关节镜下腕关节囊外透骨修复三角纤维软骨复合体深层止点损伤

目的探讨应用腕关节镜下腕关节囊外尺骨透骨缝合技术修复三角纤维软骨复合体(triangular fibrocartilage complex, TFCC)深层止点撕裂的疗效。方法自2017年5月至2020年9月我科通过腕关节镜诊断ⅠB型TFCC损伤伴有桡尺远侧关节(distal radioulnar joint, DRUJ)关节不稳定患者25例。采用腕关节镜下腕关节囊外透骨缝合技术, 根据Mayo腕关节评分系统、DASH评分、VAS疼痛评分和手术后DRUJ关节稳定性检查等方面评价手术效果。结果 25例患者术后随访12～36个月, 平均18个月。本术式可以有效修复TFCC损伤。DRUJ评分, 术前平均3.5, 术后10;VAS评分, 术前平均5.0, 术后1.0;DASH评分, 术前平均36, 术后9;Mayo评分, 术前平均87, 术后60。术后效果优15例, 好6例, 良3例, 差1例。结论应用腕关节镜下腕关节囊外透骨缝合技术修复TFCC隐窝止点撕裂是一种安全、有效、可靠的修复方法。     

腕关节三角纤维软骨复合体损伤的关节镜治疗

目的：对外伤性腕关节三角纤维软骨复合体(TFCC)损伤关节镜治疗后疗效评价。方法：选有急慢性外伤史的13例14侧腕关节三角纤维软骨复合体损伤病例，年龄21～45岁，平均28．3岁。经关节造影、物理检查及MRI检查有异常者施行关节镜检查，其中8例TFCC中心性撕裂在关节镜下行游离边缘切除术，5例6侧TFCC边缘部撕裂施行缝合修复术，术后平均随访28个月。利用Green-O’Brien功能评定方法。结果：优9例，良3例，可2例。其中12例疗效良好以上者恢复原来工作。结论：对腕关节三角纤维软骨复合体损伤关节镜治疗是明确诊断及术后可以得到良好疗效并早期康复的一种有效术式。     

腕关节镜视下治疗三角纤维软骨复合体损伤

目的 总结应用腕关节镜技术诊断并治疗40例单纯三角纤维软骨复合体(TFCC)损伤的经验.方法 40例患者中男24例,女16例;平均年龄37.3岁.应用常规腕关节镜入路和器械对桡腕关节和腕中关节进行检查,对TFCC损伤的诊断采用Palmer分型,腕关节镜视下诊断为TFCC Ⅰ型损伤30例、Ⅱ型损伤10例.明确诊断后对TFCCⅠ A、ⅠD型行清创术;ⅠB、ⅠC型行镜下修复术;TFCCⅡ型损伤行清创术;对有尺骨撞击的TFCCⅡC和ⅡD型损伤行关节镜下尺骨头部分磨除术(Wafer术)治疗.术前和术后随访评定采用改良Mayo腕关节功能评分.结果 镜下TFCC清创及修复术均顺利;术后有1例患者出现环指主动背伸不能(后经手术探查为环指指伸肌腱断裂),余患者均无并发症;平均随访时间为11.6个月.经改良Mayo腕关节功能评分:优21例,良13例,可5例,差1例;优良率为85.0％,患者自我满意率为97.5％.结论 应用腕关节镜技术诊断并治疗TFCC损伤安全有效,随访效果确切可靠,值得推广应用.     

桡腕关节造影和MRI在腕三角纤维软骨板撕裂的诊断应用

三角纤维软骨板(triangularfibro-cartilagecomplexTFCC)撕裂是引起尺侧腕关节疼痛最常见的损伤。迄今为止,桡腕关节和下尺桡关节造影仍是诊断TFCC撕裂的有效方法[1,2],但不能显示其撕裂部位,且为侵入性检查方法。核磁共振成像(magneticresonanceimagingMRI)可多平面、多层次的显示骨和软组织结构,定位准确,为诊断TFCC提供了一条新的途径。我们对临床怀疑为三角软骨损伤的13例尺侧腕关节疼痛患者进行了桡腕关节造影,对其中8例进行了MRI检查,从所得结果来探讨两者在TFCC撕裂中的诊断作用。一、资料与方法1.一般资料:本组共13例,男10…     

创伤性三角纤维软骨复合体损伤的腕关节镜诊断及治疗

目的 评价腕关节镜对创伤性腕关节三角纤维软骨复合体(TFCC)损伤进行诊断及治疗的效果.方法 选有急慢性外伤史的16例腕关节三角纤维软骨复合体可疑损伤患者,年龄19～39岁,平均27.6岁.对经体格检查、关节造影或MRI检查有异常,疑为TFCC损伤者施行关节镜检查.按照Palmer分型:I A型6例,I B型9例,I D型1例.I A型、I D型在关节镜下行TFCC修整术,IB型行边缘部撕裂缝合修复术.结果 术后平均随访19个月.按Green-O'Brien功能评定法评定:优13例,良2例,可1例.结论 腕关节镜手术治疗TFCC是一种微创、有效、安全的治疗方式.     

