Triangular Fibrocartilage Complex Injury & Treatment

The triangular fibrocartilage complex (TFCC) is a set of related structures at the distal ulnar aspect of the wrist, it physically separates the distal radioulnar joint (DRUJ) from the radiocarpal joint. TFCC was first described by Palmer and Werner in 1981.

TFCC Anatomy

The five structures that comprise the TFCC are:

1. The articular disk,
2. the distal radioulnar ligaments (palmar and dorsal),
3. the meniscal homologue,
4. the extensor carpi ulnaris (ECU) subsheath, which is confluent with the (ulnocarpal collateral ligament).

The central portion of the complex consists of an articular disk called the triangular fibrocartilage (TFC). The disk is composed predominately of type II collagen, which is consistent with its role in distributing compressive forces. It lies in the axial plane and structurally represents an extension of the articular surface of the distal radius. Dorsally and palmarly, the TFC is surrounded by the radioulnar ligaments, which are transverse bands that derive their broad origin from the sigmoid notch of the distal radius and insert on the base of the ulnar styloid.

The ulnotriquetral and ulnolunate ligaments form the palmar border of the TFCC, and, although Palmer and Werner did not include them in their original description of the TFCC, they serve an important role in the stability of the ulnar side of the wrist.

The ulnar and dorsal edges of the complex consist of the ECU tendon subsheath and dorsal radial triquetral ligament, respectively. When viewed in the axial plane, these borders form a stout pyramid that attaches the TFCC to the ulnar side of the carpus. Stability of the TFCC is a prerequisite for smooth pronosupination and pain-free load bearing through the articular disk. The vestigial meniscal homologue derives from synovium. Its function is unclear, and it is often absent.

The blood supply of TFCC enters from the periphery. The ulnar periphery of the TFCC has the richest blood supply and, consequently, the greatest potential for healing. It is fed predominantly via the dorsal and palmar radiocarpal branches of the ulnar artery. Dorsal and palmar branches of the anterior interosseous artery supply the more radial part of the complex.

Triangular Fibrocartilage Complex Features

1. The TFCC must be simultaneously robust and flexible.
2. It must have the strength to transmit 20% of the load of the carpus to the ulna and to stabilize the DRUJ and ulnar carpus in conjunction with the bony architecture of the sigmoid notch.
3. It is must also be supple enough to accommodate the significant, complex motion that occurs during forearm rotation.
4. The motion of the DRUJ is a combination of approximately 150 degrees of rotation and sliding. This occurs because the radius of curvature is 50% larger on the radial side of the DRUJ (15 versus 10 mm). The axis of rotation passes through the fovea of the ulnar head, which is a major attachment site for the TFCC.

TFCC Tear Classification

Triangular Fibrocartilage Complex Tear is anatomically subdivided into radial, central, and ulnar tears. This classification bears consideration, because the vascular anatomy dictates the healing potential and therefore the treatment and prognosis for TFCC tears, similarly to tears of the knee’s meniscus.

Palmer’s original classification divides injuries of the TFCC into degenerative and acute tears.

Palmer class 1 injuries are acute, traumatic injuries. They are subdivided into four types, based on the site of injury:

1. Type 1A lesions involve the central avascular portion; the rim is still attached to the radius. This lesion usually is not amenable to direct repair. Arthroscopic treatment is limited to débridement of the central tear to remove any flaps that may impede movement.
2. Type 1B (ulnar-avulsion) lesions are peripheral tears that occur when the ulnar side of the TFCC complex is avulsed from its capsule; they can be associated with ulnar styloid fractures.
3. Type 1C (ulnar-distal) injuries involve ruptures along the volar attachment of the TFCC or distal ulnocarpal ligaments; they are variably amenable to repair.
4. Type 1D (radial-avulsion) injuries are rare injuries with tears from the radial attachment. These represent traumatic avulsions of the TFCC from the attachment at the sigmoid notch, with or without a fracture of the sigmoid notch.

