ic05-l: ulnar wrist pain - assh

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IC05-L: Ulnar Wrist Pain

Moderator(s): William B. Kleinman, MD

Faculty: Nancy M. Cannon, OTR, CHT, Thomas J. Fischer, MD, Sanjeev Kakar, MD,

FAOA, and David S. Zelouf, MD

Session Handouts

Thursday, October 01, 2020

75TH VIRTUAL ANNUAL MEETING OF THE ASSH

OCTOBER 1-3, 2020

822 West Washington Blvd

Chicago, IL 60607

Phone: (312) 880-1900

Web: www.assh.org

Email: [email protected]

http://www.assh.org/

mailto:[email protected]

9/24/2020

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IC05: Ulnar Wrist Pain

William B. Kleinman, MD

Speaker has no relevant financial relationships with commercial interest to disclose.

IC05L - Advanced

ANATOMY and BIOMECHANICS at the DISTAL END of the ULNA, as UNDERSTOOD in 2020

Moderator – William B. Kleinman, M.D.The Indiana Hand to Shoulder Center

Indianapolis

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FOREARM AXIS-OF-ROTATION

RADIUS HEAD TO ULNA FOVEA

HINGED, GINGLYMUS

ULNO-TROCHLEAR JOINT

FOREARM AXIS-OF-ROTATION

RADIUS HEAD TO ULNA FOVEA

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ULNA FOVEA

Axis-of-

Rotation

THE “BOWED” RADIUS

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ULNA

MINUS

VARIANCE

ULNA

PLUS

VARIANCE

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(Radius Shorter)

(Radius Longer)

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ULNA

RADIUS/CARPUS/HAND

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DEEP FIBERS OF THE TFC(Ligamentum Subcruentum)

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CARL-GORAN HAGERT

Scand J Plast Reconstr Surg: 1994

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SUPINATION

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DIAGNOSTIC WORK-UP FOR SUSPECTED INJURIES OF THE TFC

o HISTORYo PHYSICAL EXAMINATION

- POINT TENDERNESS- SHUCKING INSTABILITY- PIANO KEY SIGN- STRESS-TESTING THE DEEP FIBERS (Ligamentum subcruentum)

o PLAIN X-RAYSo BONE SCANo MRIo ARTHROSCOPY

GOLD STANDARD

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WHAT ABOUT AVULSION OF THE CRITICAL DEEP PORTION?

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Superficial TFCC INTACT

Ligamentum Subcruentum TORN

Superficial TFCC INTACT

Ligamentum Subcruentum TORN

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RIGHT WRIST

PROXIMAL

DISTAL

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THE UNSALVAGEABLE TFC

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Nancy Cannon, OTR, CHTIndianapolis, IN

Indiana Hand to Shoulder Center

Sanj Kakar, M.D.Rochester, MN

The Mayo Clinic

Dave Zelouf, M.D.Philadelphia, PA

Philadelphia Hand Center

Tom Fischer, M.D.Indianapolis, IN

Indiana Hand to Shoulder Center

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Sanjeev Kakar, MD, FAOA

Royalty: Arthrex

Consulting Fees: Arthrex

Ownership Interests: Sonex

My Preferred Surgical Approach to Repair or

Reconstruct the Damaged, Dysfunctional Triangular

Fibrocartilage Complex

A Case Based Approach

Sanj Kakar MD, FAOA

Professor of Orthopaedic Surgery

Mayo Clinic

Rochester, MN USA

Acknowledgements

▪ Marc Garcia-Elias MD, PhD

▪ Richard Berger MD, PhD

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35F RHD s/p rt wrist fusion & failed foveal

TFCC repair with ulnar wrist pain

Three Key Questions To Ask

Yourself When Managing Ulnar

Wrist Pain?

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Categorization Of Ulnar Wrist Pain

• Pain

• Pain with instability

• Pain with arthritis

Distal Radioulnar Joint Pathology

A Difficult Problem To Treat !!!!

