Injury of the Dorsal Sensory Branch of the Ulnar Nerve as a Complication of Arthroscopic Repair of the Triangular Fibrocartilage

Abstract

This report presents a case of direct injury to the dorsal sensory branch of the ulnar nerve caused by arthroscopic repair of the triangular fibrocartilage complex. The dorsal sensory branch of the ulnar nerve was strangulated by one of the three pull-out sutures of the joint capsule, just ulnar to the extensor carpi ulnaris tendon. Pain and dysaesthesia of the ulnar side of the wrist was completely relieved after excision of the injured nerve segment. This complication can be avoided by careful exploration of the dorsal sensory branch of the ulnar nerve prior to suturing or passage of instruments during arthroscopy.

Clinical experience with arthroscopically-assisted repair of peripheral triangular fibrocartilage complex tears in adolescents—technique and results

“…We currently do not perform foveal TFCC repair in this age group because of its increased invasiveness and the good results with our described technique. Previous reports demonstrated an eminent possibility of damaging the dorsal sensory ulnar nerve during suture passage or when tying the repair knot [24,25]. For this reason we prefer the mini-open approach as proposed by McAdams and Hentz to protect these variable branches, and to safely bury the relatively irritating knot ends down to the ulnar capsule with an additional absorbable suture [25].…”

Complications of Elbow and Wrist Arthroscopy

“…51 The only consistent finding about the nerve is that it and its branches travel intimately around the ECU and can be located on either side of the tendon at the level of the joint placing it dangerously close to the either 6R or 6U portals, or both. 52 Unfortunately, the arborization pattern of both the SBRN and the DSBUN is highly variable. 49 The distal posterior interosseous nerve is the terminal portion of the PIN, carrying purely sensory fibers.…”

“…There are anatomic studies proving that use of either or both portals comes with increased risk of damaging the DBUN. 47,[49][50][51][52]54,[56][57][58][59] Some authors recommend routine use of midcarpal arthroscopy to supplement wrist arthroscopy to identify midcarpal disorders. 60 The midcarpal radial portal is routinely created 1 cm distal to the 3-4 portal in line with the radial margin of the third metacarpal and just radial to the EDC tendon of the index finger.…”

“…More minor complications included transient nerve injury, prolonged portal site drainage or superficial infection, transient stiffness, and extensor tendon irritation. The literature includes case series 20,46,59,[62][63][64][66][67][68][69] (Table 3) and several case reports of neurological 52,57,70 and non-neurological complications (Table 4). 71 Prevention of complications involves understanding of distraction techniques, patient positioning, anatomy, and instrumentation.…”

“…49,51,52 One of the procedures implicated as a cause of iatrogenic DSBUN injury is arthroscopic primary TFCC repair. The suture passed through the injured TFCC is tied down on the capsule, the ECU sheath, or a button on skin.…”