acute druj instability & tfcc tears keox 2014
TRANSCRIPT
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Nickolaos A. Darlis, MD
To access this presentation on the web:
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“Forearm Joint”“Forearm Joint”
One functional unit
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“Forearm Joint”“Forearm Joint”
The forearm as a ring
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Anatomy Distal RadiusAnatomy Distal Radius
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DRUJ AnatomyDRUJ Anatomy
• Radii of curvature differ – 10mm vs 15mm– Full congruity impossible
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DRUJ anatomyDRUJ anatomy
• Congruity of DRUJ– Neutral rotation: 60% of
sigmoid notch in contact– Extremes of rotation: 10%– Dorsal and palmar rims
important
• Little osseous stability
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TFCC componentsTFCC components
VRULDRUL
ARTICULARDISC
UL, UTr ECU sub sheath
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Volar & Dorsal RU lig.-Deep bundleVolar & Dorsal RU lig.-Deep bundle
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Distal Radio-ulnar ligamentsDistal Radio-ulnar ligaments
Exact role disputed for years• Primary constraint to volar dislocation?• Primary constraint to dorsal dislocation?
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However, most common explanation:However, most common explanation:
• Pronation– Ulnar head dorsal– DRUL taut– If PRUL ruptures,
dislocates dorsally• Supination– Ulnar head volar– PRUL taut– If DRUL ruptures,
dislocates volarly
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Deep bundle, Foveal attachmentDeep bundle, Foveal attachment
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The Iceberg Concept Atzei &Lucetti 2011The Iceberg Concept Atzei &Lucetti 2011
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TFCC anatomyTFCC anatomy
• Vascular supply– Central portion• avascular
– Periphery (dorsal and palmar radio-ulnar ligaments)• vascularized
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DRUJDRUJ
• Rotation• Load transmission• Stability
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KinematicsKinematics
• Radius rotates about the distal ulna• “Ulnar head dislocation” by convention• Axis of rotation
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Load transmission (RH intact )Load transmission (RH intact )
80%
20%
40% 60%
Halls 1964, Palmer 1984, Birkbeck 1997
U
U
R
R
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Load TransmissionLoad TransmissionExplains common fracture patterns
Galeazzi
Forearm
Monteggia
Essex-Lopresti
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Interosseous Membrane AnatomyInterosseous Membrane Anatomy
Two main bands:• Central Band (volar)• Proximal Interosseous
Band (dorsal)
• Accessory bands (1-5)• Membranous portion
Skahen 1997
CB
PIOB
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IOM-Central BandIOM-Central Band
• 70% of forearm stability
• Injury of other elements of IOM (partial tears), increase CB strains
Hotchkiss,1989, Lafferty 1990, Rabinowitz, 1994, Skahen III 1997
Radius
Ulna
CB
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IOM AnatomyIOM Anatomy
60%
40%
35%
75%250120mm
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outlineoutline
Acute DRUJ instabilityDistal radius-Galeazzi-Essex Lopresti
TFCC management
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Acute DRUJ instabilityDistal radius-Galeazzi-Essex Lopresti
TFCC management
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Common misconceptionsCommon misconceptions
• TFCC tear ≠ DRUJ instability– In fact: most tears don’t cause instability
• Ulnar styloid fracture ≠ DRUJ instability– Styloid fractures may co-excist with TFCC tears
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Acute Ulnar head Dislocation
without fracture
Acute Ulnar head Dislocation
without fracture• Dorsal: reduce in supination• Palmar: reduce in pronation• Global instability: usually requires
stabilization
• If stable: immobilize in stable position– Sugartongue splint for 6 weeks
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• Failed closed reduction may result from trapped ECU, capsule, ulnar styloid, extensor tendon
• Open reduction dorsal - 5th compt.