▪ LOW BACK PAIN OF THE WRIST

▪ Multifactorial pathology

• Bony Deformity

• Cartilage injury

• TFCC disorders

• Soft tissue injury e.g. ECU instability

▪ These are NOT mutually exclusive

• Failure to recognize this → suboptimal results

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✓ Bone deformity ? YES / NO

✓ Cartilage damage ? YES / NO

✓ TFCC injury ? YES / NO

✓ Unstable ECU tendon ? YES / NO

Unstable

ECU

Cartilage

defect

Bone deformity

TFCC

injury

Four Important Questions To Ask

Forget About The Acuity Of The

Injury When Deciding Upon Repair

Or Reconstruction

Is The Quality Of The Tissue Able To

Withstand The Repair?

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How Do You Test Foveal

Attachment?

▪Arthroscopic assessment

• Hook test Ruch et al.

• Trampoline test Hermansdorfer & Kleinman

• DRUJ arthroscopy Nakamura

– But what if it’s scarred down peripherally?

Hook Test

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Trampoline Test

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DRUJ Arthroscopy

Easier Way

▪ Scope (1.9 mm) in 3-4 portal

▪ Needle in presumed DRUJ portal under

TFCC

• Incise skin

in under

TFCC

▪ Scope in DRUJ portal

DRUJ Arthroscopy

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Case

RHD s/p ATV accident

CRPP (paeds ortho)

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4 months later

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Unstable

ECU

Cartilage

defect

Bone deformity

TFCC

injury

One of Four Factors Injured & must be Addressed

Negative Trampoline Sign & Hook Test

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Making DRUJ Portal

DRUJ Arthroscopy Showing Foveal Deatachment

Working DRUJ Portal

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Debridement of Fovea

Needle Through Ulnar Tunnel

Foveal Repair

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Immediate Stability

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RHD s/p fall

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8 months later, ↑ ulnar wrist pain refractory to

non operative treatmentUlnar impaction & TFCC tenderness

DRUJ Examination





Unstable

ECU

Cartilage

defect

Bone deformity

TFCC

injury

Four Important Questions To Ask

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Wafer Procedure

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Indications

▪ Failed conservative treatment

▪ DRUJ instability

▪ Reparable TFCC with foveal disruption

Contra- indications

▪ Irreparable TFCC

▪ DRUJ arthritis

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What If The TFCC Is Irreparable?

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3 drill holes

- Ulnar tunnel

- Volar margin of

sigmoid notch to BR

footprint on radius

- Dorsal margin of

sigmoid notch to BR

footprint

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Back To Our Case

35F RHD s/p rt wrist fusion & failed foveal

TFCC repair with ulnar wrist pain

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1.35 mm Fibertack Anchors

Ulnar Head Within Calamari

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▪ 4 pts

• 10 DRUJ arthritis

▪ Follow up: 15M-26M

▪ ROM:

• Pronosupination: 1580

• Flexion-extension: 1230

• ↑ function & ↓ pain

• NO revisions

Summary

Forget About The Acuity

It’s The Quality Of The Tissue That

Determines Repair Versus

Reconstruction?

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Thank You For The Privilege Of Your Time

Email: [email protected]

DISCLOSURES

Thomas J. Fischer, MD

Consulting Fees: Synthes/Depuy

When Is an Arthroscopic TFCC

Repair Indicated, and When Do I

Feel That Only an Open TFCC

Repair Should Be Performed

Thomas J. Fischer, M.D.

Clinical Associate Professor,

Department of Orthopedic Surgery

Indiana University School of Medicine

The Indiana Hand Center

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Conflict of Interest

• Depuy-Synthes (DPS) technical writer and consultant

(Contract)

• AO International Foundation, Technical Commission,

Chair, Hand Expert Group, developers of plates and

screws of the distal radius and hand (Per Diem)

• None apply to this topic

Gratitude - Spanning the Start

• My partner of 33 years, Bill Kleinman who

taught me how to love anatomy and especially

for this convo, TFCC anatomy and function

• Andy Palmer, who brought TFCC pathology

into a collective understanding and shaped

mine

• Gary Poehling, Terry Whipple and Champ

Baker, whose principled teaching of the subject

of wrist arthroscopy allowed me to take the

leap into the small joint world of arthroscopy

A Postage Stamp Size Piece of Real Estate

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Unifying Concept – Forearm Axis

