Triangular Fibrocartilage Injury Research Articles

Arthroscopic Treatment of Traumatic Isolated Volar Dislocation of the Distal Radioulnar Joint: Case Report and Management Proposal

Abstract Background Traumatic isolated dislocation of the distal radioulnar joint (DRUJ) has always been an injury recognized for its rarity, misdiagnosis, and possibility of inability to be reduced at emergency care. As a result, little has been discussed so far about the guidelines and routines for its treatment.It is known that some degree of injury to the triangular fibrocartilage (TFC) is required for a DRUJ to be dislocated. However, there is no evidence to prove that this injury will cause any degree of DRUJ instability following reduction. Methods We show a case of a patient with traumatic isolated volar dislocation of the DRUJ in which, after failure in the attempt to reduce it in the emergency room, surgical treatment was performed using an arthroscopic method. Results Computed tomography and magnetic resonance imaging axial sections showed the impaction of the distal ulna, with its groove to the extensor carpi ulnaris tendon blocked in the anterior labrum of the sigmoid notch of the radius. Arthroscopy before reduction showed that the distal portion of the TFC was intact, with damage to the foveal insertion (Palmer Type 1B, Atzei Class 3). After joint reduction, a loop-shaped repair of the TFC foveal lesion was performed through the central disc and attached to the distal ulna footprint. The patient presented good progression, with quick recovery, and no serious complications or the need for a second surery. Conclusion We indicate the use of arthroscopy in patients with irreducible isolated volar dislocation, with subacute or chronic presentation, who have to be managed in the operating room. It is a useful method for diagnosing and repairing the TFC injury. This will prevent possible complications and provide faster recovery, mainly reducing the time of immobilization.

Hand and Wrist Injuries in Tennis Players.

The purpose of this article is to review common hand and wrist injuries experienced by tennis players. A myriad of different wrist pathologies can be seen in tennis players ranging from metacarpal and carpal stress fractures to triangular fibrocartilage injuries and ulnar impaction. These vary depending upon the nature of the player, stroke mechanics, and time point within the season. A broad differential should guide work-up and management of wrist pain in tennis players.

Perceptions and experiences of wrist surgeons on the management of triangular fibrocartilage complex tears: a qualitative study.

There is lack of consensus on the management of triangular fibrocartilage injuries. The aim of this study was to investigate wrist surgeons' experiences and perceptions regarding treatment of triangular fibrocartilage complex injuries and to explore the rationale behind clinical decision-making. A purposive sample of consultant wrist surgeons (n = 10) was recruited through 'snow-balling' until data saturation was reached. Semi-structured interviews were conducted, digitally recorded and transcribed verbatim. Two researchers independently analysed data using an iterative/thematic approach. Findings suggest that surgeons rely more on their own training and experience, and patient-related factors such as individual expectations, to inform their decision-making, rather than on published material. Current classification systems are largely considered to be unhelpful. Level of evidence: V.

WRIST ARTHROSCOPY: BASIC TIPS FOR DRY ARTHROSCOPIC EXPLORATION.

ABSTRACTObjective:This article provides details and tips on the dry arthroscopic technique, based on our experience and its clinical applications. Method:The technique was applied to 65 patients (33 men and 32 women) aged between 20 and 62 years (average of 35.4 years) for treating: synovial cyst resection, scapholunate ligament injury repair, ulnocarpal impact correction, triangular fibrocartilage injury repair, and assisted reduction of distal radius fractures. Results:A minimally invasive intra-articular evaluation has been observed as a benefit, with low infection rate, small scars, and high rates of early recovery, without affecting intra-articular fluid use, reducing the risk of compartment syndrome and infiltrated soft tissues, in the case of need for associated open surgery. As for the difficulties, we report the surgeon’s view, which is commonly prevented by optical blurring or debris that hit the lens, and the need for radiofrequency care, since the heat generated is dissipated with greater difficulty than in the classical technique. Conclusion:Dry arthroscopy emerges as an effective choice to treat wrist pathologies, however, deep knowledge and ease with the classical technique, as well as a learning curve, are key to obtain a good outcome. Level of Evidence V, Expert Opinion.

