Concomitant Ulnar Styloid Fractures in Distal Radius Osteosynthesis Does Not Impact Radiographic Outcomes, Ulnar Sided Symptoms and Patient Outcomes

@#Introduction: Current literature reports varied significance of ulnar styloid fractures (USF) associated with distal radius fractures. Our study assesses the role of ulnar styloid fractures and fragment size in surgically managed distal radius fractures. Materials and methods: We reviewed patients who underwent surgical fixation of distal radius fractures between January 2004 to June 2006. Patients were divided into those with (Group 1) and without (Group 0) USFs. Post-operative radiographic parameters, clinical outcomes and overall wrist function were analysed. Outcomes included ulnar-sided wrist pain, extensor carpi ulnaris (ECU) tendinitis, triangular fibrocartilage complex (TFCC) grind test, distal radioulnar joint (DRUJ) instability and pain. Overall wrist function was assessed with range of motion and Disabilities of the Arm, Shoulder and Hand (DASH) score. Results: Our study cohort included 31 males and 23 females, and 38.9% of these patients had concomitant USFs. There was no difference in terms of demographic data and fracture configuration between groups. Radiographic parameters were similar, except for palmar tilt, which was significantly higher in Group 1 (4.6º vs 9.4º, p=0.047). At 24 months, there were no differences in clinical outcomes and overall wrist function. A sub-group analysis showed that mean USF fragment size was larger in patients with a positive TFCC grind test (3.9mm vs 7.3mm, p=0.033). Conclusion: The presence of USFs in surgically managed distal radius fractures does not compromise clinical and functional outcome. Similarly, the size of USFs does not impact clinical and functional outcome but is associated with the presence of a positive TFCC grind test.

Analysis of Results of Arthroscopic Repair of Triangular Fibrocartilage Complex (TFCC) Injury.

Background: Triangular fibrocartilage complex (TFCC) tears are a major source of ulnar-sided wrist pain and may result in patient disability, ranging from activities of daily living to high-level athletics. The purpose of this study is to evaluate the long-term clinical outcomes in patients affected by TFCC lesion and in association with or without distal radio ulnar joint (DRUJ) instability after arthroscopic repair. Methods: Younger patients (50 years of age or younger), presented with mechanical symptoms at least 6 weeks of failed conservative treatment, a positive, fovea! tenderness test, were included in the study. Patients were excluded if they had ulnar impaction syndrome, arthritis of wrist joint or other wrist pathology on arthroscopic examination. Final results were evaluated after 1 year. Results: Forty-nine wrists in 48 patients had arthroscopy for a possibly repairable peripheral TFCC tear during the study period. Thirty four wrists in 34 patients remained after exclusions. The Mayo score from pre-operative value 46.9±10.4 was increased to 91.7±5.0 postoperatively. At final follow-up, 2 patients had fovea! tenderness, and no patients had a piano-key sign or caput ulna. Conclusion: Arthroscopic repair for traumatic TFCC fovea! tear can restore stability to the DRUJ and provide satisfactory subjective and objective results without serious complications after more than 12 months' follow-up.

Progress in diagnosis and treatment of traumatic injury to triangular fibrocartilage complex / 中华创伤骨科杂志

Triangular fibrocartilage complex (TFCC) plays an important role in maintaining stability of the distal radioulnar joint (DRUJ),buffering the ulnar carpal axial impaction and holding the proximal carpal bones.Patients with injured TFCC may suffer pain over the ulnar side of the wrist and DRUJ instability.Many of them may have difficulty in undertaking daily activities,leading to even psychological problems.With the development of arthroscopic technology and updated understanding of the mechanisms of TFCC injury,great progress has been made in the diagnosis and treatment of the traumatic injury,especially in the arthroscopy-assisted treatment.

