Οξεία Αστάθεια της Άπω Κερκιδωλενικής 016/ acute druj instability...
TRANSCRIPT
Nickolaos A. Darlis, MD
Acute DRUJ Instability
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DRUJ Instability is a clinical diagnosis
Radioulnar ballottement test (Neutral- pronation- supination) DRUJ compression test
Piano- Key sign
ECU subluxiation in supination- ulnar deviation
The unsolved question• How do you define and test DRUJ stability in
the acute setting?
The unsolved question• How do you define and test DRUJ stability in
the acute setting?
“Forearm Joint”
One functional unit
“Forearm Joint”
The forearm as a ring
Anatomy Distal Radius
DRUJ Anatomy
• Radii of curvature differ – 10mm vs 15mm– Full congruity impossible
DRUJ anatomy
• Congruity of DRUJ– Neutral rotation: 60% of
sigmoid notch in contact– Extremes of rotation: 10%– Dorsal and palmar rims
important
• Little osseous stability
The Iceberg Concept Atzei &Lucetti 2011
radius
ulna
N.D
radius
ulna
N.D
radius
ulna
N.D
Volar & Dorsal Radioulnar Lig
Foveal attachment
TFC MENISCUS
radiusulna
N.D
radiusulna
N.D
TFC CRUCIATE Lig
Volar & Dorsal RU lig.-Foveal Attachment
TFCC anatomy
• Vascular supply– Central portion
• avascular
– Periphery (dorsal and palmar radio-ulnar ligaments)
• vascularized
DRUJ
• Rotation• Load transmission• Stability
Kinematics
• Radius rotates about the distal ulna• “Ulnar head dislocation” by convention• Axis of rotation
Load transmission (RH intact )
80%
20%
40% 60%
U
U
R
R
Load TransmissionExplains common fracture patterns
Galeazzi
Forearm
Monteggia
Essex-Lopresti
Interosseous Membrane Anatomy
Two main bands:• Central Band (volar)• Proximal Interosseous
Band (dorsal)
• Accessory bands (1-5)• Membranous portion CB
PIOB
IOM-Central Band
• 70% of forearm stability
• Injury of other elements of IOM (partial tears), increase CB strains
Radius
Ulna
CB
IOM Anatomy
60%
40%
35%
75%250120mm
Essex –Lopresti injury
Acute TFCC tear management
Galeazzi Fracture /Dislocation
Distal Radius Fractures
Isolated Ulnar head dislocation
Acute DRUJ Instability:
Isolated Ulnar head Dislocation
• Dorsal: reduce in supination• Palmar: reduce in pronation• Global instability: usually requires
stabilization
• If stable: immobilize in stable position– Sugartongue splint for 6 weeks
• Failed closed reduction may result from trapped ECU, capsule, ulnar styloid, extensor tendon
• Open reduction dorsal - 5th compt.• TFCC repair if avulsed
Isolated Ulnar head Dislocation
DRUJ in Distal Radius Fractures
• 1777 Desault isolated DRUJ dislocation• 1814 Colles: DRUJ with distal radius
– “at some remote period again enjoy perfect freedom”• 1837- Diday
– “the problem is really the overriding ulna”• 1934 Galeazzi • 1951 Essex-Lopresti• 1967 Frykman
– “Disturbances of the DRUJ make for worse results”
DRUJ in Distal Radius Fractures• “Most common source of pain following distal
radius Fx”Fernandez &Geissler JHS 1992
• Loss of supination most common functional complaint following distal radius Fx
Hanel AAOS ICL 2004
