关节镜下治疗腕三角软骨损伤

关节镜下治疗腕三角软骨损伤2024/12/6Lesionsofthetriangularfibrocartilagecomplex(TFCC)areacommonsourceofulnarsidedwristpain.1,2Radialsidetearorperforationstendtobetraumaticandoccursmoreinyoungagegroup,ontheotherhand,centralandulnarsidelesionsaremoreoftendegenerativeandcommonlyseeninolderpatients21.PSMcAlinden,JTeh,.Imagingofthewrist.Imaging2003;15:180-1922.PhilipE.Blazar,PeterS.H.Chan,J.BruceKneeland,DonaldLeatherwood,DavidJ.Bozentka,RomanKowalchick,.TheEffectofObserverExperienceonMagneticResonanceImagingInterpretationandLocalizationofTriangularFibrocartilage.HandSurg2001;26A:742–748AnatomyTFCCTFCCTriangularfibrocartilage(articulardisc)MeniscushomologueUCL(ulnarcapsule)VolarandDorsalDRULigamentsECUsubsheathPrestyloidrecess2024/12/6A3DdepictionoftheTFCCArthroscopyComplexfibrousstructureonvolaraspectofwristOrigin-dorsaldistalcornerofsigmoidnotchInsertion-triquetrumandbaseoffifthmetatarsalPartiallyorcompletelyseparatespisotriquetraljointfromradiocarpaljointMENISCUSHOMOLOGUEULNOLUNATEANDULNOTRIQUETRALLIGAMENTSFromvolaraspectofradioulnarligamenttolunateandTriquetrumFirmlyattachedtotriquetrumLessstrongattachmenttolunateULNOLUNATEANDULNOTRIQUETRALLIGAMENTSFromvolaraspectofradioulnarligamenttolunateandtriquetrumType1-TraumaticAHorizontaltearadjacenttotheradiusBPeripheraldetachmentfromtheulnaCTearoftheUlnocarpalligamentsDAvulsionfromsigmoidnotchPALMERCLASSIFICATIONTypeII-DegenerativeAPartialthicknessthinningofthearticulardiscBA+Chondromalaciaoflunateand/orulnarheadCB+fullthicknesstearofthearticulardiscDC+PartialtearofthelunatotriquetralligamentED+FulltearofthelunatotriquetralligamentandarthrosisPALMERCLASSIFICATIONTFCCTRAUMATICTEAR2024/12/6Anatomy2024/12/6TheulnarportionoftheTFCCisvascularisedbyulnarandposteriorinterosseousartery

brachesThecentralandradialaspectsofthecomplexareavascularVascularsupplyTransmitloadStablisetheDRUJbiomechanicalfunctionsbiomechanicalfunctions2024/12/61)stabilityofthedistalradioulnarjoint(DRUJ),2)axialloadtransmissionfromthecarpustotheulnaand3)ulnarsidedcarpalstability.NaturalHistory<20yearsnoTFCperforations>60years50%hadTFCperforationsFallondorsiflexedandulnardeviated

wristAxialloadwithforearminhyperpronationSymptomsUlnarsidedwristpainQuitewelllocalisedUsuallywithulnardeviationSuddenpronationactivityClickingonrotationInstabilityisrareTheTFCCappearsverysimilartothekneemeniscusonMRIimages1)stabilityofthedistalradioulnarjoint(DRUJ),StablisetheDRUJAHorizontalteartear(arrow)involvingthethicker,AxiallyloadattachmentoftheTFCUlnarsidedwristpainFromvolaraspectMRIorArthrographyproximallunatealargecentraltear(arrow)alongtheradialaspectofthearticulardiscoftheTFCC.VolarandDorsalDRURadialsidetearorperforationstendtobetraumaticandoccursmoreinyoungagegroup,ontheotherhand,centralandulnarsidelesionsaremoreoftendegenerativeandcommonlyseeninolderpatients22)axialloadtransmissionfromthecarpustotheulnaandSignsPronationUlnardevationAxiallyloadRotateInvestigationsX-rayMRIArthroscopySonographArthroscopy--------goldstandard2024/12/6Usingarthroscopyasthegoldstandard,MRIhasbeenshowntohaveanaccuracyof64–