Traumatic Triangular Fibrocartilage Complex Injuries and Instability of the Distal Radioulnar Joint / 대한정형외과학회잡지

Traumatic triangular fibrocartilage complex (TFCC) injuries require multidisciplinary approach and plan. Trauma to TFCC can lead to instability of the distal radioulnar joint (DRUJ). Injury to TFCC is classified as a stable type that does not cause unstable lesions for DRUJ or unstable type that can cause instability of DRUJ. According to the location and severity of the injury, arthroscopic debridement or arthroscopic repair may be considered. In the ulnar side avulsion of TFCC, which could cause DRUJ instability, arthroscopic examination should be performed to identify an accurate location of the damaged structures, followed by arthroscopic debridement and repair. In the event of TFCC and DRUJ injuries with ulnar positive variance, arthroscopic TFCC repair or ulnar shortening osteotomy after arthroscopic debridement could be considered to solve the instability and ulnar side pain. However, if peripheral TFCC tear with ulnar impaction syndrome and DRUJ instability, it combined operation of ulnar shortening osteotomy and TFCC foveal fixation could be considered. An accurate classification of TFCC and DRUJ injuries is necessary. It is important to resolve and prevent recurrence of ulnar wrist pain caused by instability.

Scaphoid fracture treated by percutaneous fixation with arthroscope assistance / 中国内镜杂志

Objective To investigate the preliminary clinical results of treating scaphoid fracture by percutaneous fixation with arthroscope assistance. Methods From October 2009 to May 2015, a consecutive series of 12 patients with scaphoid fracture were treated by percutaneous fixation with arthroscope assistance. Meanwhile TFCC was man-aged if necessary. As followed, X-ray was adopted for assessment bone healing at 6-month postoperation, 12-month postoperation. Postoperative evaluations included clinical measurement (grip strength and motion range), radiograph-ic, and functional (modified Mayo wrist score) parameters, Herbert and Fisher scaphoid fracture parameters. Healthy wrist as control group. Results All the scaphoid fracture were healed with an average healing time of 24 weeks. All 12 cases were followed for an average of 18.5 months. The function was rated excellent in 7 cases, good in 5 cases according to the modified Mayo wrist score. There was no difference between the injuried wrist and control group. Conclusion For scaphoid fracture, percutaneous fixation with arthroscope assistance is a reliable and minimally in-vasive method to treat scaphoid fracture.

Luxación radio-cubital distal expuesta por mordedura canina no asociada con fractura: Técnica quirúrgica reconstructiva mediante anclaje para sindesmosis e injerto tendinoso. Reporte de caso / Exposed distal radio-ulnar dislocation by dog bite: Reconstructive surgical technique using a soft tissue graft and a syndesmotic fixation implant. Case report

La función principal del antebrazo es la pronosupinación, la cual se logra en gran medida mediante la estabilidad y características biomecánicas de la articulación radio-cubital distal. Existen diversas técnicas quirúrgicas para el tratamiento de las luxaciones radio-cubitales distales aisladas o asociadas con fractura. Presentamos el caso de un paciente entrenador canino quien fue mordido a nivel de la muñeca y antebrazo distal acudiendo al Servicio de Urgencias en donde se diagnostica una luxación cubital distal con exposición músculo tendinosa. Debido al agente lesivo y las múltiples lesiones de partes blandas resultó imposible realizar las técnicas habituales de tratamiento. Se describe la técnica utilizada para el manejo de este paciente mediante la colocación de injerto tendinoso autólogo de gracilis, plasma rico en plaquetas y dos sistemas de anclaje para sindesmosis de tobillo. Se inmovilizó por seis semanas e inició rehabilitación subsecuente y valorándolo a las 12, 18 y 28 semanas mediante la escala de MAYO, DASH y PRWE encontrando un resultado bueno que implica la reincorporación a las actividades laborales y cotidianas del paciente con un mínimo dolor y limitación.

