap tears. In 21 (42%) of 50 patients, arthroscopic findings were not appropriate to define the disease stage with Palmer’s original description. Eight wrists exhibited tears or perforations of the TFCC without evidence of chondromalacia. Seven patients had an LTIL tear without perforation of the TFCC. Lunotriquetral interosseous ligament tears without lunate chondromalacia were found in 7 patients. Arthroscopic debridement was performed in 23 patients based on the clinical judgment that the procedure would help alleviate symptoms postoperatively. Arthroscopy during ulnar shortening osteotomy addresses intra-articular pathologies and may be helpful for symptom improvement.

Feasibility and preliminary results of SPECT/CT arthrography of the wrist in comparison with MR arthrography in patients with suspected ulnocarpal impaction

To evaluate the feasibility and performance of SPECT/CT arthrography of the wrist in comparison with MR arthrography in patients with suspected ulnocarpal impaction. This prospective study included 28 wrists of 27 patients evaluated with SPECT/CT arthrography and MR arthrography. Iodine contrast medium and gadolinium were injected into the distal radioulnar and midcarpal joints. Late-phase SPECT/CT was performed 3.5 h after intravenous injection of approximately 650 MBq (99m)Tc-DPD. MR and SPECT/CT images were separately reviewed in relation to bone marrow oedema, radionuclide uptake, and tears in the scapholunate (SL) and lunotriquetral (LT) ligaments and triangular fibrocartilage complex (TFCC), and an overall diagnosis of ulnar impaction. MR, CT and SPECT/CT imaging findings were compared with each other, with the surgical findings in 12 patients and with clinical follow-up. The quality of MR arthrography and SPECT/CT arthrography images was fully diagnostic in 23 of 28 wrists (82%) and 25 of 28 wrists (89%), respectively. SPECT/CT arthrography was not diagnostic for ligament lesions due to insufficient intraarticular contrast in one wrist. MR and SPECT/CT images showed concordant findings regarding TFCC lesions in 22 of 27 wrists (81%), SL ligament in 22 of 27 wrists (81%) and LT ligament in 23 of 27 wrists (85%). Bone marrow oedema on MR images and scintigraphic uptake were concordant in 21 of 28 wrists (75%). MR images showed partial TFCC defects in four patients with normal SPECT/CT images. MR images showed bone marrow oedema in 4 of 28 wrists (14%) without scintigraphic uptake, and scintigraphic uptake was present without MR bone marrow oedema in three wrists (11%). Regarding diagnosis of ulnar impaction the concordance rate between CT and SPECT/CT was 100% and reached 96% (27 of 28) between MR and SPECT/CT arthrography. The sensitivity and specificity of MR, CT and SPECT/CT arthrography were 93%, 100% and 100%, and 93%, 93% and 93%, respectively. SPECT/CT arthrography of the wrist is feasible. Regarding diagnosis of ulnar impaction we found a high concordance with MR arthrography. SPECT/CT arthrography of the wrist is an alternative to MR arthrography in patients with contraindications to MR imaging.

Comparison between open and arthroscopic-assisted foveal triangular fibrocartilage complex repair for post-traumatic distal radio-ulnar joint instability

The aim of this study was to assess the objective and subjective functional outcomes after foveal reattachment of proximal or complete ulnar-sided triangular fibrocartilage complex lesions by two surgical procedures: an open technique or an arthroscopically assisted repair. The study was done prospectively on 49 wrists affected by post-traumatic distal radio-ulnar joint instability. Twenty-four patients were treated with the open technique (Group 1) and 25 by the arthroscopically assisted technique (Group 2). Magnetic resonance imaging demonstrated a clear foveal detachment of the triangular fibrocartilage complex in 67% of the cases. Arthroscopy showed a positive ulnar-sided detachment of the triangular fibrocartilage complex (positive hook test) in all cases. Distal radio-ulnar joint stability was obtained in all but five patients at a mean follow-up of 6 months. Both groups had improvement of all parameters with significant differences in wrist pain scores, Mayo wrist score, Disability of the Arm, Shoulder and Hand questionnaire and Patient-Rated Wrist/Hand Evaluation questionnaire scores. There were no significant post-operative differences between the two groups in the outcome parameters except for the Disability of the Arm Shoulder and Hand questionnaire score, which was significantly better in Group 2 (p < 0.001).

