Triangular Fibrocartilage Tears Research Articles

853 The Use of 3d-Printed Wrist Models to Aid Patient Understanding of Diagnosis and Treatment

Abstract Aim Models of the wrist allow for complex anatomy to be visualised and explained, aiding clinician to patient discussion. This pilot study aimed to investigate in impact on patient understanding of their diagnosis and treatment using a 3D-printed model hand in consultation. Method 3D-printed model wrists based on dissection specimens done in Anatomy, University of Edinburgh, were created to demonstrate a variety of pathologies, including triangular fibrocartilage tears and scapholunate ligament injuries. Patients participated by questionnaire at hand clinic appointment with responses recorded on a visual analogue scale (VAS) for criteria including confidence explaining their condition to others, and satisfaction before and after use of the models. Results 48 patients participated in the study with 38 questionnaires fully completed. Median age was 44 years old; the right hand was affected more than the left (17 vs. 15) and bilateral in 6 patients. Use of the models saw a significant improvement in patient confidence to explain their condition to a family member (mean change 2.46, range -3 to 8.5; p<0.001), although a wide range of responses were recorded demonstrating individual differences and preferences. Patient satisfaction was excellent (mean 9.25) when the models were used, and a positive net promoter score (mean 9.29) showing patients would recommend the consultation style. Conclusions This pilot study suggests that 3D-printed wrist models aid in patient education at consultation, building patient confidence and maintaining satisfaction. Given the range of responses and individual nature of learning it is likely these models will complement radiological images in this setting.

Ulnar-Sided Traumatic Wrist Pain. High Resolution Ultrasound Effectiveness versus MRI Assessment and Accuracy

Abstract Background: This work was conducted to assess the effectiveness of high resolution Ultrasonography (USG) compared with Magnetic Resonance Imaging (MRI) in inves-tigating causes of ulnar sided wrist pain in traumatic patients, as this entity represents a diagnostic dilemma, owing to the anatomical complexity and small sized structures, as well as diversity of causes. Imaging plays an important role in guiding the diagnosis and minimizing unwanted surgical interventions. Aim of Study: To evaluate the diagnostic performance of both ultrasonography and MRI in ulnar sided wrist pain, high-lightening both the strengths and weaknesses of these two imaging modalities. Patients and Methods: This study included fifty patients presenting with ulnar sided wrist pain. MRI and Ultrasonog-raphy were done in all patients. Results: Out of 50 patients, 30 males (60%) and 20 females (40%), age ranging 23-65 years, were included in this study. A comparative analysis was done using MRI versus USG findings. The sensitivity, specificity, and accuracy of USG for Scapho-lunate ligament injury were 45.5%, 100%, 88% respectively, as MRI was positive in 11 cases, while USG only diagnosed 5 cases. The sensitivity, specificity, and accuracy for Triangular Fibrocartilage (TFCC) tear, were 64.71%, 90.91% and 82% respectively, as MRI was positive in 17 cases, while USG diagnosed 14 cases. For Extensor Carpi Ulnaris (ECU) injury, were 100%, 89.1% and 92% respectively, as MRI was positive in 13 cases, while USG diagnosed 17 cases. For extensor carpi ulnaris tendon sublux-ation, were 100%, 100% and 100% respectively, as both modalities were successful in diagnosing the same three cases, for ganglion cysts, were 100%, 100% and 100% respectively. For trabecular bone edema, MRI was positive in 24 cases, and for distal radioulnar joint instability MRI was positive in 9 cases, which were not diagnosed by USG, with lack of agreement between both modalities. Conclusion: Both magnetic resonance imaging and mus-culoskeletal ultrasound are essential and complement each other in the evaluation of causes of ulnar sided wrist pain in trauma patients. Musculoskeletal ultrasound is highly recom-mended for the examination of tendon injuries, while MRI is more efficient and suitable for assessing deeper structures, such as bone or ligaments.

Arthroscopic Capsular Repair for Triangular Fibrocartilage Complex Tears.