Preserve Forearm Function

• Distal Radius

• Distal Radioulnar Joint (DRUJ)

• Distal Ulna

• Ulna Shaft

• Olecranon

• Proximal Radioulnar Joint

• Radiocapitellar Joint

• Radial Head

• Radial Shaft

I fix the TFCC when the hinge is broken

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Disclaimer - Central Flap Tears

• Not a source of instability

• These are not part of the discussion today

• Only if they occur in conjunction with other instabilities

are they included for this discussion

Two Kinds of Instability – pain generators

• Minor Instabilities, not unlike tennis elbow, just enough

pathology and load to create soft tissue pain, pain

inhibition and dysfunction, no gross instability

- Dorsal marginal tears, red zone tears

- Subsheath tears of ECU, detaching TFCC disc from the

influence of the ECU

- Partial foveal tears, secondary stabilizers keep the joint

from subluxating

Two Kinds of Instability – pain generators

• Major Instabilities, subtle and gross instability, ulna

loses its domain on the radius, subluxation and

dislocation

- Complete or near complete foveal disruptions with or

without intact secondary stabilizers (ECU, DOB)

- Gross instability of ECU with subluxation accompanied by

detatchment from TFCC

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Source: Journal of Hand Surgery 2009; 34:415-422 (DOI:10.1016/j.jhsa.2008.10.025 )

Copyright © 2009 Terms and Conditions

JHS 2009

2 articles

Osaka Japan

Noda

Moritomo

Yoshikawa

Sugimoto

IOM

5 components

• 3 distal

• Isometric

• Central band

• Acc Band

• DOB, distal oblique

band***

• 2 Prox

• Off axis

• NOT Isometric

I do not know how the DOB plays

into minor vs major instabilities

Surface Contact: not unlike the glenohumeral

joint

10% in

Extreme

Supination

10% in

Extreme

Pronation

60% in

Neutral

Berger’s radiographic method for

determining instability

Open repair

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http://www.jhandsurg.org/article/S0363-5023(08)00956-8/abstract

http://www.jhandsurg.org/misc/terms

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Ulna Fovea– is the location for a

“spot weld” of the TFCC onto the

distal end of the ulna

FZ – Fusion Zone

The Scene of the Crime

KLEINMAN/SCHNITZ

My 4 Repairs for TFCC

1. Ulna Fovea tears, partial and complete

2. Dorsal Marginal tears, aka ECU

subsheath tears, retinacular tears, red

zone tears

3. Palmar Ulno Carpal ligament tears, rare

4. Combinations of 1,2,3

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OPEN vs CLOSED Repair

• Any foveal repair is an open repair for me

- Determined by:

• Physical exam

• MRI

• Radiographic subluxation criteria

• Arthroscopic determination by probe, hook, manipulation

• Previous failed instability surgery

Foveal Repairs

• Open, palmar approach along subQ border

of ulna

• Debride granulation tissue

• Large diameter drill hole for bone anchor

du jour

• Three sutures – attached to single anchor

- Disc, absorbable suture (placed with scope)

- Dorsal limb TFCC, fiberwire

- Palmar limb TFCC, fiberwire type

Drill Hole Placement - Crucial

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The Anchor

Anchor Characteristics

• Static, not necessarily absorbable

• Free shackle to place secondary surtures of various

diameters

• Free running of suture through eyelet of anchor

• Subsheath tears, dorsal marginal tears can be repaired

this way for combination injuries extending dorsally.

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1 Dorsal ligaments

deep and

superficial

2 Ventral limb of

TFCC

3 Central disc,

absorbable

Dorsal Marginal Repairs

• Arthroscopic assisted with placement of

sutures in dorsal rim TFCC outside in

• Can be done with a myriad of soft tissue

fixation techniques, absorbable sutures

• Avoid DSBrUN, transverse branch

• Don’t include ECU tendon in repair,

respect the sheath

• Re integrate the vertical septum between

5th and 6th Dorsal compartments to TFCC

LUNATE FOSSA

OF RADIUS

DISTALLY

• Retinaculum of

the 6th

compartment

• ECU subsheath

• Vertical septum

between 5th and

6h compartment

• Vertical septum

of 6U

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Inside out technique – taken from

lateral meniscus repair techniques

THE WRIST STABLE

PLATFORM OF LOAD

How it transmits that load to the

ulna hence to the elbow starts at

the DRUJ

SUMMARY

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DISCLOSURES

David S. Zelouf, MD

Speaker has no relevant financial relationships

with commercial interest to disclose.