The main function of the forearm is the supination, which is achieved largely through the biomechanical characteristics and stability of the distal radio-ulnar joint. There are several surgical techniques for the treatment of distal radio-ulnar dislocations isolated or associated with a fracture. We report the case of a canine trainer who was bitten at the wrist and distal forearm that came to the emergency department in where distal ulnar dislocation with muscle tendon exposure was diagnosed. Due to the offending agent and multiple soft tissue injuries the treatment with standard techniques was impossible. We describe the technique of treatment of this patient by placing autologous gracilis tendon graft, platelet rich plasma and two anchoring systems for ankle syndesmosis. Immobilization was maintained for six weeks with a subsequent rehabilitation and posterior valuation at 12, 18 and 28 weeks by the scale of MAYO, PRWE and DASH and finding a good result which implies the return to work and daily activities of the patient with minimal pain and limitation.

Magnetic resonance imaging of the triangular fibrocartilage complex / 实用放射学杂志

Objective To investigate the value of MR 3D fs SPGR(three-dimensional fat-suppressed spoiled gradient echo se-quence)in displaying the general structure of normal triangular fibrocartilage complex(triangular fibrocartilage disc,palm dorsal dis-tal radioulnar ligament,ulnolunate ligament,ulnotriquetral ligament,ulnar collateral ligament,extensor carpi sheath and articular disc homologues).Methods 1 5 normal adults(30 carpals)were examined withconventional sequences including axial fast spin-echo T1-weighted images (FSE T1 WI)or T2-weighted images (T2 WI),coronal fat-suppressed fast spin-echo T2-weighted images (FSE fsT2 WI)and coronal 3D fs SPGR.As well,3D image reconstruction was performed.Two experienced radiologists read the images with an agreement and recorded the display rate of general structure of TFCC.Results Triangular fibrocartilage disc,articular disc homologuespalm,dorsal distal radioulnar ligament,and extensor carpi sheath were totally showed on coronal and cross sections.Ulnolunate liga-ment and ulnotriquetral ligament were totally seen on the coronal plane,and the display rates on cross-section were 93.3%(28/30), 96.7%(29/30)respectively.Ulnar collateral ligament was seen on cross-section and coronal plane 83.3%(25/30),86.7%(26/30)re-spectively.Conclusion Coronal 3D fs SPGR sequence can be used as a regular sequence for observing TFCC and the surrounding lig-aments .

Clinical Outcomes of Open Surgical Repair for Triangular Fibrocartilage Complex Foveal Detachment

PURPOSE: To investigate short term clinical outcomes of the open surgical repair for triangular fibrocartilage complex (TFCC) foveal detachment. METHODS: We retrospectively reviewed 8 patients (5 men, 3 women) who had been treated with open surgical repair of the TFCC type 1B injury, from 2005 to 2013 and who were followed up for more than one year after surgery. Mean age at time of surgery was 34 years. The right side was involved in 3 patients, and the left in 5. The clinical results of surgery were assessed with modified Mayo wrist score (MMWS), disabilities of the arm, shoulder and hand (DASH) score and pain-visual analogue scale (VAS). Physical examination was performed to evaluate the prescence of distal radioulnar instability, preoperatively and at the latest follow-up. RESULTS: The mean follow up period were 36.5 months (range, 12-64 months). The mean MMWS improved from 52.5 (range, 25-85) preoperatively to 82.5 (range, 75-100) postoperatively (p=0.02). The mean DASH score improved from 39.6 (range, 65-13.5) preoperatively to 13.4 (range, 2.5-33.3) postoperatively (p=0.012). The preoperative mean pain-VAS was 4.6 (range, 6-3); these value was reduced to mean 2 (range, 0-3) at the latest follow-up (p=0.016). There were no patients remaining instability after the surgery, although four patients showed distal radioulnar joint (DRUJ) instability before surgery. CONCLUSION: The surgical outcomes of open repair for TFCC foveal detachment (type 1B) was contentable. Also, in cases of type 1B injury associated with DRUJ instability were managed sucessfully without additional procedure.