Background The triangular fibrocartilage complex (TFCC) lesions are frequently implicated as a cause of ulnar wrist pain following impact and loading injuries. The objective of this study was to describe the clinical outcomes following TFCC lesion repair with the arthroscopic outside-in technique. Description of Technique We inserted a 21-gauge needle with 4-0 nylon loop perpendicular to the injured triangular fibrocartilage (TFC). We held two 4-0 nylon loops with mosquito forceps, drew them once out of the joint through a 4 to 5 portal, and put both sides through each loop. After that, we pulled out the 21-gauge needles and performed outside-in sutures after making a small incision and tying directly over the capsule. Patients and Methods Twenty-one wrists who underwent arthroscopic capsular repair were included. Arthroscopic findings were evaluated, and we used a distal radioulnar joint (DRUJ) evaluation system to monitor relief of pain, forearm rotation range of motion, and DRUJ stability postoperatively. Results Simple ulnar avulsion (Palmer 1B, Atzei Class 1) was recognized in ten wrists. A combination of the 1B tear with a horizontal TFC tear was noted in five wrists; and ulnar avulsion extending to the dorsal half of the TFC was identified in six wrists, including complete dorsal avulsion of the TFC from the capsule. There are significantly better results in the cases whose preoperative periods were 15 months or less. Conclusion The outside-in TFC repair technique produced excellent clinical results for peripheral detachment of the TFC in cases without severe DRUJ instability and with a preoperative period less than 15 months.

Comparison between conventional MRI and MR arthrography in the diagnosis of triangular fibrocartilage tears and correlation with arthroscopic findings

PurposeThe triangular fibrocartilage complex is one of the most important stabilizers of the wrist and a defect in its anatomical structure is a possible cause of ulnar sided wrist pain. The aim of this study is to compare the diagnostic accuracy between conventional MRI and MR arthrography (MRA) in the depiction of triangular fibrocartilage complex (TFCC) tears. Methods-materialsA total of 60 patients with clinical findings that suggested TFCC tears underwent wrist MRI and MRA. All the MRI and MRA results were compared with the arthroscopic findings. Results40 tears were confirmed by arthroscopy. 38/40 tears were identified by MRA while MRI identified 26/40 tears. There were also 8 false positives and 13 false negative results identified by MRI. Two false negative results were identified by MRA. No false positive results were identified. ConclusionMR arthrography is more sensitive and specific method in terms of the diagnosis of TFCC tears compared to conventional wrist MRI. There was no difference in the diagnostic accuracy between wrist arthroscopy and MRA.

Evaluation of the triangular fibrocartilage: comparison of two-compartment wrist CT arthrography using the distal radioulnar and radiocarpal joints and unicompartment wrist CT arthrography using the radiocarpal joint

To compare the diagnostic performance of two-compartment wrist CT arthrography of the distal radioulnar and radiocarpal joints and unicompartment wrist CT arthrography of the radiocarpal joint in depiction of the triangular fibrocartilage tear. From January 2016 to December 2017, two-compartment CT arthrography of 74 consecutive patients (36 females, 38 males; mean age, 37.2 years) and unicompartment CT arthrography of 51 consecutive patients (18 females, 33 males; mean age, 40.1 years) were obtained. All CT arthrography images were independently and blindly evaluated by two radiologists for the presence of the triangular fibrocartilage tear by grade (partial or full thickness) per its locations: central disc proper, central-peripheral junction, proximal and distal laminae of its ulnar attachment. Fisher's exact test was used for a statistical analysis, and a p-value less than 0.05 was considered as significant. The arthroscopic findings of 47 patients (34 patients with two-compartment CT arthrography and 13 patients with unicompartment CT arthrography) were evaluated for calculating sensitivity, specificity, and accuracy. All partial and full thickness triangular fibrocartilage tears were identified more commonly by their location except for distal laminae on two-compartment CT arthrography than were unicompartment CT arthrography (p = 0.001-0.022). Two-compartment CT arthrography had high sensitivity (90.9-100%) and low specificity (33.3-76.5%) for detecting central disc proper and proximal lamina tears, comparing with unicompartment CT arthrography. Two-compartment wrist CT arthrography is more helpful for detecting triangular fibrocartilage tears than unicompartment wrist CT arthrography. It could be important to evaluate the ulnar foveal insertion of the TFCC in clinical practice, which plays the most important role in DRUJ instability and ulnar-sided wrist pain. Two-compartment wrist CTA of the DRUJ and RCJ could improve diagnostic sensitivity in the TFC tear in terms of its location and torn degree over that of unicompartment wrist CTA of the RCJ. Two-compartment wrist CTA of the DRUJ and RCJ may be recommended as a diagnostic imaging, rather than unicompartment wrist CTA of the RCJ, when peripheral foveal tear of TFC is suspected, especially in young patients.

