TRIANGULAR FIBROCARTILAGE COMPLEX, TFCC INJURY , MENISCAL HOMOLOGUE, ATICULAR DISC , LIGAMENTS OF DRUJ , DRUJ INJURY

1. TFCC INJURIES
Arjun Das
Resident of
Department of Orthopedics
Kathmandu University of School of Medical
Sciences

2. Importance
• TFCC Injury – m/c ligament injury
• >40 % of displaced distal radial fractures associated with instability of DRUJ
• In 1981, Palmer and Werner introduced term TFCC

3. Osteology
• Stabilise during pronation and supination
• Sigmoid notch of the radius

4. • Origin
• Concave sigmoid notch medial to the distal end of radius from its
hyaline cartilage
• Insertion
• Fovea
• Base of ulnar styloid
• ECU subsheath
• Ulnocarpal ligaments

5. TFCC components
• Dorsal and Volar radioulnar
ligaments(Superficial )
• Deep ligaments known as
ligamentum subcruentum
• Central fibro-cartilaginous
disc
• Meniscal homologue
• Ulnar collateral ligament
• ECU Tendon subsheath
• Ulnolunate and
Ulnotriquetral ligaments

7. Central Disc
• Occupies 80 % of area
• Composed of fibrocartilage
• Type I collagen bundles with interspersed
chondrocytes
• Avascular
• Poor healing potential
• Attaches to hyaline cartilage of sigmoid notch
Peripheral Disc
• Outer 20 % of area
• Vascular connective tissue along with
fibroblasts
• Good healing potential

8. • Blood supply
• Periphery portion : branch from ulnar artery and also from Ant. and Post. interosseous
arteries
• Central portion :nourished by synovial fluid

9. Biomechanics

10. Biomechanics

12. Symptoms of TFCC Injury
• Ulnar sided wrist pain
• Popping/clicking with pronation and
supination
• Decreased rotational movements
• Decreased grip strength
• Instability of DRUJ

13. Diagnosis of TFCC Injuries
• Physical examination of the TFCC
• Palpable tenderness over the TFCC
• Combined ulnar deviation and pronation /supination may cause pain and
popping/clicking sounds
• Ulnar impingement sign
• TFCC Stress Test
• “Press Test”: has been shown to have 100 % sensitivity for TFCC tears

14. Physical Examination
• Ulnar impaction test
• Wrist hyperextension and ulnar deviation with
axial compression
• Press Test
• Seated patient is asked to lift himself/herself out of
chair while bearing weight on extended wrists

15. • Piano key test
• Shuck test
• Radial aspect of wrist
stabilized
• Anteroposterior stress is
applied to the ulnar side of
wrist
• Fovea sign

16. Radiology
• X-ray
• Ulnar variance is calculated in neutral position
• (+) is associated with TFCC Tears
• MRI
• Radioulnar ligaments ,ulnocarpal ligaments and the TFCC with its foveal
attachment to ulna can be visualized
• Sensitivity and specificity for TFCC tears (100%)

17. Arthroscopic Evaluation
• Trampoline test
• Hook test

18. Differential Diagnosis

19. Non –operative
• Immobilisation ,NSAIDS ,Steroid Injections
• All acute Type I injuries
• First line of treatment for Type 2 injuries

20. Surgical repair
• For patients with isolated or associated injuries yielding significant
DRUJ instability
• Often does not itself restore stability of the joint
• Careful patient selection

21. Traumatic Lesion of TFCC (Palmer Class 1A):
• Traumatic central tears of the TFCC with no instability
• Initial treatment non-operative for 4 weeks.
• Persistent pain relieved by
• Arthroscopic debridement of the flap portion of tear
• No more than two thirds of the central disc should be excised
• 2mm of the TFCC peripheral rim should be preserved

23. Lesions of TFCC (Palmer Class 1B):
• Traumatic detachment of TFCC from ulna with or without ulnar
styloid fracture
• Initially conservative
• A/w ulnar styloid fracture
• ORIF or
• Excision of small fragment –usual T/T
• Open repair of TFCC
• A/w injury to ECU sheath
• Arthroscopic repair of TFCC
• Open ECU sheath reconstruction

