Introduction

• Athletic soft-tissue injuries of the wrist may be acute or degenerative in nature.

• Injuries of the TFCC are a frequent source of ulnar side wrist pain.

• Wrist arthroscopy is often employed to repair or débride TFCC tears.

• The preferred treatment of acute disruption of the scapholu-nate ligament is open repair.

• Chronic scapholunate injuries are more difficult to treat and often require a salvage procedure.

• Other wrist soft-tissue problems include tendonitis, de Quervain's disease, and intersection syndrome.

Figure 40-1 Palmer classification of triangular fibrocartilage complex (TFCC) injuries. A, Type I injuries are traumatic in nature. A type IA lesion involves a perforation near the radius. A type IB lesion is an avulsion of the TFCC from the ulnar attachment. A type IC lesion is an avulsion of the ulnar ligaments. A type ID lesion is an avulsion from the distal radius.

Figure 40-1 Palmer classification of triangular fibrocartilage complex (TFCC) injuries. A, Type I injuries are traumatic in nature. A type IA lesion involves a perforation near the radius. A type IB lesion is an avulsion of the TFCC from the ulnar attachment. A type IC lesion is an avulsion of the ulnar ligaments. A type ID lesion is an avulsion from the distal radius.

subclassified A, B, C, D, and E. Ulnar impaction syndrome is a degenerative condition usually associated with a length imbalance between the distal radius and ulna (i.e., the ulna is longer than the radius). This syndrome can present in a wide age range depending on the predisposing condition. Conditions that predispose to this syndrome include Madelung's deformity, premature closure of the radial physis secondary to trauma, naturally positive ulnar variance, malunions of distal radius fractures leading to shortening of the distal radius, or excision of the radial head with distal forearm instability (i.e., Essex-Lopresti injury). On physical examination, symptoms can be reproduced with an axial load applied to an ulnar deviated wrist and extremes of pronation and supination. A posteroanterior radiograph of the affected wrist will typically reveal a positive ulnar variance or ulnar styloid index. The ulnar styloid index is equal to the ulnar styloid length minus the ulnar variance divided by the ulnar head width. An index greater than 0.22 is considered elevated. Radiographs may also reveal sclerotic or cystic changes between the lunate and ulnar styloid. Magnetic resonance imaging of the wrist may reveal edema on the ulnar side of the lunate. This can be confused with Kienbock's disease, but findings on the ulnar aspect of the lunate are not characteristic of Kienbock's disease.

Arthroscopy may reveal a TFCC tear or a lunotriquetral ligament tear. TFCC tears secondary to degenerative change are classified according to the presence or absence of a TFCC tear and/or chondromalacia. Type IIA lesions involve wear of the horizontal portion of the TFCC without perforation. Type I IB involves wear of the TFCC plus lunate or ulna chondromalacia. Type IIC involves perforation of the TFCC and chondromala-cia. Type IID lesions are TFCC perforation, chondromalacia, and lunotriquetral ligament perforation. Type IIE lesions are the final stage of ulnar impaction syndrome including TFCC perforation, chondromalacia, lunotriquetral ligament perforation, and ulno-carpal arthritis.

Relevant Anatomy

The TFCC has three major functions: First, it is considered the primary stabilizer of the DRUJ; second, it transmits approximately 20% of the load across the wrist; and third, it supports the ulnar carpus. Palmer and Werner2 described the TFCC as the triangular fibrocartilage proper, the palmar and dorsal radioulnar ligaments, the ulna collateral ligament, the subsheath of the ECU tendon and the ulnolunate and ulnotriquetral ligaments (Fig. 40-2). Volar and dorsal branches of the anterior

Type IIA Type IIB

Type IIA Type IIB

Figure 40-1—cont'd B, A type II lesion is a degenerative lesion. A type IIA lesion is TFCC wear without perforation. A type IIB lesion involves TFCC wear and lunate or ulnar chondromalacia. A type IIC lesion involves TFCC perforation. A type IID lesion involves TFCC perforation, chondromalacia, and lunotri-quetral ligament perforation. L, lunate; R, radius; S, schaphoid; T, triquetrum; U, ulna. (From Palmer AK, Werner FW: The triangular fibrocartilage complex of the wrist—Anatomy and function. J Hand Surg [Am] 1981;6:153-162.)

