《关节镜下治疗腕三角软骨损伤英文版》由会员分享，可在线阅读，更多相关《关节镜下治疗腕三角软骨损伤英文版（66页珍藏版）》请在金锄头文库上搜索。
1、Zhi-jie Xi, MDZhi-jie Xi, MD2012-09-222012-09-22Triangular Fibrocartilage Complex (TFCC) Tear2024/8/6Lesions of the triangular fibrocartilage complex (TFCC) are a common source of ulnarsided wrist pain.1,2Radial side tear or perforations tend to be traumatic and occurs more in young age group , on t
2、he other hand , central and ulnar side lesions are more often degenerative and commonly seen in older patients21. P S McAlinden, J Teh, . Imaging of the wrist. Imaging 2003; 15:180-1922. Philip E. Blazar, Peter S.H. Chan, J.Bruce Kneeland, Donald Leatherwood, David J. Bozentka,Roman Kowalchick, . Th
3、e Effect of Observer Experience on Magnetic Resonance ImagingInterpretation and Localization of Triangular Fibrocartilage . Hand Surg 2001;26A:742748AnatomyTFCCTFCCTriangular fibrocartilage (articular disc)Meniscus homologueUCL ( ulnar capsule)Volar and Dorsal DRU Ligaments ECU subsheath Prestyloid
4、recess2024/8/6A 3D depiction of the TFCCArthroscopyComplex fibrous structure on volar aspect of wristOrigin-dorsal distal corner of sigmoid notchInsertion- triquetrum and base of fifth metatarsalPartially or completely separates pisotriquetral joint from radiocarpal jointMENISCUS HOMOLOGUEULNOLUNATE
5、 AND ULNOTRIQUETRAL LIGAMENTSFrom volar aspect of radioulnar ligament to lunate and Triquetrum Firmly attached to triquetrumLess strong attachment to lunateULNOLUNATE AND ULNOTRIQUETRAL LIGAMENTSFrom volar aspectof radioulnarligament to lunateand triquetrumType 1-TraumaticA Horizontal tearadjacent t
6、o the radiusB Peripheraldetachment from the ulnaC Tear of theUlnocarpal ligamentsD Avulsion fromsigmoid notchPALMER CLASSIFICATIONType II-DegenerativeA Partial thickness thinningof the articular discB A + Chondromalacia oflunate and/or ulnar headC B + full thickness tear ofthe articular discD C + Pa
7、rtial tear of thelunatotriquetral ligamentE D + Full tear of thelunatotriquetral ligamentand arthrosisPALMER CLASSIFICATIONTFCC TRAUMATIC TEAR2024/8/6Anatomy2024/8/6The ulnar portion of the TFCC is vascularised by ulnar and posterior interosseous artery brachesThe central and radial aspects of the c
8、omplex are avascularVascular supplyTransmit loadStablise the DRUJbiomechanical functionsbiomechanical functions2024/8/61) stability of the distal radioulnar joint (DRUJ), 2) axial load transmission from the carpus to the ulna and 3) ulnar sided carpal stability.Natural History60 years 50% had TFC pe
9、rforationsFall on dorsiflexed and ulnar deviated wristAxial load with forearm in hyperpronationSymptomsUlnar sided wrist pain Quite well localisedUsually with ulnar deviationSudden pronation activityClicking on rotation Instability is rareSignsPronationUlnar devationAxially loadRotateInvestigationsX
10、-rayMRI ArthroscopySonographArthroscopy -gold standard2024/8/6Using arthroscopy as the gold standard, MRI has been shown to have an accuracy of 64 75% for perforations or tears . 1 The inhomogeneous signal intensity and striated appearance of the TFCC especially the ulnar side may make these disrupt
11、ions more difficult to detectP S McAlinden, J Teh, . Imaging of the wrist. Imaging 2003; 15:180-192Marius R Schmid, Thomas Schertler, Christian W Pfirrmann, Nadja Saupe, Mirjana Manestar, Simon Wildermuth et al . Interosseous ligament tears of the wrist: comparison of multi-detector row CT arthrogra