• Residual depression of the lunate facet ≥2mm results in articular incongruity and arthrosis
Jupiter JBJS 1986
Highly possible when:• shortening >5-7mm
Highly possible when:• shortening >5-7mm• radialy displaced fx base
of the ulnar styloid
Highly possible when:• shortening >5-7mm• radialy displaced fx base
of the ulnar styloid, • angulation >25-300 any
plane
Highly possible when:• shortening >5-7mm• radialy displaced fx base
of the ulnar styloid• angulation >25-300 any
plane• DRUJ diastasis in PA Rö
projection
DRUJ in Distal Radius Fractures
• Accurate osseus reduction first– Ulnar column stabilization
Common pitfalls
• Radial translocation- sigmoid notch malreduction
Common pitfalls
• Excessive volar tilt/ translocation
DRUJ in Distal Radius Fractures
• Geissler and Fernandez Instabilty classification AFTER radius reduction– Type I: Stable– Type II: Unstable– Type III: Potentially Unstable
Type I: Stable
• minimally displaced avulsion tip of the ulnar styloid
• fracture of the neck of the ulna (just fix)
Type III: Potentially Unstable
• Fx through sigmoid notch (4-part fracture) or• Ulnar head fracture
(fix & test)
Type II: Unstable
• avulsion Fx base of the ulnar styloid or• massive tear of the TFCC and/or secondary
stabilizers
Ulnar styloid Fx
• Management controversial• May be fixed or tends to reduce in supination• Fix when DRUJ unstable, usually base.• Make sure TFCC attaches to fragment
Ulnar styloid Fx
• CRIF: easier said than done; supinate
• Re-check stability
Ulnar styloid Fx
• ORIF: ample skin incision– Kirschner wires,– tension band wire– screw– suture anchors
• Re-check stability
Ulnar styloid Fx
• ORIF– Dedicated plates
• Re-check stability
Ulnar styloid Fx
• However, if no clinical instability, value of fixation questionable
152 pts with displaced fx involving 75% of ulnar styloid– 76 treated and 76 untreated• The fracture itself trended to worse outcomes than if there
was no fracture• No differences noted between the treated group and the
untreated group
Ulnar styloid non-unions
• Type I- tip - stable → excision• Type II- base – unstable →ORIF ± TFCC repair
DRUJ in Distal Radius Fractures
If DRUJ stable after osseus fixation (distal radius ± ulna):
• Immobilize in stable position for 4-6 weeks– Sugartongue splint– Avoid excessive pronation (DRUJ stable but
associated w loss of forearm motion)
DRUJ in Distal Radius Fractures
Congruent reduction with an unstable joint, consider:
• Cross pinning– Pin breakage
• TFCC repair• External fixation
Galeazzi fracture/dislocation
• Accurate ORIF first• Same principles for DRUJ as for distal radius Fx
Essex Lopresti injury
Failure of the IOM• Acute• Secondary to overload following Radial Head Excision
Essex Lopresti injury- Diagnosis• Distal Radioulnar Joint pain
and dissociation
• Distraction-compression X-rays
• Intraoperative manual testing
Essex Lopresti injury- Diagnosis
• MRI
• Ultrasound
• Radial Head Reconstruction- Replacement
• DRUJ reduction- pinning• TFCC repair?
