Wrist Trauma/Injuries/Pain Slac

Hand and Upper Extremity Center
of Northeast Wisconsin, Ltd.
Upper Extremity Care
in an Aging Population
Symposium
February 24, 2012
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Objectives
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Wrist Injuries/Pain
Anatomy
History/Evaluation
Late effects
Complexities
by
Jon J. Cherney, M.D.
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Fractures of the Distal
Radius
Wrist Fractures
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Anatomy
Anatomy
• Angular alignment
• Ulnar head anatomy
– Radial inclination - 20 degrees
– Volar tilt - 12 degrees
– Radial length, +/- 2 mm
– Largely covered by articular cartilage
– Cylindrical shape
– Ulnar styloid
• Dorsal and volar radioulnar
ligaments insert at base
– Ulnar Groove
• Dorsal to ulnar styloid
• Extensor carpi ulnaris resides in groove
Essentials of Hand Surgery 2002
Courtesy of Craig S. Williams, MD
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Ligamentous Anatomy
Ligamentous Anatomy
• Volar ligament complex
• Dorsal ligament complex
– Dorsal radiocarpal
ligament
(radius->triquetrum)
– Dorsal intercarpal
ligament
(triquetrum->distal
scaphoid)
• Triangular fibrocartilage
complex (TFCC)
– Volar and dorsal
radioulnar ligaments
– Articular disc
ASSH Original Artwork
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ASSH Original Artwork
Mechanism of Injury
Demographics
• Low energy
• Incidence
– Fall from standing height
– Extension mechanism
– ~15% of all extremity fractures
– Most common upper extremity fracture
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• Age range
– Low energy fractures
• More common
• Two peak age ranges
– Flexion mechanism
– 6-12 years
– > 60 years (female predominance)
» Pathologic/osteopenia
• Less common
• Fall on flexed wrist
• Dorsal cortex fails in tension
– High energy fractures
• Young adults (MVA)
• Working males (fall from height)
Primary mechanism (90%)
Land on palm with extended wrist
Tension failure through volar cortex
Fracture propagates to dorsal cortex which fails in
compression
Essentials of Hand Surgery 2002
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Evaluation
Evaluation
• Radiographic evaluation
– Standard AP and lateral radiographs
– Oblique radiographs
• Clinical examination
– Motor and sensory evaluation of median,
ulnar and superficial radial nerves
• Consider acute carpal tunnel syndrome for
severely displaced fractures
– Evaluate for open fracture
– Evaluate vascular status
– Assess compromise of soft tissues due to
severe deformity
• Evaluate for nondisplaced fractures not
visualized on the AP and lateral views
– 20 degree lateral- evaluate lunate facet
– Computerized tomography with coronal
and sagittal reconstructions to evaluate
articular surface if needed
Courtesy of Craig S. Williams, MD
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Principles of Treatment
Principles of Treatment
• Radiographic Goals
– Intra-articular step-off(B) /gap(A)
• Goals
– For given severity of fracture, the general
functional outcome correlates with
maintenance/restoration of normal distal
radial morphology
– Physiologic age significant factor in the
above
– Digital stiffness correlates with poor
functional outcome
• Restoration of articular congruity <= 2 mm
• Significant (>2 mm) stepoff ->radiographic
evidence of post-traumatic arthritis
B
A
(Knirk and Jupiter, JBJS 1986)
– Radial length(C) within
2 mm of normal
– Dorsal tilt, neutral to
no more than 10 º
C
• Note capitolunate angle
Essentials of Hand Surgery 2002
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Principles of Treatment
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Treatment Recommendations
• Distal radioulnar joint (DRUJ)
• Must be individualized
– Congruity
– Stability
– Physiologic age
– Individual needs
– Medical co-morbidities
• Radiographic? Reduced on
true lateral
• Clinical assessment
• Primary decision – non-operative
vs. operative treatment
Courtesy of Craig S. Williams, MD
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Specific Treatment
Recommendations
Specific Treatment
Recommendations
• Non-displaced fractures
• Non-displaced fractures
– Immobilization
– ? early active range of motion at 4 weeks
• Short arm cast
• Well-molded thermoplastic splint or bivalve
splint
• Off-the-shelf splint
• Reliable patient
– Follow up 7 to 10 days after initiation of
treatment to check for displacement
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– Wean/discontinue immobilization after
6 weeks