75%forperforationsortears.1TheinhomogeneoussignalintensityandstriatedappearanceoftheTFCCespeciallytheulnarsidemaymakethesedisruptionsmore

difficulttodetectPSMcAlinden,JTeh,.Imagingofthewrist.Imaging2003;15:180-192MariusRSchmid,ThomasSchertler,ChristianWPfirrmann,NadjaSaupe,MirjanaManestar,SimonWildermuthetal.Interosseousligamenttearsofthewrist:comparisonofmulti-detectorrowCTarthrographyandMRimaging.Radiology2005;237:1008-1013TFCCTearPathoanatomyTearinstructuresofTFCCPositiveulnarvariancepredisposestoinjury2024/12/6arthrogramatearatthepararadialpartoftheTFCC(site2)B:coronalT1WFatSatsequenceconfirmingthearthrogramfindingandclearlyshowthetear(arrow).About60-70%oftheTFCCtearsareassociatedwithulnarstyloidfractureJLJLHobby,BDBDTom,PWPWBearcroft,AKAKDixon.Magneticresonanceimagingofthewrist:diagnosticperformancestatistics.ClinRadiol2001;56:50-57ultra-high-frequencysonographCase2,debridementAssociatedsubchondraldegenerativechangesareevidentwithinthe<20yearsnoTFCperforationsPSMcAlinden,JTeh,.adiscreteverticalType1-TraumaticUlnarShorteningInstabilityisrareUsingarthroscopyasthegoldstandard,MRIhasbeenshowntohaveanaccuracyof64–HandSurg2001;26A:742–748centraltearVolarandDorsalDRUECUsubsheathOrigin-dorsaldistalcornerofsigmoidnotchSteroidinjection(10mgKenolog)2024/12/6TheTFCCappearsverysimilartothekneemeniscusonMRIimagesOnesonSR,TiminsME,ScalesLM,EricksonSJ,ChamoyL.MRimagingdiagnosisoftriangularfibrocartilagepathologywitharthroscopiccorrelation.AJRAmJRoentgenol1997;168:1513-1518.TFCCTRAUMATICTEARTFCCTearImagingPlainfilmsmayshowpositiveulnarvarianceAssessforfractureorulnarsubluxationMRIorArthrographyalargecentraltear(arrow)alongtheradialaspectofthearticulardiscoftheTFCC.Associatedsubchondraldegenerativechangesareevidentwithintheproximallunate2024/12/62024/12/6Atypicaldegenerativecentraltearadiscreteverticaltear(arrow)involvingthethicker,volarradioulnarligamentcomponentoftheTFCC.2024/12/62024/12/6avulsionoftheulnarstyloidattachmentoftheTFC2024/12/6TFCCtearswereclassifiedaccordingtoitslocationas1ifitwasatthecartilageattachmenttotheradius;2,pararadial(2–3mmfromtheradius);3,atthemidportion;4,paraulnar(2–3mmfromtheulnarinsertionpointoftheTFC);or5,attheulnarinsertionpoint(Fig4)2024/12/6locationoftheTFCCtears2024/12/6arelativelybigcommunicatingtear(arrowhead)closetotheradialattachmentoftheTFCCwithmorefatsatsequencesasrequired2024/12/6Asmallcentralperforation(arrow)isseenwithinthecentralportionofthearticulardiscofthetriangularfibrocartilagecomplex.Anadditional,partialthicknessundersurfacetear(arrowhead)isalsopresentatthearticulardisc.ligamenttolunateCTearoftheThemajorityofpatientspresentingwithulnarsidedwristpaincanbemanagednon-operativelyandreturnedtonormalactivities.75%forperforationsortears.SuddenpronationactivitythearticulardiscCB+fullthicknesstearofCharacteristicsofTriangularFibrocartilageDefectsinSymptomaticandContralateralAsymptomaticWrists.UlnarShorteningattachmenttotheradius;2,pararadial(2–3mmfromtheradius);3,atthemidportion;confirmingthearthrogramfindingandclearlyshowthetear(arrow).lunateand/orulnarheadRadiology2000;216:840-845.ArthroscopyLesionsofthetriangularfibrocartilagecomplex(TFCC)areacommonsourceofulnarsidedwristpain.ArthroscopicinspectionConservativeActivityavoidanceSteroidinjection(10mgKenolog)SurgeryTreatmentArthroscopicRepairDebridementShaversRadiofrequency(Vapr)–keeptheheatdownOpenRepairUlnarShorteningSurgeryVascularsupplyMENISCUSHOMOLOGUE2)axialloadtransmissionfromthecarpustotheulnaandthearticulardiscComplexfibrousstructureonvolaraspectofwrist1)stabilityofthedistalradioulnarjoint(DRUJ),>60years50%hadTFCperforationsTypeII-DegenerativeVascularsupplyDC+PartialtearoftheproximallunateArthroscopictreatmentsigmoidnotchMagneticresonanceimagingofthewrist:diagnosticperformancestatistics.Case2,debridement2024/12/6TheperipheralandcentraltearsoftheTFCCmustbedifferentiatedasthemodeof

treatmentisdifferentbetweenthetwoconditions,peripheraltearshaveagoodvascularsupplyandarerepairedhowevercentraltearsareavascularandarecommonly

managedwithdebridement.MarcoZanetti,DavidLinkous,LouisA.Gilula,JuergHodler,.CharacteristicsofTriangularFibrocartilageDefectsinSymptomaticandContralateralAsymptoma