關(guān)節(jié)鏡下治療腕三角軟骨損傷

1、Zhi-jie Xi, MD2012-09-22,Triangular Fibrocartilage Complex (TFCC) Tear,2024/3/23,Lesions of the triangular fibrocartilage complex (TFCC) are a common source of ulnarsided wrist pain.1,2Radial side tear or perforations

2、tend to be traumatic and occurs more in young age group , on the other hand , central and ulnar side lesions are more often degenerative and commonly seen in older patients2,1. P S McAlinden, J Teh, . Imaging of the wris

3、t. Imaging 2003; 15:180-1922. Philip E. Blazar, Peter S.H. Chan, J.Bruce Kneeland, Donald Leatherwood, David J. Bozentka,Roman Kowalchick, . The Effect of Observer Experience on Magnetic Resonance ImagingInterpretatio

4、n and Localization of Triangular Fibrocartilage . Hand Surg 2001;26A:742–748,Anatomy,,TFCC,TFCC,Triangular fibrocartilage (articular disc)Meniscus homologueUCL ( ulnar capsule)Volar and Dorsal DRU Ligaments ECU

5、 subsheath Prestyloid recess,2024/3/23,A 3D depiction of the TFCC,Arthroscopy,Complex fibrous structure on volar aspect of wristOrigin-dorsal distal corner of sigmoid notchInsertion- triquetrum and base of fifth metat

6、arsalPartially or completely separates pisotriquetral joint from radiocarpal joint,MENISCUS HOMOLOGUE,ULNOLUNATE AND ULNOTRIQUETRAL LIGAMENTS,From volar aspect of radioulnar ligament to lunate and Triquetrum Firmly

7、attached to triquetrumLess strong attachment to lunate,ULNOLUNATE AND ULNOTRIQUETRAL LIGAMENTS,From volar aspectof radioulnarligament to lunateand triquetrum,Type 1-TraumaticA Horizontal tearadjacent to the radius

8、B Peripheraldetachment from the ulnaC Tear of theUlnocarpal ligamentsD Avulsion fromsigmoid notch,PALMER CLASSIFICATION,Type II-DegenerativeA Partial thickness thinningof the articular discB A + Chondromalacia of

9、lunate and/or ulnar headC B + full thickness tear ofthe articular discD C + Partial tear of thelunatotriquetral ligamentE D + Full tear of thelunatotriquetral ligamentand arthrosis,PALMER CLASSIFICATION,TFCC TRAU

10、MATIC TEAR,,,2024/3/23,Anatomy,2024/3/23,The ulnar portion of the TFCC is vascularised by ulnar and posterior interosseous artery brachesThe central and radial aspects of the complex are avascular,Vascular supply,Tr

11、ansmit loadStablise the DRUJ,biomechanical functions,biomechanical functions,2024/3/23,1) stability of the distal radioulnar joint (DRUJ), 2) axial load transmission from the carpus to the ulna and 3) ulnar sided carp

12、al stability.,Natural History,60 years 50% had TFC perforationsFall on dorsiflexed and ulnar deviated wristAxial load with forearm in hyperpronation,,Symptoms,Ulnar sided wrist pain Quite well localisedUsually with

13、 ulnar deviationSudden pronation activityClicking on rotation Instability is rare,,Signs,PronationUlnar devationAxially loadRotate,Investigations,X-rayMRI ArthroscopySonographArthroscopy --------gold standard,

14、2024/3/23,Using 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

15、 ulnar side may make these disruptions more difficult to detect,P S McAlinden, J Teh, . Imaging of the wrist. Imaging 2003; 15:180-192,Marius R Schmid, Thomas Schertler, Christian W Pfirrmann, Nadja Saupe, Mirjana Ma

16、nestar, Simon Wildermuth et al . Interosseous ligament tears of the wrist: comparison of multi-detector row CT arthrography and MR imaging. Radiology2005 ;237:1008 -1013,TFCC Tear Pathoanatomy,Tear in structures of TFCC

17、Positive ulnar variance predisposes to injury,2024/3/23,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 tear ( arrow)

18、.,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 Rad

19、iol 2001;56:50 -57,ultra-high-frequency sonograph,2024/3/23,The TFCC appears very similar to the knee meniscus on MRI images,Oneson SR, Timins ME, Scales LM, Erickson SJ, Chamoy L. MR imaging diagnosis of triangular fibr

20、ocartilage pathology with arthroscopic correlation. AJR Am J Roentgenol 1997; 168:1513-1518.,,,TFCC TRAUMATIC TEAR,TFCC Tear Imaging,Plain films may show positive ulnar varianceAssess for fracture or ulnar subluxationM

21、RI or Arthrography,,a large central tear (arrow) along the radial aspect of the articular disc of the TFCC.Associated subchondral degenerative changes are evident within theproximal lunate,2024/3/23,,,2024/3/23,A typic

22、al degenerative central tear,,a discrete verticaltear (arrow) involving the thicker,volar radioulnar ligament componentof the TFCC.,2024/3/23,,2024/3/23,avulsion of the ulnar styloidattachment of the TFC,2024/3/23,,

23、TFCC tears were classified according to its location as 1 if it was at the cartilageattachment to the radius; 2, pararadial (2–3 mm from the radius); 3, at the mid portion;4, paraulnar (2–3 mm from the ulnar insertion

24、point of the TFC); or 5, at the ulnarinsertion point(Fig 4),2024/3/23,,location of the TFCC tears,2024/3/23,,a relatively big communicating tear (arrow head)close to the radial attachment of the TFCC,with more fat sat

25、sequences as required,,2024/3/23,A small central perforation (arrow) is seen within the central portion of the articular disc of the triangular fibrocartilage complex. An additional, partial thicknessundersurface tear (

26、arrowhead) is also present at the articular disc.,,,,,,,,,,,,Arthroscopic inspection,ConservativeActivity avoidanceSteroid injection (10mg Kenolog)Surgery,Treatment,ArthroscopicRepair Debridement ShaversRadiofrequ

27、ency (Vapr) – keep the heat downOpenRepairUlnar Shortening,Surgery,,,,,,,2024/3/23,The peripheral and central tears of the TFCC must be differentiated as the mode of treatment is different between the two conditi

28、ons, 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, . Characte

29、ristics of Triangular Fibrocartilage Defects in Symptomatic and Contralateral Asymptomatic Wrists. Radiology 2000 ;216 : 840-845.,Arthroscopic treatment,2024/3/23,Case 1, suture,Case 2, debridement,Pearls,Patients with

30、 injuries to the wrist, particularly displaced distal radius fractures, should be examined after reduction for instability of the DRUJ.The majority of patients presenting with ulnar sided wrist pain can be managed non-o

31、peratively and returned to normal activities.The central component of the TFCC can be excised to a stable rim without compromising its biomechanical function.,2024/3/23,Pitfalls,The differential diagnosis of ulnar sided

32、 wrist pain is lengthy. A careful 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