Deep fiber tears lead to distal radioulnar joint instability

Robert W. Wysocki

BOSTON — Tears of the triangular fibrocartilage complex superficial fibers that leave the deep fibers intact can be repaired with an outside-in repair of the articular disc back to the ulnar capsule, according to a study presented here.

Robert W. Wysocki, MD, described his team’s findings at the 2010 Annual Meeting of the American Society for Surgery of the Hand.

He noted that the repair method demonstrates a significant improvement in pain and function with no measurable objective losses.

“Our hypothesis was that patients with [triangular fibrocartilage complex] tears of the superficial fibers would present with ulnar-sided wrist pain, and no evidence of [distal radioulnar joint] instability, and would be effectively treated by repairing the articular disc back to the ulnar capsule from which it likely tore,” Wysocki said.

Retrospective review

Wysocki’s team treated 29 wrists for peripheral triangular fibrocartilage complex (TFCC) tears during a 2-year period, utilizing outside-in suture repair of the articular disc to the ulnar capsule. They then retrospectively reviewed all of the cases to assess the physical exam, MRI, and intraoperative findings.

Patients were reportedly evaluated at a follow-up of greater than 1 year with clinical outcome measures including range of motion, grip strength, DASH scores, Visual Analogue Scale (VAS) scores and a survey that assessed return to work and sport.

Study results

Preoperatively, all of the patients complained of ulnar-sided wrist pain and presented with foveal tenderness, but had a clinically stable distal radioulnar joint (DRUJ). MRI revealed that the deep fibers in all cases were intact and inserted into the fovea, with superficial fibers performing comparatively in 22 (76%) cases.

At 31 months, 27 wrists (93%) were available for follow-up. Wysocki reported improved DASH and VAS scores at the final follow-up, with side-to-side comparisons demonstrating no measurable loss in range of motion or grip strength.

Wysocki noted that there were no cases of clinical DRUJ instability at the final follow-up. Out of 12 high-level athletes in the total cohort, seven (58%) were able to return to sport.

“Return to sport was somewhat interesting,” he said. “Sixty-four percent returned to their sport at the same level, with 100% of the racquet sport patients returning, but 0% of the patients who weight-bear through their hands, such as gymnasts or martial artists.”

No objective losses

“I think we demonstrated excellent pain and functional outcome scores in this very specific patient population of TFCC tears with no objective losses compared to the contralateral side,” Wysocki concluded.

He added that return to sport for these patients is variable depending upon the sport played, and the return to sport may be worse for those who weight-bear through their hands.

Reference:
Wysocki RW, Ruch DS. Arthroscopic treatment of peripheral triangular fibrocartilage complex tears with the deep fibers intact. Presented at the 2010 Annual Meeting of the American Society for Surgery of the Hand. Oct. 7-9. Boston.

The authors bring to our attention an arthroscopic method to repair TFCC injuries of the superficial portion of the DRUJ ligament.

I believe the importance of this presentation lies in the fact that the presenter has made a distinction in Palmer 1B tears. The clinician needs to be aware of the fact that if the deep foveal fibers are also torn, instability can result. He presents tears of the more superficial portion of the ligament, which are amenable to arthroscopic repairs.

The take-home message is that not all 1B tears are the same.

— Steven L. Moran, MD

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