Transcript Triangular Fibrocartilage Complex

Triangular Fibrocartilage
Complex
Nancy Beaman MBA, OTR/L, CHT
New England Hand Society Annual
Meeting
4 December 2009
TFCC: AKA…
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Triangular Fibrocartilage
Carpal Articular Disc
Discus Articularis
Triangular Ligament
Triangular Cartilage
Triangular Disc
Meniscus
Ulnocarpal Complex
Ulnocarpal Ligament Complex
Triangular Fibrocartilage Complex
a complex structure
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Consists of
Triangular Fibrocartilage
 Ulnocarpal ligaments
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TFC Anatomy
Triangular in shape
 Cartilaginous
 Ligamentous
 Interposed between ulnar carpus and
distal ulna
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TFC Anatomy
Arises from articular cartilage on corner of
sigmoid notch of the radius
 Inserts into base of ulnar styloid and
volarly into ulnocarpal ligament complex
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Ulnocomplex: ulnolunate & ulnotriquetral
ligaments
TFC Anatomy
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Dorsal and volar radioulnar ligaments are
fibrous thickenings w/in the dorsal and volar
edges of TFC
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Peripheral margin: thick lamellar collagen
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Adapted to bear tensile load
Thin central portion
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Articular disc: chondroid fibrocartilage
Avascular and aneural
Occasionally absent
Often so thin, is tranluscent
TFC Anatomy
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Blood supply: Ant Interosseous Artery
TFC Anatomy
Radial origin 1-2mm thick at base
 Stretches across ulnar articular dome
 Apex attached to eccentric concavity of
head and projecting styloid
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Ulnar origin may be up to 5mm thick
TFC Anatomy
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Volar and dorsal radioulnar ligament are
confluent w/ TFC
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Dorsal RU lig is stouter
Volar RU lig is origin for ulnocarpal ligs
RU ligs can be considered 2 separate laminae
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Proximal lamina inserts on fovea adjacent to
styloid
Distal lamina inserts into base of syloid proper
Separated by ligamentum subcruentum
Triangular
Fibrocartilage
The ulnocarpal or
Combined TFC and
“V” ligament
Ulnocarpal ligaments
Green’s Hand Surgery
Biomechanical Functions
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Provides continuous gliding surface
across distal radius and ulna for carpal
flexion, extension and translation
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Provides flexible mechanism for stable
rotation of the radiocarpal unit about the
ulnar axis
Biomechanical Functions
Suspends the ulnar carpus from the
dorsal ulnar face of the radius
 Connects the ulnar axis to the volar
carpus
 Major stabilizer of DRUJ and ulnar
carpus
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Biomechanical Functions
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Amount of load xferred to distal ulna is
directly proportional to the ulnar variance
neutral: ~20%
 Positive ulnar variance
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Load increases w/ corresponding decreased
thickness in articular disc
(Hulten’s) Ulnar Variance
Ulnar zero: radius and ulna the same
length
 Ulna positive: ulna 1-5mm longer
 Ulna negative: ulna 1-6mm shorter
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Variance is independent of styloid length
Measurement is affected by
FA rotation
Wrist position
Grip loading
Xray techniques
Biomechanical Functions
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Dynamic load xmission w/ rotation
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Ulna moves w/in sigmoid notch
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Supination: radius moves distally creating a relative
negative ulnar variance
Pronation: radius moves prox’ly creating and
relative positive ulnar variance
Dorsal with pronation
Volarly with supination
During FA rotation dorsal and volar radioulnar
ligamentous portions of TFCC become tense,
stabilizing DRUJ
Biomechanical Functions:
Compressive Force
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Force across carpal-ulnar articulation is
partially transmitted thru center of TFC to
ulnar dome
Tends to separate radius and ulna
 Variance changes w/ grip and FA position
 Neutral variance: static axial load
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80% radius, 20% ulna
 w/ positive ulnar variance 2-2.5mm, load
increases 5 – 40% (Palmar and Werner)
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Later study by Palmer showed weak correlation
Compressive Forces
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DRUJ is most stable in extremes of
rotation where compressive forces are
resisted by reciprocal tensile forces
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Pressure concentrates
Dorsally in pronation
 Palmarly in supination
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Compressive Forces
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In pronation
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the palmar margin of TFC is taut as the dorsal
margin of radius and the ulnar articular surface are
compressed
If palmar margin is attenuated or torn, dorsal sublux
of distal ulna occurs relative to radius
Compressive Forces
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In supination
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The dorsal margin becomes taut while the palmar
margin of the sigmoid notch and ulnar articular
surface are compressed
If dorsal margin is torn or attenuated, palmar sublux
of distal ulna relative to radius occurs
Traumatic Injuries
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Fall on an outstretched hand
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Extension-pronation force to an axial-loaded
wrist
A dorsal rotation injury
When a drill binds and rotates the wrist
 A distraction force applied to the volar FA or
wrist
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Common with Distal Radius Fractures
Clinical History: Mechanism of Injury
TFCC injury or…
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Carpal hypersupination w/ UD
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Hyperpronation w/ dorsiflexion
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Lunotriquetral ligament injury
Repeated pronation/supination
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ECU instab
May produce chondromalacia of ulnar head
Ulnocarpal impaction, abutment or loading syndrome seen w/
ulna positive
Sudden onset of pain accompanied by redness and
swelling point to inflammatory process
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Frequently calicific tendonitis
Classification of Injury
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Class 1: Traumatic
A. Central perforation
B. Ulnar avulsion
With distal ulnar fracture
Without distal ulnar fracture
Classification of Injury
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Class 1: Traumatic
C. Distal avulsion
D. Radial avulsion
With sigmoid notch fracture
Without sigmoid notch fracture
Classification of Injury
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Class 2: Degenerative
(ulnocarpal abutment syndrome)
A.