– Occupational therapy occasionally
necessary
– Risk of EPL rupture
• Rare
• Occurs late (beyond 6 weeks)
Specific Treatment
Recommendations
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Specific Treatment
Recommendations
• Displaced fractures
• Displaced fractures
– Post reduction radiographs
– Attempt closed reduction
• Remain acceptable
• Hematoma block
• +/- IV sedation
– Follow up at 6 weeks
» Removable splint/ instruct in gentle ROM
– Follow up at 8 weeks - evaluate need for therapy
– 6 months to maximum range of motion and strength
– Up to 1 year maximum subjective improvement
– Initial splint or cast
• Plaster or fiberglass
• Long arm or short arm
– Position of rotation: arguments for pronation,
neutral and supination exist
• Are unacceptable identified at 0, 1, 2, or 3 weeks
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– Usually recommend change to operative treatment
– May consider re-reduction in first one to two weeks
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Operative Treatment
Operative Treatment
• Closed reduction and percutaneous pinning (CR/PP)
– Indications
• Isolated radial styloid fracture
• Minimal comminution
– Intrafocal vs. extrafocal pinning
• Intrafocal- pins placed in fracture
site and act like buttress pins
• Extrafocal- pins used to pin
fragment(s) to proximal
unfractured metaphysis
– Oscillating driver
– Requires supplemental casting
– Pins removed in office @ 6 weeks
– Rehab similar to closed treatment
• Options
– Closed reduction and percutaneous pinning
(CR/PP)
– External fixation (ExFix)
– Arthroscopically assisted reduction
– Open reduction internal fixation (ORIF)
• Dorsal approach/ plate
• Volar approach/ plate
• Fragment specific fixation
– Combination of above
– Bone graft/ bone graft substitute
Courtesy of Craig S. Williams, MD
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Operative Treatment
Operative Treatment
• External fixation (ExFix)
– Indications
• Arthroscopically assisted articular
reduction
• Displaced fractures
• Comminution
• Able to achieve satisfactory reduction
via closed or percutaneous means
– May be used to evaluate/ manipulate
articular surface in conjunction with
– Stabilize fracture via ligamentotaxis
• May be supplemented with percutaneous
pinning or limited internal fixation
• Percutaneous Pinning with or without
External Fixation
• Limited open procedures
– Fixator may be used as a
neutralization device
• Must be supplemented with
percutaneous pinning
or limited internal fixation
– Best done within the first few weeks
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Courtesy of Craig S. Williams, MD
Operative Treatment
Operative Treatment
• Fragment specific fixation
• Volar buttress plate
– Uses plate to support fractures
of volar margin of distal radius
• Relies on solid screw fixation at
uninvolved radial shaft
• Primarily indicated for partial articular
fractures of the volar rim (volar Barton)
• Screw fixation at the metaphysis
is optional and not always reliable
– Volar approach through the
FCR sheath (Henry approach)
• Consider concomitant
carpal tunnel release
– Generally excellent stability
allowing early range of motion
– Learning curve
• Somewhat steep
• Technique somewhat tedious
Courtesy of Craig S. Williams, MD
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Aftercare for Surgical
Treatment
Associated Ulnar Fractures
• Ulnar styloid
– Usually requires no specific treatment
– Basilar ulnar styloid fracture may contain
peripheral ulnar attachment of the TFCC
• Resultant distal radioulnar joint instability
• Requires fixation (screw, pin, tension band) if displaced
– Nonunion occasionally source of persistent
ulnar pain
• Ulnar head/neck
– Nondisplaced fractures may be managed in a
closed fashion
– Displaced or unstable fractures may require
ORIF
Courtesy of Craig S. Williams, MD
• Immediate range of motion of
digits/elbow/shoulder; +/- forearm
• Within 10 days (if stable) - thermoplastic
removable splint
– Except percutaneous pinning and ex-fix
– Supervised (OT) range of motion of wrist and
forearm
– Remove for hygiene
• Follow up within 10 days to repeat x-rays
• By four weeks, begin to wean from splint
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Aftercare for Surgical
Treatment
Complications
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• At six weeks, early strengthening and
discontinue splint
• Full activity at 10 to 12 weeks,
including weight-bearing
• If unstable or external fixation, then
above is delayed for six weeks
Stiffness - digits/wrist/forearm
Carpal tunnel syndrome
