5 0
When a patient presents with ulnar-sided wrist pain, the history and physical exam may prompt conservative treatment initially, un- less symptoms are chronic. Because the diagnostic ac- curacy of wrist arthroscopy exceeds that of either MR imaging or triple-phase arthrography,1,2 many clini- cians may justifiably recommend arthroscopy when a triangular fibrocartilage complex (TFCC) or inter- carpal ligament tear is suspected, avoiding these stud- ies completely. Indeed, wrist arthroscopy allows not only diagnosis but also minimally invasive treatment of internal derangement of the wrist.
Whether a TFCC tear is repaired or debrided, and whether concomitant ulnar shortening needs to be performed depends upon its location and blood sup- ply, its chronicity, the ulnar variance, and the arthro- scopic skills of the surgeon. This chapter will address these issues as they pertain to the diagnosis and man- agement of Palmer Type C TFCC tears.3Palmer’s clas- sification of TFCC lesions divides tears into traumatic (Type I) and degenerative (Type II) tears, and each type is further subdivided based on the details of the ana- tomic lesion (Figure 8.1).
PREOPERATIVE PLANNING
Diagnosis
Traumatic and degenerative TFCC tears may be in- distinguishable in terms of the symptoms they elicit.
Both result in ulnar wrist pain, particularly with ac- tivities that load the wrist during pronation and supination. The pain may also be accompanied by a sensation of catching or snapping in the wrist. It would seem, therefore, that Palmer’s classification highlights differences in the etiologies of these two types of tears, rather than differences in symptoms. Indeed, Type I lesions are more apt to follow a fall on an outstretched hand, or an abrupt load to the pronated and/or ulnarly deviated wrist. By contrast, the history for Type II le- sions may be more insidious and chronic, without any history of a traumatic precipitant.
Physical examination is the most valuable method of evaluating a suspected TFCC tear. When a com-
plaint of ulnar wrist pain exists, other causes should first be excluded, such as extensor carpi ulnaris tenosynovitis or subluxation, isolated lunotriquetral ligament strain or disruption, pisotriquetral arthritis, and ulnar styloid–carpal impaction. Exclusion of these potential diagnoses is relatively easy by means of a careful exam and the selective injection of lidocaine when necessary. The two most valuable and sensitive tests include Nakamura’s ulnocarpal stress test4 and Berger’s fovea test. Nakamura’s test is performed by passively pronating and supinating the wrist while it is axially loaded and ulnarly deviated. While it may not differentiate between a traumatic, degenerative TFCC tear, or an LT tear, this test is sufficiently sen- sitive to warrant further evaluation by arthroscopy if crepitus is palpated. The fovea test is performed by palpating the volar aspect of the TFCC between the flexor carpi ulnaris (FCU) tendon volarly, and the ul- nar styloid process dorsally. The presence of tender- ness suggests a lesion of the ulnocarpal ligaments.5
Radiographic assessment includes the use of neu- tral rotation6and pronated grip radiographs.7,8These will allow assessment of both static and dynamic ul- nar variance. If physical examination suggests a TFCC lesion, MR imaging is not required preoperatively, since wrist arthroscopy is more sensitive and allows concomitant treatment as well. But, if one is con- cerned that the potential lesion is degenerative—con- sistent with ulnar impaction syndrome (a Type II tear)—an MRI may be helpful in showing marrow edema in the ulnar corner of the lunate.9In cases where a TFCC perforation is not present but exam and MR imaging suggest ulnar impaction (Type II A and B le- sions), an ulnar recession procedure may be indicated nevertheless.10–14The availability and scope of MR im- aging, when further preoperative workup is felt to be necessary, has significantly decreased the indications for either bone scintigraphy or wrist arthrography.