What do I do when a Surgical TFC Repair or

Reconstruction Fails?

ASSH 2020, ICL 05

David S. Zelouf, MD

I have nothing to disclose

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How does one define “failed surgery?”

There are always lawyers who want to help out…

How does one define “failed” surgery?

◼ No meaningful improvement or worsening of one’s symptoms at

final follow/up

◼ It can be subjective, as in ongoing pain and reported dysfunction

◼ It can be objective, with a loss of motion, strength or both

◼ Just remember, there isn’t anything surgery can’t make worse

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How about “outcome measures?”

◼ QuickDASH score

◼ I find it very useful preop,

and I have all new patients

complete it

PRWE

Modified Mayo Wrist Score

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Four main reasons for failed TFCC surgery

◼ Improper patient selection

◼ Improper diagnosis

◼ Complications leading to failure

◼ Technical issues

Improper patient selection

◼ Beware of patients with very high QuickDASH scores

◼ Beware of patients with significant anxiety, depression and

catastrophizing behavior

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Improper patient selection

◼ Patients in litigation

◼ Workers’ compensation patients,

especially those with legal representation

◼ MVA cases

◼ “Slip and falls”

◼ Other third-party litigation

Improper diagnosis

◼ Not all ulnar sided wrist pain is

secondary to TFCC pathology

◼ Take care to really examine the

patient

Failure to address…

◼ ECU tendinopathy

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◼ ECU instability

◼ Can be isolated or associated with peripheral TFCC pathology

The ECU is properly located in its groove in pronation…

But dislocates or “snaps” out of its groove in supination

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◼ Pisotriquetral arthritis

◼ Be sure to perform the pisotriquetral shear test


◼ Hamate chondromalacia (HALT)

◼ Always scope the midcarpal joint!


◼ Hamate hook non-union

◼ Patients often present with dorsal ulnar wrist pain

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◼ Ulnocarpal impaction

◼ Obtain grip loaded pronated x-rays pre-op

◼ May need to perform an ulnar shortening osteotomy in addition

to addressing TFCC pathology


◼ DRUJ instability, either isolated or in association with a radius

malunion

◼ Take care to examine for DRUJ instability

◼ An arthroscopic peripheral TFC repair to capsule may not

address DRUJ instability as a foveal repair is typically necessary

EH

◼ 25 y/o RHD man with long standing ulnar sided right wrist pain

◼ Sustained a right distal radius fracture at age 15 treated with a

closed reduction and casting

◼ Subsequently developed ulnar sided wrist pain

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EH

◼ Underwent TFCC repair by another hand surgeon 5 years ago

with no improvement

◼ PE: mature 3cm longitudinal ulnar scar

◼ Near full rotation, flexion 45 vs 60, extension 60/60

◼ Grip 130/150

◼ “Click” noted from neutral to supination

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Supination dissociation: Radius malunion

◼ Apex volar radius malunion which results in displacement of

the ulna in supination

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Forearm fracture malunions and their effect on DRUJ stability

◼ Childhood radius fractures are forgiving but there is a limit

◼ Some will lead to problems at the DRUJ including decreased rotation and

DRUJ instability

◼ The fracture may have occurred many years ago, and the problem is often late

in developing

◼ Be mindful of subtle malunions and always obtain forearm films, including the

opposite side

10+ cm

2.5c

m

Repair of childhood forearm malunions and DRUJ instability

◼ A 10 degree flexion osteotomy 10cm from the growth plate will create a spatial change of 2.5cm at the joint

◼ With advanced diaphyseal remodeling the corrective osteotomy will appear overly angulated

◼ A TFCC repair for an unstable DRUJ without correcting the angular malunion will fail!

