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PubMed2006

Triangular fibrocartilage complex tears: a review.

Triangular fibrocartilage complex (TFCC) tears are a common source of ulnar sided wrist pain. Originally described by Palmer, in 1981, as a complex of several structures, our understanding of the anatomy and the function of the TFCC has been refined by histologic studies. The TFCC plays an important role in load bearing across the wrist as well as in distal radioulnar joint (DRUJ) stabilization. A thorough knowledge of the anatomy as well as the Palmer classification system helps to guide treatment options.

Arthroscopy↗
PubMed2001

The innervation of the triangular fibrocartilage complex: nitric acid maceration rediscovered.

Injury to the triangular fibrocartilage complex (TFCC) is frequently implicated in the etiology of ulnar-sided wrist pain. This study examines the nervous anatomy of the TFCC using a nitric acid maceration technique and attempts to correlate this information with known tear patterns. Ten fresh frozen cadaveric specimens were studied in detail. Gross dissection of each upper-extremity specimen included removal of all flexor and extensor tendons. After identification and labeling with permanent color of the ulnar nerve, dorsal sensory branch of the ulnar nerve, posterior interosseous nerve, anterior interosseous nerve, and median nerve, an en bloc excision of the distal radioulnar region was performed. Digestion of the soft tissue was performed with nitric acid at sequential concentrations of 50% and 33% for 9 of 10 specimens. The digestion was halted by immersing the specimen in a mixture of 10% formaldehyde and 1% glycerine. After removal of bone, the specimens were fixed in paraffin, sectioned, and stained with hematoxylin and eosin. Nine of the 10 specimens were studied microscopically to determine the contribution of the grossly identified nerves to each zone of the triangular fibrocartilage complex as defined by Palmer's classification of acute TFCC tears. The anterior interosseous, median, and superficial radial nerves did not contribute to the innervation of the TFCC. The intraarticular course of the peripheral nerves could not be defined in the one specimen that was not digested with nitric acid. Nitric acid maceration is a rediscovered technique for identifying the nervous anatomy of soft tissues. The study showed that the triangular fibrocartilage complex is innervated by branches of the posterior interosseous, ulnar, and dorsal sensory ulnar nerves in a fairly consistent manner. Improved treatment of TFCC tears may result from an enhanced understanding of the supporting structures' innervation and mechanical function.

Cartilage, Articular↗
PubMed1991

Hemiresection-interposition arthroplasty of the distal radioulnar joint associated with repair of triangular fibrocartilage complex lesions.

Sixteen wrists of 15 patients with traumatic triangular fibrocartilage complex tears were treated by hemiresection-interposition arthroplasty of the distal radioulnar joint combined with repair of the torn triangular fibrocartilage complex. The surgical procedure was performed to avoid impingement of the ulnar head against the reconstructed triangular fibrocartilage complex. Most of the wrists showed a positive ulnar variance. The average age of the patients was 39 years. Follow-up averaged 41 months. Complete relief of pain was obtained in 10 wrists. Slight pain persisted in 6 wrists, although it was less than before surgery. The range of motion of the wrist joint and forearm improved postoperatively. Grip strength in all wrists increased. Postoperative complications occurred in 7 wrists of 6 patients: reoperation in 2 wrists, fracture in 1, and tendinitis of the extensor carpi ulnaris in 4. All 15 patients subsequently returned to their previous occupations.

Adult↗
PubMed2001

The role of radiocarpal injection arthrography and magnetic resonance imaging in the diagnosis of triangular fibrocartilage complex injuries.

OBJECTIVE: To investigate the radiocarpal joint injection arthrography and magnetic resonance imaging for diagnosis of the triangular fibrocartilage complex (TFCC) injuries. METHODS: Thirteen cases whose main complaints were ulnar wrist pain were given radiocarpal joint arthrography and eight of them were also given magnetic resonance imaging for evaluating the integrity of the triangular fibrocartilage complex. RESULTS: Ten of thirteen cases presented the leakage of contrast medium to distal radioulnar joint from the radiocarpal joint, in whom, 8 were demonstrated triangular fibrocartilage tear on magnetic resonance imaging, and 3 located at radial side, 2 at central, 3 at ulnar side. One of three cases which were demonstrated without the leakage of contrast medium in arthrography were displayed with marked TFCC tear on magnetic resonance imaging. CONCLUSIONS: The wrist arthrography can provide a definite diagnosis for triangular fibrocartilage disruption with higher sensitivity. magnetic resonance imaging not only demonstrates the site of triangular fibrocartilage disruption as the same value as wrist arthrography, but also displays the other related bony and soft tissues changes.

Adult↗
PubMed1995

"Press test" for office diagnosis of triangular fibrocartilage complex tears of the wrist.