Biomechanical Considerations
Both traumatic and degenerative TFCC lesions de- velop because of similar biomechanical alterations. In- deed, an increase in ulnar variance results in an in-
crease in load transfer across the ulnocarpal joint.15 Whether as a result of a fall or the impact, over time, of the combination of forearm pronation and forceful grip, the TFCC either acutely tears or gradually at- tenuates and perforates because of its role in load transfer. And even though Type II tears occur most commonly in ulnar-positive wrists,10,11“dynamic” in- creases in variance which accompany forceful grip7,8,12 explain why ulnar impaction syndrome may also de- velop in wrists with neutral and negative ulnar vari- ance,13,14and why pain relief following debridement alone for Type I tears is not always satisfactory.16–19
Incomplete pain relief has been reported following TFCC debridement alone in as many as 25% of wrists, regardless of whether the tear is posttraumatic or de- generative, but only recently have the potential im- plications of positive ulnar variance been consid- ered.8,16–19 In 1996, Minami et al. were the first to report that positive ulnar variance was associated with poor outcome following TFCC debridement alone.19 They measured ulnar variance with the forearm in pronation to mimic the dynamic increases in ulnar variance that might accompany functional activity.
Their suggestion that persistent pain was related to positive ulnar variance was consistent with two other reports that showed the efficacy of combining ulnar shortening with TFCC repair to improve pain re- lief.20,21 Similarly, Hulsizer et al. reported that ulnar shortening provided successful treatment of persistent ulnar wrist pain following TFCC debridement,22 and most recently, Minimi and Kato reported successful treatment of TFCC tears associated with positive ul- nar variance using ulnar shortening osteotomy alone.23 TFCC debridement alone may not provide com- plete pain relief in wrists with positive ulnar variance, regardless of whether the etiology is “traumatic” or
“degenerative.”24,25 Tomaino and Weiser prospec- tively evaluated the feasibility and efficacy of com-
bining arthroscopic TFCC debridement with an ar- throscopic “wafer procedure” as treatment for wrists in which both TFCC disruption and positive ulnar variance coexisted.26Seven Type I and 5 Type II tears were treated, and all patients reported satisfactory res- olution of preoperative pain.
Therefore, whether the a TFCC lesion is classified as Type I or Type II may have more to do with etiol- ogy than with management. The management of Type C lesions will be discussed in the following section.
SURGICAL MANAGEMENT
A standard arthroscopic setup is used, and 10 to 12 pounds of traction are administered via index and long finger traps. A 2.7 mm arthroscope is used. Initially the 3-4 and 6-R portals are made, and occasionally a 4-5 portal is added. An 18-gauge needle attached to plastic IV tubing is placed in the radial styloid–
scaphoid joint for outflow. Debridement is typically performed using a combination of a motorized shaver and the Mini-VAPR device (Mitek, Westwood, MA).
A 2 mm burr is used to perform a wafer resection of the ulnar head when indicated.
Type IC Lesions
It is unusual to see a frank avulsion of the ulnocarpal ligaments from the carpus. Rather, partial fraying is identified—often at the junction with the volar rim of the articular disk (Figure 8.2). Thus, debridement is performed to remove any unstable ligamentous flaps both to prevent impingement, a mechanical source of pain, and to remove a potential source of pain- mediating cytokines.
Although simple debridement is likely to be ef- fective, particularly since the mechanical integrity of
A B
FIGURE 8.1. Illustration of a Type IC and IIC TFCC lesion. A. A Type IC lesion involves the volar ulnocarpal ligaments (ulnolunate and/or ulnotriquetral), which extend from the carpus to the volar rim (volar radioulnar ligament) of the articular disk of the TFCC. B. A Type IIC lesion involves a perforation of the articular disk of the TFCC with chondromalacia of the ulnar head or lunate.
the TFCC and its role in stabilizing the distal ulna is not typically compromised, repair of Type IC tears has also been described.27The authors emphasize the im- portance of identifying and protecting the ulnar nerve.