Scaphoid fracture combined with triangular fibrocartilage injury and radial head fracture: a new type of forearm injury triad

Objective To introduce a new triad of forearm injury: scaphoid fracture, triangular fibrocartilage (TFC) injury and radial head fracture, and discuss the similarities and differences comparing to Essex-Lopresti injury. Methods Six male patients of closed forearm injuries treated from October 2011 to May 2013 were involved in this study. They all had scaphoid and radial head fractures on the same side. Wrist arthroscopic examination was carried out in 3 cases that revealed injury to the radial rim of the TFC. One case had olecranon fracture on the contralateral side, while 5 cases had no other accompanying fractures.Two cases were non-surgically treated, while 4 cases were surgically managed where the scaphoid fracture was treated with percutaneous compressive cannulated screw fixation, and the laceration or perforation at the radial rim of the TFC revealed under wrist arthroscopy in 3 cases was treated with arthroscopic debridement. The radial head fracture in 3 cases was categorized as Mason type Ⅰ and treated with splint immobilization. Open reduction and internal fixation was used in 1 case of Mason type Ⅱ radial head fracture. Results All 6 patients were follow-up for 12 to 24 months. The mean follow-up period was 17 months. Fracture union was achieved in all six patients. Clinical evaluations using modified Mayo wrist scoring system and modified Morrey elbow score revealed excellent wrist and elbow functional results in all the patients. Conclusion Comparing to the typical Essex-Lopresti injury, the reported new triad of forearm injury has subtler clinical manifestations due to the relatively low energy impact despite of the similar injury mechanisms. Consequently, misdiagnosis or missed diagnosis is more likely to happen. Successful outcomes rely on prompt diagnosis and proper treatment. Key words: Scaphoid bone; Radius; Fractures, bone; Triangular fibrocartilage

Diagnosis and Management of Ligament Injuries of the Wrist

The wrist joint is formed by the distal end of the radius and ulna proximally, and eight carpal bones distally. It has many ligaments to maintain stability of the complex bony structures. The incidence of ligament injuries of the wrist has increased due to sports activities. However, diagnosis and management of these injuries are sometimes difficult because of the anatomic complexity and variable injury patterns. Among them, scapholunate ligament injury and triangular fibrocartilage tears are the two most common injuries resulting in chronic disabling wrist pain. Thorough understanding of the wrist anatomy and physical and radiologic examination is mandatory for proper diagnosis and management of these conditions. This article will briefly discuss the wrist joint anatomy and biomechanics, and review the diagnosis and management of the scapholunate ligament injury and triangular fibrocartilage injury.

Síndrome de impactación ulnocarpiano, manejo artroscópico

Ulnocarpal impaction is one of the most common causes of ulnar-sided wrist pain. It is a progressive degenerative condition caused by chronic impaction of the ulnar head against the triangular fibrocartilage (TFC) and the ulnar portion of the carpus. The aim of surgical treatment is to perform a decompression of the ulnar column of the wrist, in the ulnocarpal joint.With the advances in wrist arthroscopic surgery it is possible to shorten the ulnar head (Wafer procedure) by an arthroscopic approach, at the same time as assessing and treating the injuries associated with the ulnar impaction (TFC injuries, chondral injuries, lunopyramidal ligament tears, synovitis, etc.), thus allowing a more complete and accurate treatment, and with some very satisfactory results.

Sonographically Guided Distal Radioulnar Joint Injection

Distal radioulnar joint (DRUJ) disorders are uncommon but important causes of ulnar-sided wrist pain and disability. Fluoroscopically guided injections may be performed to diagnose or treat DRUJ-related pain or as part of a diagnostic arthrogram. Sonographic guidance may provide a favorable alternative to fluoroscopic guidance for distal DRUJ injections. This report describes and validates a sonographically guided technique for DRUJ injections in an unembalmed cadaveric model. An experienced clinician used sonographic guidance to inject diluted colored latex into the DRUJs of 10 unembalmed cadaveric specimens. Subsequent dissection by a fellowship-trained hand surgeon confirmed accurate injections in all 10 specimens. Two cases of ulnocarpal flow, indicative of triangular fibrocartilage injury, were noted during injection and subsequently confirmed during dissection. Clinicians should consider using sonographic guidance to perform DRUJ injections when clinically indicated. Further research should explore the efficacy of sonographically guided DRUJ injections to treat patients with painful DRUJ syndromes or to evaluate the triangular fibrocartilage complex in patients with ulnar wrist pain syndromes.

(iv) Wrist arthroscopy

Abstract Wrist arthroscopy is nowadays a commonly used procedure employed in the diagnosis and treatment of traumatic pathologies, such as triangular fibrocartilage injuries, distal radius fractures, malunions and scaphoid fractures, as well as degenerative conditions such as scapholunate advanced collapse, wrist, Kienbock’s disease and dorsal wrist ganglia cysts. Several procedures have recently been undertaken arthroscopically, such as radial styloidectomy, distal ulnar excision (“wafer procedure”), and proximal row carpectomy. Wrist arthroscopy has become the “gold standard” for the diagnosis of certain wrist injuries such as scapholunate instability. Compared to open techniques, arthroscopic procedures improve the postoperative management in terms of pain and early movement thus allowing an earlier return to work and resumption of daily living activities.