Figure 40-1—cont'd B, A type II lesion is a degenerative lesion. A type IIA lesion is TFCC wear without perforation. A type IIB lesion involves TFCC wear and lunate or ulnar chondromalacia. A type IIC lesion involves TFCC perforation. A type IID lesion involves TFCC perforation, chondromalacia, and lunotri-quetral ligament perforation. L, lunate; R, radius; S, schaphoid; T, triquetrum; U, ulna. (From Palmer AK, Werner FW: The triangular fibrocartilage complex of the wrist—Anatomy and function. J Hand Surg [Am] 1981;6:153-162.)

interosseous artery supply the TFCC. The central portion of the TFCC is relatively avascular, while the peripheral portion is well vascularized. This pattern is analogous to the knee menisci and explains why central tears are debrided and peripheral tears may by repaired.

The relationship between the distal radius and distal ulna is important in the transmission of forces across the wrist. When the variance is neutral, 80% of a load will be transmitted through the radius and 20% through the ulna. A positive ulnar variance leads to increased load sharing by the ulna and the opposite is also true; decreased ulnar variance leads to decreased load sharing across the ulna. Ulnar variance is measured on a pos-teroanterior neutral rotation radiograph of the wrist and is equal to the difference between a line drawn across the lunate fossa of the distal radius and another line drawn across the top of the ulnar head.

Treatment Options

Initial treatment of acute TFCC injuries is immobilization for 6 to 8 weeks. Significant instability of the DRUJ and ECU sub luxation should be ruled out. Peripheral tears are expected to heal because of their vascularity, and central tears may become asymptomatic despite not healing. Indications for wrist arthroscopy include a proven or suspected TFCC injury with ulnar wrist symptoms that interfere with activities. Patients should have failed 3 to 4 months of conservative management including rest, immobilization, and anti-inflammatory medications.

Surgery

Wrist arthroscopy has gained a prominent role in the diagnosis and treatment of wrist disorders. It may used in the débride-ment and repair of TFCC tears, débridement of intercarpal ligament tears, visualization of scaphoid and distal radius fractures, removal of loose bodies, débridement of articular injuries, excision of ganglion cysts, radial and ulnar styloidectomy, synovec-tomy, and débridement of septic joints. The Palmer classification of TFCC injuries serves as a guide to surgical treatment. Type IA lesions, isolated central tears of the TFCC, can be treated with limited arthroscopic débridement of the tear. It has been

Figure 40-2 Anatomy of the triangular fibrocartilage complex (TFCC). Ulnolunate ligament (A); ulnotrique-tral ligament (B); palmar radioulnar ligament (C); ECU sheath (D); triangular fibrocartilage proper (E); dorsal radioulnar ligament (F). L, lunate, R, radius; S, scaphoid; T, triquetrum; U, ulna.

Figure 40-2 Anatomy of the triangular fibrocartilage complex (TFCC). Ulnolunate ligament (A); ulnotrique-tral ligament (B); palmar radioulnar ligament (C); ECU sheath (D); triangular fibrocartilage proper (E); dorsal radioulnar ligament (F). L, lunate, R, radius; S, scaphoid; T, triquetrum; U, ulna.

reported that 80% to 85% of patients have had a good result with limited debridement. Type IB lesions, a peripheral detachment from the ulnar styloid, are often diagnosed by a diagnostic arthroscopy. The pathognomic sign is the "trampoline" sign, which is the loss of the normal tautness of the TFCC when probed. Type IB lesions can be associated with ECU subluxation, which, if present, requires an open repair of the ECU sub-sheath in addition to an arthroscopic or open repair of the TFCC. In the acute setting of DRUJ instability associated with an ulnar styloid fracture, an open repair of the fracture may be required. This scenario is often associated with displaced distal radius fractures. After repair, 85% to 90% of patients have good to excellent results.3 A type IC lesion, a distal avulsion of the ulnolunate and ulnotriquetral ligaments, theoretically can be repaired because it is peripheral and well vascularized. A type ID lesion, avulsion of the TFCC from the sigmoid notch, is most commonly associated with a distal radius fracture and may be repaired by open or arthroscopic techniques. The preferred treatment for type ID lesions remains controversial.

Degenerative tears of the TFCC are related to chronic overloading of the ulnar side of the wrist. These lesions are the result of ulnar impaction. Diagnostic arthroscopy is the best method to stage the ulnar impaction lesion. The primary goal in treating ulnar impaction is unloading the ulnar head. This is usually done by an ulnar shortening procedure such as a shortening osteotomy, partial ulnar head resection, or ulnar salvage procedures. Arthroscopy will reveal TFCC wear and chondromalacia associated with type IIA and IIB lesions. They can be treated with TFCC debridement arthroscopically, followed by an open or arthroscopic Feldon ulnar shortening procedure (distal ulnar head resection)4 or an ulnar shortening procedure proximal to the wrist. Type IIC lesions, including TFCC perforation and chondromalacia, are treated with arthroscopic debridement of the TFCC and/or an ulnar shortening procedure. Type IID and

IIE lesions are the end stage of ulnar impaction syndrome. Arthroscopic debridement of the TFCC and ulnar shortening may be performed. The assessment of the integrity of the lunotriquetral ligament is the primary indication for arthroscopy. If the lunotriquetral ligament is unstable after ulnar shortening osteotomy, the lunotriquetral joint can be pinned or a lunotri-quetral fusion can be performed. Lesions with ulnocarpal arthritis are treated with a Bower's distal ulna resection5 or Suave-Kapandji procedure,6 if the surgeon thinks that a distal ulnar resection will be sufficient.