CRPS
Infection
Symptomatic hardware
Hardware failure
Pain
Post-traumatic arthritis
Malunion
Non-union
Courtesy of John G. Seiler, MD
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Scaphoid Fractures
Fractures and Dislocations of
the Carpus
• 60-80% of carpal fractures
• Waist fractures
– Requires twice the force needed to cause a
distal radius fracture
Common in
– Athletes
– Males
– Motor vehicle accidents
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Imaging
Examination
• Non-displaced
fractures frequently
missed on initial
radiographs
• Scaphoid normally
rests in 45o of flexion
relative to the radius
• Result: a fracture
may not be visible if it
rests in a plane
oblique to beam of
radiograph
• Wrist swelling
• Tender snuff box
• Tender dorsal
scaphoid
• Tender scaphoid
tubercle
Courtesy of Mark E. Baratz, MD
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Courtesy of Mark E. Baratz, MD
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“Occult” scaphoid fracture
Scaphoid Oblique
• Posteroanterior (PA) view with wrist in
ulnar deviation and the beam angled
20o distal to proximal
• Will often show fractures not seen on
PA or lateral view
Courtesy of Mark E. Baratz, MD
PA view
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Other imaging tools
Scaphoid Oblique
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Non-operative treatment with cast
• Bone scan
– Sensitive, not specific
• Wrist position
• CT scan
(Jupiter et al. AAOS ICL #50,
2001)
– Take in plane of scaphoid
– Sensitive, defines comminution and
angulation of the fractured scaphoid
– Excellent to assess healing
– Palmar flexion and radial deviation
• Reduces the gap, but may lead to collapse
– Ulnar deviation
• MR
• Helps reduction; may cause distraction
– Sensitive, defines vascularity of
proximal pole
– Neutral position: just right.
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Consider long arm cast for 6 weeks
followed by short arm cast until
healed for:
• Patient
• Smoker
• Poor compliance
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Duration of immobilization
• Distal pole: 4 to 6 wks
• Waist fracture: 6 to 8 weeks
• Proximal pole: 6 weeks to 4 months
• Fracture
• All proximal pole
• Waist fracture “at risk”
• Comminution
• Oblique
• Fracture separation
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Surgical Treatment for Scaphoid
Fractures
Some surgeons consider surgical
treatment for the “at risk”
fracture to avoid the morbidity of
prolonged immobilization.
• Questions to answer
– Is it fresh?
– Is it displaced?
– Is there arthritis?
Some surgeons consider surgery
for all fractures to minimize the
duration of immobilization
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Wrist dislocations with fracture
Techniques
• Percutaneous or limited open
• Open reduction & fixation
• Vascularized bone grafts
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Courtesy of Mark E. Baratz, MD
Priorities
Initial Treatment
• Median nerve
• Skin
• Associated carpal injuries
• Attempt closed reduction
– Yes… when there is nerve compromise or
gross deformity of the wrist
• Open surgical reduction
– Required for most wrist dislocations and
fracture dislocations
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Surgical Approach
• Dorsal
• Combined
Support for both. Either can be done in
the absence of acute carpal tunnel
syndrome
Pre-reduction
Post-reduction; no smile on PA, scaphoid
broken, can’t draw line on lateral
Courtesy of Mark E. Baratz, MD
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Post-operative Care
• Cast for 8 weeks
• Splint for 4 weeks; allow intermittent
motion out of splint
• Pins out at 12 weeks
Courtesy of Mark E. Baratz, MD
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Expected Outcome
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Scaphoid heals
Carpal position maintained
Wrist stiffness
Midcarpal arthritis (about 50%)
Note restoration of
“smile”, rhomboidshaped lunate
Courtesy of Mark E. Baratz, MD
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SLAC
Scapholunate Ligament
Injuries
• Scaphoid palmar
flexes-shifts forces
to the dorsum of
the radius
In 1984, Watson
and Ballet
described the
inexorable
degenerative nature
of SL injury and
coined the term
SLAC wrist
Courtesy of Leon S. Benson, MD
Courtesy of Leon S. Benson, MD
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Open SL Repair with
Capsulodesis and Pinning
Indications
SLAC
• Lunate dorsiflexesCapitate flexes and
incongruous
midcarpal joint
Acute injury - less than 3mo
T.R.