Open Repair of Triangular Fibrocartilage Complex Type 1B Tear

Most common traumatic type 1B tear of triangular fibrocartilage complex (TFCC), according to the Palmer's classification, may lead to the loss of the stability of distal radioulnar joint and is known to be one cause of the persisted ular side wrist pain. Recently as the knowledge of the anatomical structures of the TFCC accumulates and the deep fiber of the distal radioulnar ligament is recognized to play a central role, an attempt to repair it to the original ulnar fovea insertion site has been done and reported successful results. Since the introduction of open technique, numerous arthroscopic technique has been developing. Here careful considerations ought to be given during open repair will be taken with review of the related articles.

Surgical Techniques for Repairing Foveal Tear of the Triangular Fibrocartilage Complex: Arthroscopic Transosseous Repair

As the importance of the foveal attachment of the triangular fibrocartilage complex (TFCC) on the stability of the distal radioulnar joint (DRUJ) is emphasized, the traditional repair techniques such as arthroscopic capsular repair for the 1B TFCC tear become accepted as ineffective method for treating DRUJ instability. Recently, several techniques which repair the TFCC directly to the ulnar fovea have been developed and introduced. Further advances of the techniques will be expected with increasing knowledge of the anatomy and biomechanics of the TFCC and DRUJ. Regardless of the techniques, fundamental principle of anatomical repair of the TFCC to the ulnar fovea is utmost important. Herein we present our technique of arthroscopic transosseous repair by making a drill hole in the ulnar and securing the sutures with Pushlock anchors.

Surgical Technique for Repairing Foveal Tear of the Triangular Fibrocartilage Complex: Arthroscopic Knotless Repair

Knotless repair of triangular fibrocartilage complex has several advantages. All procedures for triangular fibrocartilage complex repair could be done under arthroscopy in this technique. In addition, this technique allows for repair of deep layers of triangular fibrocartilage complex down to fovea of the ulnar head. This article describes arthroscopic repair of the Palmer type 1B triangular fibrocartilage complex tear using arthroscopic knotless technique.

Treatment of Palmer Class 1A Triangular Fibrocartilage Complex Injuries with Arthroscopic Partial Resection

PURPOSE: We reported the clinical results of Palmer class 1A triangular fibrocartilage complex (TFCC) injuries treated with arthroscopic partial resection. METHODS: This study included eighteen patients with Palmer class 1A TFCC injury. The results of arthroscopic partial resection were analyzed based on the preoperative and postoperative evaluation of visual analogue scale pain scale, range of motion, grip strength, Mayo wrist score, ulna grind test, ulna stress test and ulnocarpal tenderness. RESULTS: According to the Mayo wrist score, the results were excellent in 10 patients, good in 4, fair in 2, and poor in 2. There was no correlation among the worker's compensation, interval from injury to surgery, age and the treatment results. Patients with complication and scapholunate interosseous ligament tears had a poor clinical outcome. CONCLUSION: The arthroscopic TFCC partial resection is considered as an useful and effective treatment in Palmer class 1A TFCC injuries.

The Short Term Results of All-inside Arthroscopic Repair of the Triangular Fibrocartilage Complex Type 1B Tear by Knotless Suture Anchor

PURPOSE: We studied the short term results of the arthroscopic repair of 1B type triangular fibrocartilage complex (TFCC) tear using a knotless suture anchor. METHODS: We evaluated 23 patients who underwent all-inside arthroscopic TFCC repair using a knotless suture anchor. The average follow-up duration was 6.6 months (range, 3-10 months). Mean duration of symptom was 10.9 months (range, 1 week-7 years). The arthroscopic finding documented 15 type 1B, 2 1B with 1D, and 6 1B with 2C lesions. All showed the positive hook test. The concomitant pathologies were 16 scapholunate injuries and 10 lunotriquetral injuries. TFCC tears were repaired by the knotless suture anchor. The Wafer procedure was done for 2C lesions. RESULTS: According to Mayo modified wrist score, the result was excellent in 4, good in 14 and fair in 5. Nineteen patients (82.6%) could return to his job or hobby. CONCLUSION: The all-inside arthroscopic repair using knotless suture anchor for TFCC 1B tear can provide good results. The appropriate management should be done for the concomitant pathologies for the better results.

