The TFCC How I Do It! · 2016. 11. 14. · Non Operative Treatment Thermoplastic Wrist Splint x...
Transcript of The TFCC How I Do It! · 2016. 11. 14. · Non Operative Treatment Thermoplastic Wrist Splint x...
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The TFCC
How I Do It! Mr Jason N Harvey
Hand, Wrist & elbow
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Before Surgery
History
Examination
X-ray Ulna variance
MRI If not classic
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TFCC Anatomy
Specific anatomic site
helps determine
diagnosis
Careful palpation
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Examination
Individually stress
joints
Duplicate
motion/position that
causes pain
Examine wrist in
pronation and
supination
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Non Operative Treatment
Thermoplastic Wrist Splint x 6/52, usually custom moulded
Steroid Injection, (+/-Guided) + splint x 6/52
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Factors to consider Previous Treatment
Time since injury
Age
DRUJ Stability
Associated Injuries
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Differential Diagnosis Isolated DRUJ
pathology, eg OA
Ulnocarpal abutment
Lunotriquetral
Instability
ECU pathology
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Ulnocarpal abutment
Associated with
TFCC tears
Tenderness more
dorsally ulnolunate
Prominent ulnar
head
Pain on stressing
ulno-carpal joint,
RD & UD
Ulna +ve variance
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Luno-triquetral instability
Sensation of
instability or giving
way in the wrist
Painful click on ulnar
deviation
Tenderness over L-T
joint
Ballotment test
Schuck or shear test
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ECU tendon subluxation
Injury eg tennis
Painful soft snap in
wrist
Subluxation ECU:
resisted ulnar
deviation in
supination
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MRI If clinical exam not
typical
Dedicated wrist coil
Not insignificant false
negative rate
Lesions beyond
articular disc difficult
to identify
Arthroscopy remains
gold standard
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TFCC tears
approx. 50% population
> 50 years have
attritional lesions of the
TFCC
Consider addressing
ulna
rare < 20 years
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TFCC tears
Repair if peripheral
If no DRUJ instability
soft tissue through
floor of ECU
If instability through
bone
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Central TFCC tear
Debride to stable rim
Use Biter and shaver
Radius
TFCC
Ulna Head
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Degenerative Tear with Abutment
Debride TFCC tear
If mild ulna +ve variance can do an arthroscopic wafer
If > 2mm or so then ulna shortening
If evidence of abutment, no tear and +ve can do under TFCC from DRUJ
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Combined Tear
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Peripheral Tear, No DRUJ instability
Identify tear
Determine if it is repairable
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Peripheral Tear cont
Debride edges of tear
Debride synovitis in ulna aspect of wrist
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Peripheral Tear, suture
Avulsion from dorsal capsule
Repair through the ECU subsheath
Use 2-0 PDS, tie in subsheath
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Peripheral Tear, DRUJ instability
Foveal disruption
Repair through drill holes in the ulna
I use a targeting jig to make tunnels
Just like an ACL guide but smaller
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If Normal TFCC
Arthroscopy of DRUJ to evaluate the underside of the TFCC
Can see foveal fibres
May see undersurface tear
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Lunotriquetral Instability
L-T ligament poorly seen on MRI
See step in midcarpal joint
L-T ligament torn, see from radiocarpal joint, especially membranous portion
Volar portion more difficult to see, may need volar portal
Lunate
Tq
L-T Lig
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Lunotriquetral Instability
Lunate
Triquetrum
Lunotriquetral Step Reduced
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Conclusion
History
Examination
Plain x-rays
Result in accurate diagnosis in most cases
Arthroscopy good addition to armamentarium and therapeutic
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Thank You