Introduction
- Sidney M. Jacoby, MD
- Paul A. Sibley, DO
- Leo T. Kroonen, MD
- Paul A. Sibley, DO
Epidemiology
Age
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Acute tears are most common in the active individual during the second and third decades of life.
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Degenerative tears begin in the third decade of life, with increasing frequency and severity with each passing decade.
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No completely normal triangular fibrocartilage complex (TFCC) after seventh decade, based on a cadaveric study
Sex
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Predominantly males but is most often sport specific, with a preponderance in athletic individuals
Sport/Position
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Most common in athletes who grip bats, clubs, sticks, etc. In particular, baseball players, golfers, racquet sports, hockey, gymnastics, boxing, pole-vaulting
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No position-specific factors; however, tears commonly occur in dominant wrist
Pathophysiology
Intrinsic Factors
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TFCC composed of a confluence of soft-tissue elements that surround and stabilize the distal radioulnar joint (DRUJ)
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Wedge-shaped disc of fibrocartilage with thick cartilaginous attachments to sigmoid notch of radius
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Very little stability provided by bony elements
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Anatomy ( Figures 15-1 and 15-2 )
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Dorsal and volar radioulnar ligament (main stabilizers of DRUJ)
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Superficial attachment to mid-point of styloid
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Deep attachment to the fovea
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Central articular disc
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Extends from sigmoid notch of radius to its insertion at the base of the ulnar styloid
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Meniscus homologue
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Function is ill-defined
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Vascularized tissue between the ulnar capsule, TFCC, and triquetrum
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Ulnar collateral ligament
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Extensor carpi ulnaris (ECU) subsheath
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TFCC acts as a pulley for the ECU tendon
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Ulnocarpal ligament complex
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Lunocapitate (LC), ulnolunate (UL) and ulnotriquetral (UT) ligaments
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FIGURE 15-1
Schematic components of the triangular fibrocartilage complex. R, radius; U, ulna; ECU, extensor carpi ulnaris; DRUL, dorsal radioulnar ligament; PRUL, palmar radioulnar ligament; L, lunate; T, triquetrum; UL, ulnolunate ligament; UT, ulnotriquetral ligament.
FIGURE 15-2
Meniscus homologue is an irregularly shaped soft tissue structure that variably fills the space between the ulnar capsule, disk, and proximal aspect of the triquetrum. L, lunate; R, radius; Tq, triquetrum; U, ulna; 1, articular disk of triangular fibrocartilage; 2, meniscus homologue.
(From Adams BD: Distal radioulnar joint instability. In Wolfe SW, Pederson WC, Hotchkiss RN, Kozin SH, editors: Green’s operative hand surgery, 6th ed, Philadelphia, 2010, Elsevier, Figure 16-7.)
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Blood supply ( Figure 15-3 )
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Peripheral 10% to 40% is well vascularized (ulnar more than radial aspect)
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Dorsal and palmar branches of anterior interosseous artery
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Dorsal and palmar radiocarpal branches of ulnar artery
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Central portion is avascular
FIGURE 15-3
TFCC is well vascularized in its periphery, whereas only the outer 15% of the disk has vascular penetration. Arrows in A and B identify avascular regions of TFCC at its attachment to radius. A, Coronal section through wrist. B, Axial view of TFCC. L, lunate; R, radius; T, triquetrum; U, ulna.
(From Adams BD: Distal radioulnar joint instability. In Wolfe SW, Pederson WC, Hotchkiss RN, Kozin SH, editors: Green’s operative hand surgery, 6th ed, Philadelphia, 2010, Elsevier, Figure 16-8.)
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Ulnar positivity (positive ulnar variance)
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Normal axial loading has 20% of load through ulna, with 80% through radius
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+2.5 mm ulnar positivity can increase load through the ulna to 40%
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Positivity increases with pronation and grip
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Extrinsic Factors
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Power drills, whereby the drill rotates the wrist instead of the drill-bit
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Rotational torque such as those that occur with athletics or a fall on outstretched wrist
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Sports activities that involve high level of grip activities
Traumatic Factors
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Palmer Type I (traumatic)
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Mechanism
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Sudden, rotational traumatic event
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Racquet sports with sudden, abrupt supination
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Most common is fall on extended wrist with forearm pronation
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Traction injury to ulnar side of wrist
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Distal radius fractures
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Palmer Type II (degenerative)
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Associated with positive ulnar variance
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Classic Pathological Findings
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Palmer Classification ( Figure 15-4 ), Type I (traumatic)
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IA: isolated central perforation or tear, no instability
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Pain, mechanical clicking
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IB: peripheral tear at base of ulnar styloid (with or without ulnar styloid fracture), mild DRUJ instability, may have ECU instability
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Painful forearm rotation
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IC: distal avulsion of origin of ulnar extrinsic ligaments (UL and LT ligaments)
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Least common
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Painful rotation
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May be associated with IB tear
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ID: radial detachment of the TFCC from the sigmoid notch of the distal radius
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May be associated with distal radius fracture
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May include both radioulnar ligaments
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Often in the avascular zone
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FIGURE 15-4
Palmer’s classification separates TFCC lesions into two broad categories: traumatic (class IA-D) and degenerative (class IIA-E). See text for descriptions.
