ANATOMY Triangular Fibro cartilage of Palmar and Werner Ulna to radius and ulnar side of carpus TFCC includes1. Dorsal &Volar Radio-ulnar ligs( Primary Restraint)2. Volar Ulno-lunar lig.3. Ulno-triquetral lig.4. Ulnar collateral lig.5. Articular disc6. Extensor Carpi Ulnaris Sheath
TFCC AnatomyOrigin: Ulnar side of lunate fossa of radius (base-5mmthick)Insertion: Head of ulna & base of ulnar styloid (apex-1mm thick)Joined by ulnar collateral ligDorsal Insertions:1. Triquetral2. Hamate3. Base of 5th metacarpal
FUNCTIONS OFTFCC1. Gliding surface at distal face of forearm bones2. Provides flexible mechanism for stable rotationalmovements of the radiocarpal unit around ulnar axis3. Suspends the ulnar carpus from the dorsal ulnar faceof the radius4. Cushions forces transmitted through ulnocarpal axis5. Connects ulnar axis to volar carpus
ADDITIONAL STABILITYTO DRUJ1. Contour of sigmoid notch2. Interosseous membrane3. Extensor Retinaculum4. Dynamic forces of ECU and pronator quadratus
In Ulna neutral Position ofWrist20% applied load – Ulna80% applied load – RadiusImp: Ulnar variance affects load distributionTFCC thinner in wrists with +ve ulna varianceTFCC thicker in wrists with –ve ulna variance
a. Full Supination – Full pronation 1mmapparent increase in length of ulnab. Head of ulna also dorsally displaced relativeto lunate and triuetrum in full pronationa. +b. = Minimal affect on axial forcetransmission
IN PRONATION: DORSAL RUL under tension IN SUPINATION:VOLAR RUL under tension“PIANO KEY SIGN”Avulsion of RUL from radial or ulnar attachmentsIncreased mobility of ulnar head on radiusAppreciated by ballottement test
INVESTIGATIONS RADIOGRAPHSa. AP or PA wrist- semipronated (45*)USE: for dorso ulnar structuresb. Semisupinated/ Reverse Oblique/Ball catcher view(30-45* supination)USE:Volar ulnar quadrant of the wrist especiallypisotriquetral jt and hook of hamate
c. Dynamic/Provocative/ Loaded viewsPt. made to make a fist/ squeeze an objectCompare with opposite sideUSE:To recognize instabilityd. Loaded PA radial and ulnar deviation viewsUSE: Movt. Of proximal row in relation with distalradius andTFC.
TOMOGRAPHYUSE: accurate for DRUJ subluxation/dislocationADVANTAGES:1. Does not require precise positioning2. Can be done through a plaster cast3. Sigmoid notch abnormalities assessed best MRIUSE: location of ECU tendon, joint capsule,TFCC tears.
ARTHROSCOPYUSE: Small joint arthroscope--TFCC tears-Synovitis-Erosion areas- Rim avulsion of radial head ofTFCC
TREATMENT For acceptable redn-intra articular # must beanatomically aligned and jt. congruityrestored Ulnar articular surface must not be translatedin any direction COMMINUTED STABLE #:Closed reduction and External fixation SEVERELYCOMMINUTED+ UNSTABLEORIF and Bone graft
Ulnar articular #: Open fix with k-wire or screw Comminuted # ulna head: 1* resection of thehead preserving shaft axis Minimal displacement Rx with BE castimmobilization with interosseous moulding andavoiding more than mid pronation.Wrist neutraland slight ulnar deviation.
ESSEX- LOPRESTI INJURY DRUJ disruption + displaced radial head + Proximalmigration of radius ~ 5-10mmDISRUPTION OF:1. DRUJ ligament2. Interosseeos membrane3. Radiocapitular articular surfaceRADIOGRAPH: X ray Elbow+forearm+wristCT: Comparison of DRUJMRI: Interosseous haematomaRx: Fixation of large radial head fragment+ Reducn repairfixn of DRUJRadial head comminuted-Excise itUlnocarpal impaction: hemiresection and arthroplasty
IsolatedTFCC disruption=Periulnar dislocation ofradiocarpal mass/Dislocation of lower end ofulna -ulna in N position at elbow Volar Ulnar dislocation-reduced by pronation Dorsal Ulnar dislocation-reduced by supinationAE cast x 6 weeksGreen recommends neutral rotation + ulnardeviation for bothDirectTFCC Repair-intraosseous wire technique 24gauge wire
IsolatedTFCC damagewithout Instability OPTION A: completeexcision OPTION B: Repair oftear if it is in Peripheralvascular zone;debridement if incentral avascular zone.