Preo

pPosto

p

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◼ DRUJ arthrosis


◼ Associated LT tears

◼ Ulnar extrinsic ligament tears

◼ Associated SL instability

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Complications leading to failure

◼ Neuroma formation secondary to portal placement during wrist

arthroscopy

◼ If one chooses a 1-2 portal, place it within the “safe zone”

◼ Avoid 6U portal as a working portal due to its proximity to the dorsal

cutaneous branch of the ulnar nerve

◼ Look for the dorsal cutaneous branch of the ulnar nerve if an open

incision is utilized about the ulnar side of the wrist


◼ Infection

◼ Prophylactic antibiotics somewhat controversial

◼ Have a low threshold for a return to the OR for a wash

out if a postop infection develops


◼ Stiffness

◼ Avoid prolonged immobilization following TFCC debridement

◼ No more than 4-6 weeks of immobilization post TFCC repair

while allowing elbow flexion/extension

◼ Early use of hand therapy is recommended, particularly in those

patients with early identified stiffness

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◼ Iatrogenic tendon, cartilage and ligament injury from poorly

positioned portals and forceful insertion of instruments

Technical issues

◼ Inadequate debridement of central TFCC tears

◼ Failure to diagnose peripheral tears in need of repair back to

capsule

◼ Failure to diagnose foveal disruption; consider DRUJ arthroscopy

◼ Avoid excessive use of a heat probe without adequate outflow

that may result in chondrolysis

Summary

◼ Failed TFCC surgery may result from:

◼ Poor patient selection

◼ Improper or incomplete diagnosis

◼Avoidable and unavoidable complications

◼Technical issues

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Summary

◼ Whether to perform further surgery in the setting of “failed TFC

repair or reconstruction” depends on the identified reason for said

failure

◼ Patients with an “agenda” may may not improve with further

surgery unless a clear reason for the failure is identified, and even

then, success is unpredictable

Summary

◼ If a clear cause of the surgical failure is identified, revision surgery

may be successful

◼ Goals should be clearly outlined to the patient and both the

surgeon and patient must be realistic

◼ Revision surgery may include a procedure to address previously

unaddressed pathology, or possibly reconstructive surgery as in the

use of a tendon graft for ongoing DRUJ instability following TFC

repair, or a salvage procedure in selected cases deemed “non-

repairable”

Thank you

David S. Zelouf, MD

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DISCLOSURES

Nancy M. Cannon, OTR, CHT

Speaker has no relevant financial relationships

with commercial interest to disclose.

I N D I A N A H A N D T O S H O U L D E R C E N T E R • I N D I A N A P O L I S , I N D I A N A

Maximizing Post-Operative Function following TFCC Repairs

& Reconstructions

Nancy M. Cannon, OTR,CHT

~ No Disclosures ~ ASSH Annual Meeting

2020


Focus…

▪Therapy for TFCC Ligament Repairs

▪Key Exercises – Favorably Influence Outcomes

▪Orthoses – Immobilization and Exercise

▪Research

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Valuable Information – Therapist

▪ Initial Therapy Orders…and…

▪Operative Note & MRI Report ▪Specific structures involved

▪Specific procedures performed

▪Stability – DRUJ pre-op, intra-op

▪Favorably Influence▪Quality – therapy program

▪Quality – patient outcome


Initial Therapy Visit

▪10–14 Days Post-op [Arthroscopic or Open Repair]

▪Bulky dressing & sutures removed

▪Scar massage & manual desensitization

▪Edema control – light compression stockinette

Patients often wearing at discharge!Appreciate circumferential support


Post-Op Immobilization Orthosis

▪Bivalve Wrist Immobilization Orthosis

▪Long Arm Orthosis▪ Forearm neutral

▪Preferred position

▪ Shortest length of the volar & dorsal radioulnar ligaments▪ Position surgery – repair tight (stability)

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Post-Op Immobilization Orthosis

▪Muenster Orthosis [IHTSC design]

▪ Full elbow motion, prevents supination/pronation

▪Sugar Tong Orthosis or Short-Long Arm Cast


Period of Immobilization – Literature

▪Arthroscopic Debridement▪ 5 – 7 days

▪Arthroscopic Repair▪ 4 – 6 wks

▪Open Repair▪ 6 – 8 wks [grafts +1-4 wks]