(Redrawn from Palmer AK: Triangular fibrocartilage complex lesions: a classification, J Hand Surg [Am] 14:594–606, 1989.)
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Palmer Type II (degenerative [developmental or acquired] with ulnar impaction)
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IIA: TFCC wear and thinning without perforation, tear, or chondromalacia
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IIB: TFCC wear with lunate and/or ulnar head chondromalacia
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IIC: TFCC perforation with lunate chondromalacia
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IID: TFCC perforation with ulna and/or lunate chondromalacia and LT ligament injury but without carpal instability
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No volar intercalated segment instability (VISI)
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IIE: TFCC perforation with arthritic changes involving ulnocarpal and DRUJ ( Figure 15-5 )
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LT ligament injury
FIGURE 15-5
Palmer class IIE lesion (ulnocarpal osteoarthritis). Ulnocarpal impaction with positive ulnar variance. The TFCC is completely absent, and large communication between ulnocarpal and distal radioulnar joints is seen in this Multidetector CT arthrography coronal view obtained after single- compartment injection (black arrow). The lunotriquetral ligament is completely disrupted ( white arrow ), and communication between the midcarpal and ulnocarpal joints is also seen. No articular cartilage is observed at the ulnar aspect of lunate or at the radial aspects of the ulnar head and triquetrum. Subchondral bone attrition is visible at ulnar aspect of lunate, and a large osteophyte is seen at ulnar head.
(From Crema MD, Marra MD, Guermazi A, et al: MDCT arthrography features of ulnocarpal impaction syndrome. AJR Am J Roentgenol 193(5):1376–1381, 2009.)
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Clinical Presentation
History
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Traumatic
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Fall on outstretched, pronated hand
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Acute or chronic rotational wrist injury
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Forced ulnar deviation
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Radial deviation traction injury
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Ulnar-sided wrist pain often accompanied with clicking
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Baseball players, golfers have pain during hitting
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Nontraumatic
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Pain with activities that require forearm pronation
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Gripping and twisting doorknobs, trying to open jars, or turning a door key is often painful.
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Deep, aching discomfort
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May be associated with mechanical elements of locking, clicking, or catching
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Firm gripping activities are painful, especially in patients with dynamic ulnar impaction.
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Physical Examination
Abnormal Findings
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Examine patient where she or he can rest both elbows on a flat surface with hands toward ceiling
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Enables examiner to access forearm rotation with the wrist in any position and compare to uninvolved wrist
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Inspect
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Usually no visible deformity
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Subtle fullness or swelling of ulnar wrist
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Visible swelling may be evident in patients with synovitis of ulnocarpal joint
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Palpate (most important)
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Localize area of maximal tenderness
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Also palpate pisotriquetral articulation, lunotriquetral articulation, soft tissue elements (ECU, dorsal sensory branch of ulnar nerve)
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Point foveal tenderness located at base of ulnar snuffbox between triquetrum and ulnar styloid ( Figure 15-6 )
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Most common finding
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Soft spot on ulnar side between FCU and ECU
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Palpate dorsal TFCC with pronation, volar portion with supination
FIGURE 15-6
Tenderness at the ulnar fovea.
(Courtesy of Sidney Jacoby, MD.)
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Provocative maneuvers
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Assess volar/dorsal stability of DRUJ with shuck test ( Figure 15-7 )
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Compare to uninvolved side
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Piano key sign
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Prominent dorsal distal ulna with full pronation
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FIGURE 15-7
Shuck test.
(Courtesy of Sidney Jacoby, MD.)
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Ulnocarpal stress test (rotation with ulnar deviation) ( Figure 15-8 )
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Pain suggests ulnocarpal impaction
FIGURE 15-8
TFCC grind test.
(Courtesy of Sidney Jacoby, MD.)
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“Press test”
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Pushing up on chair rails from a seated to a standing position elicits pain ( Figure 15-9 )
FIGURE 15-9
Press test.
(Courtesy of Sidney Jacoby, MD.)