Return to sport following surgical management of triangular fibrocartilage tears: a systematic review.

This review aims to provide information on return rates and times to return to sport following surgical management of triangular fibrocartilage (TFC) tears. A systematic search of CINAHAL, Cochrane, EMBASE, Google Scholar, Medline, PEDro, Scopus, SPORTDiscus and Web of Science was performed using the keywords 'triangular', 'fibro-cartilage', 'complex', 'tear', 'distal radio-ulnar joint', 'athletes', 'sports', 'non-operative', 'conservative', 'operative' and 'return to sport'. In all of the 10 studies included, conservative management for 6weeks to 6months was the first-line treatment. If symptoms persisted following this period, surgical management was advised. Arthroscopic debridement was recommended for central tears, and arthroscopic repair was recommended for peripheral tears. The optimal treatment modalities for TFC tears remain to be defined. Traumatic central tears can be treated with arthroscopic debridement alone. Arthroscopic repair with an all-inside repair can improve return rates to sport over an outside-in technique for ulna-sided tears. Future prospective studies should aim to establish the optimal treatment modalities for TFC tears.

Outcomes of Operative Treatment of Triangular Fibrocartilage Tears in Pediatric and Adolescent Athletes.

Triangular fibrocartilage complex (TFCC) tears have been treated with increasing frequency in pediatric and adolescent patients over the past decade. There is little information on these injuries in young athletes and a scarcity of data regarding their ability to return to preinjury levels of athletic participation. The purpose of this study was to review the outcomes of pediatric and adolescent athletes with operatively treated TFCC tears with or without a concurrent ulnar shortening osteotomy and to determine their ability to return to their preoperative level of activity. A retrospective chart review was performed for all patients who underwent operative treatment of TFCC tears between 2006 and 2012 within one Upper Extremity practice. Patients were included if they were high-level athletes, unable to participate in their sport secondary to wrist pain and desired to return to their sport. All operative patients had imaging studies and clinical findings consistent with TFCC injury as the primary source of their activity-limiting pain and had failed nonoperative management prior to surgery. Patients without at least 3 months of documented postoperative follow up were excluded. In total, 22 patients were included in the chart review with 20 patients willing to participate in a telephone survey and PODCI. Eighty percent of patients returned to their sport following operative treatment of their injury at an average of 4.8 months. Seven of the 22 patients underwent a concurrent ulnar shortening osteotomy for ulnar positive variance. All 20 patients reported satisfaction with the outcomes of their surgery and treatment. Operative treatment of TFCC injuries in adolescent and pediatric athletes after failure of conservative treatment allowed return to sport at the previous level of participation. Concurrent ulnar shortening osteotomy in the setting of ulnar positive variance did not prohibit return to high-level athletic participation. Level IV.

The Factors Correlated with the Extensor Carpi Ulnaris Tendon and Distal Radioulnar Joint Disorder in Patients with Chronic Triangular Fibrocartilage Tears: Level 3 Evidence

There is no financial information to disclose. The purpose of this study was to analyze the predictor of extensor carpi ulnaris (ECU) tendon and distal radioulnar joint (DRUJ) disorders in patients with chronic triangular fibrocartilage (TFCC) tears. We hypothesized that magnitude of ulnar variance, age and duration of symptoms would be correlated with these disorders. Since 2006 to 2013, a total of consecutive 596 wrists that underwent wrist MRI were collected. We excluded rheumatoid arthritis, acute injury and patients under the age of 15. As the TFCC tears group, consecutive 70 cases that were diagnosed of chronic TFCC tears were selected. We classified the TFCC tears group as 40 cases of foveal tear and 30 cases of disc tear. As a control group, we selected 70 cases that were age and gender matched with TFCC tears group without any ulnar-sided wrist pain. We measured ulnar variance and investigated ECU tendon and DRUJ disorders on MRI. Regarding ECU tendon disorder, we focused on ECU tenosynovitis and longitudinal rupture of the ECU tendon (Figure 1). We compared the incidence of the ECU tendon and DRUJ disorders between the TFCC tears group and the control group. In the TFCC tears group, we investigated the correlation between the variables including age, gender, duration of symptoms, ulnar variance, foveal tear or disc tear and the ECU tendon and DRUJ disorders. In the TFCC tears group, there were 29 wrists (41%) with the DRUJ arthritis, 30 wrists (43%) with the ECU tenosynovitis, and 22 wrists (31%) with the longitudinal rupture of the ECU tendon. Meanwhile, in the control group, we found 9 wrists (13%) with the DRUJ arthritis, 5 wrists (7%) with the ECU tenosynovitis, and 14 wrists (20%) with the longitudinal rupture of ECU tendon. There were significant differences regarding the incidence of these associated pathologies between the 2 groups (DRUJ arthritis: P = 0.001, ECU tenosynovitis: P = 0.000, longitudinal rupture of the ECU tendon: P = 0.001) (Table 1). Ulnar variance and disc tear were significantly correlated with the DRUJ arthritis (P = 0.04 and 0.02, respectively). There was no significant correlation between the ECU tendon disorders and variables including gender, age, duration of symptoms, ulnar variance, foveal tear or disc tear. •We found a higher frequency of accompanying ECU tendon and/or DRUJ disorders in patients with chronic TFCC tears as compared to the control group.•UV and disc tear were significant predisposing factors for the DRUJ arthritis.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