BUNNEL-BOYES RECONSTRUCTIONOF DRUJFor dorsal dislocationDistally based FCU harvested proximally, strippeddistally to pisiform attachmentNew ligament woven through the volar capsuleStress on pisotriquetral jt relievedNew lig. Passed through drill hole in styloid to exit inaxilla of ulnar styloid processImbrication with dorsal capsuleC/I: VOLAR DISLOCATION
Moving pronator quadratus to a more lateraland dorsal insertion for stability-Johnson Fascia lata used to stabilise DRUJ Fernandez Osteotomy:Osteotomy of distal radiusre-establishes length, volar tilt and ulnarinclination of radius
IMPINGEMENT ULNOCARPAL IMPACTION SYNDROMEUlnar head impinges against carpusLimitation of Rotation-ligaments relax around wristSymptoms:1. Ulnar wrist pain2. Rotation/Ulnar deviation3. Clicks/crepitus inTFCC region4. Long ulna relative to radiusX RAYS: Sclerotic/cystic changes in ulnar head &lunate
PREDISPOSING CONDITIONS1. Premature closure radial epiphysis 2* to trauma(Acquired Madelung’s deformity)2. Premature wrist fusion3. Excision of radial head or shaft4. Fracture malunions with shortening of radius5. Normal variant long ulnaTFCC examined with MRI & ArthroscopyUlnar unloading-Feldon, Belsky andTorrono “Wafer”Osteotomy-2-4mm wafer of cartilage & bone fromulnar articular dome underTFC.
FOR DRUJ INCONGRUITY1. Darrach and modifications-Ulna head excision2. Sauve-kapandji Procedure: Ulnar recession &fusion ulnar head with radius+ proximal pseudo arthrosis for restoration offorearm motion3. Bowers resection-hemiresection arthroplastywith shortening4. Swanson resection and replacementarthroplasty
INDICATION-HEMIRESECTIONARTHROPLASTY1. RA a. Early: Bower’s arthroplastyb. Late: Modified Darrach’s procedure2. OA of DRUJ along with osteophyte resection3. Ulnocarpal impaction Syndrome4. Painful Instability of DRUJ5. Rotational Contractures with radio ulnar disease
DISADVANTAGES OF BOWER’S ARTHROPLASTY1. Fails ifTFCC is not functioning (trauma/severe RA)2. Cannot restore stability in an unstable painful DRUJ3. Unsuccessful if stylocarpal impingement is notanticipated.4. In long standing contractures may not restore rotation C/ITO BOWER’S OSTEOTOMY1. UnreconstructableTFCC2. Advanced RA3. Ulnocarpal translation (post traumatic/arthritic)
DARRACH’S PROCEDUREIncision proximal from ulnar styloidSeparate ECU and FCUBEWARE: Dorsal cutaneous br. Ulnar nerveOsteotomy 2.5cm proximal to styloidMobilization encouraged within 24 hrs.DISADVANTAGES:1. Increased Ulnocarpal translocation/instability2. Decreased Grip Strength
MODIFIED DARRACH’S PROCEDURES1. Blatt and Ashworth: flap of volar capsule to dorsalulnar stump2. O’Donovan and Ruby: tethering distal ulnar stumpwith distally based strip of ECU3. Kessler and Hecht: dynamic stabilisation loopingtendon around distal ulnar stump and the ECU4. Goldner and Hayes: ECU through drill hole in ulnarstump –forearm in supination5. Tsai and Stilwel: FCU to stabilise ulnar stump andECU6. Johnson: Pronator advancement
SAUVE KAPANDJI POCEDURE Radio ulnar jt. Fusion Creation of pseudoarthrosis proximal to fusion INDICATIONS:1. OA/Chondromalacia of DRUJ2. Post traumatic ulno carpal impingement a/wDRUJ arthrosis3. Yong RA pt. with ulnar translocation + DRUJdisease4. RA pt. who may need a stable radioulnarsurface for support of an arthroplasty or