Current Treatment of Triangular Fibrocartilage Complex Injuries

The Palmer class 1B triangular fibrocartilage complex injury has two entities: a lesion with stable distal radioulnar joint and a lesion with distal radioulnar joint instability. Arthroscopic debridement of fibrocartilage disk is used in Palmer class 1A lesion. The surgeon should remove the portion of the fibrocartilage tissue until a mechanically stable and smooth residual rim remains. Arthroscopic repair is used in Palmer class 1B or 1D lesion using meniscal repair sutures. Ulnar detachment that can produce distal radioulnar ligament instability can also be repaired using bone anchor or pull out suture. Old age as well as positive ulnar variance is poor prognostic factors.

Ganglion of the Triangular Fibrocartilage Complex: A Case Report

Ganglions are the most common mass occurred in the wrist and hand. Ganglion usually arises from the dorsal aspect of the radiocarpal joint that may lead to the wrist pain. We report a patient with a ganglion of the triangular fibrocartilage complex. Using arthroscopic technique, ganglion located in triangular fibrocartilage complex was successfully excised.

A Comparison of Ulnar Shortening Osteotomy Alone Versus Combined Arthroscopic Triangular Fibrocartilage Complex Debridement and Ulnar Shortening Osteotomy for Ulnar Impaction Syndrome

BACKGROUND: This study compared the results of patients treated for ulnar impaction syndrome using an ulnar shortening osteotomy (USO) alone with those treated with combined arthroscopic debridement and USO. METHODS: The results of 27 wrists were reviewed retrospectively. They were divided into three groups: group A (USO alone, 10 cases), group B (combined arthroscopic debridement and USO, 9 cases), and group C (arthroscopic triangular fibrocartilage complex [TFCC] debridement alone, 8 cases). The wrist function was evaluated using the modified Mayo wrist score, disabilities of the arm, shoulder and hand (DASH) score and Chun and Palmer grading system. RESULTS: The modified Mayo wrist score in groups A, B, and C was 74.5 +/- 8.9, 73.9 +/- 11.6, and 61.3 +/- 10.2, respectively (p 0.05). CONCLUSIONS: Both USO alone and combined arthroscopic TFCC debridement with USO improved the wrist function and reduced the level of pain in the patients treated for ulnar impaction syndrome. USO alone may be the preferred method of treatment in patients if the torn flap of TFCC is not unstable.

Arthroscopic Repair for Traumatic Peripheral Tear of Triangular Fibrocartilage Complex

PURPOSE: To assess the results of an arthroscopic repair for traumatic peripheral tears of triangular fibrocartilage complex (TFCC, Palmer type Ib). MATERIALS AND METHODS: 10 patients with traumatic peripheral TFCC tear were treated with outside-in technique with arthroscope and evaluated with an average follow-up of 19 months (range, 15 to 28 months). The clinical outcomes were assessed with investigation of pain, range of motion, grip strength, return to job and patient's satisfaction. RESULTS: The arthroscopic repair of traumatic peripheral TFCC tear resulted in significant pain relief and increase in functional ability of wrist, that is, 8 excellent, 1 good and 1 fair results. At last follow-up, the average of flexion was 79° (range 76~86°), average of extension was 78° (range 70~84°), average pronation was 85° (range 75~91°) and average supination was 87° (range 79~92°). Nine patients except one were back to their original job. CONCLUSION: Arthroscopic repair of traumatic peripheral TFCC tear could be used for pain relief and increase in functional ability of wrist.