三角纤维软骨复合体解剖及生物力学研究

目的从解剖完整的腕关节入手,阐明三角纤维软骨复合体各组成部分的解剖特点,评估三角纤维软骨复合体(TFCC)对于维持远侧桡尺关节稳定的重要性。方法对8个新鲜解冻的腕关节和6个经甲醛浸泡的腕关节进行显微解剖。同时对影响远侧桡尺关节稳定性的因素作了初步的评估。前臂中旋位,垂直于尺骨予20N拉力下测量尺骨相对于桡骨的位移,然后先后切断掌背侧桡尺韧带,测量尺骨相对于桡骨的位移变化。结果发现掌背桡尺韧带由三角纤维软骨盘外周增厚而成,止于尺骨茎突基底部,是维持远侧桡尺关节稳定性的主要因素之一,切断掌背侧桡尺韧带会导致远侧桡尺关节明显不稳。结论TFCC由三角纤维软骨盘、掌背侧桡尺韧带、尺骨月骨韧带、尺骨三角骨韧带、尺侧腕伸肌下腱鞘、半月板同源物、尺侧囊组成。掌背桡尺韧带是维持远侧桡尺关节稳定性的主要因素之一,掌背侧桡尺韧带损伤会导致远侧桡尺关节明显不稳。     

腕关节镜下治疗三角纤维软骨复合体损伤

目的 探讨腕关节镜下治疗三角纤维软骨复合体(triangular fibrocartilage complex,TFCC)损伤的方法及疗效.方法 2006年1月-2008年12月,收治TFCC损伤16例.男11例,女5例;年龄25～51岁,平均32.5岁.扭伤12例,跌伤4例.左侧10例,右侧6例.病程3个月～6年2个...     

外踝解剖型钩状钢板在Weber A型踝部骨折固定中的生物力学分析

目的探讨外踝解剖型钩状钢板在WeberA型踝部骨折固定中的生物力学作用及优势。方法选用2005年6月-2006年10月经防腐处理的成人尸体下肢标本（含完整膝关节）48个，男26个，女22个；年龄18～55岁。将外踝以线锯于踝关节平面处横行截断，制备WeberA型骨折模型。随机将模型分成4组（n=12），A、B、C、D组分别采用外踝解剖型钩状钢板、螺钉、1／3管型钛合金钢板和标准张力带固定。每组再分为2个亚组（n=6），A1、B1、C1、D1组进行压力实验，A2、B2、C2、D2组进行抗扭矩实验，测量各自的峰值并进行比较。结果A1、B1、c1、D1组的压力实验峰值分别为（799．83±105．47）、（699．17±63．81）、（598．83±123．14）、（453．00±111．67）N，A1组显著高于其他3组（P〈0．01）。A2、B2、C2、D2组的扭矩实验峰值分别为（37．17±1．81）、（30．33±2．22）、（20．50±2．92）、（24．83±3．47）Nm，A2组显著高于其他3组（P〈0．01）。结论外踝解剖型钩状钢板在外踝骨折的诸多固定方法中有明显优势。     

小切口第一跖骨远端截骨术矫正踇外翻畸形

目的：探讨小切口第一跖骨远端截骨术矫正踇外翻畸形的疗效。方法：2003年以来采用小切口第一跖骨远端截骨术治疗踇外翻畸形300例共542只足，不做内固定。对所有患者采用美国骨科足踝外科学会（AOFAS）蹲趾-跖趾-趾间评分标准进行临床评估，并结合影像学诊断综合评价手术疗效。结果：AOFAS总平均分为89．4±10．2分。影像学评估，术后踇外翻角（HVA）为12．8°±5．8°（4°～22°），较术前34．6°±9．6°（18°～68°）改善22°±8．4°；第一二跖骨间角（IMA）为7．6°±1．8（6°～11°），较术前14．3°±3．2°（11°～21°）改善6．7°±2．4°，P〈0．05表示有显著性差异。542只患足，498只对术后疗效满意，满意率91．5％。结论：小切口第一跖骨远端截骨术矫正踇外翻，临床效果可靠，不需内固定，手术切口美观，值得推广。     

