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HAND AND MICROSURGERY > DRUJ AND TFCC INJURIES > Flashcards

DRUJ AND TFCC INJURIES Flashcards

1
Q

4 main conditions associated with DRUJ

A
  1. DRUJ instability = acute vs. chronic
  2. TFCC tears
  3. Ulnocarpal abutment syndrome
  4. DRUJ arthritis
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2
Q

Movement at the DRUJ

A

ROC of sigmoid notch 15mm
ROC of ulnar head 10mm
Results in rotation and translation
Pronation associated with dorsal translation
Supination associated with volar translation

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3
Q

Shape of DRUJ articular surfaces in coronal plane

A
  1. Parallel = most common
  2. Oblique
  3. Reverse oblique
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4
Q

Shape of DRUJ articular surfaces in axial plane

A
  1. Flat = most common
    - flat DRUJ = higher risk of instability
  2. C-type
  3. S-type
  4. Ski slope
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5
Q

Fovea and ulnar styloid attachments

A

Fovea
- at base of ulnar styloid
- devoid of articular cartilage
- primary attachment for radioulnar ligaments
- secondary attachment for ulnocarpal ligaments
Ulnar styloid
- secondary attachment for radioulnar ligaments

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6
Q

Stabilisers of the DRUJ

A

Static vs. dynamic or bony vs. soft-tissue
Static stabilisers:
1. Articular congruity = minor factor
- max articular contact in neutral rotation = 60%
- min articular contact in terminal pronation/ supination = 10%
2. Capsule
3. Ligaments = TFCC
4. Interosseous membrane
Dynamic stabilisers:
1. ECU
2. PQ

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7
Q

Structures that form TFCC

A
  1. Superficial and deep dorsal radioulnar ligaments
    - main dorsal stabilisers
    - taut in pronation
  2. Superficial and deep volar radioulnar ligaments
    - main volar stabilisers
    - taut in supination
  3. Central articular disc
    - central 2/3 avascular with no healing potential
  4. Meniscal homolog
  5. Ulnar collateral ligament
  6. Origin of ulnotriquetral and ulnolunate ligaments
  7. ECU subsheath
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8
Q

Blood supply to TFCC

A
  1. Dorsal and volar branches of anterior interosseous artery
  2. Radiocarpal branches of ulnar artery
    - ulnar aspect and peripheral 1/3 are vascular
    - radial aspect and central 2/3 are avascular
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9
Q

Origin and insertion of radioulnar ligaments

A

Origin = sigmoid notch of radius
Insertion
- deep fibres = fovea
- superficial fibres = ulnar styloid

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10
Q

Positive fovea sign

A
  • Tenderness in foveal soft spot = depression bounded by FCU tendon, ECU tendon, ulnar styloid and triquetrum
  • 90% sensitivity and specificity for TFCC or ulnocarpal ligament tears
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11
Q

Ulnocarpal stress test

A
  • Wrist in pronation and ulnar deviation
  • Axial load with flexion and extension of wrist
  • Positive test is reproduction of pain
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12
Q

Classification of TFCC injuries

A

Palmer classification = based on mechanism of injury and location of tear
Class 1 = traumatic TFCC tears
Class 2 = degenerative TFCC tears
- central tears are most common

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13
Q

General principles for management of traumatic and degenerative TFCC tears

A 
Traumatic tears:
1. Immobilisation = supination cast 4/52 + SA cast 2/52
2. Repair
3. Reconstruction
Degenerative tears:
1. Immobilisation
2. Debridement
3. Address underlying cause
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14
Q

3 indications for surgical management of traumatic TFCC tears

A
  1. Failure of nonoperative measures = persistent pain
  2. Joint instability
  3. Associated fractures = anatomical reduction of fractures often restores stability
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15
Q

Plain radiographs to assess DRUJ

A

90-90 position with forearm in neutral rotation

  • On PA view, neutral position indicated by ECU groove lying radial to ulnar styloid
  • On lateral view, neutral position indicated by pisiform lying midway between scaphoid tubercle and volar capitate
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16
Q