We present a simple provocative diagnostic office test for detection of triangular fibrocartilage complex tears of the wrist. Twenty-seven patients with a working diagnosis of a triangular fibrocartilage complex tear complained of wrist pain caused by forceful use; 18 had a history of trauma. A "press test" was performed in each, requiring the seated patient to push the body weight up off a chair using the affected wrist, creating an axial ulnar load. A positive test provoked focal ulnar wrist pain replicating the discomfort that had prompted the patient to seek medical attention. Thirteen patients improved with conservative treatment. Seventeen underwent magnetic resonance imaging (showing 13 tears and 4 normal results) and two patients had arthrograms (both had tears). Fourteen patients had wrist arthroscopy; all had triangular fibrocartilage complex tears, which were debrided, with postoperative clinical improvement. As verified by arthroscopy, the press test had 100% sensitivity in preoperative tear detection compared with 79% for magnetic resonance imaging. The press test is recommended as a useful, free, noninvasive clinical test for triangular fibrocartilage complex tears of the wrist.

Adult↗
PubMed2002

Early isolated triangular fibrocartilage complex tears: management by arthroscopic repair.

BACKGROUND: Tears in the traumatic triangular fibrocartilage complex (TFCC) are generally caused by falling accidents with pronated, hyperextended wrists, or by distraction injuries that pull the ulnar side of the wrist out of place. Tears in the triangular fibrocartilage complex often appear in association with ulnar wrist pain and limited wrist function in work or sport. This study addressed the arthroscopic repair of peripheral tears in the TFCC, in a sample of 37 patients who were undergoing TFCC repair by wrist arthroscopy. METHODS: From September 1996 to February 1999, 37 patients underwent TFCC repair by wrist arthroscopy. The mean follow-up period was 25.6 months (range, 22-28 months), and the patients' average age was 21 years. The study included 30 men and 7 women. All patients had early peripheral TFCC tears and no wrist fractures. The inside-out method was used to repair the tears and the distal radioulnar joint was fixed for 6 weeks using a 2.0-mm Kirschner wire. After operation, patients were rehabilitated, reexamined, and followed up at the clinic. Complications were also recorded. RESULTS: The results were graded with a Mayo Modified Wrist Score. Ten of the 37 wrists were rated excellent, 24 were good, and 3 were fair. Overall, 34 of 37 patients (92%) rated satisfactorily and returned to sporting or work activities. Four patients experienced mild pain during work or exercise. Although motion remained normal for these patients, grip strength on the affected hand was at least 72% of that on the other hand. CONCLUSION: Arthroscopic repair of early peripheral tears of the triangular fibrocartilage complex is a satisfactory method of repair. The procedure can enhance patients' wrist function by relieving pain and increasing tolerance for work or sport.

Adult↗
PubMed2004

Open repair of the ulnar disruption of the triangular fibrocartilage complex with double three-dimensional mattress suturing technique.

Open repair technique of the ulnar disruption of the triangular fibrocartilage complex is described. This technique is indicated for a fresh or a relatively fresh (less than 1 year after the initial injury) ulnar foveal detachment tear, horizontal tear, and proximal slit tear of the triangular fibrocartilage complex, all of which are accompanied by severe dorsal, palmar, or multidirectional instability of the distal radioulnar joint. A chronic tear greater than 1 year from initial injury and a fresh triangular fibrocartilage complex tear without distal radioulnar joint instability, such as central slit tear, are excluded from our indications. A dorsal C-shaped skin incision, a longitudinal incision of the radial edge of the extensor carpi ulnaris subsheath and the dorsal distal radioulnar joint capsule, exposes the distal radioulnar joint. A small, 5-mm longitudinal incision at the origin of the radioulnar ligament exposes its fovea detachment and/or the proximal slit tear of the triangular fibrocartilage complex. The disrupted radioulnar ligament is sutured in a pullout fashion to the ulna with a 3-dimensional double mattress technique through 2 bone tunnels that is precisely made at the central portion of the fovea with 1.2-mm K-wire. An additional horizontal mattress suture is used for closure of the small incision made at the radioulnar ligament, then the extensor carpi ulnaris is repaired. This open-repair technique is complex and requires precise technical skills; however, early results have been more rewarding than the conservative treatment.

Journal Article↗
PubMed1998

Morphology and distribution of nerve endings in the human triangular fibrocartilage complex.