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.

Arthroscopic knotless anchor repair of triangular fibrocartilage in distal radius fracture

Introduction and objectiveLesions of triangular fibrocartilage (TFC) are associated with distal radioulnar joint instability. Arthroscopic treatment of these lesions improves functional outcome of affected patients. The aim of the present work is to evaluate functional and occupational outcome of TCF repair using an arthroscopic knotless anchor device in patients with associated distal radius fracture. Material and methodsAn observational, descriptive study was carried out between November 2011 and January 2014 including 21 patients with distal radius fracture and Palmer 1B lesions of TCF (Atzei class 2 and 3) that were treated by arthroscopic knotless anchor (PopLok® 2.8mm, ConMed, USA). Mean follow-up was 18 months. Functional (Mayo Wrist Score) and occupational outcome results were analyzed. Mean age of the group was 43.0±8.8 years, with 19% of the patients being female. There was an associated scapholunate lesion in 5 cases. ResultsFunctional results reached a mean of 83.4±16.1 points on Mayo Wrist Score. Mean sick-leave time was 153.16±48.5 days. Complete occupational reintegration was reached in 89.5% of the cases. There were no postoperative complications. ConclusionsArthroscopic knotless anchor repair of 1B TFC tears is a minimally invasive method of treatment that improves tension of fixation, avoiding subsequent loosening, in our experience, with few complications and good functional and occupational results.

Resultados de la reparación artroscópica mediante anclaje óseo sin nudo de lesiones del fibrocartílago triangular asociadas a fractura de extremidad distal de radio

Introduction and objectiveLesions of triangular fibrocartilage (TFC) are associated with distal radioulnar joint instability. Arthroscopic treatment of these lesions improves functional outcome of affected patients. The aim of the present work is to evaluate functional and occupational outcome of TCF repair using an arthroscopic knotless anchor device in patients with associated distal radius fracture. Material and methodsAn observational, descriptive study was carried out between November 2011 and January 2014 including 21 patients with distal radius fracture and Palmer 1B lesions of TCF (Atzei class 2 and 3) that were treated by arthroscopic knotless anchor (PopLok® 2,8mm, ConMed, USA). Mean follow-up was 18 months. Functional (Mayo Wrist Score) and occupational outcome results were analyzed. Mean age of the group was 43.0±8.8 years, with 19% of the patients being female. There was an associated scapholunate lesion in 5 cases. ResultsFunctional results reached a mean of 83.4±16.1 points onMayo Wrist Score. Mean sick-leave time was 153.16±48.5 days. Complete occupational reintegration was reached in 89.5% of cases. There were no postoperative complications. ConclusionsArthroscopic knotless anchor repair of 1B TFC tears is a minimally invasive method of treatment that improves tension of fixation, avoiding subsequent loosen, in our experience, with few complications and good functional and occupational results.

