Triangular Fibro Cartilage Complex

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Triangular Fibro Cartilage Complex

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The triangular fibrocartilagenous complex is a key element in the stability and force transmission across wrist joint. Introduction It is considered by some as the new frontier in wrist surgery.

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TFC is a Fibro cartilaginous disk that has its origin on the distal radius and insertion at the base of ulnar styloid. Anatomy

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Zones of Triangular Fibrocartilage There are 4 Zones Radial Attachment Zone Central Cartilagenous Zone Ulnar Attachment Zone near ulnar styloid Palmer Attachment Zone

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Vascular Supply of TFC

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The blood supply is greatest at the periphery of the cartilage. Base of styloid area is richly supplied. The vascular ring around the cartilage is incomplete because the Radial Border is Avascular. The inner portion of TFC is devoid of Vessels

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History Wrist pain Loss of strength Painful rotation of the Distal Radial Ulnar Joint History of injury to wrist (hyperpronation) Sensation of catching and snapping of the wrist Clinical Presentation

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Palpation Tenderness at the base of ulnar styloid or ulnar collateral Stress loading the DRUJ at the extreme of pronation and supination, pain expressed at these positions is pathognomic of a TFC injury The Piano Key Sign - Dorsal palmar ballottement of distal ulna.

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The Piano Key Sign

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X-Ray examination – Positive ulnar variance Ulna – carpal abbuttment Arthritis of DRUJ Ulnar styloid avulsion # Arthrogram of Wrist Less reliable in age >40 yrs Positive for peripheral TFC tear MRI of wrist joint Diagnostic Examinations

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Diagnostic Test Trampoline test for resilience of ligament It provides excellent view of internal derangements Wrist Arthroscopy

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Trampoline test

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Classification of Disorders of the Distal Radioulnar Joint And Triangular Fibrocartilage Complex BY BOWERS Fractures – acute Radioulnar Joint Surface # Styloid # Joint Disruption – acute Isolated Dislocation TFC injury with partial dislocation Disruption associated with other injuries Joint Disruption - chronic CLASSIFICATION

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Joint Disorders Length Discrepancies of Ulna Arthritis Triangular Fibro cartilage tears, perforations and attritional changes. Joint Area Problems Extensor Carpi ulnaris subluxation or dislocation Ulnocarpal problems Note :- Group 2B and 4C are associated with TFC injury

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Traumatic Tear Central tear (within the cartilage may be horizontal, vertical, stellate) Medial ( it is an avulsion tear from the base of the ulnar styloid) Distal ( tear of palmar third of the TFC involving ulnocarpal ligaments) Lateral (Radial avulsion of TFC usually associated with # distal radius) Classification of TFC Injury by PALMER

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Degenerative Tear TFC Wear TFC wear and chondromalacia TFC perforation and chondromalacia TFC perforation + chondromalacia + lunotriquetral ligament tear TFC perforation + ulnocarpal arthritis

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Traumatic Tear (types) Radial Rim (detachment) Central Ulnar (similar to ulnar styloid #) Palmer Degenerative tear Central tear Central tear, ulnocarpal impingement Central tear, lunotriquetral impingement Central tear, lunotriquetral athritis Mayo Classification of TFC Tear

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Acute Traumatic Tear of TFC If there is displacement of the Ulnar Styloid of 3-4mm or more or associated with # base of ulnar styloid then CRIF with pin or open reduction should be done. Isolated TFC Tears – acute tear Isolated traumatic disruption of the DRUJ can involve a significant tear of the TFC treatment is CR and pinning in full supination or OR and repair. Repair is by reattaching all peripheral tears with mersilene or dacron Treatment

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Open Repair of TFC All central lesion should be repaired Palmarly and ulnar lesions are accessible for repair Radial lesion is controvertial becoz blood supply to the TFC radially is meager compared with other peripheral injuries.

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Open repair of TFC Radial lesion If lesion is more towards the central cartilagenous portion of the TFC in the “area of debridement” then excision of TFC is method of treatment. If lesion is peripheral then open repair of the radial margin of the TFC back to the distal radius for radial rim tear. Although this area is avscular compared with other peripheral attachments.

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Open Repair of TFC Ulnar lesions Recommended for all peripheral tears from ulnar styloid. Procedure Dorsal ulnar incision 6 cm in length centered over distal ulna. Divide and reflect extensor retinaculum between fifth and sixth extensor retinaculum. The ulnar styloid region is exposed

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Ulnocarpal joint is entered with transeverse incision parallel to TFC. TFC is mobilised from radial to ulnar direction with blunt dissection TFC is reattached to ulnar styloid with mattrice sutures.

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Bone Avulsion injury (Reattachment of Ulnar Styloid) If displaced more than 2-3mm repair is recommended. Procedure Ulnar incision 2 cm long centered over distal ulna. The dorsal branch of ulnar nerve is protected. Ulnar avulsion site is exposed and bone ends freshened 2 k-wires inserted retrogradely through ulnar styloid. TBW is inserted through TFC attachment and through proximal ulna at head neck jn. and tightened. TBW can be retained or removed if wire is firmly attached.

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Open Repair of Palmer Tears Least common tear due to trauma Palmar TFC tear are related to injuries of the ulnolunate and ulnotriquetral ligaments and can have ulnocarpal disruptions. For maximum exposure an ulnar ostetomy is performed, derotating the ulna and releasing the Extensor Carpi Ulnaris Sheath. Repair is performed with mattress sutures.

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Traumatic Tear Place operative scope in dorsal 3-4 position Place examining scope in dorsal 4-5 position If central tear – simple exision of loose end is done If radial or ulnar tear repair is done arthroscolpically. Arthroscopic Repair

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Degenerative Tear Debridement is necessary before definitive procedure. With chronic degenerative tear the edges of the TFC are cleaned up with suction punch and when necessary the central 3-4mm of the TFC is excised. If ulnocarpal abutment excision of the head of ulna can be performed. Resection of 2mm of the ulna by any technique changes the loadbearing characteristics of the wrist.

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The Wrist are immobilized for 4 weeks with 2.0mm K-wire. After that, a rehabilitation program including wrist motion and occupational therapy is started. Post Operative Care

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Thank You

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