We studied the morphology and distribution of nerve endings in the human triangular fibrocartilage complex using both silver staining and immunohistochemical staining using a protein specific to nerve fibres. Free nerve endings were found in the ulnar side of the triangular fibrocartilage complex, especially in the ulnar collateral ligament, meniscus homologue and the adjacent collagen fibre area of the peripheral part of the ulnar side of the articular disc. Meissner's and Krause's corpuscles were observed in the ulnar collateral ligament and meniscus homologue. The fact that free nerve endings were observed in the meniscus homologue and adjacent collagen fibre area of the peripheral part of the ulnar side of the articular disc suggests that this disc may be a source of wrist pain. The presence of nerve end bulbs in the triangular fibrocartilage complex also suggests a possible role for corpuscles as mechanoreceptors.

Adult↗
PubMed1996

Arthroscopic repair of radial-sided triangular fibrocartilage complex tears.

Treatment of triangular fibrocartilage complex (TFCC) tears is receiving considerable attention. Repair of peripheral tears of the TFCC has been recommended to restore the important functions of stability and load-bearing. Techniques for the reattachment of the periphery of the TFCC are evolving. Previous reports have mainly dealt with ulnar-sided (Palmer Class I-B) repairs. This report describes an arthroscopic technique for repair of radial-sided (Palmer Class I-D) TFCC tears. The procedure utilizes arthroscopic visualization with direct reattachment of the radial edge of the horizontal disk of the TFCC into the sigmoid notch of the distal radius. Fixation is achieved using sutures driven through the distal radius using long straight meniscal repair needles. Early clinical results following arthroscopic reattachment of radial-sided TFCC tears using this technique have been favorable. The technique is presented as an alternative method for repair of these lesions.

Arthroscopes↗
PubMed1994

Congenital perforation of the triangular fibrocartilage of the wrist.

The triangular fibrocartilages (TFC) of 136 wrist joints from 48 fetuses and 20 infants fresh cadavers without any evidence of known deformity and injury were studied. Perforations of the TFC were found not only in infants (18.8%), but also in fetuses (25%). The difference between the incidences of the perforations in the two groups is not statistically significant (P > 0.05). Furthermore, we did not find that perforation of the TFC is correlated with either sex or side of wrists (P > 0.05). Histologically, the vascularity and cellularity of the TFC have no significant correlation with the absence or presence of perforation in it. We believe that, besides trauma, inflammation and degeneration, some perforations of the TFCs are congenital in origin, which all take the form of fissure and are located mainly in the radial half of the TFC.

Cartilage, Articular↗
PubMed2005

Arthroscopic triangular fibrocartilage complex debridement using radiofrequency probes.

The initial results of using radiofrequency probes for debridement of a torn triangular fibrocartilage complex were studied in 20 patients with a mean age of 44 (range 27-56) years presenting with ulnar-sided wrist pain. On arthroscopic examination, 18 central and two radial triangular fibrocartilage complex tears were identified and debrided to a stable rim using radiofrequency probes. The mean follow-up was 22 (range 9-35) months. Seventeen patients experienced substantial pain relief. In three, the pain was unchanged. The mean flexion extension arc was 132 degrees , pronosupination arc 155 degrees and mean grip strength was 83% of that of the unaffected side. Using the modified Mayo wrist score, there were ten excellent, seven good and three fair results. No perioperative complications occurred. Radiofrequency probes were found to be safe and effective for use in triangular fibrocartilage complex debridement. These results compare favourably with other standard methods of treatment of this problem.

Adult↗
PubMed1994

Triangular fibrocartilage tears.

From a series of 56 patients with triangular fibrocartilage injury, 33 patients with peripheral rim tears not associated with instability of the distal radioulnar joint were identified by arthrography or arthroscopy. Open repair of the peripheral tear produced 11 excellent, 15 good, 6 fair, and 1 poor result (grading based on a Mayo modified Green-O'Brien wrist score). Ulnar recession improved surgical exposure and corrected ulnar variance in 11 patients. A dorsal approach for repair of radial and anterior peripheral rim tears was used in 28 patients. Repair of peripheral tears restored functional integrity to the triangular fibrocartilage, and good to excellent results are reported in 26 of the patients treated.

Adolescent↗
PubMed1998

Triangular fibrocartilage perforations with bilateral negative ulnar variant wrists: a case report.

Triangular fibrocartilage (TFC) constitutes the major part in the triangular fibrocartilage complex, which stabilizes the distal radioulnar joint and functions as a cushion for axial compression forces. Tears in the TFC are often encountered with positive ulnar variance and regarded as part of a degenerative process of the ulnocarpal joint. They are occasionally seen as the result of trauma and are less likely to be found in a young population, especially in those who are in the first two decades of life, without causative traumatic injury. We report the case of a 12-year-old boy with bilateral negative ulnar variances with incidental findings of TFC tears in both wrists. This is a rare case, as he had no history of a traumatic event.

