关节镜下治疗腕三角软骨损伤英文版.ppt

Triangular Fibrocartilage Complex(TFCC)Tear2023-11-14 Lesions of the triangular fibrocartilage complex(TFCC)are a common source of ulnarsided wrist pain.1,2 Radial side tear or perforations 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 patients21.P S McAlinden,J Teh,.Imaging of the wrist.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 ImagingInterpretation and Localization of Triangular Fibrocartilage.Hand Surg 2001;26A:742748AnatomyTFCCTFCCTriangular fibrocartilage (articular disc)Meniscus homologueUCL(ulnar capsule)Volar and Dorsal DRU Ligaments ECU subsheath Prestyloid recess2023-11-14A 3D depiction of the TFCCArthroscopyComplex fibrous structure on volar aspect of wristOrigin-dorsal distal corner of sigmoid notchInsertion-triquetrum and base of fifth metatarsalPartially or completely separates pisotriquetral joint from radiocarpal jointMENISCUS HOMOLOGUEULNOLUNATE AND ULNOTRIQUETRAL LIGAMENTSFrom volar aspect of radioulnar ligament to lunate and Triquetrum Firmly attached to triquetrumLess strong attachment to lunateULNOLUNATE AND ULNOTRIQUETRAL LIGAMENTSFrom volar aspectof radioulnarligament to lunateand triquetrumType 1-TraumaticA Horizontal tearadjacent to the radiusB Peripheraldetachment from the ulnaC Tear of theUlnocarpal ligamentsD Avulsion fromsigmoid notchPALMER CLASSIFICATIONType II-DegenerativeA Partial thickness thinningof the articular discB A+Chondromalacia oflunate and/or ulnar headC B+full thickness tear ofthe articular discD C+Partial tear of thelunatotriquetral ligamentE D+Full tear of thelunatotriquetral ligamentand arthrosisPALMER CLASSIFICATIONTFCC TRAUMATIC TEAR2023-11-14Anatomy2023-11-14The ulnar portion of the TFCC is vascularised by ulnar and posterior interosseous artery brachesThe central and radial aspects of the complex are avascularVascular supplyTransmit loadStablise the DRUJbiomechanical functionsbiomechanical functions2023-11-14 1)stability of the distal radioulnar joint(DRUJ),2)axial load transmission from the carpus to the ulna and 3)ulnar sided carpal stability.Natural History60 years 50%had TFC perforationsFall on dorsiflexed and ulnar deviated wristAxial load with forearm in hyperpronationSymptomsUlnar sided wrist pain Quite well localisedUsually with ulnar deviationSudden pronation activityClicking on rotation Instability is rareSignsPronationUlnar devationAxially loadRotateInvestigationsX-rayMRI ArthroscopySonographArthroscopy-gold standard2023-11-14Using 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 ulnar side may make these disruptions more difficult to detectP S McAlinden,J Teh,.Imaging of the wrist.Imaging 2003;15:180-192Marius R Schmid,Thomas Schertler,Christian W Pfirrmann,Nadja Saupe,Mirjana Manestar,Simon Wildermuth et al.Interosseous ligament tears of the wrist:comparison of multi-detector row CT arthrography and MR imaging.Radiology2005;237:1008-1013TFCC Tear PathoanatomyTear in structures of TFCCPositive ulnar variance predisposes to injury2023-11-14 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).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 Radiol 2001;56:50-57ultra-high-frequency sonograph2023-11-14The TFCC appears very similar to the knee meniscus on MRI imagesOneson SR,Timins ME,Scales LM,Erickson SJ,Chamoy L.MR imaging diagnosis of triangular fibrocartilage pathology with arthroscopic correlation.AJR Am J Roentgenol 1997;168:1513-1518.TFCC TRAUMATIC TEARTFCC Tear Imaging Plain films may show positive ulnar variance Assess for fracture or ulnar subluxation MRI 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 the proximal lunate2023-11-142023-11-14A typical degenerative central tear a discrete vertical tear(arrow)involving the thicker,volar radioulnar ligament component of the TFCC.2023-11-142023-11-14avulsion of the ulnar styloidattachment of the TFC2023-11-14 TFCC tears were classified according to its location as 1 if it was at the cartilage attachment to the radius;2,pararadial(23 mm from the radius);3,at the mid portion;4,paraulnar(23 mm from the ulnar insertion point of the TFC);or 5,at the ulnar insertion point(Fig 4)2023-11-14location of the TFCC tears2023-11-14a relatively big communicating tear(arrow head)close to the radial attachment of the TFCCwith more fat sat sequenc