TFCC Tears

Definition

 

Present with pain but not instability

 

Types

 

Traumatic

Degenerative

 

Different treatment algorithms for each

 

History

 

Ulna side wrist pain

- may be worse with rotation

- opening doors and jars

 

History of trauma

 

Examination

 

Local tenderness DRUJ

 

Supinate / pronate

- pain

- click

 

Forcibly ulna deviate and pronate wrist

- grinds carpus against TFCC
- generates pain

 

Check for DRUJ instability / Piano Key

 

Ulna variance

 

Position

 

Xray in neutral supination / pronation

 

Variance is not static

- Pronation increases ulnar variance

- Supination decreases variance

- May be up to 3 mm

 

Measurement

 

Transverse line of lunate fossa

Transverse line of ulna head

 

Variation

 

Population is on average 1 mm ulna plus

- wide variation

- 1/4 wrists are ulna negative

 

Importance

 

Neutral variance

- Takes < 20% of load

 

Ulna Variance Neutral

 

2.5mm Ulnar negative

- 4.3% of load

 

Ulna NegativeUlna Variance Negative

 

2.5mm Ulnar positive

- 42% of load

 

Ulna Variance PositiveUlna Positive with abutmentUlna Variance Positive

 

Xray

 

Ulna Variance

 

Evidence ulnocarpal abutment / arthritis

 

MRI

 

Look for discontinuity of TFCC

- radial / ulna / central / carpal

 

TFCC Tear Ulna Side

 

Wang et al, J Hand Surg Eur Vol

- 154 patients >20y with assymptomatic wrists had MRI performed

- 44% had full thickness tear

- Worse with age, 17% 20-29y; 77% if > 60y

 

Palmer Classification TFCC Lesions

 

Class 1 Traumatic

 

A. Central perforation

B. Ulnar avulsion 

- With distal ulnar fracture

- Without distal ulnar fracture

C. Carpal / Distal avulsion

- ulno-carpal ligament injury

D. Radial avulsion (+/- sigmoid notch fracture) 

 

Class 2 Degenerative 

 

Central

 

A. TFCC wear

B. TFCC wear

+ lunate and/or ulnar chondromalacia

C. TFCC perforation

+ lunate and/or ulnar chondromalacia 

D. TFCC perforation

+ lunate and/or ulnar chondromalacia

+ Luno-Triquetral ligament perforation

E. TFCC perforation

+ lunate and/or ulnar chondromalacia

+ Luno-Triquetral ligament perforation

+ ulnocarpal arthritis

 

TFCC Degenerative Tear with Chondromalacia

 

Arthroscopy

 

Diagnose central tears

 

Trampoline test

- TFCC should bounce on probe

- if very soft, likely has a peripheral tear

 

Management

 

Concepts

- acute repair if DRUJ unstable

- delayed repair if continued symptoms and ulna / radial tear

- debridement of central tears + ulna shortening if ulna positive

- ulna shortening if ulnocarpal abutment / arthritis

 

Class 1 Traumatic

 

A.  Ulna

 

Acute Injury

 

1.  Stable DRUJ

- immobilise in neutral rotation

- need long arm cast

- surgical repair if continued symptoms / non healing

 

2.  Unstable DRUJ

 

A.  Obtain closed reduction / supination

- immobilise

 

B.  Failure closed reduction

- open / arthroscopic TFCC repair to stabilise DRUJ

 

Operative repair

 

Indications

- acute instability

- continues pain / late presentation

 

Open

- good success as very vascular

- 5/6 approach / bed of EDM

- interval between EDM and ECU

- open capsule

- sutures in TFCC, pass  through drill holes in base ulna styloid

- immobilise in cast

 

Arthroscopic

 

B.  Radial

 

Commonest

- difficult to access / repair / very avascular

 

Open repair

- 5/6 approach

- drill holes through dorsal radius into ulna fossa

- use suture retriever

- stabilise with RU K wires if continued instability

 

C.  Central 

 

Site

- usually occur along avascular origin from radius 

- usually 1-2mm from origin

- may be traumatic or degenerative

 

Neutral ulna variance

- Arthroscopic debridement

- 73% success complete pain relief

- Can take central 2/3 of disk without problems

 

Positive ulna variance

- do worse if debride disc alone

- consider combining with ulnar shortening as well

 

Class 2 Degenerative 

 

Class 2A - C

 

Definition

- TFCC wear or perforation

- lunate and / or ulna chondromalacia

- lunate triquetral ligament intact

 

1.  Positive ulna variance

 

Shorten ulna +/- arthroscopic debridement TFCC

 

Options

 

A.  Ulnar shortening and plate fixation

- specific plates (Trimed)

- have advantage of rotational control throughout procedure

- midportion ulna, apply plate dorsal

- fix distally, sliding screw proximally

- oblique osteotomy through jig

- 5 or 8 mm

- shorten, lag screw through plate

- apply proximal screw

 

Ulna PositiveUlna Shortening

 

B.  Wafer / Bower's hemiresection procedure

- open or arthroscopic

- remove 2-3 mm ulna head

- aim to make ulna negative

- not indicated if > 4mm ulna positive

- leave ulna styloid / TFCC intact

 

2.  Ulna neutral

- arthroscopic debridement

- +/- ulna shortening

 

Class 2D

 

Definition

- Lunotriquetral ligament perforation

 

Options

- Arthroscopic debridement / ulna shortening 

- LT fusion if unstable

 

Type 2E / Ulnocarpal Impaction Syndrome

 

Definition

- LT ligament perforated

- ulnocarpal abutment / arthritis

 

Associated with positive ulnar variance

- from repetitive loading

 

Ulnocarpal Abutment

 

Options

 

1.  Bower's ulna head hemiresection

- resect 2mm ulna head leaving ulna styloid

- +/- interposition of dorsal capsule

 

2.  Darrach's

- excision of distal ulan

- +/- stabilisation with tendon transfer

 

3.  Suave-Kapandji

- distal radioulna fusion