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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

      Abstract

      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.
      With his landmark work on the importance of the triangular fibrocartilage complex (TFCC), Andrew Palmer helped to “light a candle” in the “black box” that is the ulnar-sided wrist.
      • Palmer A.K.
      Triangular fibrocartilage complex lesions: A classification.
      ,
      • Palmer A.K.
      Triangular fibrocartilage disorders: Injury patterns and treatment.
      Drs. Atzei and Luchetti helped to further illuminate this dark corner of the wrist through their work investigating the importance of the foveal attachment of the TFCC.
      • Atzei A.
      New trends in arthroscopic management of type 1-B TFCC injuries with DRUJ instability.
      ,
      • Atzei A.
      • Luchetti R.
      Foveal TFCC tear classification and treatment.
      We have come a long way with our treatment of ulnar-sided wrist pain in the past 30 years, but we still lack a complete understanding of which treatment options produce superior patient outcomes and what needs to be addressed to help prevent the long-term effects of distal radioulnar joint (DRUJ) pathology that results from TFCC insufficiency.
      Concurrent TFCC tears and ulnar styloid process fracture nonunions (USPFN) are one such example of our lack of a thorough understanding. Although relatively uncommon, multiple authors have reported their experience with this combination of injuries. Most of the published data come from small retrospective case series where open TFCC repair was performed at the same time as open excision of the ulnar styloid process nonunion fragment. These reports have demonstrated overall improved postoperative pain and function; however, it is not clear from this body of work whether it was the TFCC repair or the ulnar styloid fracture fragment excision, or both, that produced improved patient outcomes.
      • Lee K.H.
      • Shim B.J.
      • Gong H.S.
      Open foveal repair of the triangular fibrocartilage complex tears associated with symptomatic ulnar styloid non-union.
      ,
      • Protopsaltis T.S.
      • Ruch D.S.
      Triangular fibrocartilage complex tears associated with symptomatic ulnar styloid nonunions.
      A meta-analysis of published data for USPFNs and distal radius fractures suggested that ulnar styloid fracture nonunions may not be as menacing to the ulnar-sided wrist as we think. Although plagued with heterogeneity, this investigation pooled data for 365 patients (135 with healed ulnar styloid fractures and 230 with nonunion), and no significant clinical differences were found between the groups.
      • Wijffels M.M.
      • Keizer J.
      • Buijze G.A.
      • et al.
      Ulnar styloid process nonunion and outcome in patients with a distal radius fracture: A meta-analysis of comparative clinical trials.
      Despite this inconsistency, 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 DRUJ instability and wrist dysfunction and should be addressed sooner rather than later to prevent long-term consequences including DRUJ osteoarthritis.
      In their retrospective study “Clinical Outcomes of Arthroscopic One-Tunnel Triangular Fibrocartilage Complex Transosseous Suture Repair Are Not Diminished in Cases of Ulnar Styloid Process Fracture Nonunion,” Nam, Choi, Kim, and Park
      • Nam J.J.
      • Choi I.C.
      • Kim Y.B.
      • Park J.W.
      Clinical outcomes of arthroscopic one-tunnel triangular fibrocartilage complex transosseous suture repair are not diminished in cases of ulnar styloid process fracture nonunion.
      compared patients with and without USPFN after arthroscopic repair of a Palmer 1B foveal TFCC tears. The authors treated both groups with arthroscopic 1-tunnel transosseous suture repair (N = 66), with no modification of their technique for patients with USPFN (N = 22).
      • Park J.H.
      • Kim D.
      • Park J.W.
      Arthroscopic one-tunnel transosseous foveal repair for triangular fibrocartilage complex (TFCC) peripheral tear.
      Although underpowered, their report suggests that nonunions of the ulnar styloid process do not require additional treatment at the time of TFCC foveal repair because there were no differences found between the groups for preoperative and postoperative subjective outcome measures, pain scores, or grip strength. This finding is important for surgeons that treat wrist injuries because it means 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.
      In my experience, differentiating between potential pain generators in the ulnar-sided wrist can be challenging, even humbling. The anatomy is complex, and our understanding, although dramatically improved over the past 30 years, remains incomplete. For the best chance of getting it right, I recommend using all of the tools at your disposal to help correctly diagnose what is causing the problem. Obtain a good set of radiographs. Magnetic resonance imaging arthrography and ultrasonography can help aid in diagnosis, but don’t hang your hat on a negative study when you have a reliable patient with reproducible physical examination findings. Most importantly, talk to your patient and have them show you the maneuver(s) that causes their symptoms. Coalesce this information, and come up with a plan. Whether you choose to approach the problem arthroscopically or open, the foveal TFCC tear should be repaired to prevent long term sequalae.

      Supplementary Data

      References

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