Arthroscopic Repair of Triangular Fibrocartilage Tears: A Biomechanical Comparison of a Knotless Suture Anchor and the Traditional Outside-In Repairs

To compare the biomechanical strength of a knotless suture anchor repair and the traditional outside-in repair of peripheral triangular fibrocartilage complex (TFCC) tears in a cadaveric model. We dissected the distal ulna and TFCC from 6 matched cadaveric wrist pairs and made iatrogenic complete peripheral TFCC tears in each wrist. In 6 wrists, the TFCC tears were repaired using the standard outside-in technique using 2 2-0 polydioxane sutures placed in a vertical mattress fashion. In the other 6 wrists, we repaired the TFCC tears using mini-pushlock suture anchors to the fovea. The strength of the repairs was then determined using a materials testing machine with the load placed across the repair site. We loaded the repairs until a gap of 2 mm formed across the repair site, and then subsequently loaded them to failure. Thus, for each repair we obtained the load at 2-mm gap formation, load to failure, and mode of failure. At the 2-mm gap formation, the suture anchor repairs were statistically stronger than the outside-in repairs. For load to failure, the suture anchor repairs were also statistically stronger than the outside-in repairs. Failure in both techniques occurred most commonly as suture pull-out from the soft tissues. The all-arthroscopic suture anchor TFCC repair was biomechanically stronger than an outside-in repair. The suture anchor technique allows for repair of both the superficial and deep layers of the articular disk directly to bone, restoring the native TFCC anatomy. By being knotless, the suture anchor repair avoids irritation to the surrounding soft tissues by suture knots.

MR imaging of overuse injuries in the skeletally immature gymnast: spectrum of soft-tissue and osseous lesions in the hand and wrist

BackgroundIn the pediatric gymnast, stress-related physeal injuries have been well described with characteristic imaging findings. However, a spectrum of overuse injuries, some rarely reported in the literature, can be encountered in the gymnast’s hand and wrist.ObjectiveTo demonstrate the MR appearance of a spectrum of overuse injuries in the skeletally immature wrist and hand of pediatric gymnasts.Materials and methodsA total of 125 MR exams of the hand and wrist in skeletally immature children were performed at our institution during a 2-year period. Clinical histories were reviewed for gymnastics participation. MR studies of that subpopulation were reviewed and abnormalities tabulated.ResultsOf the MR studies reviewed, ten gymnasts were identified, all girls age 12–16 years (mean age 14.2 years) who presented with wrist or hand pain. Three of these children had bilateral MR exams. Abnormalities included chronic physeal injuries in three children. Two girls exhibited focal lunate osteochondral defects. Triangular fibrocartilage tears were present in three girls, one of whom had a scapholunate ligament tear. Two girls manifested metacarpal head flattening and necrosis.ConclusionA variety of soft-tissue and osseous lesions can be encountered in the skeletally immature gymnast. Familiarity with these stress-related injuries is important for accurate diagnosis.

Depiction of the triangular fibro-cartilage in patients with ulnar-sided wrist pain: comparison of direct multi-slice CT arthrography and direct MR arthrography

To compare direct multi-slice CT arthrography (MSCT-AG) and direct MR arthrography (MR-AG) of the wrist with regard to the depiction of the triangular fibro-cartilage (TFC). Fifteen consecutive patients with ulnar-sided wrist pain suspicious for TFC tear underwent both MSCT-AG and MR-AG of the wrist. Images obtained were evaluated by two radiologists in a blinded fashion for the depiction of six anatomical areas (radial, central and ulnar portion on the proximal and distal side) of the TFC by means of a five-point scoring system (1 = excellent visibility to 5 = not visible). Scores for MSCT-AG and MR-AG were compared using the Student's t-test. Mean scores for MSCT-AG and MR-AG, respectively, were 2.5/2.0, 3.2/2.5 and 2.8/2.4 for the radial, central and ulnar portion of the TFC on its proximal side, and 2.7/2.0, 3.1/2.3 and 2.9/2.4 for the radial, central and ulnar portion on its distal side (n = 15). Paired Student's t-test showed no significant difference between MSCT-AG and MR-AG (P > 0.05). In a first, small series, depiction of the TFC with MSCT-AG is comparable to that of MR-AG. Further evaluation of direct multi-slice CT arthrography of the wrist in a larger patient population would be promising.