Palmer class 2 (degenerative TFCC lesions) all involve the central portion and are staged from A to E, depending on the presence or absence of a TFCC perforation, lunate and ulnar chondromalacia, a lunotriquetral ligament perforation, or degenerative radiocarpal arthritis. These degenerative lesions usually arise from ulnar abutment. Class 2 lesions usually are not amenable to surgical repair and are treated with débridement.

TFCC tears can be further subdivided by their acuteness. The chronicity has prognostic implications, and addressing tears in the acute phase usually provides better results:

• Acute tears (0 to 3 months): Arthroscopic repair of these injuries results in the recovery of 80% of grip strength and range of motion (ROM) compared with the contralateral side.
• Subacute tears (3 to 12 months): These tears are amenable to direct repair of the TFCC, but these patients usually regain less strength and ROM than those with acute injuries.
• Chronic tears (>1 year): These tears are reparable, but, presumably because of contraction of the ligaments and degeneration of the torn fibrocartilage margins, outcomes lag behind those for acute or subacute tears. The treatment of chronic injuries frequently requires an ulnar shortening osteotomy, with or without TFCC débridement, to decrease load distribution to the distal ulna.

TFCC Tear Symptoms

The typical history for an acute TFCC tear involves a fall on an outstretched hand:

1. Ulnar-sided wrist pain: Acute or delayed complaint, often radiating dorsally and exacerbated by firm grasp and push-off (wrist extended, getting up from a table). Aching with repetitive supination and pronation tasks is also common. The pain is often characterized as diffuse, deep, and sometimes burning.
2. Degenerative changes: it results from repetitive overloading. Ulnar deviation of the wrist, along with forearm supination and power grasp, increase the damage from axial loads. Patients with acquired ulnar positive variance are at higher risk for degenerative changes and recurrent injury from minor trauma.
3. A clicking sensation may be present with wrist pronation and supination.
4. Generalized weakness with and without wrist loading.

Physical Examination

1. Ulnarsided wrist swelling that may reverse the normal convex shape of the ulnar wrist border.
2. The soft, ballotable region between the ulnar styloid and the triquetrum can frequently be point tender.
3. Clicking can often be elicited with passive and active circumduction of the wrist.

Specialized tests to distinguish TFCC injuries from other ulnar wrist injuries include:

1. The TFCC compression test: Significant pain from axial loading of the TFCC, in conjunction with ulnar deviation, is a positive compression test.
2. The ulnar impaction test: pain with the combination of wrist hyperextension and the previous maneuvers indicates a positive ulnar impaction test.
3. The piano key test: Comparison of any dorsal-volar plane instability of the DRUJ with the normal contralateral side is the piano key test.
4. Lunotriquetral ballottement test for ligament stability.
5. Pisotriquetral manipulation should be performed to rule out arthrosis of this joint.

Radiology

Recommended views include:

1. Posteroanterior, lateral, oblique radiographs of the wrist.
2. True neutral rotation, posteroanterior radiographs are taken with the shoulder in 90 degrees of abduction and the elbow in 90 degrees of flexion.

Radiograph findings may include:

1. ulnar styloid fracture,
2. comminution of the articular surface of the distal radius,
3. more than 20 degrees of dorsal angulation of the distal radius,
4. subluxation or dislocation of the DRUJ.

Wrist arthrography can be used to help diagnose tears of the scapholunate and lunotriquetral interosseous ligaments.

MRI for the diagnosis of TFCC injuries is a controversial issue. The specificity and sensitivity of MRI for detection of central and radial detachments vary but can be improved by dedicated musculoskeletal radiologists using specialized equipment such as wrist surface coils and higher Tesla magnets.

TFCC Tear Treatment

The appropriate treatment for TFCC injuries depends on the type of injury and the stability of the DRUJ and the ulnar-sided carpus.