三角纤维软骨复合体损伤的诊断和治疗研究进展

三角纤维软骨复合体(Triangular fibrocartilage complex,TFCC)是腕部一个解剖学和生物力学意义上的多种坚韧组织复合体。具有承受、传递和缓冲压力的作用,是维持腕关节尺侧稳定的主要结构,也是桡尺远侧关节的主要稳定结构之一。近年来,随着对其解剖及生物力学研究不断深入,已认识到TFCC损伤是尺侧腕痛、尺骨撞击征及桡尺远侧关节(Distal radioulnar jont,DRUJ)不稳定等症的主要原因,并在诊断和治疗方面取得了新的进展。     

Editorial Commentary: In Cases of Concurrent Triangular Fibrocartilage Complex Tears and Ulnar Styloid Process Fracture Nonunions,We May Neither Need to Excise nor Repair the Ulnar Styloid Fracture Nonunion Fragment

The ulnar-sided wrist contains multiple potential pain generators that may present in isolation. Occasionally, however, wrist trauma results in multiple concurrent and overlapping injuries that make diagnosis and treatment of these conditions challenging. Deep/foveal tears of the triangular fibrocartilage complex (TFCC) may occur in the setting of nonunited ulnar styloid process fractures. Treatment of these injuries has historically included open TFCC repair with fixation or excision of the ulnar styloid fracture nonunion fragment; however, recent literature suggests that addressing the ulnar styloid nonunion fragment may not be as important as we think. Recent research shows that we may not need to excise or repair the ulnar styloid fracture nonunion fragment, which in turn may help preserve the complex ligamentous architecture that stabilizes the ulnar-sided wrist. One thing we know for sure is that foveal tears of the deep fibers of the TFCC, with or without ulnar styloid fracture (Palmer 1B, Atzei class 2 or 3), can produce distal radioulnar joint (DRUJ) instability and wrist dysfunction and should be addressed sooner rather than later to prevent long-term consequences, including DRUJ osteoarthritis. Whether you choose to approach the problem arthroscopically or open, the foveal TFCC tear should be repaired to prevent long-term sequalae.     

腕关节镜下治疗尺骨茎突骨折

目的 探讨腕关节镜监视下治疗尺骨茎突骨折的方法,以获得更好的治疗效果.方法 对15例尺骨茎突骨折的患者,在C臂透视机及腕关节镜监视下先将合并的桡骨远端骨折进行复位,经皮穿针内固定或切开复位钢板内固定,然后在腕关节镜下检查三角纤维软骨复合体(triangular fibrocartilage complex,TFCC)是否损伤,并作修整、清理等相应的处理,在关节镜监视下将尺骨茎突骨折复位,经皮作钢丝张力带内固定.结果 11例合并有TFCC损伤,经平均15.4个月的临床随访,X线片检查显示尺骨茎突骨折全部骨性愈合,骨性愈合时间平均5.2个月.按照Green-O'Brien功能评定方法进行腕关节功能评定,优良率为93.3%,无腕关节尺侧疼痛及腕关节不稳等并发症发生.结论 腕关节镜下治疗尺骨茎突骨折既可以对骨折进行有效的复位及固定,有利于骨折的愈合;又可以了解腕关节内TFCC等结构的损伤程度,便于早期处理,以免遗留慢性腕痛或腕关节不稳定.     

Pathomechanisms of ulnar ligament lesions of the wrist in a cadaveric distal radius fracture model

Background and purpose

Mechanisms of injury to ulnar-sided ligaments (stabilizing the distal radioulnar joint and the ulna to the carpus) associated with dorsally displaced distal radius fractures are poorly described. We investigated the injury patterns in a human cadaver fracture model.

Methods

Fresh frozen human cadaver arms were used. A dorsal open-wedge osteotomy was performed in the distal radius. In 8 specimens, pressure was applied to the palm with the wrist in dorsiflexion and ulnar-sided stabilizing structures subsequently severed. Dorsal angulation was measured on digitized radiographs. In 8 other specimens, the triangular fibrocartilage complex (TFCC) was forced into rupture by axially loading the forearm with the wrist in dorsiflexion. The ulnar side was dissected and injuries were recorded.