• TFCC repair if avulsed
Acute Ulnar head Dislocation
without fracture
Acute Ulnar head Dislocation
without fracture
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DRUJ in Distal Radius FracturesDRUJ in Distal Radius Fractures
• 1777 Desault isolated DRUJ dislocation• 1814 Colles: DRUJ with distal radius– “at some remote period again enjoy perfect freedom”
• 1837- Diday– “the problem is really the overriding ulna”
• 1934 Galeazzi • 1951 Essex-Lopresti• 1967 Frykman– “Disturbances of the DRUJ make for worse results”
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DRUJ in Distal Radius FracturesDRUJ in Distal Radius Fractures
• “Most common source of pain following distal radius Fx”
Fernandez &Geissler JHS 1992
• Loss of supination most common functional complaint following distal radius Fx
Hanel AAOS ICL 2004
• Residual depression of the lunate facet ≥2mm results in articular incongruity and arthrosis
Jupiter JBJS 1986
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DRUJ injury in distal radius FxDRUJ injury in distal radius Fx
Highly possible when:• shortening >5-7mm• displaced fx base of the
ulnar styloid, • angulation >25-300 any
plane• DRUJ diastasis in PA Rö
projection
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DRUJ injury in distal radius FxDRUJ injury in distal radius Fx
Highly possible when:• shortening >5-7mm• displaced fx base of the
ulnar styloid, • angulation >25-300 any
plane• DRUJ diastasis in PA Rö
projection
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DRUJ injury in distal radius FxDRUJ injury in distal radius Fx
Highly possible when:• shortening >5-7mm• displaced fx base of the
ulnar styloid, • angulation >25-300 any
plane• DRUJ diastasis in PA Rö
projection
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DRUJ injury in distal radius FxDRUJ injury in distal radius Fx
Highly possible when:• shortening >5-7mm• displaced fx base of the
ulnar styloid, • angulation >25-300 any
plane• DRUJ diastasis in PA Rö
projection
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DRUJ injury in distal radius FxDRUJ injury in distal radius Fx
Highly possible when:• shortening >5-7mm• displaced fx base of the
ulnar styloid, • angulation >25-300 any
plane• DRUJ diastasis in PA Rö
projection
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DRUJ in Distal Radius FracturesDRUJ in Distal Radius Fractures
• Accurate osseus reduction first– Ulnar column stabilization
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Common pitfallsCommon pitfalls
• Radial translocation- sigmoid notch malreduction
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Common pitfallsCommon pitfalls
• Excessive volar tilt/ translocation
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DRUJ in Distal Radius FracturesDRUJ in Distal Radius Fractures
• Geissler and Fernandez Instabilty classification AFTER radius reduction– Type I: Stable– Type II: Unstable– Type III: Potentially Unstable
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Type I: StableType I: Stable
• minimally displaced avulsion tip of the ulnar styloid
• fracture of the neck of the ulna
(just fix)
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Type III: Potentially UnstableType III: Potentially Unstable
• Fx through sigmoid notch (4-part fracture) or• Ulnar head fracture
(fix & test)
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Type II: UnstableType II: Unstable
• avulsion Fx base of the ulnar styloid or• massive tear of the TFCC and/or secondary
stabilizers
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Ulnar styloid FxUlnar styloid Fx
• Management controversial• May be fixed or tends to reduce in supination• Fix when DRUJ unstable, usually base.• Make sure TFCC attaches to fragment
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Ulnar styloid FxUlnar styloid Fx
• CRIF: easier said than done; supinate
• Re-check stability
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Ulnar styloid FxUlnar styloid Fx
• ORIF: ample skin incision– Kirschner wires,– tension band wire– screw– suture anchors
• Re-check stability
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Ulnar styloid FxUlnar styloid Fx
• ORIF– Dedicated plates
• Re-check stability
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Ulnar styloid FxUlnar styloid Fx
• However, if no clinical instability, value of fixation questionable
152 pts with displaced fx involving 75% of ulnar styloid
– 76 treated and 76 untreated
• The fracture itself trended to worse outcomes than if there was no fracture
• No differences noted between the treated group and the untreated group
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The unsolved questionThe unsolved question• How do you define and test DRUJ stability in
the acute setting?
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DRUJ in Distal Radius FracturesDRUJ in Distal Radius Fractures
If DRUJ stable after osseus fixation (distal radius ± ulna):
• Immobilize in stable position for 4-6 weeks– Sugartongue splint– Avoid excessive pronation (DRUJ stable but
associated w loss of forearm motion)
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DRUJ in Distal Radius FracturesDRUJ in Distal Radius Fractures
Congruent reduction with an unstable joint, consider:
• Cross pinning– Pin breakage
• TFCC repair• External fixation
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Galeazzi Fx DlGaleazzi Fx Dl
• Accurate ORIF first• Same principles for DRUJ as for distal radius Fx
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Essex Lopresti injuryEssex Lopresti injury
Failure of the IOM• Acute• Secondary to overload following Radial Head Excision
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Essex Lopresti injury- DiagnosisEssex Lopresti injury- Diagnosis
• Distal Radioulnar Joint pain and dissociation
• Distraction-compression X-rays
• Intraoperative manual testing
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Essex Lopresti injury- DiagnosisEssex Lopresti injury- Diagnosis
• MRI
• Ultrasound
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• Radial Head Reconstruction- Replacement (Titanium-Vitallium-Allograft)
• DRUJ reduction- pinning in supination
• TFCC repair
Mayhall 1981, Morrey 1981, Gordon 1982
Acute Essex Lopresti injury-TreatmentAcute Essex Lopresti injury-Treatment
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Essex Lopresti injury- complicationsEssex Lopresti injury- complications
• Proximal radial migration• Symptomatic DRUJ
subluxation
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Essex Lopresti- Chronic insufficiencyEssex Lopresti- Chronic insufficiency
• Ulnar shortening • Radial Head Replacement
Results inconsistent
Bowers 1999
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Essex Lopresti- Chronic insufficiencyEssex Lopresti- Chronic insufficiency
• Attempts at IOM reconstruction
60%
40%
35%
75%250
120mm
BPTB
IOM
FCR
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Acute DRUJ instabilityDistal radius-Galeazzi-Essex Lopresti
TFCC management
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The unsolved questionThe unsolved question• How do you define and test DRUJ stability in
the acute setting?
