Διάγνωση και αντιμετώπιση Οξέων Ρήξεων του Καρπού

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Acute TFCC tearsAcute TFCC tears
Nickolaos A. Darlis, MD, PhD

3. Journal of Hand Surgery (Am), 1981

5. Palmer, JHS (A) 1981
Triangular FibroCartilage Complex
MH: Meniscal Homologue
AD: Articular Disc
UCL: Ulnar Collateral Lig
RUL: Radio Ulnar Lig

6.  Triangular fibrocartilage
(TFC)
 Dorsal radio-ulnar lig.
 Palmar radio-ulnar lig.
 Articular disc
 Ulnocarpal ligaments
 Volar ulno-lunate
 Volar ulno-triquetral
 Volar ulno-capitate
 Infratendinous extensor
retinaculum
( ECU sub sheath)
Triangular FibroCartilage Complex

7. Triangular FibroCartilage Complex
Palmer Classification of TFCC tears
Confusing

9. TFCC 3-D structure Nakamoura T et al, 1996

11. Hyaline cartilage at the tip
of the ulnar styloid
Sharpey’s fibers at the
fovea

12. The Hammoc paradigm
Nakamoura T et al 1996

13. TFCC impaction
test
Nakamura/ ulnocarpal stress test

15. The Iceberg Concept Atzei &Lucetti 2011

16. radius
ulna
N.D

17. radius
ulna
N.D

18. radius
ulna
N.D
Volar & Dorsal Radioulnar Lig
Foveal attachement

19. TFCC MENISCUS
radius
ulna
N.D

20. radius
ulna
N.D
TFCC CRUCIATE Lig

21. Volar & Dorsal RU lig.-Foveal Attachment

22. Class 1: Traumatic Injuries
A Central perforation of the disk proper
B Peripheral avulsion from the ulna
Without styloid fracture
With styloid fracture
C Distal avulsion from the carpus
D Radial avulsion
Without sigmoid notch fracture
With sigmoid notch fracture
Class 2: Degenerative Injuries
A TFCC wear
B TFCC wear + lunate and/or head chondromalacia
C TFCC perforation + lunate and/or head chondromalacia
D TFCC perforation + lunate and/or head chondromalacia +
lunotriquetral ligament perforation
E TFCC perforation + ulnocarpal arthritis
Palmer Classification

23. Palmer Classification
• Traumatic (Class 1)
• Degenerative (Class 2)- associated with
ulnocarpal impaction syndrome

24. Central tear
Peripheral tear)
Radial tear
Tear location
Deep bundle
of TFCC
Volar radioulnar
lig.
radius
ulna
N.D

25. Acute TFCC tears
ISOLATED WITH DISTAL RADIUS Fx

26. Wrist arthroscopy in distal radius Fx
Concomitant lesions increasingly recognized:
• ΤFCC ≈60% (43-78%)
• SL lig.≈ 40% (32-75%)
• LT lig. ≈20% (15-61%)
• Chondral lesions ≈20% (19-32%)

27. Highly possible when:
• shortening >5-7mm

28. Highly possible when:
• shortening >5-7mm
• radialy displaced fx base
of the ulnar styloid

29. Common misconceptions
• TFCC tear ≠ DRUJ instability
– In fact: most tears do not have evident instability
• Ulnar styloid fracture ≠ DRUJ instability
– Styloid fractures may co-excist with TFCC tears

30. Highly possible when:
• shortening >5-7mm
• radialy displaced fx base
of the ulnar styloid,
• angulation >25-300
any
plane

31. Highly possible when:
• shortening >5-7mm
• radialy displaced fx base
of the ulnar styloid
• angulation >25-300
any
plane
• DRUJ diastasis in PA Rö
projection

