Triangular Fibrocartilage Complex Injuries

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Clinically Relevant Anatomy

The Triangular Fibrocartilage Complex is the ligamentous and cartilaginous structures that separate the radiocarpal from the distal radioulnar joint.  The TFCC consists of an articular disc, meniscus homologue, ulnocarpal ligament, dosal & volar radioulnar ligament and extensor carpi ulnaris sheath. 

Origin: Medial border of distal radius

Insertion: Base of ulnar styloid

Vascular Supply: central disc is avascular, peripheral blood vessels penetrate TFCC margins

Function of TFCC:

1. Main stabilizer of distal radioulnar joint
   

         - Volar portion of TFCC prevents dorsal displacement of ulna and is tight in pronation
         - Dorsal portion of TFCC prevents volar displacement of ulna and is tight in supination

    2. Contributes to ulnocarpal stability

Mechanism of Injury / Pathological Process

Mechanism of Injury

• Occurs with compressive load on TFCC during marked ulnar deviation
  
• Commonly associated with positive ulnar variance (radial shortening, average of 4.5 mm)
• Forced ulnar deviance (i.e. swinging bat, racket, etc) causes increased load on TFCC

Clinical Presentation

• Ulnar sided wrist pain often with clicking/grinding
  
• Weakness

Diagnostic Procedures

Physical Examination

• TFCC Compression Test: reproduction of pain/clicking with ulnar deviation of wrist with forearm in neutral
• Piano Key Sign: prominent distal ulna with full pronation
• Ulnar Carpal Sag
• Lunotriquetral interval tenderness

Radiographs: may reveal avulsion of ulnar styloid, scaphoid fracture, distal radial fracture, volar tilt of lunate or triquetrum; ulnar variance

Triple Injection Arthrography: identification of tear (low specificity)

MRI: identification of tear (high sensitivity and specificity)

Palmar Classification of TFCC Abnormalities

• Class 1: Traumatic

         - Class 1A: Central Perforation

    - Class 1B: Ulnar Avulsion with or without distal ulnar fracture

    - Class 1C: Distal Avulsion

    - Class 1D: Radial Avulsion with or without sigmoid notch fracture

• Class 2: Degenerative

    - Class 2A: TFCC wear

    - Class 2B: TFCC wear with lunate and/or ulnar chondromalacia

    - Class 2C: TFCC perforation with lunate and/or ulnar chondromalacia

    - Class 2D: TFCC perforation with lunate and/or ulnar chondromalacia and lunotriquetral ligament perforation

    - Class 2E: TFCC perforation with lunate and/or ulnar chondromalacia, lunotriquetral ligament perforation, and 

      ulnocarpal arthritis

Outcome Measures

• DASH Outcome Measure
  
• Modified Mayo Wrist Score
• Activities of Daily Living Score

Management / Interventions

Conservative Treatment

• NSAIDs
• Immobilization in cast/splint with wrist in slight flexion and ulnar deviation
• Physical Therapy

Surgical Intervention

• Open Repair or Arthroscopic Repair

Differential Diagnosis

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Key Evidence

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