Triangular fibrocartilage injury: surgery on posterior tear

29 mars, 2016

Rotura posterior fibrocartílago_20160328_01

The triangular fibrocartilage is in the ulnar side of the wrist and is a major cause of pain in the area. This diagnostic label can include up to 60 different pathologies in just one square centimeter of body surface (1).

Rotura posterior fibrocartílago_20160328_02
Illustration offers a partial view of the suturing technique ‘from the inside’ in fibrocartilage injuries (in this case dorsal tear) described by Dr. Del Pinal. Source: ‘A technique for arthroscopic all-inside suturing in the wrist’ – J. Hand Surg Eur Vol OnlineFirst published on February 11, 2010 as doi: 10.1177/1753193409361014. The Journal of Hand Surgery (2010) 0: 0: 1–5 .

A tear in the fibrocartilage, which may appear in many forms, is one of the most common diseases of  the wrist.

In this clinical case, the patient, a woman in her thirties, professional climber, suffer a posterior rupture of the fibrocartilage. The tear is hardly one millimeter (mm) and would be “compatible” with an ordinary activity, but incapacitates her to practice her sport.

Fibrocartilage injuries are especially constraining, given its role in the loads distribution of the upper limb, helping also to absorb and distribute the force exerted when tightening the fist, grasping an object, etc. In turn, the fibrocartilage balances various complex structures of the wrist, such as carpal bones, and allows them to move in harmony.

Rotura posterior fibrocartílago_20160328_03
The patient’s fibrocartilage injury could be ‘acceptable’ for a common functional intensity, but incapacitating for a professional practice of climbing.

One of the warning signs for this condition, besides the pain, is the instability in the wrist, ie the feeling of abnormal movement inside that leads to failure of the executed action.

The problem

The posterior injury of the fibrocartilage don’t allow the patient to precisely exert the necessary strength in high-level climbing. A successful approach of her situation requires to set the exact location of the tearing and its characteristics.

The objectives

The goals of the procedure designed by Dr. Del Piñal are two, in essence: to eliminate the pain and to give back the wrist a functional level in line with the demands of the professional activity of the patient.

The plan

The use of dry arthroscopy allows pinpointing the rupture point of the fibrocartilage more accurately than other diagnostic technics, both in the identification of pathology and in its surgical resolution. In this regard, Dr. Del Piñal uses with the patient one of his described techniques for arthroscopic suture of the fibrocartilage from the inside, published by the European Volume of the Journal of Hand Surgery.

Thus, puncturing the fibrocartilage, Dr. Del Piñal performs a repair on the dorsal capsule. The spinal needle is inserted from the proximal area, the absorbable surgical thread is removed and the needle is retracted, ‘skating’ on the area, then re-enters and sutures with a  point less than 1 mm.

The outcome

The procedure is successful, allowing the patient to resume the practice of professional climbing.

(1) Addressed by Dr. Del Piñal in his book ‘Arthroscopic Management of Ulnar Pain‘.