Triangular Fibrocartilage Complex Tears Research Articles

The effect of observer experience on magnetic resonance imaging interpretation and localization of triangular fibrocartilage complex lesions.

This study investigates the effect of experience of the interpreter on the ability of magnetic resonance imaging (MRI) to identify the presence and anatomic location of a triangular fibrocartilage complex (TFCC) lesion. Fifty-one patients who underwent wrist arthroscopy with preoperative MRI studies were reviewed retrospectively. Two radiologists with different levels of training and experience evaluated the MRI scans in a blinded manner. The sensitivity rates of the 2 observers for detection of TFCC lesions were 86% and 80%. The specificity rates were 96% and 80%. The accuracy rates for prediction of a TFCC tear were 83% and 61% for the 2 observers. The correct location of a TFCC lesion was predicted by the more experienced observer for 12 of 19 central, 3 of 4 radial, and 6 of 12 peripheral lesions. The less experienced observer correctly identified 8 of 19 central, 2 of 4 radial, and 2 of 12 peripheral tears. The overall accuracy rates for prediction of a TFCC lesion and its location were 69% and 37%. Our data indicate that the published accuracy rates for prediction of TFCC lesion location may be reproducible only in very specialized centers.

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.

Arthroscopic Capsulodesis of the Lunotriquetral Joint

A case series consisting of 20 consecutive patients with persistent ulnar-sided mechanical wrist pain, lunotriquetral interosseous (LTIOL) ligament tears resulting in joint incongruity and increased laxity, and traumatic triangular fibrocartilage complex (TFCC) tears was reviewed. Each patient underwent an arthroscopic reduction and internal fixation (ARIF) of the lunotriquetral joint, arthroscopic disk-carpal (disklunate-ulnocapitate-disktriquetral, DL-UC-DT) ligament plication, and TFCC repair or débridement. There were 12 right wrists and 8 left wrists, of which 12 were dominant. The mean patient age was 33 years; 7 patients had workers' compensation claims and 2 had legal claims. Fourteen patients recalled a specific injury mechanism, such as hyperextension or rotation. The accompanying traumatic TFCC tears were peripheral in 15 and linear radial in 6 patients (one patient had concomitant peripheral and radial linear tears), and in 6 cases, the palmar ulnocarpal extrinsic ligaments were partially torn. The mean preoperative modified Mayo Wrist Score was 50, and at a mean of 3.1 years after surgery, the score had increased to 88. There were 13 excellent, 5 good, and 2 fair results. Four patients had complications, including transient tenderness along the extensor carpi ulnaris and persistent neuritis of a dorsal branch of the ulnar nerve. Overall wrist comfort and function, as indicated by the modified Mayo Wrist Scores, improved after arthroscopic stabilization of ulnar-sided wrist injuries (pinning of the lunotriquetral joint, disk-carpal ligament plication, and TFCC repair or débridement).

The holmium:yttrium-aluminum-garnet laser in wrist arthroscopy: a five-year experience in the treatment of central triangular fibrocartilage complex tears by partial excision.

Arthroscopic debridement of the articular disk is an accepted method for the treatment of symptomatic central tears of the triangular fibrocartilage complex. Current techniques use punches, knives, and shavers to debride the torn disk back to a stable peripheral rim. The holmium:yttrium-aluminum-garnet laser offers an alternative method for disk debridement with potential advantages of enhanced speed, precision, and hemostasis. We present a retrospective review of 35 patients who underwent arthroscopic laser debridement for a Palmer type IA tear in the triangular fibrocartilage complex. Overall response to treatment was good to excellent in 68% of patients and return to work was seen in 88%. One patient developed a deep wound infection. Clinical results after arthroscopic laser debridement are comparable to those reported by other investigators using conventional techniques.

Ulnar shortening after failed arthroscopic treatment of triangular fibrocartilage complex tears.

Ulnar shortening osteotomy was performed in 11 wrists with ulnar abutment syndrome, after failed arthroscopic surgery on the TFCC (ten debridements, one repair). A delayed union was present in three, a non-union occurred in two, of whom one needed a revision and grafting procedure. According to the Mayo wrist score, only four had an acceptable outcome. Patient's satisfaction was higher: seven were satisfied, four were not. The postoperative wrist pain score was good in ten patients. Overall outcome was not very successful. Problems related to the procedure could be avoided by adapting the technique (oblique osteotomy, palmar placement of the plate, and compression devices). The key statement remains however to us; ulnar sided wrist pain thought to be caused by an ulnar abutment is not necessarily resolved by decompressing the ulnocarpal joint.