B.
TFCC Wear
TFCC Wear, plus lunate &/or ulnar
chondromalacia
Classification of Injury
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Class 2: Degenerative
(ulnocarpal abutment syndrome)
C. TFCC perforation
plus lunate &/or ulnar chondromalacia
plus lunotriquetral ligament perforation
D. TFCC perforation
plus lunate &/or ulnar chondromalacia
plus lunotriquetral ligament perforation
plus ulnocarpal arthritis
Contribution of age
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Age related changes begin as early as
3rd decade
Increase rapidly by age 50
 Virtually all wrists have significant
degenerative changes and 50% or more will
have arthrographically demonstrable
“lesions”
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Symptoms
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Ulnar-sided wrist pain
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Frequently with clicking
May be a history of a fall on a pronated
wrist, traction or twisting injury
 Improved by rest, worsened by load
activity
 Often assoc’d w/ tendonitis of ECU
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Physical Exam
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Swelling w/ a reversal of normal convex shape
at ulnar border of wrist
 Tenderness along soft region of ulnar border of
wrist between ulnar styloid and triquetrum
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Bring hand into UD compresses TFCC
RD can apply pressure to peripheral tissues
Dimpling along dorsal surface, particularly in
supination—indicative of volar sublux of ulna
 Ask pt to duplicate motion that causes
symptoms
Physical Exam: provocative tests
Only meaningful if they reproduce pt’s symptoms
 TFC compression test
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Examiner axially load the wrist then add UD or rotatory motion
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Painful click that reproduces symptoms
Always compare to the other side
Piano key sign: test for DRUJ stability
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Grasp distal ulna and attempt to passively move the ulna
volarly and dorsally in various degrees of pronation and
supination.
Pain and tenderness w/ inc’d motion suggest DRUJ
involvement
Gross laxity represents significant TFCC disruption
Physical Exam: provocative tests
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Test LT ligament w/ Ballottement test
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Examiner hold lunate between thumb and IF of one
hand and triquetrum in thumb and IF of the other.
Move triquetrum volar and dorsal to appreciate
instability or elicit pain.
Physical Exam: provocative tests
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Check ECU tendon for subluxation
on supination w/ wrist-ulnar deviation,
tendon displaces, often w/ audible snap,
when moved in the ulnar and palmar
directions
 on pronation, it relocates into its normal
sulcus
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Physical Exam: provocative tests
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Articular Disc Shear
Examiner stabilizes the distal radius while
thumb is positioned dorsally over distal
ulnar head
 Grasp pisotriquetral complex w/ other thumb
and IF
 Produce a dorsal glide of pisotriquetral
complex on the ulnar head producing a
shearing of the articular disc
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Positive if produces patient’s pain &/or laxity
Physical Exam: provocative tests
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Measure grip strength
Will see decrease grip w/ TFCC injury
 Pain w/ tight grip
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Testing ligamentum subcruentum
In supination: pressure to distal ulna volarly
should cause pain
 In pronation: pressure to distal ulna dorsally
should cause pain
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Differential Diagnosis
ECU subluxation
 LT ligament injury
 Pisotriquetral arthritis
 Chondral lesions of lunate or midcarpal jt
 Ulnar artery thrombosis
 Ulnar neuropathy at wrist
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Objective testing
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Differential anesthetic injection may be helpful
to localize symptomatic source of pain
 X-ray
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Carpal alignment
Ulnar styloid morphology
Ulnar variance
MRI: to differential soft tissues
 Arthrography: evaluation of integrity of
intercarpal and capsular wrist ligaments
 Arthroscopy
Management
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Immobilization x 2 weeks (normal xray)
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Reexamine after 2 weeks, continue immob if still
tender
Still painful after 6 weeks then MRI
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Arthroscopic evaluation
 Surgical debridement
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Central or peripheral tears
Repair of peripheral tear
 Distal ulna resection / ulnar osteotomy
Post-operative Care:
Central Debridement
Wrist Immob Orthosis and begin AROM
at 3-5 days
 Scar mgt once sutures removed
 3-4 weeks add resistance, PROM and
dynamic splinting if needed
 6 weeks progressive strengthening
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Post-operative Care
Peripheral Repair
Long arm cast at 10 days when sutures
removed. Short arm cast at 3 weeks.
 6 weeks: cast removed, wrist immob
orthosis. Initiate AROM and scar mgt.
PROM to elbow if needed.
 8 weeks: PROM & dynamic splinting if
needed.
 10-12 weeks: begin strengthening.
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References
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Green’s Operative Hand Surgery 5th Ed
Review of Hand Surgery
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Examination of the Hand and Wrist
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Handout from Drexel University, 3 Mar 07
Atlas of the Hand Clinics: Disorders of the Lunotriquetral Joint,
March 2004
The Wrist: Diagnosis and Operative Treatment
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Trumble
Anatomy, Biomechanics and Pathomechanics
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Tubiana, Thomine, Mackin
Principles of Hand Surgery and Therapy
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Beredjiklian & Bozentka
Cooney, Linscheid, Dobyns
Rehabilitation of the Hand and Upper Extremity
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Hunter, Mackin, Callahan