Courtesy of Leon S. Benson, MD
Courtesy of Leon S. Benson, MD
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ACUTE TEARS
• Repair
SALVAGE
+/- Internal fixation
+/- Capsular reinforcement
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Treatment of SLAC Wrist
Treatment of SLAC Wrist
Excise the
scaphoid and
allow the lunate to
articulate with the
radius; need to
stabilize the
lunate, so fuse it
to the capitate
Proximal Row
Carpectomy-Allows
the Capitate to
articulate with the
radius
Courtesy of Leon S. Benson, MD
Courtesy of Leon S. Benson, MD
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Wrist Arthritis
• Radiocarpal – Intercarpal arthritis
– Sequela of trauma
WRIST ARTHRITIS
• Distal radius fractures
• Scaphoid fractures
• Intercarpal – radiocarpal dislocation
– Scapholunate advanced collapse (SLAC) wrist
• Scaphoid – Trapezium – Trapezoid arthritis
• Primary osteoarthritis
– uncommon
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Scapholunate Advanced
Collapse (SLAC) Wrist
• Progressive condition
• Begins with incompetence of the
scapholunate interosseous ligament
• Follows a predictable radiographic
pattern
• Radioscaphoid arthritis followed by
capitolunate arthritis
Scapholunate Advanced
Collapse (SLAC) Wrist
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Scapholunate Advanced
Collapse (SLAC) Wrist
Scapholunate Advanced
Collapse (SLAC) Wrist
• Symptoms
– Activity related pain
– Loss of motion
– Dorsoradial wrist pain
• Clinical findings
– Dorsoradial tenderness
– Scaphoid shift test
SLAC wrist with scapholunate widening and radioscaphoid arthritis
Courtesy of Donald H. Lee, MD
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Scapholunate Advanced
Collapse (SLAC) Wrist
Scapholunate Advanced
Collapse (SLAC) Wrist
• Surgical options
• Non-operative treatment
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– SLAC wrist reconstruction
Wrist splints
NSAIDs
Activity modification
Injections
• Scaphoid excision with capitate-lunatehamate-triquetrum fusion (4 corner fusion)
– Proximal row carpectomy
– Wrist arthrodesis
– Wrist arthroplasty
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SLAC Wrist Reconstruction
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SLAC Wrist Reconstruction
Scaphoid excision with fusion of
capitate-lunate-hamate-triquetrum
Post-operative radiographs
Courtesy of Donald H. Lee, MD
Courtesy of Donald H. Lee, MD
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Proximal Row Carpectomy
Proximal Row Carpectomy
• Indications
– Radiocarpal arthrosis
– Arthrosis with deformity or malalignment of
proximal carpus
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Kienböck’s disease
Chronic scapholunate dissociation
Failed silicone implants
Scaphoid nonunion
• Requirements
– Normal articular surface of proximal pole of
capitate and lunate fossa of the distal radius
– Preservation of radioscaphocapitate ligament
Excision of scaphoid, lunate, and triquetrum with
preservation of the radioscaphocapitate ligament (arrow)
Courtesy of Donald H. Lee, MD
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Wrist Arthrodesis
Wrist Arthrodesis
• Indications
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Post-traumatic arthrosis
Failed previous limited wrist fusion
Failed arthroplasty
Paralysis
Reconstruction
• Tumor
• Infection
– Spastic hemiplegia
– Rheumatoid arthritis
Specialized plate used for wrist arthrodesis
Courtesy of Donald H. Lee, MD
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Scaphoid Nonunion with
Wrist Arthritis
Wrist Arthrodesis
Intraoperative view
Pre-operative radiographs of
patient with scaphoid nonunion
Wrist fusion with dorsal plate
Courtesy of Donald H. Lee, MD
Courtesy of Donald H. Lee, MD
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Wrist Arthrodesis
Scaphoid – Trapezium
– Trapezoid Arthritis
Post-operative radiographs
Courtesy of Donald H. Lee, MD
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Scaphoid – Trapezium –
Trapezoid Arthritis
Scaphoid – Trapezium –
Trapezoid Arthritis
• Surgical indications
• Clinical findings
– Pain refractory to nonoperative treatment
– Advanced arthritis
– Radial sided wrist /
hand pain
– Activity related
• Non-operative
treatment
