CHAPTER 52 • SOFT TISSUE INJURIES OF THE WRIST IN ATHLETES 301volar and dorsal radiocarpal ligaments must take place.
As a result, the carpus is allowed to slide along the
incline of the radius in the ulnar direction. Physical
examination includes severe swelling, loss of motion,
and deformity. Radiographic evaluation will demon-
strate translation of the carpus, as well as rotation of the
proximal carpal row into palmarflexion, and scapholu-
nate disastasis due to ulnar displacement of the lunate.- There is no role for nonoperative treatment in this injury.
Surgical exploration reveals extensive capsular tears,
frequently including the scapholunate ligament.
Taleisnik believes that capsular reattachment commonly
results in recurrence and if stability is achieved, it is usu-
ally at the expense of loss of motion (Taleisnik, 1980).
As a result, he recommends radiolunate arthrodesis to
maintain reduction that results in a stable, pain-free
wrist with satisfactory preservation of motion. This may
allow an athlete to return to strenuous activity when full
range of motion is not mandatory.
TRIANGULAR FIBROCARTILAGE
COMPLEX INJURY
- The triangular fibrocartilage complex(TFCC) is made
up of the triangular fibrocartilage(TFC) a cartilagi-
nous disc, which lies on the ulnar head, and several
supporting ligaments, and acts as a stabilizer of the
distal radioulnar joint(DRUJ). Injury to this structure
may result in two forms, perforation of the disk (trau-
matic or degenerative), or avulsion (traumatic) of the
disk with or without avulsion of the supporting liga-
ments. Avulsion of the TFCC occurs following acute
dislocation or subluxation of the distal ulna relative to
the radius. Degenerative tears usually occur after the
third decade (Mikic, 1978). Ulnar variance may play a
role in degenerative changes of the TFC. Palmer found
the center of the TFC to be thinner in ulna plus wrists
(Palmer, Glisson, and Werner, 1984). Lunotriquetral
tears may occur following degenerative perforation of
the TFC leading to carpal instability. Young athletes
with ulna plus variants, who participate in repetitive
loading of the wrist, may be susceptible to degenera-
tive changes of the TFC similar to older patients
(Halikis and Taleisnik, 1996).
•Patients with injury to the TFC frequently complain of
ulnar sided wrist pain, exacerbated by forearm rota-
tion. It is important to discern injury to TFC from
injury to the DRUJ. Injury to the TFC is suspected
when tenderness and crepitus are palpated between the
ulna and triquetrum. Relief of pain during manual sta-
bilization of the DRUJ during forearm rotation may be
an indicator of DRUJ instability. Diagnostic evaluation
may include plain radiographs, MRI, arthrography,
and/or arthroscopy. Demonstration of ulna plus vari-
ance on plain radiographs adds to suspicion of TFC
injury. Arthrography may exhibit a communication
between the radiocarpal and distal radioulnar joints.
MRI and arthroscopy have been helpful in determining
the size and location of lesion of the TFC.
•Treatment of acute injury of the TFC includes immo-
bilization of the wrist in neutral rotation for up to 4 to
6 weeks. Gradual progression of activities may then
begin with the use of supportive splinting. An injec-
tion into the ulnocarpal space with steroid may also be
helpful and diagnostic prior to immobilization. If the
athlete is unable to return to sport and symptoms per-
sist, then surgical debridement of the perforation
and/or decompression of the ulnocarpal space should
be performed. Decompression can be obtained
through ulnar shortening (Linscheid, 1987), DRUJ
excisional hemiarthroplasty (Bowers, 1985), or the
Kapanji procedure (Goncalves, 1974). If a peripheral
tear is found in the outer 15 to 20% of the TFC, a
repair may be considered in conjunction with ulnar
recession (Taleisnik, 1992). For patients with ulna
plus variance and a degenerative tear of the TFC,
ulnar shortening is the treatment of choice, while
excision of the TFC and Darrach procedure should be
avoided. For patients with ulna minus variant,
debridement of the TFC defect may relieve pain and
will not increase load transmission providing only the
central third is removed. For acute avulsions causing
DRUJ instability, above elbow immobilization with
the DRUJ reduced, usually is successful. If instability
persists, reattachment of the TFC is performed, usu-
ally at the fovea of the ulnar styloid using suture and
drill holes (Hermansdorfer and Kleinman, 1991).COMPRESSION NEUROPATHIES- Compression neuropathies in athletes may be subtle
and often overlooked. Nerve injuries can result from a
single violent injury, or from repetitive stress.
Compression may also result from anatomic structures
(e.g., muscles, vessels, fibrous bands), or pathologic
structures (e.g., ganglia, aneurysms, inflammation).
Nerve injuries are often classified as described by
Seddon (1943) in order of severity as neurapraxia,
axonotmesis, or neurotmesis.
MEDIAN NERVE- Compression of the median nerve at the carpal tunnel is
the most common compressive neuropathy in the gen-
eral population, but is not regularly seen in athletes.