24. Class 1C Lesions
• Disruptions of ulnocarpal ligaments
• A/w injuries include lunotriquetral and class 1B tears
• Difficult to diagnose
• Usually conservative management
• Operative treatment
• Late open or arthroscopic repair

25. Class 1D Lesions
• Tear of TFCC from the radius at the distal end of sigmoid notch
• Oriented in AP direction
• May involve radioulnar ligaments
• Frequently a/w distal radius fractures
• Satisfactory reduction of radial fracture-healing with stable DRUJ
• If instability after fracture reduction
• Arthrocopic /Open repair

26. Arthroscopic Repair of Class
1D Injury

27. Open Repair of Class 1D Injuries

28. Chronic Instability of DRUJ
• After unsuccessful attempts to repair the TFCC
• Failed primary TFCC repair
• Other causes
• After isolated trauma to the DRUJ
• After fracture of distal radius and ulna
• Inflammatory arthritis

29. Procedures to stabilize DRUJ
• Soft tissue procedures
• TFCC Repair
• TFCC Reconstruction
• Malunited distal radius fracture
• Distal radial osteotomy and bone grafting
• Ununited displaced ulnar styloid fracture
• Open reduction and internal fixation

30. Anatomical reconstruction of distal radio
ulnar ligaments(Adam and Berger)

32. Ulnar impaction and DRUJ arthritis
• Non operative
• Operative
1. Without DRUJ arthritis
• Arthroscopic joint debridement
• Open/arthroscopic distal ulnar resection
• Ulnar shortening osteotomy
2. With DRUJ Arthritis
• Excisional or interposition arthroplasty
• Modified arthrodesis

33. Ulnar shortening osteotomy

35. Limited Ulnar Head Excision :Hemiresection
Interposition Arthroplasty
• Indications
• Unreconstructable fractures of ulnar head
• Ulnocarpal impingement syndrome with incongruity of the DRUJ
• Rheumatoid arthritis involving the DRUJ
• Posttraumatic arthritis and osteoarthritis of the DRUJ
• Chronic painful triangular fibrocartilage tear
• Contraindications
• No reconstructable TFCC

36. Hemiresection arthroplasty

37. “WAFER” distal ulna resection
• Symptomatic tear of TFCC or ulnar impaction syndrome or both
• Preserves ulnar styloid process and attached liagments
• Not indicated for
• DRUJ instability
• Distal radioulnar degenerative arthritis
• Carpal instability

38. “WAFER” Distal Ulna Resection

39. Sauve-Kapandji procedure
• Used to salvage painful wrist caused by previous surgery , traumatic
arthritis and RA

40. Modified Sauve- Kapandji procedure

41. Darrach resection

42. • Procedure to stabilize unstable proximal ulnar segment after distal
ulnar excision
• Volar, distally based capsular flap attached to the ulna proximally
• Slip of the ECU tendon, based proximally or distally, passed through drill
holes in the ulna or wrapped around ulna
• PQ as a combination interposition-stabilizer
• Slip of FCU tendon, usually distally based and passed through drill holes in
ulna
• Combination of ECU tenodesis and dorsal transfer of PQ

43. Tenodesis of ECU and Pronator Q transfer

44. Combination Tenodesis of ECU & FCU

46. 44/M

48. Take Home Message
• TFCC injury is most common
• Multiple causes of ulnar sided wrist pain
• Conservative treatment is mainstay of treatment
• Persistent pain and instability only requires operative treatment

49. References
• Campbell’s Operative Orthopaedics ,14th Edition
• Hand and Wrist Surgery ,Operative Techniques ,13th edition
• IFSSH Scientific Committee on Anatomy and Biomechanics ,2013
• Anatomy of the Triangular Fibrocartilage Complex (TFCC)
,ISSHACADEMICS

50. THANK YOU