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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.

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