Triangular Fibrocartilage Complex Injuries

Original Editor - Kristen Mason

Top Contributors - Kristen Mason, Admin, Kim Jackson, Laura Ritchie, Lucinda hampton, Jess Bell, Rachael Lowe, Shauni Van Overstraeten, Shaimaa Eldib, 127.0.0.1, Kai A. Sigel, WikiSysop, Wanda van Niekerk, Joseph Ayotunde Aderonmu and Evan Thomas  

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

Must differentially diagnose TFCC injury from:

• Osteoarthritis of Pisotriquetral/Distal Radioulnar Joint
• Fracture of pisiform, hamate
• Carpal/Midcarpal Instability
• Hypothenar Hammer Syndrome

Key Evidence

Lubiatowski P, Romanowski L, Spławski R, Manikowski W, Ogrodowicz P.  Treatment of injury of the triangular fibrocartilage complex (TFCC).  Ortop Traumatol Rehabil.  2006;8(3): 256-262.

The triangular fibrocartilage complex (TFCC) supplies stability and cushioning for proper wrist function. TFCC lesions, a common cause of ulnar-sided wrist pain, can be traumatic (Palmer I) or degenerative (Palmer II) in nature. Clinical assessment is basic for making the diagnosis, but imaging may be helpful. Conservative treatment is the best choice for most acute cases. If the symptoms persist, however, operative treatment has a better prognosis for pain relief. Wrist arthroscopy has a major role to play in the diagnosis and treatment of TFCC lesions. Material and methods. 29 patients were operated in the Hand Surgery Department in Poznań due to TFCC lesions. 16 patients were qualified as Palmer type I (9 sport injuries, 7 sprains). while 13 patients had Palmer type II secondary to distal radial fractures. All patients suffered ulnar wrist pain and were positive on provocation tests. The indication for surgery was a lack of response to conservative treatment. Different operative procedures were used, depending on the type of lesion: arthroscopic debridement, open or arthroscopic restabilization of the TFCC, ulnar shortening, or partial resection of the ulnar head (Wafer). Rehabilitation was introduced following a period of immobilization. Results. Wrist pain was significantly diminished or disappeared after surgical treatment and rehabilitation. Conclusions. Good functional result and pain relief can be expected following surgical treatment of TFCC injuries.

Chloros GD, Wiesler ER, Poehling GG.  Current concepts in wrist arthroscopy.  Arthroscopy.  2008;24(3):343-354.

The purpose of this article is to review the recent literature on arthroscopic treatment of distal radius fractures (DRFs), triangular fibrocartilage complex injuries, intercarpal ligament injuries, and ganglion cysts, including the use of electrothermal devices. A major advantage of arthroscopy in the treatment of DRFs is the accurate assessment of the status of the articular surfaces and the detection of concomitant injuries. Nonrandomized studies of arthroscopically assisted reduction of DRFs show satisfactory results, but there is only 1 prospective randomized study showing the benefits of arthroscopy compared with open reduction-internal fixation. Wrist arthroscopy plays an important role as part of the treatment for DRFs; however, the treatment for each practitioner and each patient needs to be individualized. Wrist arthroscopy is the gold standard in the diagnosis and treatment of triangular fibrocartilage complex injuries. Type 1A injuries may be successfully treated with debridement, whereas the repair of type 1B, 1C, and 1D injuries gives satisfactory results. For type 2 injuries, the arthroscopic wafer procedure is equally effective as ulnar shortening osteotomy but is associated with fewer complications in the ulnar positive wrist. With interosseous ligament injuries, arthroscopic visualization provides critical diagnostic value. Debridement and pinning in the acute setting of complete ligament tears are promising and proven. In the chronic patient, arthroscopy can guide reconstructive options based on cartilage integrity. The preliminary results of wrist arthroscopy using electrothermal devices are encouraging; however, complications have been reported, and therefore, their use is controversial. In dorsal wrist ganglia, arthroscopy has shown excellent results, a lower rate of recurrence, and no incidence of scapholunate interosseous ligament instability compared with open ganglionectomy. Arthroscopy in the treatment of volar wrist ganglia has yielded encouraging preliminary results; however, further studies are warranted to evaluate the safety and efficacy of arthroscopy.

Henry MH.  Management of acute triangular fibrocartilage complex injury of the wrist.  J Am Acad Orthop Surg.  2008;16(6):320-329.

Acute trauma to the triangular fibrocartilage complex includes tears of the fibrocartilage articular disk substance and meniscal homolog as well as radioulnar ligament avulsions, with or without an associated fracture. Patient evaluation includes clinical examination, imaging studies, and wrist arthroscopy (diagnostic). The Palmer classification is typically used to define injuries to the triangular fibrocartilage complex. The critical distinction is in differentiating injuries that produce instability of the distal radioulnar joint from those that do not. Also important is the recognition of acute injuries in the context of an ongoing degenerative pattern (ie, Palmer class 2 lesions). Nonsurgical management includes temporary splint immobilization of the wrist and forearm, oral nonsteroidal anti-inflammatory medication, corticosteroid joint injection, and physical therapy. Surgical strategies include debridement, acute repair, and subacute repair. Most surgical procedures can be performed arthroscopically. However, open ligament repair may be needed in the setting of distal radioulnar joint instability.

Albastaki U, Sophocleous D, Göthlin J, Pierre-Jerome C.  Magnetic resonance imaging of the triangular fibrocartilage complex lesions: a comprehensive clinicoradiologic approach and review of the literature.  J Manipulative Physiol Ther.  2007;30(7):522-526.

OBJECTIVE: This article illustrates the frequent lesions of the triangular fibrocartilage complex (TFCC) by means of magnetic resonance imaging. METHODS: We performed a retrospective chart review of the magnetic resonance images of 109 patients from our database. All subjects had history of trauma, and all underwent both radiographic and magnetic resonance imaging examination of the wrist. The changes (degeneration, tears) of the TFCC were assessed. RESULTS: Ten patients were excluded because of incomplete imaging protocol (4 patients) and low-quality images (6 patients). From the 99 wrists remaining, the TFCC was normal in 30 (30.3%). Degenerative changes were found in 40 (40.4%) wrists. Partial and complete tears were present in 17 (17.1%) and 12 (12.1%) wrists, respectively. CONCLUSION: The TFCC lesions in acute traumatic wrists should not be overlooked; they may contribute to wrist pain and disability after treatment of existing bone injuries.

Case Studies

add links to case studies here (case studies should be added on new pages using the case study template)

Resources

add appropriate resources here

Recent Related Research (from Pubmed)

Failed to load RSS feed from http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1Zkrxt7ktlC7HCSA78bQyysqaPcwrFaArccnyzF6hF4U0XyQo|charset=UTF-8|short|max=10: Error parsing XML for RSS

References

References will automatically be added here, see adding references tutorial.