Translating Carpal Biomechanics to Triangular Fibrocartilage Complex Injury: Significance of Ulnar Variance in Predicting TFCC Lesions

Ulnar variance (UV) describes the cranio‐caudal position of the distal ulna in relation to the distal radius at the wrist. Neutral ulnar variance (ulna and radius articulating at the carpus at exactly the same level) transmits 20% of the compressive load across the wrist to the distal ulna and 80% to the distal radius. A +2.5mm positive UV has been shown to increase the ulnocarpal load to 40%. The triangular fibrocartilage complex (TFCC) acts as a cushion for the ulnar carpus and transmits axial loads from the wrist to the ulna in a longitudinal direction across the ulnar column of the wrist. Consequently, a positive ulnar variance implicates a greater risk of TFCC injury. This study sought to calculate the prevalence of traumatic TFCC injury in those with a positive UV versus those with a negative UV. 20 cadaveric wrists aged 50 – 90 were assessed for TFCC damage via gross examination and classified according to Palmer's schema. A plain film PA radiograph of each wrist was then taken to measure the degree of UV. Results showed that all wrists had degenerative Class II lesions of the TFCC, while traumatic Class I lesions of the TFCC were found in 69% of wrists with positive UV as compared to 0% of wrists with negative UV (p&lt;0.05). Our investigation prompts further research exploring a “dose‐response” relationship between UV and TFCC damage as well as between the degree of TFCC damage and clinical symptoms or diminished quality of life.Grant Funding Source: SUNY Downstate College of Medicine Alumni Association

Pathomorphologic Findings of Wrist Arthroscopy in Children and Adolescents With Chronic Wrist Pain

The purposes of this diagnostic study were to show pathomorphologic findings of children and adolescents with persistent wrist pain and to compare these arthroscopic findings with preoperative magnetic resonance imaging (MRI). A total of 41 arthroscopies in 39 patients were retrospectively reviewed. The patients underwent diagnostic wrist arthroscopy because of persistent wrist pain after at least 3 months of unsuccessful conservative treatment. Of the patients, 22 (56.4%) reported an injury before the onset of pain. The mean age at arthroscopy was 15.3 years (range, 9.8 to 19.4 years), and the mean duration between the onset of symptoms and arthroscopic exploration was 19.9 months (range, 3.0 to 121.0 months). Among all affected wrists, 33 (80.5%) showed a triangular fibrocartilage complex (TFCC) tear on arthroscopy, with 75.6% also showing other pathomorphologic findings. Retrospectively, the condition of the TFCC was correctly identified by MRI in only 17 wrists (41.5%). In contrast, 23 wrists were incorrectly classified as having "no tear" whereas arthroscopy later indeed showed a TFCC tear. Concerning the TFCC, MRI and arthroscopy showed a significant difference of outcome (P < .01), indicating low agreement (κ = 0.09) for the outcome of the 2 methods. A larger proportion of TFCC tears was found for patients with injuries (91.3%) as compared with the other patients (66.7%), although this was not significant on statistical analysis (P = .11). No significant difference in the time to surgery was found between patients with TFCC tears and those without TFCC tears classified by MRI (P = .76) and by arthroscopy (P = .99). Wrist arthroscopy in children and adolescents with chronic wrist pain shows TFCC lesions in a high percentage. However, most of these lesions have not been correctly identified by MRI before arthroscopy. Thus diagnostic wrist arthroscopy may be recommended to rule out underlying pathologies and initiate further therapeutic steps. Level III, diagnostic study of nonconsecutive patients.

A Novel Technique for Detecting Instability of the Distal Radioulnar Joint in Complete Triangular Fibrocartilage Complex Lesions

We performed this study to investigate whether discrepancy of bilateral dorsovolar shift of the distal radioulnar joint (DRUJ) is decisive for the diagnosis of DRUJ instability. Although several cadaver studies have quantified the amount of physiological dorsovolar shift, so far, there is no reliable method of quantification of DRUJ mobility in daily practice. The aim was to describe a novel sonographic method of quantifying DRUJ instability and evaluate its reliability and validity. In this study, 40 healthy volunteers and 17 patients with complete rupture of the triangular fibrocartilage complex (TFCC) underwent sonographic quantification of the grade of instability of their DRUJ bilaterally. Dorsovolar ulnar head translation relative to the distal radius was quantified by means of ultrasonography performed in a transversal plane through the ulnar head and Lister tubercle. Measurements were done while actively pressing the volar surface of the hand onto a brick 30 degrees pronated, and after lifting the hand. A quotient Q of the radioulnar distance (distance between the dorsal radius surface and the ulnar head) between the unloaded and loaded wrist was calculated for differentiation of a normal and unstable DRUJ. The Q ratio of the 17 patients with unilateral TFCC lesion was significantly different between the pathologic side and the contralateral wrist (1.19 vs. 0.54, p < 0.001). There was no significant difference in the Q ratio in the 40 healthy volunteers between the right and left side or dominant and nondominant wrist. A Q ratio > 0.8 was found to be a reasonable cut-off for pathologic laxity of the DRUJ with a sensitivity of 88% and a specificity of 81%. A quotient Q > 0.8 determines instability of the DRUJ reliably. This was a level II diagnostic study.