Surgical Technique: Wrist Arthroscopy

Regional anesthesia is generally used and a tourniquet is placed. After the patient has been placed under anesthesia, an examination of the wrist should be performed. The patient is placed supine and the wrist is then placed under 10 to 15 pounds of distraction force. Distraction towers are available commercially for this purpose. Arthroscopes are between 2 and 3 mm and a 30-degree arthroscope is the most commonly used. Arthroscopic portals are named in relation to the extensor tendon compartments. There are five radiocarpal portals, two midcarpal portals, one STT (scapho-trapezio-trapezoid) portal, and two DRUJ portals. Portals are named for their relationship to the extensor compartments. The 3-4 portals are the primarily visualization portals, the 4-5 portals are work portals, and the 6-R and 6-U portals are used as outflow portals or working portals for the ulnar wrist. The portals can be used interchangeably. Portals used depend on the pathology present. Following the 12-degree volar tilt of the radius, an 18-gauge needle is introduced into the third to fourth interval, distal to Lister's tubercle, and the joint is injected with 5 to 7 mL of normal saline. A skin incision is made and a blunt trocar is introduced into the joint (Fig. 40-3). From the 3-4 portal, 70% of the joint can be examined including the radial styloid, scaphoid, scapholunate ligament, radial

Figure 40-3 A, Arthroscopic setup. B, Portals. Cannula is placed in 3-4 portal. Midcarpal portal is marked 1 cm distal to 3-4 portal.

Figure 40-3 A, Arthroscopic setup. B, Portals. Cannula is placed in 3-4 portal. Midcarpal portal is marked 1 cm distal to 3-4 portal.

attachment of the TFCC, extrinsic ligaments, and tautness of the TFCC. An ulnar portal such as the 6-R or 4-5 is made when needed to improve visualization. A shaver can be introduced to remove synovitis that is present. A probe is inserted to test for a flap tear, the tautness of the TFCC (trampoline sign), and the integrity of the intercarpal ligaments (Fig. 40-4). From the ulnar portal, the lunate, triquetrum, lunotriquetral ligament, TFCC, ulnolunate ligament, and ulnotriquetral ligament can be examined if the arthroscopic portal is switched. For resection of an unstable flap, a punch is used and the edges can be débrided with a shaver. Alternatively, a bipolar or monopolar electro-cautery can débride the tissue. Only unstable portions are débrided. If chondromalacia is present indicating a type II lesion, a distal ulna resection can be performed arthroscopically using a bur. Once the radiocarpal joint has been examined from the radiocarpal and ulnar portals, the midcarpal joint must be examined. The radial midcarpal portal is 1 cm distal to portal 3/4. From this portal, the scapholunate and lunotriquetral articulations, distal scaphoid, proximal capitate, and proximal hamate can be examined. After wrist arthroscopy has been completed, the wrist should be re-examined and clicks present secondary to TFCC injury should not be present. The portals are closed with a nylon suture. The wrist is placed in a splint for 1 week to support the extensor tendons and then intermittently for 3 weeks with restrictions on grasping and repetitive activities.

Postoperative Rehabilitation

For TFCC lesions in which only a debridement is performed, the wrist is placed in a splint for 1 week and then used intermittently as needed for the next 3 weeks. At 1 week, range-of-motion exercises are started with restrictions on lifting and repetitive motions. Repaired TFCC lesions should be immobilized in either a splint or cast for 4 to 6 weeks and then range-of-motion exercises are begun with restrictions on lifting and repetitive motion.

Return to Sports

Patients may return to athletics once they have demonstrated progress in strength and range of motion of the affected extremity. For debridement, this is typically at 4 to 6 weeks. Three months is typically the minimum after a repair. One to 3 months of a supervised physical therapy program is normally required. A protective splint should be worn while participating in athletic activities. The protective splint may be discontinued once full strength and range of motion have been obtained.

Complications

Complications of wrist arthroscopy involve injury to superficial nerves during portal placement. The dorsal cutaneous branch of the ulnar nerve can be injured during the placement of the 6-U portal. The superficial radial and lateral antebrachial cutaneous nerves may be injured during placement of the 1-2 portal.

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