The Rate of Triangular Fibrocartilage Injuries Requiring Surgical Intervention

Triangular fibrocartilage complex injuries are one of the most common causes of ulnar-sided wrist pain. Although pain and discomfort may improve with simple immobilization for a short period of time, a significant number of patients eventually require surgical intervention. The purpose of this study was to investigate the incidence of surgical intervention on patients with a clinical diagnosis of a triangular fibrocartilage complex injury. A retrospective chart review was performed to identify patients with ulnar-sided wrist pain identified with the appropriate ICD-9 code from September 2005 to September 2007. All patients were evaluated and treated by a board-certified, fellowship-trained hand surgeon. Any patients with associated pathology were excluded from the study. All patients were initially treated with a minimum of 4 weeks of either a volar wrist splint worn all the time or a short-arm cast. Magnetic resonance images were obtained on patients without symptomatic relief, and in these cases, surgical arthroscopy was performed. Of the 84 patients identified, 36 patients required surgical intervention. All 36 patients had evidence of triangular fibrocartilage complex injury during arthroscopy. All patients had symptomatic improvement postoperatively. The use of short-arm cast versus a splint did not affect the rate of surgical intervention (P=.38). Among the patients with clinical diagnosis of triangular fibrocartilage complex injury, the rate of surgical intervention required after a minimum 4 weeks of immobilization was 43%. The use of a short-arm cast or volar wrist splint did not affect the rate of surgical intervention.

The Painful Wrist in the Pediatric Athlete

Wrist pain is common among pediatric and adolescent athletes, either as a result of acute injury or chronic stress. Referring and treating physicians must be aware of occult bony and ligamentous injuries about the wrist in order to properly evaluate and treat acute injuries. The clinician must also be aware of the consequences of repetitive loading of the wrist during upper extremity weight-bearing, especially with regard to distal radius physeal injury in skeletally immature gymnasts. The present review provides current strategies for evaluation and treatment of several less commonly discussed sources of wrist pain in the pediatric athlete, including scaphoid fractures, scapholunate ligament injuries, triangular fibrocartilage injuries, dorsal carpal impingement, and gymnast wrist.

Arthroscopic Treatment of Triangular Fibrocartilage Wrist Injuries in the Athlete

Background Triangular fibrocartilage (TFC) injuries are an increasingly recognized cause of ulnar-sided wrist pain and can be particularly disabling in the competitive athlete. Previous studies show that arthroscopic debridement or repair can improve symptoms, but the results of arthroscopic treatment of TFC injuries in high-level athletes have not yet been reported. Hypothesis Arthroscopic debridement or repair of wrist TFC injury will allow a high rate of return to full function in the elite athlete. Study Design Case series; Level of evidence, 4. Methods Between 2001 and 2005, 16 competitive athletes (mean age, 23.4 years) with wrist TFC injuries underwent arthroscopic surgery. Repair was performed in unstable tears, and all others underwent debridement alone. Presurgery and post-surgery mini-DASH (Disabilities of the Arm, Shoulder, and Hand) scores were recorded for each athlete through medical record review and clinical evaluation. The mean duration of follow-up was 32.8 months (range, 24-51 months). Results The TFC was repaired in 11 (68.8%) and debrided in 5 (31.3%) patients. The tear was ulnar-sided in 12 (75%), radial-sided in 2 (12.5%), combined radial-ulnar in 1, and central-sided in 1 patient. Mean mini-DASH scores improved from 47.3 (range, 25-65.9) to 0 (all patients) (P =. 002), and the mean mini-DASH sports module improved from 79.7 (range, 68.8-100) to 1.95 (range, 0-18.8) (P =. 002). Return to play averaged 3.3 months (range, 3-7 months). Associated conditions in the 2 patients unable to return to play at 3 months were distal radioulnar joint (DRUJ) instability with ulnar-carpal abutment (n = 1) and extensor carpi ulnaris (ECU) tendinosis (n = 1). Conclusion Arthroscopic debridement or repair of wrist TFC injury provides predictable pain relief and return to play in competitive athletes. Return to play may be delayed in athletes with concomitant ulnar-sided wrist injuries.