Detailed analysis of contrast-enhanced MRI of hands and wrists in patients with psoriatic arthritis

The objective was to perform detailed analysis of the involved soft tissues, tendons, joints, and bones in the hands and wrists of patients with psoriatic arthritis (PsA). We reviewed 23 contrast-enhanced MR imaging studies (13 hands and 10 wrists) in 10 patients with the clinical diagnosis of PsA. We obtained clinical information from medical records and evaluated images for the presence of erosions, bone marrow edema, joint synovitis, tenosynovitis, carpal tunnel, and soft tissue involvement. Two board-certified musculoskeletal radiologists reviewed all images independently. Differences were resolved during a subsequent joint session. The average duration of disease was 71.3 months, ranging from 1 month to 25 years. Eight of the 10 wrists (80%) and 6 of the 13 hands demonstrated bone erosions. Bone marrow abnormalities were shown in 5 of the 10 wrists (50%) and 4 of the 14 hands (31%). Triangular fibrocartilage tears were seen in 6 of the 10 wrists (60%). Wrist and hand joint synovitis were present in all studies (67 wrist joints and 101 hand joints). Wrist soft tissue involvement was detected in 9 of the 10 wrists (90%) and hand soft tissue involvement was present in 12 of the 13 wrists (92%). Findings adjacent to the region of soft tissue involvement included synovitis (4 wrists) and tenosynovitis (3 wrists). Bone marrow edema adjacent to the region of soft tissue involvement was seen in one wrist. Bulge of the flexor retinaculum was seen in 4 of the 10 wrists (40%) and median nerve enhancement was seen in 8 of the 10 wrists (80%). Tenosynovitis was seen in all studies (all 10 of the hands and all 13 of the wrists). The "rheumatoid" type of distribution of bony lesions was common in our study. Interobserver agreement for various findings ranged from 83% to 100%. Contrast-enhanced MRI unequivocally demonstrated bone marrow edema, erosions, tendon and soft-tissue disease, and median nerve involvement, with good interobserver reliability in patients with PsA of the hands and wrists. Disease was more extensive in the wrists than in the hands.

Suture Welding for Arthroscopic Repair of Peripheral Triangular Fibrocartilage Complex Tears

This report presents a method of arthroscopic repair of the peripheral triangular fibrocartilage tears by using ultrasonic suture welding technique, thus avoiding the need for traditional suture knots. This technique eliminates the potential causes of ulnar-sided wrist discomfort especially during the postoperative period. Twenty-three patients (9 women and 14 men; mean age, 35 years; range, 18-52 years) were operated during a 1-year period in 2001 for Palmer grade 1B triangular fibrocartilage complex tear and followed up for 17 months. At the final follow-up, the average wrist arc of motion was as follows: extension, 65 degrees; flexion, 56 degrees; supination, 80 degrees; pronation, 78 degrees; radial deviation, 12 degrees; and ulnar deviation, 25 degrees. Grip strength measured with a dynamometer (Jamar) averaged 81% of the contralateral side at the final evaluation (range, 53%-105%).

DISTAL RADIOULNAR JOINT INSTABILITY

The distal radioulnar joint is inherently unstable. Pathologic instability can be acute or chronic; it can be dorsal, palmar, or multidirectional; and it can result primarily from soft-tissue injury or osseous malunion. Recognition of the type and cause of instability is fundamental in order to provide effective treatment. The distal radioulnar joint is a distal articulation in the biarticulate rotational arrangement of the forearm. This articulation allows only one degree of motion: pronation and supination. The sigmoid notch of the radius is concave and is shallow with a radius of curvature of 15 mm. The ulnar head is semicylindrical and has an articulate convexity of 220° with a radius of curvature of 10 mm1. The ulnar head is surrounded by an ulnar carpal ligament complex. This consists of the ulnolunate and ulnotriquetral ligaments, which originate from the palmar radioulnar ligament near the ulnar styloid process. When seen through an arthroscope, these ligaments appear to be continuous with the triangular fibrocartilage. The triangular fibrocartilage is a fibrocartilaginous disk originating at the junction of the lunate fossa and the sigmoid notch and inserting at the base of the ulnar styloid. Its central portion is cartilaginous, and it is designed for weight-bearing. It is also avascular. The peripheral margins are composed of thick lamellar cartilage designed for tensile loading and are called the dorsal and palmar radioulnar ligaments . The peripheral margins of the triangular fibrocartilage are well vascularized from the palmar and dorsal branches of the anterior interosseous artery and from the ulnar artery. The ulnar styloid is the continuation of the subcutaneous ridge of the ulnar shaft, and it stands as a strut on the end of the ulna to stabilize the ulnar soft tissues of the wrist. The sheath of the extensor carpi ulnaris, the ulnocarpal ligaments, and …

