Triangular Fibrocartilage Complex

- See:
    - Ligaments of the Wrist and RU Joint

- Discussion:
    - is ulnar continuation of distal radius & presents concave surface for articulation w/ lunate & triquetrium;
    - ular side of the wrist is supported by the TFCC, which articulates w/ both the lunate and the triquetrum;
    - TFCC is prone to injury due to the axial and shear forces that are applied to it as the carpi rotate over the radius and ulna;

- Anatomy and Function of the TFCC

- Injury to TFCC:
    - mechanism of injury includes twisting w/ palmar rotation;
    - commonly associated with positive ulnar variance crepitus, pain, and tenderness between the ulna and triquetrum;
           - ulnocarpal impaction syndrome is a common inciting cause of degenerative tears;
    - mechanism:
           - during marked ulnar deviation, compressive load on TFC, particularly w/ positive ulnar variance, may increase markedly;
                 - forced ulnar deviance, such as batting a baseball, subjects the TFC  to heavy loads;
           - ref: Strains in the articular disk of the triangular fibrocartilage complex: a biomechanical study
    - classification:
           - central perforations are usually due to degeneration process (most common) - these occur in a minority of cases;
           - displacement of the lunate fossa with the TFFC;
           - in substance tears of the peripheral rim - peripheral radial attachments are common, and these are amenable to repair;
           - include avulsion of TFC from ulnar styloid - least common, but most amenable to surgical repair;
    - associated injuries
    - diff dx of ulnar sided wrist pain

- Exam of TFCC Injury

- Radiographs:
    - may reveal avulsion of ulnar styloid, scaphoid frx, distal radius frx, or there may be volar tilt to the lunate and triquetrum (VISI deformity);
    - ulnar variance: (requires zero rotation view);
          - variable length of the ulna as a positive or negative variance may influence the carpal position;
          - wrist w/ more positive ulnar variance tends to be associated with relatively thinner TFC articular disc;

- Triple Injection Arthrography:
    - study of choice, but can often miss peripheal meniscus tears;
    - identification of tears depends on contrast dye passing thru the radiocarpal and DRUJ;

- MRI:
    - normal disc: uniform low signal at both the radial and ulnar attachement;
    - complete tear: full thickness discontinuity which extends thru the articular disc;
    - reference:
          - The utility of high-resolution magnetic resonance imaging in the evaluation of the triangular fibrocartilage complex of the wrist.

- Non Operative Treatment of TFC Injuries:
    - w/ an acute injury placement of forearm in neutral rotation in long arm cast places TFCC in the best alignment for healing;
          - marked pronation is to be avoided, because this inclines the ulnar head to displace dorsally;
          - supination with imperfect radial fragment reduction may result in palmar subluxation of the ulnar head;
    - steroid injection: often these can confer significant relief of symptoms;

- Operative Treatment of TFCC Injury:
    - TFCC repair
    - ulnar shortening:
           - patients w/ a symptomatic perforation and an ulnar positive variant should be considered for an ulnar shortening along w/ treatment of the tear;
           - ulnocarpal impaction syndrome should be addressed along w/ TFCC tear;
    - wafer procedure
    - partial excision of TFCC:
           - as noted by Menon, et al (1997), there is a 30% failure rate of partial TFCC excision when concomitant ulnar shortening is not performed;
           - references:
                 Partial excision of the triangular fibrocartilage complex articular disk: a biomechanical study.
                 Isolated tears of the triangular fibrocartilage of the wrist: results of partial excision.   
                 Partial Excision of triangular fibrocartilage complex.  
                 Tears of the articular disc of the triangular fibrocartilage complex: results of excision of the articular disc. Imbriglia JE, Boland DS.  J Hand Surg. 1983;8:620.

Current Concepts Review.  Carpal Instability.

Traumatic disruption of the triangular fibrocartilage complex. Pathoanatomy.

Triangular fibrocartilage tears

Triangular fibrocartilage complex lesions: a classification

Partial excision of the triangular fibrocartilage complex.

Ulnar shortening combined with arthroscopic repairs in the delayed management of triangular fibrocartilage complex tears

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Wednesday, December 12, 2012 10:54 am