Acute Essex Lopresti injury-Treatment
Essex Lopresti injury- complications
• Proximal radial migration• Symptomatic DRUJ
subluxation
Essex Lopresti- Chronic insufficiency• Ulnar shortening • Radial Head ReplacementResults inconsistent
Essex Lopresti- Chronic insufficiency• Attempts at IOM reconstruction
60%
40%
35%
75%250
120mm
BPTB
IOM
FCR
Acute TFCC tears
ISOLATED WITH DISTAL RADIUS Fx
Wrist arthroscopy in distal radius FxConcomitant lesions increasingly recognized:• ΤFCC ≈60% (43-78%)
• SL lig.≈ 40% (32-75%)
• LT lig. ≈20% (15-61%)
• Chondral lesions ≈20% (19-32%)
Common misconceptions
• TFCC tear ≠ DRUJ instability– In fact: most tears do not have evident instability
• Ulnar styloid fracture ≠ DRUJ instability– Styloid fractures may co-excist with TFCC tears
Acute TFCC treatment
“Initial conservative treatment for 8 -12 weeks”
Literature, Conservative treatment
Literature, TFCC with Distal Radius Fx
• Contradicting …
Treatment algorithm
Isolated TearIsolated Tear ConservativeConservative
Distal Radius Fx Conservative Conservative
Distal Radius Fx OperativeDistal Radius Fx Operative Consider Arthroscopy*Consider Arthroscopy*
DRUJ Instability Consider Arthroscopy*/ Cross pinning
* Especially in young, high demand patients
Follow-up all conservative patients closely
Timing of operative repair
ACUTEGood Healing Potential
SUBACUTEUnpredictable
CHRONICPoor Healing Potential
0 6 months 1 year
3mo 6mo
Conservative treatment
• Sugartongue or Long Arm splint 3-4 weeks• Short Arm Splint 1-2 weeks
Palmer ClassificationClass 1: Traumatic Injuries
A Central perforation of the disk properB Peripheral avulsion from the ulna
Without styloid fractureWith styloid fracture
C Distal avulsion from the carpusD Radial avulsion
Without sigmoid notch fractureWith sigmoid notch fracture
D TFCC perforation + lunate and/or head chondromalacia + lunotriquetral ligament perforation
E TFCC perforation + ulnocarpal arthritis
Class 2: Degenerative InjuriesA TFCC wearB TFCC wear + lunate and/or head chondromalaciaC TFCC perforation + lunate and/or head chondromalacia
Central tear
Peripheral tear)
Radial tear
Tear location
Deep bundle of TFCC
Volar radioulnar lig.
radiusulna
N.D
Central TFCC lesions• Poorly vascularized- healing potential minimal• Arthroscopic debridement up to 2/3 of
articular disc
Shaver debridement
Central TFCC lesions
Arthroscopic TFCC debridement using radiofrequency probes Darlis NA & Sotereanos DG, JHS(B)2005
Central TFCC lesions
1. Central TFCC lesions
• Often degenerative and associated with ulnocarpal impaction syndrome
• Ulnar recession procedure to prevent symptom recurrence
Ulnocarpal Impaction SyndromeClinical features:• Ulnar sided wrist pain • Associated degenerative changes:
– Ulnar side of the lunate– Radial side of the ulnar dome– TFCC central tear– Triquetrum- LunoTriquetrum lig.
• Usually positive or neutral ulnar variance
Arthroscopic Wafer procedure
Arthroscopic Wafer procedure
Open Ulna Recession Procedures• Several options…
Open Ulna Recession Procedures
Another approach: Keep it simple…• Step-Cut Ulnar Shortening Osteotomy
Darlis & Sotereanos JHS(A), 2005
Peripheral (ulnar) TFCC tears
• Well vascularized• Repairable
Usual location of peripheral tears
Dorsal
Usual location of peripheral tears
REPAIR TO CAPSULE REATTACH TO FOVEAOR
TFCC TFCC
3. Peripheral (ulnar) TFCC tears
REPAIR TO CAPSULE
REATTACH TO FOVEA
3. Peripheral (ulnar) TFCC tears
• Clinical DRUJ instability• Fracture through the fovea• MRI findings• Arthroscopic findings
– Positive Hook Test– Direct Foveal Portal Arthroscopy
Foveal attachment involvement
Hook test
REPAIR TO CAPSULE
REPAIR TO CAPSULE
1. Mini open: Sotereanos
Chou, Sarris, Sotereanos, JHS(B), 2003
U
EDM ECU
Incision
Chou, Sarris, Sotereanos JHS(B), 2003
REATTACH TO FOVEA
2. All Arthroscopic, Knotless: Geissler
REATTACH TO FOVEA
TFCC6R
ACC 6R
TFCC6R
ACC 6R
TFCC6R
ACC 6R
TFCC6R
ACC 6R
TFCC6R
ACC 6R
Take Home Messages
Take Home Messages
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