Arthroscopic Repair for Traumatic Peripheral Tear of Triangular Fibrocartilage Complex

PURPOSE: To assess the results of an arthroscopic repair for traumatic peripheral tears of triangular fibrocartilage complex (TFCC, Palmer type Ib). MATERIALS AND METHODS: 10 patients with traumatic peripheral TFCC tear were treated with outside-in technique with arthroscope and evaluated with an average follow-up of 19 months (range, 15 to 28 months). The clinical outcomes were assessed with investigation of pain, range of motion, grip strength, return to job and patient's satisfaction. RESULTS: The arthroscopic repair of traumatic peripheral TFCC tear resulted in significant pain relief and increase in functional ability of wrist, that is, 8 excellent, 1 good and 1 fair results. At last follow-up, the average of flexion was 79° (range 76~86°), average of extension was 78° (range 70~84°), average pronation was 85° (range 75~91°) and average supination was 87° (range 79~92°). Nine patients except one were back to their original job. CONCLUSION: Arthroscopic repair of traumatic peripheral TFCC tear could be used for pain relief and increase in functional ability of wrist.

Artroscopia de muñeca en lesiones ulnares del fibrocartilago triangular / Arthroscopic repair of triangular fibrocartilage complex tears

The purpose of this study is to report the functional outcome of patients with an arthroscopic repair of ulnar tears of the triangular fibrocartilage complex, of the wrist. 12 patients operated with a standard surgical and anesthetic technique were included in the study, with a follow up of 3.8 years. The modified Mayo wrist score was used to evaluate the results. The data was analyzed by a specialist. Average surgical time was 42.6 minutes. Average time to surgery was 3.6 months. Time to return to work was 4 months in average. The average Mayo pre-operative score was 62.5 and it improved to 89.5 points in the post-operative, being significantly lower in females than in males. No relation was found between re-operative score and time to return to work, nor between surgical time and pot-operative score. There is a direct relation however, between time to surgery and post-operative score.

El propósito de este estudio es determinar los resultados funcionales del tratamiento artroscópico de lesiones del fibrocartílago triangular. Se incluyeron 12 pacientes con diagnóstico de rotura traumática del borde lunar del fibrocartílago triangular, operados con técnica artroscópica y anestésica estandarizada, con un seguimiento promedio de 3,8 años. Para evaluar los resultados se utilizó la escala de Mayo modificada. Se consignaron: puntuación pre y post-operatorio, tiempo quirúrgico (promedio 42,6 min), tiempo entre lesión y operación (promedio 3,6 meses) y el tiempo al alta laboral (promedio 4 meses). La puntuación de Mayo modificada promedio pre-operatorio fue de 62,5 puntos y aumentó a un promedio de 89,5 puntos luego de la operación, siendo inferior en mujeres que en hombres. No se encontró correlación entre puntuación pre-operatorio y tiempo al alta laboral, ni entre tiempo quirúrgico y puntuación post-operatorio. Si se encontró correlación entre tiempo entre lesión - operación con puntuación de Mayo modificada post -operatorio.

Arthroscopic assessment of soft tissue injuries in comminuted intra-articular fractures of the distal radius / 中华创伤骨科杂志

Objective To diagnose and evaluate soft tissue injuries in intra-articular fractures of the distal radius using arthroscopy. Methods Twenty young patients with displaced intra-articular fractures of distal radius were recruited in this prospective study. Three AO C2 and 17 C3 fractures were included. After arthroscopic examination fractures of distal radius were treated by external fixation with limited internal fixation or open plate fixation.Results Triangular fibrocartilage complex (TFCC) injury was found in 18 patients (90%) . Most were isolated Palmer type 1D injuries (67 %). Scapho-lunate ligament injury was found in two patients: one partial tear (grade Ⅱ) and one complete tear (grade Ⅲ). Follow-ups ranged from 6 to 18 months. At the last follow-up, wrist function was excellent in one patient (6%), good in eight(44%) and fair in 11 (50%). Conclusion TFCC injuries are common in intra-articular fractures of the distal radius while injuries to scapho-luuate ligament are uncommon.