Results

Intact ulnar soft tissues limited the dorsal angulation of the distal radius fragment to a median of 32^o (16–34). A combination of bending and shearing of the distal radius fragment was needed to create TFCC injuries. Both palmar and dorsal injuries were observed simultaneously in 6 of 8 specimens.

Interpretation

A TFCC injury can be expected when dorsal angulation of a distal radius fracture exceeds 32^o. The extensor carpi ulnaris subsheath may be a functionally integral part of the TFCC. Both dorsal and palmar structures can tear simultaneously. These findings may have implications for reconstruction of ulnar sided soft tissue injuries.A complex of ligaments on the ulnar side of the wrist supports the stability of the ulnocarpal and the distal radioulnar (DRU) joints. Included in this are the extensor carpi ulnaris (ECU) subsheath and the triangular fibrocartilage complex (TFCC), which is further subdivided into the radioulnar ligaments (RULs), the ulnotriquetral ligament (UT), and the ulnolunate (UL) ligament (Garcia-Elias 1998, Berger 2001). Injuries to the TFCC are common in dorsally angulated fractures of the distal radius fracture (Colle''s fracture) and may adversely affect functional outcome (Lindau et al. 2000). The pathomechanics of these injuries are poorly studied, however.During wrist arthroscopy, we have observed two lesions that are often present when treating TFCC lesions associated with distal radius fractures: (1) a separation of the floor of the ECU tendon sheath from the TFCC, and (2) an injury to the foveal insertion of the TFCC into the ulna. It seems probable that there must be a limit to how much the distal radius fragment can be displaced without rupture of the TFCC or fracture of the ulna.We investigated the characteristics of a TFCC injury in a cadaveric fracture model of dorsally displaced fractures. We hypothesized that (1) a TFCC lesion can be expected at a certain degree of displacement and that (2) a rupture of the foveal insertion would begin in the palmar capsule and progress dorsally, due to the dorsal displacement of the distal radius fragment.     

Pathomechanisms of ulnar ligament lesions of the wrist in a cadaveric distal radius fracture model

Background and purpose Mechanisms of injury to ulnar-sided ligaments (stabilizing the distal radioulnar joint and the ulna to the carpus) associated with dorsally displaced distal radius fractures are poorly described. We investigated the injury patterns in a human cadaver fracture model.

Methods Fresh frozen human cadaver arms were used. A dorsal open-wedge osteotomy was performed in the distal radius. In 8 specimens, pressure was applied to the palm with the wrist in dorsiflexion and ulnar-sided stabilizing structures subsequently severed. Dorsal angulation was measured on digitized radiographs. In 8 other specimens, the triangular fibrocartilage complex (TFCC) was forced into rupture by axially loading the forearm with the wrist in dorsiflexion. The ulnar side was dissected and injuries were recorded.

Results Intact ulnar soft tissues limited the dorsal angulation of the distal radius fragment to a median of 32^o (16–34). A combination of bending and shearing of the distal radius fragment was needed to create TFCC injuries. Both palmar and dorsal injuries were observed simultaneously in 6 of 8 specimens.

Interpretation A TFCC injury can be expected when dorsal angulation of a distal radius fracture exceeds 32^o. The extensor carpi ulnaris subsheath may be a functionally integral part of the TFCC. Both dorsal and palmar structures can tear simultaneously. These findings may have implications for reconstruction of ulnar sided soft tissue injuries.     

Ulnar wrist pain after Colles' fracture: 109 fractures followed for 4 years

109 patients with unilateral Colles' fracture, treated with closed reduction and cast immobilization, were re-examined after 4 (1-9) years. At follow-up, 40 patients had persistent ulnar wrist pain. The most important factor for predicting ulnar pain was final dorsal angulation of the radius. Initial and final radial shortening, fracture of the distal radioulnar joint, ulnar styloid fracture, or instability of the distal ulna were not correlated to ulnar wrist pain. We suggest that ulnar wrist pain following Colles' fracture is caused by incongruity of the distal radioulnar joint.     

Outcome study of arthroscopic suturing of ulnar avulsions of the triangular fibrocartilage complex of the wrist

INTRODUCTION: Ulnar wrist pain due to a TFCC lesion is frequent. Based on studies of the vascularity, ulnar avulsion can be sutured. Arthroscopic techniques have been designed but results are sparsely published. MATERIALS AND METHODS: This is a retrospective study of 35 patients with an ulnar avulsion of the TFCC. All the patients were treated with an originally designed arthroscopical technique. The evaluation was focused on the subjective and functional ouome. A pain score and a DASH score were used. RESULTS: The general impression was positive with a mean DASH score of 15 points. Two-thirds of the patients had a DASH score totaling less than 20. Twenty-nine patients had a good outcome, six were fair or poor. CONCLUSION: Arthroscopical repair of the TFCC is a reliable and useful technique.     

