1. MR IMAGING OF TRIANGULAR FIBROUS CARTILAGE COMPLEX
DR.PREM CHAND PALADUGU
AARUPADAI VEEDU MEDICAL COLLEGE & HOSPITAL

2. TFCC COMPONENTS TRIANGULAR FIBROUS CARTILAGE COMPLEX (TFCC) COMPONENTS
TRIANGULAR FIBROUS CARTILAGE / ARTICULAR DISC
DORSAL & VOLAR RADIOULNAR LIGAMENTS
ULNOCARPAL LIGAMENTS ( ULNOLUNATE , ULNOTRIQUETRAL )
ULNARCOLLATERAL LIGAMENT
TRIANGULAR LIGAMENT
MENISCUS HOMOLOGUE
SHEATH OF ECU TENDON

3. NORMAL ANATOMY
TFC IS A BICONCAVE DISK. ITS THICKNESS IS DIRECTLY PROPORTIONAL TO DEGREE OF ULNAR VARIANCE.
THE DORSAL AND VOLAR RADIOULNAR LIGAMENT ARE BROAD STRIATED LIGAMENT ARISING FROM THE DORSAL AND VOLAR CORTEX OF THE DISTAL RADIUS SIGMOID NOTCH RESPECTIVELY.THE RESPECTIVE LIGAMENTS BLEND WITH DORSAL AND VOLAR SURFACE OF TFC, AND ATTACHES TO ULNAR STYLOID MEDIALLY AND DISTAL RADIUS LATERALLY.
THE EXTENSOR CARPI ULNARIS TENDON SHEATH IS NORMALLY FOUND WITHIN THE GROOVE ON THE DORSUM OF ULNA IN NEUTRAL POSITION
ULNAR COLLATERAL LIGAMENT REPRESENTS THICKENING OF WRIST JOINT CAPSULE, AND EXTENDS FROM THE ULNAR STYLOID PROCESS PROXIMALLY TO THE TRIQUETRUM DISTALLY.
MENISCUS HOMOLOGUE IS THICKENING OF ULNAR JOINT CAPSULE AND IS INCONSISTENTLY PRESENT. IT IS LOCATED DISTAL TO THE PRESTYLOID RECESS AND ATTACHES TO THE TRIQUETRUM.

4. TECHNICAL PARAMETERS POSITIONING
WRIST NEUTRAL AT SIDE OR OVERHEAD WHILE PRONE; PRONE WITH AXIAL TRACTION DURING MR ARTHROGRAPHY
TECHNIQUE
AXIAL FOV 110 mm
CORONAL FOV 120 mm
SAGITTAL FOV 120 mm
NO INTERSLICE GAP
MATRIX 448 F X 314 P
BANDWIDTH 248 Hz PER PIXEL
STANDARD SEQUENCES
CORONAL GRADIENT ECHO: EVALUATION OF TFCC AND ALSO INTRINSIC LIGAMENTS AND CARTILAGE
CORONAL PD AND SAG PD : TFCC, INTRINSIC LIGAMENTS
CORONAL IR: SENSITIVE TO MARROW EDEMA AND PATHOLOGICAL FLUID
AXIAL PD FS : INTRINSIC WRIST LIGAMENTS, FLEXOR AND EXTENSOR TENDONS, DRUJ, MEDIAN AND ULNAR NERVES
T1 FAT SAT MR ARTHROGRAPHY : AXIAL , SAGITTAL, CORONAL

5. TYPES OF MR ARTHROGRAPHY
INDIRECT MR ARTHROGRAPHY
IV INJECTED CONTRAST MATERIAL DIFFUSES INTO THE JOINT IN SUCH CONCENTRATIONS THAT AN ARTHROGRAPHIC EFFECT CAN BE OBTAINED ON T 1 wt IMAGES WITHOUT DECREASE IN SNR
SIGNIFICANT IMPROVEMENT IN DETECTION OF SL LIGAMENT PATHOLOGY
NO SIGNIFICANT IMPROVEMENT IN DETECTION OF CENTRAL DISC OF TFCC / LT LIGAMENT
DIRECT MR ARTHROGRAPHY
FULLY DISTENDS JOINT CAVITY , OUTLINES TFCC, LIGAMENT DEFECTS
DEPICT PRECISE LOCATION OF TFCC, LIGAMENTOUS DEFECT
INJECTION - SINGLE/ TRIPLE COMPARTMENT
INJECTION GUIDANCE - FLOUROSCOPY, USG ,CT, MRI
MR ARTHROGRAM: 2-5 ml SOLUTION OF 0.1 ml GADOLINIUM DILUTED IN 20 ml SOLUTION COMPOSED OF 15 ml OF NORMAL SALINE AND 5 ml OF IODINATED CONTRAST( DIATRIZOATE MEGLUMINE ) 370 mg I / ml

6. COMPARTMENTAL ANATOMY
RADIOCARPAL (RC)
DISTAL / INFERIOR RADIOULNAR (DRU
MID CARPAL(MC)
4. PISOTRIQUETRAL (PT)
5. 1 st CARPOMETACARPAL
6. COMMON CARPOMETACARPAL
7. INTERMETACARPAL