Chronic Triangular Fibrocartilage Complex Tears with Distal Radioulna Joint Instability: A New Method of Triangular Fibrocartilage Complex Reconstruction

From September 1996 to September 1997, 27 adult patients were diagnosed with chronic triangular fibrocartilage complex (TFCC) tears with distal radioulna joint (DRUJ) instability in our clinic. They all received the procedure of TFCC reconstruction with partial extensor carpi ulnaris (ECU) tendon combined with or without ulnar shortening. There were 26 males and one female in the study with a mean age of 22.4 years. The follow-up period ranged from 22 to 28 months with a mean of 26.2 months. 24 patients who had positive or zero ulnar variance received the procedure of ulnar shortening. Three patients who had minus ulnar variance only received TFCC reconstruction. After the operation, the DRUJ was fixed by a 2.0 mm K-wire for 4 weeks. All patients underwent a rehabilitation program and they were reexamined at our outpatient department (OPD). The results were graded according to the Mayo Modified Wrist Score. Five of the 27 patients rated their wrists 'excellent', 18 rated 'good', and 4 rated 'fair. Overall, a total of 23 patients (85%) rated satisfactorily and returned to work or sport activities. In the 4 patients rated 'fair', mild pain at work and/or exercise, and mildly limited supination were found; however their grip strength was improved at least by 65% compared to the opposite hand. Therefore, as suggested by this study, TFCC reconstruction with partial ECU tendon combined with the ulnar shortening procedure is an alternative method for chronic TFCC tears with DRUJ instability.

Use of magnetic resonance imaging to diagnose common wrist disorders.

Magnetic resonance imaging is being used more frequently to diagnose and plan treatment of wrist disorders. This article reviews the common pathologic lesions of the wrist: avascular necrosis, triangular fibrocartilage complex tears, ligamentous tears, ganglion cysts, carpal tunnel syndrome, and osteoarthritis. The typical magnetic resonance imaging characteristics of these lesions is discussed.

Dynamic axial carpal instability

I was intrigued by the recent article by Shin et al entitled “Dynamic Axial Carpal Instability: A Case Report” (J Hand Surg 1999;24A:781–785) and was surprised by statements the authors made that warrant clarification. Shin et al stated that the arthrogram done as part of the patient's evaluation showed “no abnormal dye passage between the scapholunate, lunotriquetral, or capitohamate joints.” How do they explain this finding in light of the fact that arthroscopy demonstrated “complete loss of integrity of the capitohamate interosseous ligaments”? Furthermore, the preoperative arthrogram showed a “slight leak” of dye through the triangular fibrocartilage complex (TFCC) and yet the authors reported that a tear of the TFCC was diagnosed arthroscopically that was large enough to mandate repair. These discrepancies raise 2 questions. First, how do the authors reconcile the differences between the negative arthrogram and the complete capitohamate ligament incompetence? The sensitivities and specificities of arthrograms for detecting intercarpal ligament tears range from 56% to 100% and 56% to 83%, respectively, in published reports. 1Chung KC Zimmerman NB Travis MT. Wrist arthrography versus arthroscopy: a comparative study of 150 cases.J Hand Surg. 1996; 21A: 591-594Abstract Full Text PDF Scopus (72) Google Scholar, 2Cooney WP. Evaluation of chronic wrist pain by arthrography, arthroscopy and arthrotomy.J Hand Surg. 1993; 18A: 815-822Abstract Full Text PDF Scopus (113) Google Scholar, 3Weiss A-PC Akelman E Lambiase R. Comparison of the findings of triple-injection cinearthrography of the wrist with those of arthroscopy.J Bone Joint Surg. 1996; 78A: 348-356Crossref Scopus (114) Google Scholar It surprised me that Shin et al did not comment on the importance of the negative arthrogram in evaluating their patient for this proposed new disorder of dynamic axial carpal instability. Is the arthrogram superfluous in the workup of patients with similar presentations? Second, why do the authors attribute the patient's symptoms to dynamic capitohamate instability rather than the TFCC tear? The case history and physical examination, which included ulnar-sided wrist tenderness and pain with ulnar deviation following a fall on the outstretched hand, are consistent with a TFCC tear, which is a common disorder that responds well to arthroscopic management.4Trumble TE Gilbert M Vedder N. Isolated tears of the triangular fibrocartilage: management by early arthroscopic repair.J Hand Surg. 1997; 22A: 57-65Abstract Full Text PDF Scopus (133) Google Scholar Why did the authors discount the TFCC tear and its subsequent repair as the source of the patient's symptoms and recovery, respectively? Shin et al present their case as an example of dynamic carpal instability in which the energy of trauma disrupted the capitohamate and scapholunate joints. It is unclear why they conclude this if the scapholunate interosseous ligament was interpreted as being intact on arthrogram and magnetic resonance imaging and showed no tears arthroscopically (just a suggestion of slight stretching). Geissler grade 2 ligament changes do not equal joint disruption. An extensive battery of diagnostic tests was completed in the workup of the patient presented, including special view radiographs, an arthrogram, trispiral tomograms, a bone scan, a magnetic resonance imaging scan, diagnostic lidocaine injections, and arthroscopy. Are all these tests required to make the proposed diagnosis? In this time of increased cost consciousness among physicians and third-party payers alike, we should always strive to establish diagnoses as expeditiously and cost effectively as possible. The authors missed a chance to comment on their recommendations for evaluating similar patients in the future without ordering such an exhaustive and expensive array of diagnostic modalities. Finally, did the patient described in the report receive workers' compensation for his injury and treatment? Secondary gain or its absence may have affected the outcome one way or the other and it would be useful to know this when examining and counseling other patients suspected of having similar pathology in the future.