• If a patient’s history and physical examination findings are consistent with a TFCC injury, but the patient has normal radiographs and clinical stability, immobilization in a long arm cast or brace for 3 to 4 weeks is usually successful. Other nonoperative measures include corticosteroid injections and administration of nonsteroidal anti-infl ammatory drugs.
• If a patient presents with radiographic or clinical instability, arthroscopic evaluation and repair should be considered primarily.

Patients with TFCC tears that fail to respond to nonoperative therapy after 1 month and those with DRUJ instability warrant operative intervention. TFCC lesions can be divided into radial or ulnar detachments, and central attritional tears that are amenable to débridement:

• Reparable TFCC tears: Peripheral tears, such as types 1B, 1C, and 1D, do exceptionally well, in part because of their excellent blood supply. Techniques of repairing type 1B tears along the ulnar border have been demonstrated by numerous authors. Arthroscopic repair techniques for type 1D tears are continuing to be honed.
• Non-reparable TFCC tears: Central degenerative tears and central tears that that have a small rim attached to the radius (type 1A) usually cannot be repaired. In certain cases, the body of the TFCC can be advanced to the sigmoid notch and repaired, similar to a type 1D lesion. In these cases, the torn rim along the sigmoid notch can be excised, and the major body of TFCC can be advanced and sutured to the radius.
• Preferred open treatment: TFCC injuries that are less amenable to arthroscopic intervention, for which an open approach should be considered, are those with combined ECU tendon instability, a large ulnar styloid avulsion fracture that requires open reduction and internal fixation to re-establish the primary ulnar attachment of the TFCC and lunotriquetral or other intercarpal instability.