Cartilage, Articular↗
PubMed2002

Impact load on the triangular fibrocartilage of the wrist: a cadaver study.

OBJECTIVE: The aim of this study was to study the role of the triangular fibrocartilage of the wrist in attenuating and transmitting axial force on the ulnar side of the wrist. DESIGN: Ten biopsies from the triangular fibrocartilage of fresh cadaver wrists were subjected to repetitive axial load during 4 h under reproducible conditions. Another five biopsies were subjected to a higher load and for a longer compression time. Finally, five biopsies were compressed at a (three times) higher compression rate. The amount of force transmitted and attenuated as well as the loaded deformation was measured. RESULTS: From the first experiment we concluded that 53% of the axial force was attenuated. More force was attenuated (61%) if the axial load was increased but still kept within the physiological boundaries. However, increasing the compression rate beyond the physiological boundaries showed that only very little force is attenuated (11.2%). CONCLUSION: The triangular fibrocartilage of the wrist has an important force attenuating function and should not be easily resected.

Aged↗
PubMed1998

Evaluation of the triangular fibrocartilage and the scapholunate and lunotriquetral ligaments in cadavers with low-field-strength extremity-only magnet. Comparison of available imaging sequences and macroscopic findings.

RATIONALE AND OBJECTIVES: The authors assessed the ability of a low-field-strength extremity-only magnet to provide visualization of the triangular fibrocartilage and the scapholunate and lunotriquetral ligaments. METHODS: Twelve human wrists were examined with a 0.2 T extremity-only magnet. T1-weighted spin echo, proton density-weighted, and T2-weighted turbo spin echo, short-tau inversion recovery, and three-dimensional gradient recalled echo images were acquired, and sections of the specimens were then made that corresponded to the magnetic resonance images. Masked imaging analyses were correlated with macroscopic and limited histopathologic findings. RESULTS: Low-field-strength extremity-only magnet allowed consistent visualization of the triangular fibrocartilage and accurate assessment of a small number of complete tears of the triangular fibrocartilage. The scapholunate ligaments in all cases were identified using a combination of imaging sequences. Consistent visualization of the lunotriquetral ligament with a low-field-strength extremity magnet was difficult. CONCLUSIONS: Magnetic resonance imaging with a low-field-strength extremity-only magnet can be used to visualize the triangular fibrocartilage and the scapholunate ligament, but not the lunotriquetral ligament.

Aged↗
PubMed1990

Magnetic resonance imaging of the triangular fibrocartilage complex.

Magnetic resonance imaging of seven fresh human cadaveric specimens was used to evaluate the integrity of the triangular fibrocartilage complex of the wrist. A variety of imaging parameters were systematically investigated, including T1-weighted images with and without contrast, long repetition times, short echo time images, and T2-weighted sequences. A variety of imaging planes were also evaluated. Wrist arthrography, dissection, and frozen coronal sections were done to substantiate our interpretations of the magnetic resonance images. T2-weighted images in the coronal plane proved to be of the greatest diagnostic value because the synovial fluid of the joint spaces serves as an excellent endogenous contrast agent. Long repetition time, short echo time sequences could be simultaneously obtained with T2-weighted sequences with the use of a multi-echo pulse sequence to provide an excellent diagnostic package in the future. On the basis of our investigation, the triangular fibrocartilage complex can be consistently and accurately evaluated with magnetic resonance imaging. As magnetic resonance imaging technology improves, wrist probes and suitable magnets should become available that will make the evaluation of triangular fibrocartilage complex abnormalities with magnetic resonance imaging clinically useful.

Cartilage, Articular↗
PubMed1998

An anatomic study of the ligamentous structure of the triangular fibrocartilage complex.

An anatomic study of the ligamentous structures of the triangular fibrocartilage complex and their attachments on the ulnar styloid was performed using 27 embalmed cadaver wrists. The dorsal and palmar distal radioulnar ligaments of the triangular fibrocartilage complex in each specimen contained a superficial and a deep portion. The deep portion of both ligaments inserted on the fovea of the ulna. The superficial portion of both ligaments surrounded the articular disc uniting at the ulnar-most portion of the articular disc. The tissue that is between the ulnar aspect of the superficial ligament (and integrated on its periphery) and the ulnar capsule is defined as the meniscus homologue. Anatomic variations in the meniscus homologue and the prestyloid recess (the cavity adjacent to the ulnar styloid) were seen in 1 of 3 ways; the narrow opening type in 74% of specimens, the wide opening type in 11%, and the no opening type in 15%. The ulnotriquetral ligament inserted on the palmar-radial aspect of the base of the ulnar styloid and the ulnolunate ligament inserted on the palmar border of the articular disc.

Cadaver↗