Wrist arthroscopy: treatment of the triangular fibrocartilage complex injuries

Objectives: We evaluated the functional results of treatment in 55 patients who were found to have Triangular Fibrocartilage Complex (TFCC) tears during wrist arthroscopy. Methods: A total of 104 patients with chronic wrist pain underwent arthroscopic evaluation, during which 55 patients showed TFCC injuries. Primary suturing (n=2) and TFCC debridement (n=53) were performed. The functional results were evaluated using a modified Mayo scale. Results: Functional mean scores with modified Mayo scale were 47 and 74 before and at the end of the treatment, respectively. Excellent, good, moderate, and fair results were obtained in 30 (54%), 17 (31%), six (11%), and two (4%) patients, respectively. Conclusion: Arthroscopic surgery appears to be the best method of treatment in TFCC injuries.

Is a subset of wrist ganglia the sequela of internal derangements of the wrist joint? MR imaging findings.

To determine if there is an association between wrist ganglia and internal derangements of the wrist joint by reviewing magnetic resonance (MR) images. Two observers retrospectively reviewed MR images of the wrist obtained in 625 patients at 1.5 T for the presence of ganglia and associated triangular fibrocartilage complex, scapholunate ligamentous, or lunotriquetral ligamentous tears that were within 3 mm of the ganglion. When available, surgery and/or pathology records were reviewed. There were 122 ganglia and 37 internal derangements. Of the 22 ulnar-sided ganglia, 10 (45%) demonstrated associated triangular fibrocartilage complex tears. Of the 97 radial-sided ganglia, 27 (28%) demonstrated ligamentous tears related to the site of the ganglion. The radial-sided tears involved the radial aspect of the triangular fibrocartilage complex in 12 ganglia; the scapholunate ligament, in isolation, in eight ganglia; and both the triangular fibrocartilage complex and the scapholunate ligament in six ganglia. Only one of the ganglia demonstrated an associated lunotriquetral ligamentous tear. Surgical findings confirmed the ligamentous tears in 25 patients. Wrist ganglia are associated, not infrequently, with internal derangements of the wrist.