It is worth noting that fraying of the ulnocarpal liga- ments may reflect a chronic LT ligament disruption.28 Zachee et al. found 10 Type IC tears in their series of 40 wrist arthroscopies, and complete LT disruption was confirmed on midcarpal arthroscopy in 9. They rightly acknowledge that the ulnocarpal ligaments are placed under tension following LT rupture and theo- rize that this portion of the TFCC may serve as a sec- ondary restraint after LT injury. Indeed, the LT liga- ment should be assessed during the routine wrist arthroscopic exam when any lesion of the TFCC is suspected.
pingement on the triquetrum causes hyperemia, loss of articular cartilage, and softening of the bone. Sur- gical treatment consists of simply excising the im- pinging fibrous cuff.
Type IIC Lesions
Minami has emphasized that debridement of degen- erative Type IIC tears alone may not provide satisfac- tory pain relief—presumably because of ulnar im- paction. If either static or dynamic variance is positive, and a central perforation of the TFCC is identified, treatment should include either an ulnar shortening osteotomy,10,11an open wafer procedure,14,30,31or my current preference, a combined arthroscopic TFCC de- bridement and wafer procedure.26
I always excise enough of the articular disk to fa- cilitate exposure but never violate the volar or dor- sal radioulnar ligaments or the TFCC insertion at the base of the styloid (Figure 8.3). The Mini-VAPR device (Mitek, Westwood, MA) facilitates debride- ment, and cartilage of the ulnar head and subchon- dral bone are removed with a 2 mm bur. Knowing ahead of time that the diameter of the bur is 2 mm, I recess the radial portion of the ulnar head first to approximately the width of the bur beneath the top of the sigmoid notch. The bur is then moved more ulnarly toward the base of the styloid. Most of the resection can be performed with the scope in the 3- 4 portal and the bur in the 6-R. With the hand main- tained within the traction apparatus, passive fore- arm pronation provides exposure of that portion of the ulnar head that is most prominent during prona- tion. Completion of the wafer resection usually re- quires visualization through the 6-R portal to ensure that the ulnar recession is 2 mm beneath the carti- lage of the lunate fossa with the wrist in neutral rotation all the way from dorsal to volar. Visualiza- tion through the 3-4 portal ensures adequate resec- tion ulnarly to the base of the styloid. I use the tip of an arthroscopic probe, which measures 2 mm, to assess the extent of resection. Neither intraopera- tive X-ray nor fluoroscopy is used during the surgi- cal procedure. Postoperatively, X-rays often seem to A
FIGURE 8.2. Type IC TFCC lesion. A. Type IC tear (ulnocarpal ligament fraying) is identified by the black arrow. B. The flap has been debrided.
B
exaggerate the magnitude of the recession as com- pared to the intraoperative assessment (Figure 8.3).
CONCLUSION
Though the Palmer classification of TFCC tears has added tremendous value in terms of grouping lesions into traumatic and degenerative categories, it is im- portant to remember that it is more useful in terms of differentiating etiology than in designating distinct treatment recommendations. Both Type I and Type II tears may reflect the biomechanical effects of in- creased ulnar variance, and both, in that light, may re- quire more than simple debridement. Careful exami- nation and the use of preoperative MR imaging and
fastidious diagnostic use of the arthroscope may re- veal whether an element of ulnar impaction exists and, for that matter, whether other pathology, such as an LT tear, needs to be addressed.
For the most part, however, Type IC tears can be treated effectively with debridement alone and Type IIC tears by debridement and an arthroscopic wafer procedure.
References
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A
B
D
C E
FIGURE 8.3. Type IIC TFCC lesion. A. Black arrow shows perforation of the articular disk.
Above the needle, lunate chondro- malacia is visible. B. TFCC articu- lar disk has been debrided to ex- pose the ulnar head. C. Recession of the ulnar head has been per- formed with the assistance of manual pronation and supination, using the end of the probe as a depth gauge relative to the level of the lunate fossa. D. Preoperative pronated grip X-ray. E. Postopera- tive pronated grip X-ray. The post- operative grip X-ray may exagger- ate the magnitude of recession as compared to the intraoperative exam.
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