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Acute TFCC tearsAcute TFCC tears

Nickolaos A. Darlis, MD, PhD

Journal of Hand Surgery (Am), 1981

Palmer, JHS (A) 1981

Triangular FibroCartilage Complex

MH: Meniscal HomologueAD: Articular DiscUCL: Ulnar Collateral LigRUL: Radio Ulnar Lig

Triangular fibrocartilage (TFC) Dorsal radio-ulnar lig. Palmar radio-ulnar lig. Articular disc

Ulnocarpal ligaments Volar ulno-lunate Volar ulno-triquetral Volar ulno-capitate

Infratendinous extensor retinaculum( ECU sub sheath)

Triangular FibroCartilage Complex

Triangular FibroCartilage Complex

Palmer Classification of TFCC tears

Confusing

TFCC 3-D structure Nakamoura T et al, 1996

Hyaline cartilage at the tip of the ulnar styloid

Sharpey’s fibers at the fovea

The Hammoc paradigm Nakamoura T et al 1996

TFCC impaction test

Nakamura/ ulnocarpal stress test

The Iceberg Concept Atzei &Lucetti 2011

radius

ulna

N.D

radius

ulna

N.D

radius

ulna

N.D

Volar & Dorsal Radioulnar Lig

Foveal attachement

TFCC MENISCUS

radiusulna

N.D

radiusulna

N.D

TFCC CRUCIATE Lig

Volar & Dorsal RU lig.-Foveal Attachment

Class 1: Traumatic InjuriesA Central perforation of the disk properB Peripheral avulsion from the ulna

Without styloid fractureWith styloid fracture

C Distal avulsion from the carpusD Radial avulsion

Without sigmoid notch fractureWith sigmoid notch fracture

Class 2: Degenerative InjuriesA TFCC wearB TFCC wear + lunate and/or head chondromalaciaC TFCC perforation + lunate and/or head chondromalaciaD TFCC perforation + lunate and/or head chondromalacia +

lunotriquetral ligament perforationE TFCC perforation + ulnocarpal arthritis

Palmer Classification

Palmer Classification• Traumatic (Class 1)

• Degenerative (Class 2)- associated with ulnocarpal impaction syndrome

Central tear

Peripheral tear)

Radial tear

Tear location

Deep bundle of TFCC

Volar radioulnar lig.

radiusulna

N.D

Acute TFCC tearsISOLATED WITH DISTAL RADIUS Fx

Wrist arthroscopy in distal radius FxConcomitant lesions increasingly recognized:• ΤFCC ≈60% (43-78%)• SL lig.≈ 40% (32-75%)

• LT lig. ≈20% (15-61%)

• Chondral lesions ≈20% (19-32%)

Highly possible when:• shortening >5-7mm

Highly possible when:• shortening >5-7mm• radialy displaced fx base

of the ulnar styloid

Common misconceptions• TFCC tear ≠ DRUJ instability

– In fact: most tears do not have evident instability• Ulnar styloid fracture ≠ DRUJ instability

– Styloid fractures may co-excist with TFCC tears

Highly possible when:• shortening >5-7mm• radialy displaced fx base

of the ulnar styloid, • angulation >25-300 any

plane

Highly possible when:• shortening >5-7mm• radialy displaced fx base

of the ulnar styloid• angulation >25-300 any

plane• DRUJ diastasis in PA Rö

projection

• Radial translocation- sigmoid notch malreduction

Acute TFCC treatment

“Initial conservative treatment for 8 -12 weeks”

Literature, Conservative treatment

Literature, TFCC with Distal Radius Fx• Contradicting …

Treatment algorithm

Isolated TearIsolated Tear ConservativeConservative

Distal Radius Fx Conservative Conservative

Distal Radius Fx OperativeDistal Radius Fx Operative Consider Arthroscopy*Consider Arthroscopy*

DRUJ Instability Consider Arthroscopy*/ Cross pinning

* Especially in young, high demand patients

Follow-up all conservative patients closely

Timing of operative repair

ACUTEGood Healing Potential

SUBACUTEUnpredictable

CHRONICPoor Healing Potential

0 6 months 1 year

3mo 6mo

Conservative treatment

• Sugartongue or Long Arm splint 3-4 weeks• Short Arm Splint 1-2 weeks

Who would treat a meniscus lesion open nowadays?

Central tear

Peripheral tear)

Radial tear

Tear location

Deep bundle of TFCC

Volar radioulnar lig.

radiusulna

N.D

1. Central TFCC lesions• Poorly vascularized- healing potential minimal• Arthroscopic debridement up to 2/3 of articular disc

Shaver debridement

1. Central TFCC lesions

Arthroscopic TFCC debridement using radiofrequency probes Darlis NA & Sotereanos DG, JHS(B)2005

1. Central TFCC lesions

1. Central TFCC lesions

• Often degenerative and associated with ulnocarpal impaction syndrome

• Ulnar recession procedure to prevent symptom recurrence

Ulnocarpal Impaction SyndromeClinical features:• Ulnar sided wrist pain • Associated degenerative changes:

– Ulnar side of the lunate– Radial side of the ulnar dome– TFCC central tear– Triquetrum- LunoTriquetrum lig.

• Usually positive or neutral ulnar variance

Arthroscopic Wafer procedure

Arthroscopic Wafer procedure

Open Ulna Recession Procedures• Several options…

Open Ulna Recession ProceduresAnother approach: Keep it simple…• Step-Cut Ulnar Shortening Osteotomy

Darlis & Sotereanos JHS(A), 2005

2. Radial TFCC tears• Repair or debridement?

• Repair if:– VRUL or DRUL are involved– DRUJ instability

2. Radial TFCC tears

3. Peripheral (ulnar) TFCC tears• Well vascularized• Repairable

Usual location of peripheral tears

Dorsal

Usual location of peripheral tears

REPAIR TO CAPSULE REATTACH TO FOVEAOR

TFCC TFCC

3. Peripheral (ulnar) TFCC tears

REPAIR TO CAPSULE

REATTACH TO FOVEA

3. Peripheral (ulnar) TFCC tears

• Clinical DRUJ instability• Fracture through the fovea• MRI findings• Arthroscopic findings

– Positive Hook Test– Direct Foveal Portal Arthroscopy

Foveal attachment involvement

Hook test

REPAIR TO CAPSULE

REPAIR TO CAPSULE

1. Mini open: Sotereanos

Chou, Sarris, Sotereanos, JHS(B), 2003

U

EDM ECU

Incision

Chou, Sarris, Sotereanos JHS(B), 2003

REATTACH TO FOVEA

2. All Arthroscopic, Knotless: Geissler

REATTACH TO FOVEA

TFCC6R

ACC 6R

TFCC6R

ACC 6R

TFCC6R

ACC 6R

TFCC6R

ACC 6R

TFCC6R

ACC 6R

Cross Pinning• In Congruent DRUJ reduction

with an unstable joint • To protect a TFCC repair

Beware of pin breakage

Take Home Messages• Debridement ± Ulnar Shortening

• Repair or

ACUTEGood Healing Potential

SUBACUTEUnpredictable

CHRONICPoor Healing Potential

0 3 months 6 months

REATTACH TO FOVEA

REPAIR TO CAPSULE

Thank you

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