Wrist disorders in the young athlete

In the young athlete, forced dorsiflexion causes most wrist injuries. Sudden dorsiflexion from a fall onto theoutstretched hand results in fractures, ligament tears, and joint disruptions. Repetitive dorsiflexion, which occurs in activities such as weightlifting or gymnastics, leads to overuse injuries including physeal stress fractures, bone stress fractures, triangular fibrocartilage complex tears, impingement syndromes, progressive laxity and arthritic degeneration. Wrist braces have not been successful in preventing fractures. Wrist taping or bracing is inadequate to prevent wrist overuse injuries in gymnasts. Treatment of wrist injuries involves rest, splinting or casting, and both open and arthroscopic surgical techniques.

Ulnar shortening for triangular fibrocartilage complex tears associated with ulnar positive variance

Twenty-five patients with triangular fibrocartilage complex (TFCC) tears associated with ulnar positive variance who did not respond to conservative management were treated by ulnar shortening. The follow-up period averaged 35 months. All patients complained of pain, restricted forearm rotation, and weakness of grip. Arthroscopy was performed in 23 of 25 wrists to assess the status of the TFCC and the degree of the degenerative change of the proximal aspect of the lunate and triquetrum. Arthroscopic findings consisted of 15 class 1 and 8 class 2 tears according to Palmer's classification. When the TFCC showed a traumatic flap tear, only the torn flap was removed arthroscopically. Ulnar shortening averaged 3 mm. Transverse osteotomies healed in all patients at a mean postoperative time of 7 weeks. Twenty-three patients had either complete relief or occasional mild pain of the wrist. Two patients with persistent pain had additional procedures performed. Postoperative x-ray films revealed slight degenerative changes at the distal radioulnar joint in 7 patients. Complications included 1 reflex sympathetic dystrophy and 2 fractures through the osteotomy site after early plate removal. Ulnar shortening is a useful procedure for TFCC tears associated with ulnar positive variance.

Wrist arthroscopy for the treatment of ligament and triangular fibrocartilage complex injuries

The use of arthroscopy was evaluated in 47 patients who were treated for suspected triangular fibrocartilage complex (TFCC) tears, scapholunate (SL) tears, and/or lunotriquetral (LT) tears. Wrist arthroscopy was performed using traction and standard portals. Any TFCC tear found was debrided to a stable rim. SL and LT tears were debrided to bleeding bone. The range of follow-up was 1.5 to 50 months (average, 15.4 months). Patient grading was determined usin the Mayo Modified Wrist Score. For the 28 patients with TFCC tears, the results were excellent in 13, good in 8, fair in 2, and poor in 5. For the 23 patients with SL tears, the results were 11, 9, 1, and 2, respectively. Of the 5 patients with LT tears, 1 result was excellent, and 4 were poor. Workers compensation did not affect results. Arthroscopic debridement of SL and TFCC tears has proven effective. Debridement of LT tears has not been as successful. Based on our results, we feel that arthroscopic debridement of SL and TFCC tears is warranted. Arthroscopy 1998 Jul-Aug;14(5):479-83

Triangular fibrocartilage injuries in pediatric and adolescent patients

This is a retrospective review of 29 posttraumatic pediatric and adolescent patients with surgically documented triangular fibrocartilage complex tears. All patients complained of ulnar wrist pain. Fifteen patients (52%) sustained distal radius fracture at the time of the original injury. Twenty-three (79%) of the triangular fibrocartilage complex tears were Palmer 1B lesions. There were 31A, 11C, and 21D lesions. All 1B, 1C, and 1D tears were repaired. Coexisting pathology was present in 25 patients (86%). This pathology included ulnar styloid nonunion, distal radioulnar joint instability, ulnocarpal impaction, distal radius deformity, and intercarpal ligament tears, which were treated by ulnar styloid nonunion excision, distal radioulnar joint stabilization, ulnar shortening, radius corrective osteotomy, and intercarpal ligament debridement, respectively. The length of the follow-up period averaged 21 months. Three patients were lost to follow-up. Outcomes were graded by a modification of the Mayo wrist score. Twenty-four patients (89%) had excellent results, 3 had good results.

THE ROLE OF OPERATIVE ARTHROSCOPY FOR THE DIAGNOSIS AND TREATMENT OF LESIONS ABOUT THE DISTAL ULNA

Operative arthroscopy of the wrist compliments the physical examination and radiographic imaging to improve diagnosis and treatment of lesions about the distal ulna. This article reviews the relevant anatomy, biomechanics, and classification of acute and degenerative lesions of the triangular fibrocartilage complex (TFCC). Minimally invasive diagnostic and management techniques for TFCC tears are described in detail.