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• Surgical options
– Scaphotrapeziotrapezoid
(STT) arthrodesis
– Trapezium excision,
interposition
arthroplasty
Wrist splints
NSAIDs
Activity modification
Injections
Courtesy of Donald H. Lee, MD
Courtesy of Donald H. Lee, MD
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Goals
• To discuss the anatomy of the TFCC
complex
• To review the assessment of patients
who may have a TFCC tear
• To review the types of TFCC tears
• To discuss treatment alternatives for
TFCC tears
Triangular Fibrocartilage
Tears
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Anatomy – TFCC
Vascularity of TFCC
• Components
– Articular disc
(triangular fibrocartilage[TFC])
– Volar radial ulnar ligament
– Dorsal radial ulnar ligament
– Meniscal homologue
– Ulnolunate ligament
– Ulnotriquetral ligament
– Subsheath of extensor carpi ulnaris
(ECU)
• Peripheral margins
well-vascularized
• Central articular disc
and radial attachment
are avascular
Courtesy of Michael S. Bednar, MD
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Courtesy of Craig S. Williams, MD
Function of components of TFCC
Function of components of TFCC
• Articular disc (TFC)
– Transmits load between ulnar carpus and
ulnar head
– Normally ~ 20% carpal load
• Volar ulnocarpal ligaments and ECU
subsheath
• Volar RUL
– Stabilize ulnar carpus relative to ulna
– Resists carpal supination relative to ulna
– Stabilizes DRUJ
– Tightens in supination
– Resists volar subluxation of ulna (relative to
radius)
• Dorsal RUL
– Stabilizes DRUJ
– Tightens in pronation
– Resists dorsal subluxation of ulna (relative to
radius)
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Injuries to the TFCC
Injuries to the TFCC
• Mechanisms for acute injury
• Classification possible by
– Structure involved
• Articular disc most common
– Acute direct injury versus attritional tear
– Presentation – acute, subacute, or
chronic
– Primary injury to TFCC or secondary
(e.g.- secondary to malunion of distal
radius fracture)
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– Fall – extension, axial load, pronation
– Forced rotation relative to forearm –
machinery
– Associated with distal radius fracture
• Chronic injuries
– Repetitive loading of wrist in ulnar
deviation
– Attritional
– Progressive wearing of TFC, ulnar carpus,
ulnar head
– More likely with positive ulnar variance 90
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Clinical Presentation
Clinical presentation
• Examination
• Frequently presentation is weeks to
months after injury
• Common presenting symptoms:
– Ulnar-sided wrist pain
– Pain increased with rotational activities
and/or ulnar deviation activities
– Pain when lifting or carrying in supinated
position
– Ulnar swelling or prominence of ulnar
head
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– Ulnar-sided wrist click
– Negative exam radial aspect of wrist
(unless concomitant radial pathology)
– Lunotriquetral shuck/ tenderness negative
(unless LT also involved)
– Mild ulnar swelling
– +/- ECU tenderness
– Reproduction of pain with
manual pressure in soft
spot bordered by
• ECU
• FCU
• Ulnar styloid
• Triquetrum
Courtesy of Craig S. Williams, MD
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Clinical presentation
Imaging for TFCC Tears
• Examination
– Ulnar impaction sign
• Forced ulnar deviation
of wrist by examiner in
attempt to produce contact
between lunate and ulnar
head/TFCC
– Ulnar grind
– Evaluate stability of DRUJ
• Neutral
• Pronation
• Supination
• Compare to asymptomatic side
– “Piano key” sign – indicative of dorsal DRUJ
subluxation
Courtesy of Craig S. Williams, MD
• Plain radiographs
– 90/ 90 PA view
• Neutral forearm rotation
• Shoulder abducted at 90°
• Elbow flexed 90°
• Palm flat on cassette
– True lateral view
• Evaluate for dorsal subluxation of ulna
Courtesy of Craig S. Williams, MD
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Imaging for TFCC Tears
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Imaging for TFCC tears
• Plain radiographs
• MRI
– Determine ulnar variance
(=A- B)
– Ability to evaluate/visualize TFCC varies
– Depends upon technique
• Radiographic measure of
relative length of ulnar
head (B) relative to ulnar
margin of lunate facet of
distal radius(A)