Ulnar styloid impingement syndrome

The tip of an excessively long ulnar styloid can impinge upon the triangular fibrocartilage complex (TFCC) against the triquetrum. The subtleties in biomechanics of the wrist joint and their role in the production of the symptoms are presented as five cases from a retrospective study. The relationship of the symptoms to the patients’ job activities is also discussed. The embryological and anatomical studies show that the tip of the ulnar styloid is covered by the TFCC. Therefore, the term “ulnar styloid impingement syndrome” is adopted for the entity in cases in which the TFCC has remained intact.     

Wrist stability after experimental traumatic triangular fibrocartilage complex lesions

PURPOSE: The aim of this study was to evaluate changes in stability of the wrist after experimental traumatic triangular fibrocartilage complex lesions. METHODS: Sixteen cadaver wrist specimens were included: 8 were fixed in neutral rotation of the forearm, 4 in maximal supination, and 4 in maximal pronation. The specimens were tested in a multiangle and torque measuring instrument. First the intact specimen was tested, second a dorsal arthrotomy was performed, and the third test was with 1 of 4 different experimental lesions according to Palmer's classification of traumatic triangular fibrocartilage complex lesions (1A-1D). Forced radioulnar deviation and internal/external rotation were recorded with a load of 0.75 Nm in the interval -60 degrees to +60 degrees of flexion. RESULTS: We found the 1C lesion to be highly significantly related to wrist stability. Forced radioulnar deviation and forced internal/external rotation were altered significantly in 35 degrees of wrist extension. The other lesions did not alter the stability of the wrist significantly and the rotation of the forearm had no influence on the outcome. CONCLUSIONS: The 1A lesion does not alter significantly wrist stability and hence the common treatment by a two-third excision of the central part of the disk will not affect wrist stability. A 1C lesion alters significantly the stability of the wrist. At 35 degrees of wrist extension forced radioulnar deviation and forced internal/external rotation were altered significantly; this might be used in a clinical test for a 1C lesion. The rotation of the forearm has no influence on the outcome.     

Transstyloid dorsal luxation of the lunate. Case report

A case of total dorsal luxation of the lunate, combined with an avulsion of the radial styloid is recorded. Radiographs did not reveal any other signs of carpal collapse. We suggest that a concurrent hyperflexion, ulnar deviation and pronation of the wrist joint may reasonably be regarded as the etiology of this lesion, which was treated by delayed, open reduction and partial intracarpal arthrodesis. Similar cases have not been reported.     

Ulnar-positive variance as a predictor of distal radioulnar joint ligament disruption

PURPOSE: Previous cadaveric data show that disruption of the triangular fibrocartilage complex (TFCC) at the wrist allows 0.5 to 3.0 mm of proximal radius migration. Anatomic studies have documented the presence of superficial and deep fibers of both the palmar and the dorsal distal radioulnar joint (DRUJ) ligaments. The aim of this study was to determine the contribution of the superficial and deep fibers of the DRUJ ligaments to longitudinal forearm stability as measured by ulnar-positive variance. METHODS: Eight fresh-frozen cadaver specimens were included in this study. Each specimen was secured with external fixation clamps to a sequential loading frame with the elbow in 90 degrees of flexion and the forearm and wrist in neutral pronation supination, neutral ulnar-radial deviation, and neutral volar-dorsal angulation. The radial head was resected and a force gauge was applied to the proximal radius. The peripheral TFCC was identified through an incision between the fifth and sixth extensor compartments and the dorsal capsulotomy of the DRUJ capsule. After baseline measurement sequential transection of the superficial and deep fibers of the TFCC was performed. Before and after each step load application and removal were performed by attaching an 88.90-N weight to the end of a force gauge and via longitudinal traction on the proximal part of the radius, and ulnar variance was measured with wrist fluoroscopy. RESULTS: Transection of the superficial TFCC fibers resulted in radius migration of 0.70 mm. This migration, however, was not significantly different from that observed at baseline. After both the superficial and deep TFCC fibers were transected the radius migrated proximately with load. This change of ulnar variance was significantly greater than that observed at baseline or after transection of only the superficial TFCC fibers. CONCLUSIONS: Traumatic injury to the TFCC with radiographic evidence of ulnar-positive variance may be an indication of disruption of the deep TFCC fibers.