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Rule out coexisting pisotriquetral or lunotriquetral abnormalities
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ECU subluxation
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Tendon should be stable within its groove
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Forearm rotation with wrist flexion will elicit instability
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Pain elicited with ulnar deviation (TFCC compression) or radial deviation (TFCC tension)
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Decreased range of motion
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Pertinent Normal Findings
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Radial snuffbox and radial wrist often nontender
Imaging
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Radiographs—initial screening tool
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Neutral rotation PA is usually best
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Usually negative
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DRUJ
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Ulnar variance ( Figure 15-10 )
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Beware of ulnar positivity (high incidence of ulnar impaction and TFCC tears)
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Dynamic PA grip view with forearm pronation also helpful to assess dynamic ulnar impaction
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Assess volar ulnar portion of lunate for lucency often seen in those with chronic ulnar impaction
FIGURE 15-10
AP radiograph demonstrating measurement of ulnar variance.
(Courtesy of Sidney Jacoby, MD.)
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If diagnosis still unclear order advanced imaging
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MRI with or without gadolinium-enhanced arthrogram—has largely replaced plain arthrography ( Figure 15-11 )
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Tears and signal changes in the ulnar aspect of the lunate
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Consistent with ulnocarpal impaction
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Asymptomatic patients may have pathology, so correlate with history and physical exam
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Helps distinguish impaction lesions from osteonecrosis
FIGURE 15-11
MRI of an ulnar-sided peripheral tear of the TFCC demonstrated by a high intensity signal on a T 2 -weighted image ( red arrow ).
(Courtesy of Sidney Jacoby, MD.)
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Plain arthrography—joint injection shows extravasation
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Sensitivity 74% to 100%
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Other studies: three-compartment cinearthrography, plain tomography, CT, CT arthrogram
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Less diagnostic compared with MR arthrogram
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Arthroscopy—gold standard for visualizing size and stability of tear ( Figures 15-12 and 15-13 )
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Diagnostic and therapeutic
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Detects concomitant ligament or chondral injuries
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Detects peripheral vs. central tears
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Identification and treatment of loose bodies
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Types of treatment:
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Repair, debridement, and tissue ablation
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FIGURE 15-12
View of peripheral TFCC tear with ulnar-sided synovitis.
(Courtesy of Sidney Jacoby, MD.)
FIGURE 15-13
Probe entering from 6R portal revealing TFCC tear and lack of normal “trampoline” effect.
(Courtesy of Sidney Jacoby, MD.)
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Differential Diagnosis
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Extraarticular
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ECU tendonitis
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ECU instability
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Neuritis of dorsal sensory branch of ulnar nerve (“cyclist’s palsy”)
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Ulnar nerve entrapment at Guyon’s canal
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Hypothenar hammer syndrome
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Osseous
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Hamate fracture
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Pisiform fracture
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Ulnar styloid fracture
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Fracture of base of fifth metacarpal
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Periarticular
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TFCC tears
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Ulnocarpal impaction
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Impingement
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ECU subsheath
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Disc-carpal ligament injuries
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LT ligament injuries
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Synovitis
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Articular
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DRUJ arthrosis
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DRUJ instability
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LT arthrosis
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CMC arthrosis
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PT arthrosis
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Midcarpal instability
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Loose bodies
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Ulnar chondrosis
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Lunate chondrosis
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Kienbock’s disease
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Treatment
Nonoperative Management
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Type I with no instability
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Long arm immobilization with forearm in a semi-supinated position, slight flexion, and slight ulnar deviation ( Figure 15-14 )
FIGURE 15-14
Muenster splint which prevents forearm rotation.
(Courtesy of Sidney Jacoby, MD.)
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NSAID’s, ice
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Repeat exam in 4 to 6 weeks
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Type I with instability and concentric reduction of DRUJ and ulnocarpal relationship
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Long arm cast in full supination for 6 weeks followed by long arm splinting for 6 weeks
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Type II (initial)
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Activity modification and elimination of offending activities
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Long arm splinting to control rotation
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NSAIDs
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Elastic compression strap in those who work and may find the long arm splint cumbersome and impractical
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Steroid injections (diagnostic and therapeutic)
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Usually temporary relief
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Useful when associated with synovitis
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Guidelines for Choosing Among Nonoperative Treatments
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Start with activity modification and NSAIDs
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Steroid injections if continued pain
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Monitor pain while immobilized to continue nonsurgical treatment vs. pursuing surgery
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Be more aggressive with high-level athletes
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Surgical Indications
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Absolute
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Failure of nonoperative treatment (several months of wrist splinting and activity modification)
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Can be more aggressive with higher-level athletes (waiting as soon as 2 to 3 weeks if conservative measures fail)
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TFCC instability with malreduced DRUJ and ulnocarpal joint
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Congruent reduction, but with dorsal instability with 30° supination
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Relative
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TFCC instability with reduced DRUJ and ulnocarpal joint
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Palmer classification grade: see below
Aspects of History, Demographics, or Exam Findings that Affect Choice of Treatment
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Based primarily on the severity of ulnar sided wrist pain and stability of the TFCC
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Age
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Activity level/level of competition
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Occupation
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Time since injury
Aspects of Clinical Decision Making When Surgery Is Indicated
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After trying several months of wrist splinting and activity modification without a significant result
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Type IA
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Arthroscopic debridement of unstable portion
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Leave at least 2 mm peripherally to avoid instability
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Type IB ( Figure 15-15 )
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Arthroscopic repair of TFCC tear (all inside vs. outside-in); if ulnar styloid non-united with tear, need open procedure
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Pathognomonic finding is loss of “trampoline” tension effect as determined with a probe
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FIGURE 15-15
TFCC repair with restoration of normal “trampoline” effect and healthy bleeding after debridement of peripheral rim and repair of large tear following release of tourniquet.