• Magnet strength
• Use of wrist coil
• Sequences utilized
– Evaluate lunate for
cystic changes at
proximal ulnar aspect
Bottom Left Image: Courtesy of Craig S. Williams, MD
Top Right Image: Essentials of Hand Surgery 2002
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– Depends upon experience
of radiologist interpreting study
– May be greatly enhanced with
use of pre-MRI arthrogram
(gadolinium) of RC joint
– Bony signal changes (edema) may
be seen at proximal ulnar aspect
of lunate with impaction syndrome
Courtesy of Craig S. Williams, MD
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Imaging for TFCC tears
General Treatment Pathway
• CT scan may be combined with
arthrography to better demonstrate
site of TFCC tear
• History and Physical Examination
• Diagnostic Imaging
• Non Surgical Treatment
– May be utilized to demonstrate DRUJ
subluxation
– Image abnormal and normal wrists
simultaneously in pronation, neutral, and
supination
• Bone scan not frequently utilized
– May show increased uptake in face of
impaction syndrome
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Diagnosis
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Immobilization
NSAID
OT for modalities
Corticosteroid injection
• Surgical Treatment
– Usually reserved for patients with symptomatic
TFCC tears that are confirmed by diagnostic
imaging & are refractory to non-surgical
treatment
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Diagnosis
• DRUJ instability after subluxation or
dislocation
• DRUJ
instability/subluxation/dislocation
– Indicative of significant injury to V
and/or D RUL and DRUJ capsule
– Acute dislocation may be amenable to
treatment with:
– Late instability/ subluxation
• If no DRUJ arthritis
• Reduction
• Immobilization in long arm cast in position of
maximum stability x 6 weeks
– Usually will require open
reconstruction/stabilization of DRUJ
– Requires use of tendon graft
– Challenging problem
• DRUJ arthritis ->salvage procedure
– Darrach procedure
– Sauve-Kapandji procedure
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Diagnosis
• TFCC tear
– History consistent with ulnar-sided wrist
pain
– Exam consistent with TFCC
tear/pathology
– Confirmatory imaging studies
– Asymptomatic TFCC perforation
• ~ 30% incidence beyond third decade
• Increases with advancing age
• Radiographic findings must be correlated with
clinical symptoms and examination
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TFCC Tears
• Traumatic
• Attritional
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TFCC Tear
• Peripheral: May be repairable
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TFCC Tear
• Central:
Debride +/- ulnar recession
WAFER
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Ulnar Shortening
Osteotomy
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THANK YOU
Causation
• Fracture—easy
• SLAC—?
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References
References
• Lauder, Anthony J., M.D., Hanel, Douglas P., M.D.,
Trumble, Thomas E., M.D.: “The Ulnar Shortening
Osteotomy,” Wrist and Elbow Reconstruction and
Arthroscopy, 2006, ASSH, p. 96.
• Waitayawinyu, Thanapong, M.D., Lauder, Anthony
J., M.D., Trumble, Thomas E., M.D.: “Arthroscopic
Repair of the Triangular Fibrocartilage Complex
(TFCC),” Wrist and Elbow Reconstruction and
Arthroscopy, 2006, ASSH, pp. 62 & 67.
• Nagle, Daniel J., M.D.: “Degenerative Triangular
Fibrocartilage Complex Tears; Ulnar Abutment
Syndrome,” Wrist and Elbow Reconstruction and
Arthroscopy, 2006, ASSH, p. 53.
• Williams, Craig S., M.D.: “Triangular Fibrocartilage
Tears,” Crucial Elements in Hand Surgery, ASSH,
edited by John Gray Seiler,III,M.D.
113
• Williams, Craig S., M.D.: “Fracture of the Distal
Radius,” Crucial Elements in Hand Surgery, ASSH,
edited by John Gray Seiler,III,M.D.
• Baratz, Mark E., M.D.: “Fracture and Dislocations
of the Carpus,” Crucial Elements in Hand Surgery,
ASSH, edited by John Gray Seiler, III, M.D.
• Lee, Donald H., M.D.: “Arthritis of the Wrist,”
Crucial Elements in Hand Surgery, ASSH, edited
by John Gray Seiler, III, M.D.
• Ruch, David S., M.D.: “Chronic Intercarpal
Instability,” Crucial Elements in Hand Surgery,
ASSH, edited by John Gray Seiler,III,M.D.
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