32. • Radial translocation- sigmoid notch malreduction

34. Acute TFCC treatment
“Initial conservative treatment for
8 -12 weeks”

35. Literature, Conservative treatment

36. Literature, TFCC with Distal Radius Fx
• Contradicting …

37. Treatment algorithm
Isolated TearIsolated Tear ConservativeConservative
Distal Radius Fx Conservative Conservative
Distal Radius Fx OperativeDistal Radius Fx Operative Consider Arthroscopy*Consider Arthroscopy*
DRUJ Instability Consider Arthroscopy*/
Cross pinning
* Especially in young, high demand patients
Follow-up all conservative patients closely

38. Timing of operative repair
ACUTE
Good Healing Potential
SUBACUTE
Unpredictable
CHRONIC
Poor Healing Potential
0 6 months 1 year
3mo 6mo

39. Conservative treatment
• Sugartongue or Long Arm splint 3-4 weeks
• Short Arm Splint 1-2 weeks

40. Who would treat a meniscus lesion open nowadays?

41. Central tear
Peripheral tear)
Radial tear
Tear location
Deep bundle
of TFCC
Volar radioulnar
lig.
radius
ulna
N.D

42. 1. Central TFCC lesions
• Poorly vascularized- healing potential minimal
• Arthroscopic debridement up to 2/3 of articular disc

43. Shaver debridement
1. Central TFCC lesions

44. Arthroscopic TFCC debridement using radiofrequency probes
Darlis NA & Sotereanos DG, JHS(B)2005
1. Central TFCC lesions

45. 1. Central TFCC lesions
• Often degenerative and associated
with ulnocarpal impaction
syndrome
• Ulnar recession procedure to
prevent symptom recurrence

46. Ulnocarpal Impaction Syndrome
Clinical features:
• Ulnar sided wrist pain
• Associated degenerative changes:
– Ulnar side of the lunate
– Radial side of the ulnar dome
– TFCC central tear
– Triquetrum- LunoTriquetrum lig.
• Usually positive or neutral ulnar variance

47. Arthroscopic Wafer procedure

48. Arthroscopic Wafer procedure

49. Open Ulna Recession Procedures
• Several options…

50. Open Ulna Recession Procedures
Another approach: Keep it simple…
• Step-Cut Ulnar Shortening Osteotomy
Darlis & Sotereanos JHS(A), 2005

51. 2. Radial TFCC tears
• Repair or debridement?

52. • Repair if:
– VRUL or DRUL are involved
– DRUJ instability
2. Radial TFCC tears

53. 3. Peripheral (ulnar) TFCC tears
• Well vascularized
• Repairable

54. Usual location of peripheral tears
Dorsal

55. Usual location of peripheral tears

56. REPAIR TO CAPSULE REATTACH TO FOVEAOR
TFCC TFCC
3. Peripheral (ulnar) TFCC tears

57. REPAIR TO CAPSULE
REATTACH TO FOVEA
3. Peripheral (ulnar) TFCC tears

58. • Clinical DRUJ instability
• Fracture through the fovea
• MRI findings
• Arthroscopic findings
– Positive Hook Test
– Direct Foveal Portal
Arthroscopy
Foveal attachment involvement

59. Hook test

60. REPAIR TO CAPSULE

61. REPAIR TO CAPSULE

62. 1. Mini open: Sotereanos
Chou, Sarris, Sotereanos, JHS(B), 2003
U
EDM ECU
Incision
Chou, Sarris, Sotereanos JHS(B), 2003
REATTACH TO FOVEA

63. 2. All Arthroscopic, Knotless: Geissler
REATTACH TO FOVEA

65. TFCC
6R
ACC 6R

66. TFCC
6R
ACC 6R

67. TFCC
6R
ACC 6R

69. TFCC
6R
ACC 6R

70. TFCC
6R
ACC 6R

72. Cross Pinning
• In Congruent DRUJ reduction
with an unstable joint
• To protect a TFCC repair
Beware of pin breakage

73. Take Home Messages
• Debridement ± Ulnar Shortening
• Repair or
ACUTE
Good Healing Potential
SUBACUTE
Unpredictable
CHRONIC
Poor Healing Potential
0 3 months 6 months
REATTACH TO FOVEA
REPAIR TO CAPSULE

74. Thank you
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