MRI for assessment of TFCC injuries

A
  • MRI is best imaging modality for TFCC tears
  • T2 weighted images best = look for high signal
  • sensitivity = 80-100%
17
Q

Arthroscopic assessment of TFCC instability

A

Trampoline test = hypermobility indicates TFCC instability

18
Q

Radiographic assessment of DRUJ instability

A
  • Axial CT is best
  • Multiple methods
  • Congruency method = congruency of arcs formed by sigmoid notch and ulnar head
19
Q

Differentials for ulnar-sided wrist pain

A 
Bony vs. soft-tissue
Bony causes:
1. Distal radius fracture
2. Distal ulna fracture
3. DRUJ injury
4. Essex-Lopresti injury
5. Triquetral/ pisiform/ hamate fracture
6. Kienbock's Disease
7. Ulnocarpal abutment
8. Ulnocarpal arthritis
9. LT arthritis
Soft-tissue causes:
1. FCU tendonitis
2. ECU tendonitis
3. TFCC injury
4. LT ligament injury
5. Ulnar nerve neuroma
20
Q

Principles of surgical management of Galeazzi injuries

A

Anatomical reduction and fixation of radius fracture
Screen DRUJ stability:
1. Stable = early ROM
2. Unstable but reducible
- immobilise in reduced position
dorsal dislocations reduce and stable in supination
volar dislocations reduce and stable in pronation
- K-wires/ TFCC repair/ ulnar styloid fixation
3. Irreducible
- open reduction via dorsal L-shaped incision
- remove blocks to reduction = ECU tendon
- K-wires/ TFCC repair/ ulnar styloid fixation

21
Q

Indications for TFCC reconstruction

A
  1. Chronic non-repairable TFCC tears causing joint instability
  2. No arthritis
22
Q

Aetiology of DRUJ arthritis

A

4IT CASH or traumatic vs. atraumatic

  1. Idiopathic/ primary OA
  2. Inflammatory = RA
  3. Instability
  4. Traumatic
23
Q

5 main surgical options for DRUJ arthritis

A
  1. Darrach procedure
  2. Sauve-Kapandji procedure
  3. Wafer procedure
  4. Ulna hemiresection arthroplasty
  5. Ulna head replacement
24
Q 
Darrach procedure:
Advantages
Disadvantages
Indications
Contraindications
Technique
A
  1. Advantages
    - technically easier
    - faster recovery = shorter immobilisation
  2. Disadvantages = 4 main complications are
    - stump instability
    - radioulnar convergence
    - ulnocarpal translocation
    - weakness
  3. Indications
    - elderly low-demand patients
    - ulnocarpal and DRUJ arthritis
    - RA patients without ulnocarpal translocation
  4. Contraindications = high-demand patients
  5. Technique
    - Subperiosteal exposure of the ulnar head
    - Ulnar osteotomy proximal to sigmoid notch (max 2cm)
    - Preservation of ulnar styloid and its attachments
    - Bevel end of stump to smooth bullet shape to prevent tendon attrition
    - Interposition of PQ between radius and stump to prevent radioulnar convergence
    - Volar capsulodesis to dorsal ulna to stabilise stump
25
Q 
Sauve-Kapandji procedure:
Advantages
Disadvantages
Indications
Contraindications
Technique
A
  1. Advantages
    - less stump instability
    - no radioulnar convergence
    - no ulnocarpal translocation
    - less weakness
  2. Disadvantages
    - technically harder
    - slower recovery = 6wks immobilisation
    - complications = stump instability, nonunion
  3. Indications
    - active high-demand patients
    - ulnocarpal and DRUJ arthritis
    - RA patients with ulnocarpal translocation
  4. Contraindications = risk factors for nonunion
  5. Technique
    - Dorsal approach through 5th extensor compartment
    - L-shaped capsulotomy to expose DRUJ
    - Pass 2x K-wires into ulnar head
    - Prepare DRUJ surfaces
    - Centre ulnar head in sigmoid notch
    - Advance wires across sigmoid notch into radius
    - Pass 2x cannulated screws over wires
    - Resect 10mm of ulna proximal to DRUJ

HAND AND MICROSURGERY (63 decks)

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