Arthroscopic Dorsal Radiocarpal Ligament Repair

The goal of this study was to determine if arthroscopic repair of a dorsal radiocarpal ligament (DRCL) tear is effective in ameliorating wrist pain. Retrospective study. A chart review was performed of 53 patients (56 wrists) who underwent wrist arthroscopy with use of a volar radial portal. There were 21 patients with DRCL tears. Mean follow-up was 16 months. Thirteen patients underwent arthroscopic DRCL repair and/or thermal shrinkage (5 repairs, 6 repair plus shrinkage, and 2 shrinkage). Lunotriquetral tears were treated with debridement and pinning. Triangular fibrocartilage (TFC) tears were debrided or repaired. Scapholunate ligament tears/instability were treated with capsulodesis. The 4 patients who underwent repair of an isolated DRCL tear had excellent results with no or mild pain. All returned to their previous occupation. Dorsal capsulodesis was performed in 7 patients with 4 fair/poor results. Nine DRCL repairs/shrinkage were in association with other procedures for ulnar-sided pathology with 6 fair/poor results. Tears of the DRCL are more common than previously suspected. They are best seen through a volar radial portal and are amenable to arthroscopic repair. DRCL tears appear to be part of a spectrum of radial and ulnar-sided carpal instability as evidenced by the frequent association with scapholunate ligament tears/instability or ulnar-sided pathology. Isolated DRCL tears can be solely responsible for wrist pain. Good results are obtained with arthroscopic repair of isolated DRCL tears. The presence of a DRCL tear when seen in combination with a scapholunate, lunotriquetral, or TFC tear connotes a greater degree and/or duration of carpal instability, and portends a poorer prognosis following treatment. Recognition of this condition and further research into treatment methods is needed. Level IV.

The Management of Dorsal Radiocarpal Ligament Tears

The dorsal radiocarpal ligament (DRCL) has been implicated in both volar and dorsal intercalated segmental instabilities and has a role in midcarpal instability. Tears of the DRCL are more common than previously suspected. They are best seen through a volar radial portal and are amenable to arthroscopic repair. DRCL tears appear to be part of a spectrum of radial- and ulnar-sided carpal instability as evidenced by the frequent association with scapholunate and lunotriquetral ligament injuries as well as triangular fibrocartilage tears. Isolated DRCL tears can be solely responsible for wrist pain. The presence of an associated DRCL tear when seen in combination with a scapholunate, lunotriquetral, or triangular fibrocartilage tear connotes a greater degree and/or duration of carpal instability, and portends a poorer prognosis after treatment. Good results are obtained after arthroscopic repair of isolated DRCL tears. Results of DRCL repairs are less predictable when seen in combination with other types of carpal pathology. Recognition of this condition and further research into treatment methods is needed.

Biomechanical comparison of transosseous and capsular repair of peripheral triangular fibrocartilage tears

Purpose: The purpose of this study was to biomechanically compare the repair strength of peripheral triangular fibrocartilage complex (TFCC) repairs to the distal ulna using transosseous sutures (group I) versus TFCC repairs to the extensor carpi ulnaris tendon subsheath and surrounding dorsal capsule (group II). Type of Study: Cadaveric biomechanical study. Methods: Six matched pairs of fresh-frozen cadaveric upper extremities were procured. Each underwent the creation and repair of a peripheral, ulnar-sided detachment of the TFCC. Following stabilization of the humerus and radius, the maximum translations of the ulna in the dorsal and palmar directions were measured in response to an 8-lb traction load before disrupting the TFCC, after disrupting the TFCC, and after repairing the TFCC. Results: There was a significant increase in the total translation of the ulna following disruption of the TFCC (P <.001) in both groups. The mean and standard deviation of the percent total translation eliminated following TFCC repair for group I specimens (transosseous suture) were 33.8% and 11.6%, respectively. The mean and standard deviation of the percent total translation eliminated following TFCC repair for group II specimens (capsular implantation) were 59.3% and 29.7%, respectively. The observed difference between the repair groups is not significant (P =.157). Conclusions: While disruption of the TFCC does significantly increase distal radioulnar joint (DRUJ) instability and repair of the TFCC does significantly restore DRUJ stability, the results of this study do not show a significant biomechanical difference between the 2 TFCC repair techniques in a cadaveric model.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 4 (April), 2003: pp 391–396