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Wrist arthroscopy in distal radius FxWrist arthroscopy in distal radius FxConcomitant lesions increasingly recognized:• ΤFCC ≈60% (43-78%)
• SL lig.≈ 40% (32-75%)
• LT lig. ≈20% (15-61%)
• Chondral lesions ≈20% (19-32%)
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Arthroscopically assisted reduction Arthroscopically assisted reduction
• Currently indicated in selected injuries– Radial styloid Fx– Die Punch Fx– Three & Four part Fx– DRUJ instability
Especially in young, high demand patients
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1. Radial styloid
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1. Radial styloid
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1. Radial styloid
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2. die punch2. die punch
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3. Three & Four part fractures3. Three & Four part fractures
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3. Three & Four part fractures3. Three & Four part fractures
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Palmer ClassificationPalmer Classification• Traumatic (Class 1)
• Degenerative (Class 2)- associated with ulnocarpal impaction syndrome
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Central tear
Peripheral tear)
Radial tear
Tear locationTear location
Deep bundle of TFCC
Volar radioulnar lig.
radius
ulna
N.D
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1. Central TFCC lesions1. Central TFCC lesions• Poorly vascularized- healing potential minimal• Arthroscopic debridement up to 2/3 of
articular disc
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• Debridement ± pinning
1. Central TFCC lesions1. Central TFCC lesions
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• Debridement ± pinning
Darlis & Sotereanos, JHS(A), 2006
1. Central TFCC lesions1. Central TFCC lesions
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1. Central TFCC lesions1. Central TFCC lesions
• Often degenerative and associated with ulnocarpal impaction syndrome
• Ulnar recession procedure to prevent symptom recurrence
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Arthroscopic Wafer procedureArthroscopic Wafer procedure
• Preferred when modest shortening needed
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2. Radial TFCC tears2. Radial TFCC tears• Repair or debridement?
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2. Radial TFCC tears2. Radial TFCC tears• Repair if:
– VRUL or DRUL are involved– DRUJ instability
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3. Peripheral (ulnar) TFCC tears3. Peripheral (ulnar) TFCC tears
• Well vascularized• Repairable
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Usual location of peripheral tearsUsual location of peripheral tears
Dorsal
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Usual location of peripheral tearsUsual location of peripheral tears
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REPAIR TO CAPSULE REATTACH TO FOVEAOR
TFCC TFCC
3. Peripheral (ulnar) TFCC tears3. Peripheral (ulnar) TFCC tears
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REPAIR TO CAPSULE
REATTACH TO FOVEA
OR
3. Peripheral (ulnar) TFCC tears
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Hook test
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REPAIR TO CAPSULE
TFCC
3. Peripheral (ulnar) TFCC tears3. Peripheral (ulnar) TFCC tears
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REPAIR TO CAPSULE
TFCC
3. Peripheral (ulnar) TFCC tears3. Peripheral (ulnar) TFCC tears
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TFCC managementTFCC management
REATTACH TO FOVEA
TFCC
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TFCC managementTFCC management
REATTACH TO FOVEA
TFCC
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REATTACH TO FOVEA
TFCC
3. Peripheral (ulnar) TFCC tears3. Peripheral (ulnar) TFCC tears
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REATTACH TO FOVEA
TFCC
3. Peripheral (ulnar) TFCC tears3. Peripheral (ulnar) TFCC tears
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REATTACH TO FOVEA
TFCC
3. Peripheral (ulnar) TFCC tears3. Peripheral (ulnar) TFCC tears
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REATTACH TO FOVEA
TFCC
3. Peripheral (ulnar) TFCC tears3. Peripheral (ulnar) TFCC tears
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REATTACH TO FOVEA
TFCC
3. Peripheral (ulnar) TFCC tears3. Peripheral (ulnar) TFCC tears
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REATTACH TO FOVEA
TFCC
3. Peripheral (ulnar) TFCC tears3. Peripheral (ulnar) TFCC tears
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REATTACH TO FOVEA
TFCC
3. Peripheral (ulnar) TFCC tears3. Peripheral (ulnar) TFCC tears
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REATTACH TO FOVEA
3. Peripheral (ulnar) TFCC tears3. Peripheral (ulnar) TFCC tears
Alternative: Mini open
Chou, Sarris, Sotereanos, JHS(B), 2003
U
EDM ECU
Incision
Chou, Sarris, Sotereanos JHS(B), 2003
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Arthroscopically assisted reduction Arthroscopically assisted reduction
Need for routine TFCC repair unproven
But repair if:• DRUJ unstable• Young active patient
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Take Home MessagesTake Home Messages
• Much known about biology and biomechanics of DRUJ
• Little known about treatment outcomes from DRUJ disruption
• Restore osseous anatomy first• Address residual instability with soft tissue
procedures• TFCC has capacity to heal- IOM does not
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Take Home MessagesTake Home Messages
• In young active patients tend to:– Fix styloid base fx– Repair TFCC
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Whatever you doWhatever you do• Remenber Vit C for disproportionate pain• Reassess ligaments and TFCC status after
fracture healing– Still window of opportunity
ACUTEGood Healing Potential
SUBACUTEUnpredictable
CHRONICPoor Healing Potential
0 6 months 1 year
3mo 6mo
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THANK YOUTHANK YOU
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