12、phy and MR imaging. Radiology2005 ;237:1008 -1013TFCC Tear PathoanatomyTear in structures of TFCCPositive ulnar variance predisposes to injury2024/8/6 arthrogram a tear at the para radial part of the TFCC ( site 2)B: coronal T1W Fat Sat sequence confirming the arthrogram finding and clearly show the
13、 tear ( arrow).About 60-70% of the TFCC tears are associated with ulnar styloid fractureJ L JL Hobby, B D BD Tom, P W PW Bearcroft , A K AK Dixon. Magnetic resonance imaging of the wrist: diagnostic performance statistics. Clin Radiol 2001;56:50 -57ultra-high-frequency sonograph2024/8/6The TFCC appe
14、ars very similar to the knee meniscus on MRI imagesOneson SR, Timins ME, Scales LM, Erickson SJ, Chamoy L. MR imaging diagnosis of triangular fibrocartilage pathology with arthroscopic correlation. AJR Am J Roentgenol 1997; 168:1513-1518.TFCC TRAUMATIC TEARTFCC Tear ImagingPlain films may show posit
15、ive ulnar varianceAssess for fracture or ulnar subluxationMRI or Arthrographya large central tear (arrow) along the radial aspect of the articular disc of the TFCC.Associated subchondral degenerative changes are evident within theproximal lunate2024/8/62024/8/6A typical degenerative central teara di
16、screte verticaltear (arrow) involving the thicker,volar radioulnar ligament componentof the TFCC.2024/8/62024/8/6avulsion of the ulnar styloidattachment of the TFC2024/8/6TFCC tears were classified according to its location as 1 if it was at the cartilageattachment to the radius; 2, pararadial (23 m
17、m from the radius); 3, at the mid portion;4, paraulnar (23 mm from the ulnar insertion point of the TFC); or 5, at the ulnarinsertion point(Fig 4)2024/8/6location of the TFCC tears2024/8/6a relatively big communicating tear (arrow head)close to the radial attachment of the TFCCwith more fat sat sequ
18、ences as required2024/8/6A small central perforation (arrow) is seen within the central portion of the articular disc of the triangular fibrocartilage complex. An additional, partial thicknessundersurface tear (arrowhead) is also present at the articular disc.Arthroscopic inspectionConservativeActiv
19、ity avoidanceSteroid injection (10mg Kenolog)SurgeryTreatmentArthroscopicRepair Debridement ShaversRadiofrequency (Vapr) keep the heat downOpenRepairUlnar ShorteningSurgery2024/8/6The peripheral and central tears of the TFCC must be differentiated as the mode of treatment is different between the tw
20、o conditions, peripheral tears have a good vascular supply and are repaired however central tears are avascular and are commonly managed with debridement.Marco Zanetti, David Linkous, Louis A. Gilula, Juerg Hodler, . Characteristics of Triangular Fibrocartilage Defects in Symptomatic and Contralater
21、al Asymptomatic Wrists. Radiology 2000 ;216 : 840-845.Arthroscopic treatment 2024/8/6Case 1, suture Case 2, debridementPearlsPatients with injuries to the wrist, particularly displaced distal radius fractures, should be examined after reduction for instability of the DRUJ.The majority of patients pr
22、esenting with ulnar sided wrist pain can be managed non-operatively and returned to normal activities.The central component of the TFCC can be excised to a stable rim without compromising its biomechanical function.2024/8/6 PitfallsThe differential diagnosis of ulnar sided wrist pain is lengthy. A c
23、areful examination of the ulnar side of the wrist will frequently rule in others causes of patients symptoms.The dorsal branch of the ulnar nerve crosses from volar to dorsal in the region of ulnar (6U) wrist arthroscopy portals. Careful dissection and protection of this nerve is mandatory to prevent complications.2024/8/6Step by step