8. CHINESE FINGER TRAPS WITH A PULLEY SYSTEM & WEIGHTS

9. CORONAL 3D GE MRI SHOWING NORMAL TFCC (VOLAR TO DORSAL)

10. ULNAR ATTACHMENT OF TFCC
RADIAL ATTACHMENT OF TFCC

11. MR ARTHROGRAPHY SAGITTAL SECTIONS SHOWING
NORMAL TFCC

12. MR ARTHROGRAPHY AXIAL SECTIONS SHOWING
NORMAL TFCC

13. PITFALLS IN MRI INTERPRETATION OF TEAR
TRIANGULAR LIGAMENT : STRANDS OF COLLAGEN FIBRES WITH VASCULAR CONNECTIVE TISSUE PRODUCE INCREASED SIGNAL INTENSITY WITH A STRIATED PATTERN
FOVEA & BASE OF ULNAR HEAD : PROXIMAL LAMINA CONTAINS HIGHLY VASCULAR LOOSE TYPE CONNECTIVE TISSUE WITH BUNDLES OF COLLAGEN FIBRES WHICH PRODUCES RELATIVELY HIGH SIGNAL INTENSITY
TIP OF ULNAR STYLOID PROCESS : HYALINE LIKE CARTILAGE AT TIP OF ULNAR STYLOID PROCESS HAS INTERMEDIATE SIGNAL INTENSITY ON PD & GRE IMAGES
LIGAMENTUM SUBCRUENTUM : NORMALLY SHOWS INCREASED SIGNAL INTENSITY

14. PITFALLS IN MRI INTERPRETATION OF TEAR
TFCC DEGENERATION : HIGH SIGNAL INTENSITY WITHIN DISC PROPER WITHOUT EXTENSION TO ARTICULAR SURFACE
PERFORATION OF TFCC DISK : LINEAR CORRELATION BETWEEN PREVALENCE OF PERFORATION TYPE TEAR OF HORIZONTAL PORTION OF TFCC AND INCREASING AGE
SIGMOID NOTCH OF RADIUS: HYALINE CARTILAGE AT THE CENTRAL PORTION OF ATTACHMENT OF TFCC TO RADIUS SHOWS INTERMEDIATE SIGNAL INTENSITY
PRESTYLOID RECESS : VARIOUS SHAPES, SACCULAR, TUBULAR, CONICAL, TONGUE SHAPED ( IN DECREASING ORDER OF INCIDENCE)
CHANGES IN TFCC SHAPE DUE TO ROTATIONAL MOTION : NO SIGNIFICANT CHANGE IF TFCC SHAPE OCCURS THAT MIMICS A TEAR

15. 1 2 3 4 5 6 7 8 NORMAL VARIANTS THAT CAN SIMULATE TEAR(1-4)
PRESTYLOID RECESS TYPES(7-8)
DEGENERATION VS TEAR(5-6) 5 6 7 8

16. PALMER CLASSIFICATION OF
TFCC LESIONS

17. PALMER TYPE 1 : TRAUMA
TYPE 1 A : CENTRAL
PERFORATION
TYPE 1 B : ULNAR AVULSION

18. TYPE 1 C : DISTAL AVULSION
TYPE 1 D: RADIAL AVULSION

19. PALMER TYPE 2 : DEGENERATIVE
TYPE 2 A : DEGENERATIVE THINNING
OF TFCC
TYPE 2 B : TFCC THINNING + CHONDROMALACIA

20. TYPE 2 C : PERFORATED TFCC+ CHONDROMALACIA

21. TYPE 2 D: TYPE 2 C PERFORATION + LUNATE CHONDROMALACIA +
LTL PERFORATION

22. TYPE 2 E : TFCC PERFORATION +
CHONDROMALACIA +
LTL PERFORATION +
SECONDARY ARTHRITIS

23. NATHAN & SCHNEIDER CLASSIFICATION OF TFCC TEARS
INSTABILITY OF DRUJ ( # RADIUS, ULNA ; TFCC DISRUPTION DUE TO TRAUMA , INFLAMMATORY DISORDERS )
INCONGRUITY OF DRUJ ( TRAUMATIC , INFLAMMATORY DISORDERS )
IMPINGEMENT OF ULNA ON CARPUS
ISOLATED LESIONS OF ARTICULAR DISC ( WHICH OCCUR WITHOUT INSTABILITY OF DRUJ )

24. CONCLUSION
MR ARTHROGRAPHY MOST USEFUL IN DETECTING CLASS 1- B,C,D LESIONS
ARTHROSCOPY BOTH DIAGNOSTIC & THERAPEUTIC ; THERAPEUTIC FOR PALMER CLASS- 1A ,1D ,2C
A NEGATIVE MRI IS NOT AN END POINT AND NOT A CONTRAINDICATION FOR FURTHER EXPLORATION, IN PARTICULAR FOR ARTHROSCOPY

25. REFERENCES
1.INTERNAL DERANGEMENT OF JOINTS; DONALD RESNICK,HEUNG SIK KANG;
2.MEASUREMENTS & CLASSIFICATION IN MUSCULOSKELETAL RADIOLOGY , SIMONE WALDT, KLAUS WOERTLER
3.PITFALLS THAT MAY MIMIC INJURIES OF TRIANGULAR FIBROUS CARTILAGE COMPLEX AND PROXIMAL INTRINSIC WRIST LIGAMENTS AT MR IMAGING ; JOSEPH E.BURNS ET AL radiographics 2011 ; 31:63-78