- Discussion:
- indicated primary for traumatic peripheral ulnar sided TFCC tears;
- negative predictive factors for successful repair include concomitant
ulnocarpal impaction syndrome (associated
w/ degenerative tears) and peripheral radial tears (due to the relative avasucularity of the disc in this region;
- some surgeons feel that radial sided TFCC tears are not a significant risk factor for healing after a repair;
-
ulnar positive variance is another negative risk factor;
- best candidates for repair are patients who have had a single traumatic wrist injury such as a fall or an MVA (driver gripping
the steering wheel at the time of impact);
- Arthroscopic Treatment:
- outcomes: in the study by Trumble et al 1997, 3/24 patients (undergoing arthroscopic repair) had continued wrist pain;
- arthroscopic evaluation: (see:
wrist arthroscopy)
- determine whether the TFCC has a resilient quality when probed (which is normal);
- when the arthroscopic probe elicits gross softness, then a peripheral tear may be present;
- peripheral tears are often located at the dorsal ulnar peripheral border;
- peripheral detachments are ideal for repair, where as central attritional tears are not good candidates for repair;
- TFCC attachment to the sigmoid notch of the radius gives successful results despite having poor vascularity;
- arthroscopic debridement:
- may be indicated for tears occupying the central 2/3 of the disc;
- relative contra-indication: postive
ulnar variance:
- hazards: avoid injury to the dorsal and volar
wrist ligaments;
- Open Repair:
- outcomes: in the report by Hermansdorfer (JHS Vol 16-A. 1991 p 340), over 20% of patients had an unsatisfactory result;
- open repair: (for peripheral tear at ulnar styloid);
- make a 5 cm longitudinal incision centered over the distal ulna;
- take care to avoid the dorsal sensory brach of the ulnar nerve;
- dorsal incision in made between the 4th and 5th compartments;
- incise the dorsal wrist capsule in line with the incision;
- the incision should be extended to the lunotriquetral joint;
- a radially based retinacular flap is fashioned;
- enter the ulnar-carpal joint (inverted T incision) between
EDQ and
ECU;
- scar tissue surrounding the torn TFCC and its bed are debrided w/ scope;
- w/
ulnar positive variance, exposure is facilitated w/ an ulnar shortening procedure (such as the
wafer procedure);
- likewise, placement of a small lamina spreader in the RU joint may facilitate the exposure;
- repair of ulnar detachment:
- sutures are then passed thru drill holes made at the medial base of the styloid, which are then placed
thru the torn medial edge of the TFCC;
- a suture passer can be helpful to pass the suture thru the drill holes;
- repar of radial TFCC detachment:
- drill holes are made in the ulnar side of the dorsal distal radius, from a dorso-radial to a palmar ulnar direction;
- horizontal matress sutures are passed thru the TFCC and are then brought thru the distal radial drill holes;
- RU stabilization and closure:
- place the arm in neutral rotation or slight supination and insert 2 K wires across the RU joint (or just proximal to the joint);
- the TFCC sutures are then tied down;
- the radially based retinacular flap is then passed underneath the ECU tendon inorder to help prevent subluxation;
Isolated tears of the triangular fibrocartilage: management by early arthroscopic repair.
Repair of the triangular ligament in Colles' fracture. No effect in a prospective randomized study.
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Operative technique for inside-out repair of the triangular fibrocartilage complex.
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Traumatic disruption of the triangular fibrocartilage complex.
Triangular fibrocartilage tears.
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J Hand Surg 1994: 19 (1): 143-154.
Triangular fibrocartilage complex lesions: a classification.
Palmer AK.
J. Hand Surg. 1989; 14-A: 594-606;
Partial excision of the TFCC.
AK Palmer, FW Werner, RR Glisson, and DJ Murphy.
J. Hand. Surg. Vol 13-A. 1988. p 391-394.
Ulnar shortening combined with arthroscopic repairs in the delayed management of triangular fibrocartilage complex tears.
TE Trumble et al.
J. Hand Surg. 1997. Vol 22-A. p 807-813.
Isolated tears of the TFCC: management by early arthroscopic repair.
TE Trumble et al.
J. Hand Surg. Vol 22-A. 1997. p 57-65
