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The patient, 19, presents instability in the left wrist and pain at its ulnar edge. The symptoms, which limit its functionality, appear after a second injury (he had suffered a previous wrist fracture in childhood) and have their origin in a pseudoarthrosis of the ulnar styloid and the rupture of the insertion of the triangular fibrocartilage (TFC) in the ulnar fovea (bony cavity next to the styloid).
The triangular fibrocartilage or articular disc is one of the elements which compose the radioulnar distal joint. It’s a structure formed by a combination of fibrous and cartilaginous tissues, which goes from the edge of the sigmoid notch of the radius to the fovea of the ulna. The fibrocartilage is involved in load distribution in the upper limb and balances various complex structures in the wrist.
Furthermore, it is part of the so-called triangular fibrocartilage complex (TFCC), a mixture of non-bony elements such as the fibrocartilage itself, which allows us harmonic movements and strength in the grip.
The density of elements in a very small space makes the radioulnar joint prone to the appearance of combined injuries, as in the case at hand, with a styloid fracture and the simultaneous disinsertion of the fibrocartilage (isolated fibrocartilage injuries are unusual).
The problem
The pseudoarthrosis of the ulnar styloid, that is, its non-consolidated fracture and the lesion of the triangular fibrocartilage, make it impossible for the patient’s wrist to function optimally (due to the instability and pain noted), which prevents proper practice of motocross ; a sports activity in which mobility and grip play a determining role.
The goals
The goals of the procedure designed by Dr Piñal go through the elimination of pain and the return of the wrist to a level of function consistent with the demands of use of the patient.
The plan
To facilitate the approach and correct identification of the injury, Dr Piñal uses his dry arthroscopy technique (‘Dry arthroscopy of the wrist: surgical technique’, Journal of Hand Surgery American Edition Vol 32A, Issue 1, January 2007, Pages 119-123), which offers far superior visibility than conventional fluid infusion technique.
The video shows Dr Piñal elevating the fibrocartilage and showing that it is loose with respect to the fovea. In this case, dry arthroscopy is key in identifying the injury.
To suture the fibrocartilage, Dr Piñal uses all-inside suturing, that is, his arthroscopic suturing technique from inside the joint itself without additional incisions, described in his article ‘A technique for arthroscopic all-inside suturing in the wrist ‘(Journal of Hand Surgery European Volume (2010) 35: 475-479).
The results
The procedure carried out by Dr Piñal is a success. The pain and instability of the wrist disappear and the patient fully recovers the function of the injured area, allowing him to return to his sport activity.
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