The Value of Plain X-Rays in Predicting TFCC Injury after Distal Radial Fractures

In this prospective study, the plain X-rays and MRI scans of 60 patients with intraarticular distal radius fractures were examined in random order. MRI evaluation revealed that 27 of the 60 patients (45%) had triangular fibrocartilage lesions. No correlation was found between triangular fibrocartilage injury and the Melone classification system, the presence of an ulnar styloid fracture, comminution of the articular surface of the distal radius, >20 degrees dorsal angulation of the distal radius or subluxation/dislocation of the distal radioulnar joint on the plain X-rays. When Frykman Type VI and VIII fractures were compared with all the other Frykman subtypes, a significant difference in the incidence of triangular fibrocartilage complex tears was observed. We conclude that triangular fibrocartilage injury should be considered with all distal radial fractures, especially the Frykman Types VI and VIII.

Ultrasound of Intrinsic Wrist Ligament and Triangular Fibrocartilage Injuries

Ultrasound of Intrinsic Wrist Ligament and Triangular Fibrocartilage Injuries

Triangular fibrocartilage injuries in pediatric and adolescent patients

This is a retrospective review of 29 posttraumatic pediatric and adolescent patients with surgically documented triangular fibrocartilage complex tears. All patients complained of ulnar wrist pain. Fifteen patients (52%) sustained distal radius fracture at the time of the original injury. Twenty-three (79%) of the triangular fibrocartilage complex tears were Palmer 1B lesions. There were 31A, 11C, and 21D lesions. All 1B, 1C, and 1D tears were repaired. Coexisting pathology was present in 25 patients (86%). This pathology included ulnar styloid nonunion, distal radioulnar joint instability, ulnocarpal impaction, distal radius deformity, and intercarpal ligament tears, which were treated by ulnar styloid nonunion excision, distal radioulnar joint stabilization, ulnar shortening, radius corrective osteotomy, and intercarpal ligament debridement, respectively. The length of the follow-up period averaged 21 months. Three patients were lost to follow-up. Outcomes were graded by a modification of the Mayo wrist score. Twenty-four patients (89%) had excellent results, 3 had good results.

The role of arthroscopy in the investigation of wrist disorders

The findings at arthroscopy of the wrist in 48 consecutive cases carried out over a 4.5 year period have been retrospectively reviewed. In correlating the clinical and arthroscopic findings in the 36 patients with wrist instability and triangular fibrocartilage injuries we found concurrence in 28 of the cases. In the six patients in whom we were unable to make any provisional clinical diagnosis we did not find arthroscopy helpful. Arthroscopy usefully influenced the management in two of the six patients in whom the articular surface was assessed. We feel that a careful clinical examination of the wrist is the mainstay of diagnosis in wrist disorders. Arthroscopy remains useful in selected cases but has a limited specialized role which should continue to be provided from specialist centres.

Triangular fibrocartilage injury: A laboratory model

A potential injury mechanism for triangular fibrocartilage tears and ulnar styloid fractures was investigated in cadaver specimens. The distal radioulnar joint was distracted to failure, thus applying a tensile force to the triangular fibrocartilage. During distraction, strains in the triangular fibrocartilage and the anatomic site of disruption were recorded with an image analysis system. Complete avulsion of the triangular fibrocartilage from the ulnar head occurred in 7 of 10 specimens. No ulnar styloid fractures occurred. Although strains were high in the radial portion of the disk (28%), no tears occurred in the substance of the disk or at its attachment to the radius. These findings suggest that distal radioulnar joint distraction can cause avulsion of the triangular fibrocartilage. However, ulnar styloid fractures and tears within the disk are more likely caused by injury mechanisms that include shear or compressive forces. Since complete avulsions of the triangular fibrocartilage occurred without a fracture, the absence of a fracture does not rule out a destabilizing injury to the distal radioulnar joint.

Triangular fibrocartilage tears

From a series of 56 patients with triangular fibrocartilage injury, 33 patients with peripheral rim tears not associated with instability of the distal radioulnar joint were identified by arthrography or arthroscopy. Open repair of the peripheral tear produced 11 excellent, 15 good, 6 fair, and 1 poor result (grading based on a Mayo modified Green-O'Brien wrist score). Ulnar recession improved surgical exposure and corrected ulnar variance in 11 patients. A dorsal approach for repair of radial and anterior peripheral rim tears was used in 28 patients. Repair of peripheral tears restored functional integrity to the triangular fibrocartilage, and good to excellent results are reported in 26 of the patients treated.