(Courtesy of Sidney Jacoby, MD.)
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Type IC
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Arthroscopic reefing or tenodesis procedure
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Open repair for large defect
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Can augment with a strip of FCU
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Type ID
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Open radial-sided TFCC repair with Munster cast for 4 weeks
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Type II
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Decompression of ulnocarpal articulation
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Correction of concomitant positive ulnar variance recommended
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IIA/IIB
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Arthroscopic evaluation and synovectomy
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Open ulnar diaphyseal shortening
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Indicated if ulnar positive variance greater than 2 mm
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Advantage of effectively tightening the ulnocarpal ligaments and is favored with LT instability is present
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IIC
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Debridement of central tear
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Arthroscopic wafer procedure (can be performed through a central tear) vs. open ulnar shortening osteotomy
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Only if ulnar positive variance less than 2 mm
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IID
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Debridement and arthroscopic wafer
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Open ulnar shortening if LT ligament unstable
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Limited open ulnar head resection (Bowers’ hemiarthroplasty)
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Leads to creation of proximal pseudoarthrosis at the level of the ulnar neck
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TFCC needs to be intact or reconstructable
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IIE
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Ulnar shortening osteotomy with LT debridement
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LT pinning if unstable after ulnar shortening
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Sauve-Kapandji procedure (DRUJ fusion with proximal ulnar pseudoarthrosis)
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Darrach procedure (distal ulna resection)
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Avoided because of problems with distal ulnar stump instability and radio-ulnar impingement (convergence)
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Evidence
Multiple-Choice Questions
- QUESTION 1.
Which of the following is NOT considered part of the TFCC?
- A.
Meniscus homologue
- B.
Volar radioulnar ligament
- C.
FCU tendon sheath
- D.
Central articular disc
- A.
- QUESTION 2.
A 22-year-old soccer player presents to your office after a fall. He has pain and ulnar-sided catching. He has no tenderness over the ECU tendon. X-rays, including a carpal tunnel view, are normal. The most likely mechanism for his fall is
- A.
Forearm supination, wrist flexion
- B.
Forearm supination, wrist extension
- C.
Forearm pronation, wrist flexion
- D.
Forearm pronation, wrist extension
- A.
- QUESTION 3.
Which of the following is the gold standard for diagnosing stability of a TFCC tear?
- A.
Zero rotation PA radiograph
- B.
MR arthrogram
- C.
Three compartment cinearthrography
- D.
Arthroscopy
- A.
- QUESTION 4.
Which of the following should be on your differential for periarticular ulnar-sided wrist pain (besides a TFCC tear)?
- A.
Ulnar impaction
- B.
Neuritis of dorsal sensory branch of ulnar nerve
- C.
Kienbock’s disease
- D.
DRUJ instability
- A.
- QUESTION 5.
Which of the following is an appropriate treatment in a 27-year-old professional athlete who has been diagnosed with a peripheral TFCC tear at the base of the ulnar styloid and an associated ulnar styloid fracture with normal ulnar variance?
- A.
Debridement alone
- B.
Arthroscopic versus open outside-in repair
- C.
Ulnar shortening osteotomy
- D.
Short arm splint
- A.
Answer Key
- QUESTION 1.
Correct answer: C (see Pathophysiology )
- QUESTION 2.
Correct answer: D (see Pathophysiology )
- QUESTION 3.
Correct answer: D (see Clinical Presentation )
- QUESTION 4.
Correct answer: A (see Differential Diagnosis )
- QUESTION 5.
Correct answer: B (see Treatment )
Related posts:
Epiphyseolysis and Osteochondritis
Cervical Spine Disc Injuries
Lateral Collateral Ligament and Posterolateral Ligament Injuries
Superior Labral Pathology (SLAP/Long Head Biceps)
Leg Pain in the Athlete: Stress Fractures, Medial Tibial Stress Syndrome, and External Compartment Syndromes
Ulnar Collateral Ligament Injuries
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