鏡視下ＴＦＣＣ部分切除術の治療成績

We have performed wrist arthroscopic treatment in 35 patients for ulnar wrist pain associated with Triangular Fibrocartilage Complex tears, since 1994.An arthroscopic partial resection was performed in 20 cases.The age at surgery ranged from 16 to 52 years (average 32.7 years).Follow-up averaged 9.8 months.Post-Arthoscopy diagnoses were Palmer I-A; 6 cases, I-D; 3 cases, II-C; 11 cases.In all cases with ulnar variant <+3mm, the results were evaluated as excellent and good, but in all cases with ulnar variant >+3mm, we were not able to achieve satisfactory results.

Diagnostic wrist arthroscopy

Wrist arthroscopy has become an essential tool for the hand and upper extremity surgeon. It is useful in diagnosing and/or staging a wide range of conditions of the wrist, including cartilage injury, early arthritis, ligament injury, and triangular fibrocartilage complex tears. It can be of great benefit in evaluating wrist pain of unclear cause when imaging studies fail to elucidate the disease. In the hands of an experienced arthroscopist, it can be a more accurate diagnostic tool than studies such as magnetic resonance imaging or arthrography. The rate of complications is very low if proper attention is paid to details. Familiarity with the equipment, thorough knowledge of the anatomy, and development of a systematic approach are all critically essential for a surgeon performing arthroscopy of the wrist. The surgeon must also know when arthroscopy does not provide sufficient access to the wrist and an arthrotomy should be performed.

Arthroscopic diagnosis of intra-articular soft tissue injuries associated with distal radial fractures

Arthroscopy was used to assess the soft tissue injuries associated with distal radial fractures in 118 acute intra- and extra-articular fractures. The triangular fibrocartilage complex (TFCC) was torn in 46 of 118 patients--in 35% of intra-articular fractures and in 53% of extra-articular fractures. No correlation between ulnar styloid fractures and TFCC injuries could be found. Scapholunate (SL) ligament injuries with instability were present in 21.5% of intra-articular fractures and in 6.7% of extra-articular fractures. Lunotriquetral (LT) ligament injuries with instability were present in 6.7% of intra-articular fractures. and in 13.3% of extra-articular fractures. Combined SL and LT injuries were present in 5.6% of intra-articular fracture. Preoperative radiographs correlated with TFCC injury. Patients with TFCC tears had greater shortening and dorsal angulation on the preoperative radiographs. Preoperative radiographs had no predictive value for interosseous ligament injury. Ligamentous injuries are commonly associated with both intra-articular and extra-articular distal radial fractures.

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

The functional outcome after surgery was determined in 21 patients an average of 29 months (range, 24-52 months) after surgery to evaluate the efficacy of arthroscopic repair of triangular fibrocartilage complex (TFCC) tears and ulnar shortening. All of the patients had reparable lesions of the TFCC treated after a delay of more than 6 months from the time of injury. The patients' average age was 32 years and all patients had wrist pain limiting them from work and/or sports prior to surgery. After surgery, there was a significant relief of pain (p < .01). Grip strength and range of motion averaged 83% +/- 18% and 81% +/- 16%, respectively, of that of the uninjured side. At follow-up evaluation, 14 patients with repairs underwent follow-up studies; the TFCC was noted to be intact in 12 patients.

Arthroscopic Repairs of Triangular Fibrocartilage Complex Tears

Technical advancements in arthroscopic wrist procedures have improved our knowledge of normal and abnormal intraarticular wrist function. Triangular fibrocartilage complex (TFCC) tears from trauma injuries are a common source of ulnar-sided wrist pain. Fortunately, the TFCC is a structure that can be evaluated and treated arthroscopically with results that are comparable to open surgical procedures. Successful arthroscopic repairs of TFCC tears depend on a coordinated team effort between perioperative nurses, orthopedic surgeons, nurse practitioners, and occupational hand therapists, as well as cooperation from patients and family members. This article reviews the anatomy and physiology of the TFCC, the biomechanics of the wrist and mechanisms of injury, and arthroscopic repairs of TFCC tears.