▪Priority – Stability Arthrex.com


Pull-Out Strengths – Suture Anchors

▪2.9 PushLock Anchor: 105N

▪Mini 2.5 PushLock Anchor: 73N

▪5.0 Titanium Corkscrew: 110N

▪Priority – Stability▪Early motion – risks lengthening

effect on the ligament or gapping repair site Arthrex.com

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Wrist Exercises ± 4 – 6 weeks post-op

▪Short to Mid-Arc Flexion & Extension Initially▪ Forearm neutral (light fist) – slide wrist on tabletop

▪ Transition to full arc – ± 1 week later

▪Avoid Ulnar & Radial Deviation


Ulnar Deviation – Compression Ulnar Wrist

▪Scaphoid-Lunate-Triquetrium – Slide Radially▪Compression – hamate against the triquetrium

▪Compression – triquetrium against the articular disc & ulnar styloid

Neumann, Kinesiology of theMusculoskeletal SystemMosby , 2002

Supination


Forearm Exercises ± 6 weeks post-op

▪Short to Mid-Arc Motion Initially

▪Elbow Flexed 90, Forearm Neutral▪Supination & pronation (light fist)

▪ ± 1week later… full arc motion

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Rationale – Short to Mid-Arc Motion

▪Gently Elongate & Mobilize Adhesions

▪Slowly Introduce Tension, Compression & Distraction on DRUJ, TFCC, IOM, and PRUJ

▪Maximize Contact Area –between the Ulna and Sigmoid Notch for DRUJ stability

ClinicalGate.com


Rotation & Translation Exercise Important!

▪Reproduces Normal Biomechanics of the DRUJ – Forearm Rotation▪Radius – translation as it rotates

around the fixed ulna

▪Supination: radius – distal & dorsal to the ulna

▪Pronation: radius – proximal & volar to the ulna

ClinicalGate.com


Rotation & Translation – Therapist

▪Supination:▪ Fingertips on the dorsal distal

ulna; apply volar-directed pressure (lifting effect)

▪ Thumb applies pressure on the distal radius to rotate the radius around the fixed distal ulna

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Rotation & Translation – Therapist

▪Pronation▪ Fingertips on the volar distal ulna;

apply dorsal-directed pressure on the ulna (lifting effect)

▪ Thumb applies pressure to the distal radius to rotate the radius around the fixed distal ulna


Rotation & Translation – Patient

▪Supination▪Volar-directed pressure on

the dorsal ulna (fingertips)

▪ Thumb rotates distal radius around ulna

▪Pronation

▪Upward pressure on the ulna (fingertips)

▪ Thumb rotates distal radius around ulna


Exercise Orthoses – Wrist Straps

▪Beneficial – TFCC Repairs

▪ Indications – Clinical Perspective▪Pain with motion

▪Catching-clicking (wrist or forearm motion)

▪ROM plateaus – stops progressing

▪Proactively – external support – course of therapy

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▪Pre-Fabricated ▪Bulls Eye Wrist Band

▪P.O.P – 3-Points Product

▪Wrist Squeeze –Ulnar Compression Wrap

▪WristWidget

~ Examples ~



▪Custom-Fabricated▪Elastic strap + orthotic material (ulna &/or radius)

▪O’Brien & Thurn design [JHT, 2013]


Rationale – Clinical Perspective

▪Provide Lateral, Circumferential or Targeted Support [dependent on orthosis design]

▪May influence dorsal/volar translation

▪May ↓ tension/strain – TFCC ligaments

▪Pressure effect may stimulate sensory nerve fibers (A) to dampen pain [Gate control theory]

▪Circumferential support – “reassuring”! Slideserve.com

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Closing…

▪Post-op Immobilization – Prioritize Stability

▪Exercises▪Gradually restore motion [short – mid – full arc]

▪Research▪Optimal therapy program – excellent outcomes

▪Wrist straps – influence DRUJ structures & pain

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ic05-l: ulnar wrist pain - assh

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