References

1. Palmer AK, Werner FW. The triangular fibrocartilage complex of the wrist–anatomy and function. J Hand Surg Am. 1981 Mar;6(2):153-62. doi: 10.1016/s0363-5023(81)80170-0. PMID: 7229292.
2. DiTano O, Trumble TE, Tencer AF . Biomechanical function of the distal radioulnar and ulnocarpal wrist ligaments . J Hand Surg Am. 2003 ; 28 : 622 .
3. Thiru RG, Ferlic DC, Clayton ML , et al . Arterial anatomy of the triangular fi brocartilage of the wrist and its surgical significance. J Hand Surg Am. 1986 ; 11 : 258
4. Palmer AK . Triangular fi brocartilage complex lesions: a classification. J Hand Surg Am. 1989 ; 14 : 594 .
5. Trumble TE, Gilbert M, Vedder N . Arthroscopic repair of the triangular fibrocartilage complex. Arthroscopy. 1996 ; 12 : 588 .
6. Trumble TE, Gilbert M, Vedder N . Isolated tears of the triangular fibrocartilage: management by early arthroscopic repair . J Hand Surg Am. 1997 ; 22 : 57 .
7. Trumble TE, Gilbert M, Vedder N . Ulnar shortening combined with arthroscopic repairs in the delayed management of triangular fibrocartilage complex tears . J Hand Surg Am. 1997 ; 22 : 807 .
8. Labosky DA, Waggy CA . Oblique ulnar shortening osteotomy by a single saw cut . J Hand Surg Am. 1996 ; 21 : 48 .
9. Mikic ZD . Age changes in the triangular fi brocartilage of the wrist joint. J Anat. 1978 ; 126 : 367 .
10. Mikic ZD . Treatment of acute injuries of the triangular fibrocartilage complex associated with distal radioulnar joint instability . J Hand Surg Am. 1995 ; 20 : 319 .
11. Wright TW, Del Charco M, Wheeler D . Incidence of ligament lesions and associated degenerative changes in the elderly wrist . J Hand Surg Am. 1994 ; 19 : 313 .
12. Metz VM, Schratter M, Dock WI , et al . Age-associated changes of the triangular fi brocartilage of the wrist: evaluation of the diagnostic performance of MR imaging . Radiology. 1992 ; 184 : 217 .
13. Geissler WB . Arthroscopically assisted reduction of intra-articular fractures of the distal radius . Hand Clin. 1995 ; 11 : 19 .
14. Geissler WB . Intra-articular distal radius fractures: the role of arthroscopy? Hand Clin. 2005 ; 21 : 407 .
15. Geissler WB, Freeland AE . Arthroscopic management of intra-articular distal radius fractures . Hand Clin. 1999 ; 15 : 455 .
16. Geissler WB, Freeland AE, Savoie FH , et al . Intracarpal soft-tissue lesions associated with an intra-articular fracture of the distal end of the radius. J Bone Joint Surg Am. 1996 ; 78 : 357 .
17. Varitimidis SE, Basdekis GK, Dailiana ZH , et al . Treatment of intraarticular fractures of the distal radius: fl uoroscopic or arthroscopic reduction? J Bone Joint Surg Br. 2008 ; 90 : 778 .
18. Ruch DS, Yang CC, Smith BP. Results of acute arthroscopically repaired triangular fi brocartilage complex injuries associated with intra-articular distal radius fractures . Arthroscopy. 2003 ; 19 : 511 .
19. Lindau T, Arner M, Hagberg L . Intraarticular lesions in distal fractures of the radius in young adults: a descriptive arthroscopic study in 50 patients. J Bone Joint Surg Br. 1997 ; 22 : 638 .
20. de Araujo W, Poehling GG, Kuzma GR . New Tuohy needle technique for triangular fi brocartilage complex repair: preliminary studies . Arthroscopy. 1996 ; 12 : 699 .
21. Palmer AK, Glisson RR, Werner FW . Relationship between ulnar variance and triangular fi brocartilage complex thickness . J Hand Surg Am. 1984 ; 9 : 681 .
22. Tatebe M, Horii E, Nakao E , et al . Repair of the triangular fibrocartilage complex after ulnar-shortening osteotomy: second-look arthroscopy. J Hand Surg Am. 2007 ; 32 : 445 .
23. Richards RS, Bennett JD, Roth JH, Milne K Jr . Arthroscopic diagnosis of intra-articular soft tissue injuries associated with distal radial fractures. J Hand Surg Am. 1997 ; 22 ( 5 ): 772.
24. Bombaci H, Polat A, Deniz G , et al . The value of plain x-rays in predicting TFCC injury after distal radial fractures. J Hand Surg Eur. 2008 ; 33 : 322 .
25. Brown JA, Janzen DL, Adler BD , et al . Arthrography of the contralateral, asymptomatic wrist in patients with unilateral wrist pain . Can Assoc Radiol J. 1994 ; 45 : 292 .
26. Cerofolini E, Luchetti R, Pederzini L, et al . MR evaluation of triangular fibrocartilage complex tears in the wrist: comparison with arthrography and arthroscopy . J Comput Assist Tomogr. 1990 ; 14 : 963 .
27. Levinsohn EM, Palmer AK, Coren AB , et al . Wrist arthrography: the value of the three compartment injection technique . Skeletal Radiol. 1987 ; 16 : 539 .
28. Levinsohn EM, Rosen ID, Palmer AK . Wrist arthrography: value of the three-compartment injection method . Radiology. 1991 ; 179 : 231 .
29. Cooney WP, Linscheid RL, Dobyns JH . Triangular fibrocartilage tears. J Hand Surg Am. 1994 ; 19 : 143 .
30. Tanaka T, Amadio PC, Zhao C , et al . Effect of wrist and ulna head position on gliding resistance of the extensor digitorum minimi and extensor digitorum communis III tendons: a cadaver study. J Orthop Res. 2006 ; 24 : 757 .
31. Golimbu CN, Firooznia H, Melone CP Jr , et al . Tears of the triangular fibrocartilage of the wrist: MR imaging . Radiology. 1989 ; 173 : 731 .
32. Joshy S, Ghosh S, Lee K , et al . Accuracy of direct magnetic resonance arthrography in the diagnosis of triangular fi brocartilage complex tears of the wrist . Int Orthop. 2008 ; 32 : 251 .