关节镜下治疗腕三角软骨损伤

Zhi-jieXi,MD2012-09-22TriangularFibrocartilageComplex(TFCC)Tear2020/2/8•Lesionsofthetriangularfibrocartilagecomplex(TFCC)areacommonsourceofulnarsidedwristpain.1,2•Radialsidetearorperforationstendtobetraumaticandoccursmoreinyoungagegroup,ontheotherhand,centralandulnarsidelesionsaremoreoftendegenerativeandcommonlyseeninolderpatients21.PSMcAlinden,JTeh,.Imagingofthewrist.Imaging2003;15:180-1922.PhilipE.Blazar,PeterS.H.Chan,J.BruceKneeland,DonaldLeatherwood,DavidJ.Bozentka,RomanKowalchick,.TheEffectofObserverExperienceonMagneticResonanceImagingInterpretationandLocalizationofTriangularFibrocartilage.HandSurg2001;26A:742–748AnatomyTFCCTFCCTriangularfibrocartilage(articulardisc)MeniscushomologueUCL(ulnarcapsule)VolarandDorsalDRULigamentsECUsubsheathPrestyloidrecess2020/2/8A3DdepictionoftheTFCCArthroscopyComplexfibrousstructureonvolaraspectofwristOrigin-dorsaldistalcornerofsigmoidnotchInsertion-triquetrumandbaseoffifthmetatarsalPartiallyorcompletelyseparatespisotriquetraljointfromradiocarpaljointMENISCUSHOMOLOGUEULNOLUNATEANDULNOTRIQUETRALLIGAMENTSFromvolaraspectofradioulnarligamenttolunateandTriquetrumFirmlyattachedtotriquetrumLessstrongattachmenttolunateULNOLUNATEANDULNOTRIQUETRALLIGAMENTSFromvolaraspectofradioulnarligamenttolunateandtriquetrumType1-TraumaticAHorizontaltearadjacenttotheradiusBPeripheraldetachmentfromtheulnaCTearoftheUlnocarpalligamentsDAvulsionfromsigmoidnotchPALMERCLASSIFICATIONTypeII-DegenerativeAPartialthicknessthinningofthearticulardiscBA+Chondromalaciaoflunateand/orulnarheadCB+fullthicknesstearofthearticulardiscDC+PartialtearofthelunatotriquetralligamentED+FulltearofthelunatotriquetralligamentandarthrosisPALMERCLASSIFICATIONTFCCTRAUMATICTEAR2020/2/8Anatomy2020/2/8TheulnarportionoftheTFCCisvascularisedbyulnarandposteriorinterosseousarterybrachesThecentralandradialaspectsofthecomplexareavascularVascularsupplyTransmitloadStablisetheDRUJbiomechanicalfunctionsbiomechanicalfunctions2020/2/8•1)stabilityofthedistalradioulnarjoint(DRUJ),•2)axialloadtransmissionfromthecarpustotheulnaand•3)ulnarsidedcarpalstability.NaturalHistory20yearsnoTFCperforations60years50%hadTFCperforationsFallondorsiflexedandulnardeviatedwristAxialloadwithforearminhyperpronationSymptomsUlnarsidedwristpainQuitewelllocalisedUsuallywithulnardeviationSuddenpronationactivityClickingonrotationInstabilityisrareSignsPronationUlnardevationAxiallyloadRotateInvestigationsX-rayMRIArthroscopySonographArthroscopy--------goldstandard2020/2/8Usingarthroscopyasthegoldstandard,MRIhasbeenshowntohaveanaccuracyof64–75%forperforationsortears.1TheinhomogeneoussignalintensityandstriatedappearanceoftheTFCCespeciallytheulnarsidemaymakethesedisruptionsmoredifficulttodetectPSMcAlinden,JTeh,.Imagingofthewrist.Imaging2003;15:180-192MariusRSchmid,ThomasSchertler,ChristianWPfirrmann,NadjaSaupe,MirjanaManestar,SimonWildermuthetal.Interosseousligamenttearsofthewrist:comparisonofmulti-detectorrowCTarthrographyandMRimaging.Radiology2005;237:1008-1013TFCCTearPathoanatomyTearinstructuresofTFCCPositiveulnarvariancepredisposestoinjury2020/2/8arthrogramatearatthepararadialpartoftheTFCC(site2)B:coronalT1WFatSatsequenceconfirmingthearthrogramfindingandclearlyshowthetear(arrow).About60-70%oftheTFCCtearsareassociatedwithulnarstyloidfractureJLJLHobby,BDBDTom,PWPWBearcroft,AKAKDixon.Magneticresonanceimagingofthewrist:diagnosticperformancestatistics.ClinRadiol2001;56:50-57ultra-high-frequencysonograph2020/2/8TheTFCCappearsverysimilartothekneemeniscusonMRIimagesOnesonSR,TiminsME,ScalesLM,EricksonSJ,ChamoyL.MRimagingdiagnosisoftriangularfibrocartilagepathologywitharthroscopiccorrelation.AJRAmJRoentgenol1997;168:1513-1518.TFCCTRAUMATICTEARTFCCTearImaging•Plainfilmsmayshowpositiveulnarvariance•Assessforfractureorulnarsubluxation•MRIorArthrography•alargecentraltear(arrow)alongtheradialaspectofthearticulardiscoftheTFCC.•Associatedsubchondraldegenerativechangesareevidentwithinthe•proximallunate2020/2/82020/2/8Atypicaldegenerativecentraltear•adiscretevertical•tear(arrow)involvingthethicker,•volarradioulnarligamentcomponent•oftheTFCC.2020/2/82020/2/8avulsionoftheulnarstyloidattachmentoftheTFC2020/2/8•TFCCtearswereclassifiedaccordingtoitslocationas1ifitwasatthecartilage•attachmenttotheradius;2,pararadial(2–3mmfromtheradius);3,atthemidportion;•4,paraulnar(2–3mmfromtheulnarinsertionpointoftheTFC);or5,attheulnar•insertionpoint(Fig4)2020/2/8locationoftheTFCCtears2020/2/8arelativelybigcommunicatingtear(arrowhead)closetotheradialattachmentoftheTFCCwithmorefatsatsequencesasrequired2020/2/8Asmallcentralperforation(arrow)isseenwithinthecentralportionofthearticulardiscofthetriangularfibrocartilagecomplex.Anadditional,partialthicknessundersurfacetear(arrowhead)isalsopresentatthearticulardisc.ArthroscopicinspectionConservativeActivityavoidanceSteroidinjection(10mgKenolog)SurgeryTreatmentArthroscopicRepairDebridementShaversRadiofrequency(Vapr)–keeptheheatdownOpenRepairUlnarShorteningSurgery2020/2/8TheperipheralandcentraltearsoftheTFCCmustbe