1. Triangular Fibrocartilage Complex
Nancy Beaman MBA, OTR/L, CHT
New England Hand Society Annual Meeting
4 December 2009

2. TFCC: AKA… Triangular Fibrocartilage Carpal Articular Disc
Discus Articularis
Triangular Ligament
Triangular Cartilage
Triangular Disc
Meniscus
Ulnocarpal Complex
Ulnocarpal Ligament Complex

3. Triangular Fibrocartilage Complex a complex structure
Consists of
Triangular Fibrocartilage
Ulnocarpal ligaments

4. TFC Anatomy Triangular in shape Cartilaginous Ligamentous
Interposed between ulnar carpus and distal ulna

5. TFC Anatomy
Arises from articular cartilage on corner of sigmoid notch of the radius
Inserts into base of ulnar styloid and volarly into ulnocarpal ligament complex
Ulnocomplex: ulnolunate & ulnotriquetral ligaments

6. TFC Anatomy
Dorsal and volar radioulnar ligaments are fibrous thickenings w/in the dorsal and volar edges of TFC
Peripheral margin: thick lamellar collagen
Adapted to bear tensile load
Thin central portion
Articular disc: chondroid fibrocartilage
Avascular and aneural
Occasionally absent
Often so thin, is tranluscent

7. TFC Anatomy
Blood supply: Ant Interosseous Artery

8. TFC Anatomy Radial origin 1-2mm thick at base
Stretches across ulnar articular dome
Apex attached to eccentric concavity of head and projecting styloid
Ulnar origin may be up to 5mm thick

9. TFC Anatomy Volar and dorsal radioulnar ligament are confluent w/ TFC
Dorsal RU lig is stouter
Volar RU lig is origin for ulnocarpal ligs
RU ligs can be considered 2 separate laminae
Proximal lamina inserts on fovea adjacent to styloid
Distal lamina inserts into base of syloid proper
Separated by ligamentum subcruentum

10. Triangular Fibrocartilage The ulnocarpal or “V” ligament
Combined TFC and
Ulnocarpal ligaments
Green’s Hand Surgery

11. Biomechanical Functions
Provides continuous gliding surface across distal radius and ulna for carpal flexion, extension and translation
Provides flexible mechanism for stable rotation of the radiocarpal unit about the ulnar axis

12. Biomechanical Functions
Suspends the ulnar carpus from the dorsal ulnar face of the radius
Connects the ulnar axis to the volar carpus
Major stabilizer of DRUJ and ulnar carpus

13. Biomechanical Functions
Amount of load xferred to distal ulna is directly proportional to the ulnar variance
neutral: ~20%
Positive ulnar variance
Load increases w/ corresponding decreased thickness in articular disc

14. (Hulten’s) Ulnar Variance
Ulnar zero: radius and ulna the same length
Ulna positive: ulna 1-5mm longer
Ulna negative: ulna 1-6mm shorter
Variance is independent of styloid length
Measurement is affected by
FA rotation Grip loading
Wrist position Xray techniques

15. Biomechanical Functions
Dynamic load xmission w/ rotation
Supination: radius moves distally creating a relative negative ulnar variance
Pronation: radius moves prox’ly creating and relative positive ulnar variance
Ulna moves w/in sigmoid notch
Dorsal with pronation
Volarly with supination
During FA rotation dorsal and volar radioulnar ligamentous portions of TFCC become tense, stabilizing DRUJ

16. Biomechanical Functions: Compressive Force
Force across carpal-ulnar articulation is partially transmitted thru center of TFC to ulnar dome
Tends to separate radius and ulna
Variance changes w/ grip and FA position
Neutral variance: static axial load
80% radius, 20% ulna
w/ positive ulnar variance 2-2.5mm, load increases 5 – 40% (Palmar and Werner)
Later study by Palmer showed weak correlation

19. Compressive Forces
DRUJ is most stable in extremes of rotation where compressive forces are resisted by reciprocal tensile forces
Pressure concentrates
Dorsally in pronation
Palmarly in supination

20. Compressive Forces In pronation
the palmar margin of TFC is taut as the dorsal margin of radius and the ulnar articular surface are compressed
If palmar margin is attenuated or torn, dorsal sublux of distal ulna occurs relative to radius

21. Compressive Forces In supination
The dorsal margin becomes taut while the palmar margin of the sigmoid notch and ulnar articular surface are compressed
If dorsal margin is torn or attenuated, palmar sublux of distal ulna relative to radius occurs

22. Traumatic Injuries Fall on an outstretched hand
Extension-pronation force to an axial-loaded wrist
A dorsal rotation injury
When a drill binds and rotates the wrist
A distraction force applied to the volar FA or wrist
Common with Distal Radius Fractures

23. Clinical History: Mechanism of Injury TFCC injury or…
Carpal hypersupination w/ UD
ECU instab
Hyperpronation w/ dorsiflexion
Lunotriquetral ligament injury
Repeated pronation/supination
May produce chondromalacia of ulnar head
Ulnocarpal impaction, abutment or loading syndrome seen w/ ulna positive
Sudden onset of pain accompanied by redness and swelling point to inflammatory process
Frequently calicific tendonitis

24. Classification of Injury
Class 1: Traumatic
Central perforation
Ulnar avulsion
With distal ulnar fracture
Without distal ulnar fracture

25. Classification of Injury
Class 1: Traumatic
C. Distal avulsion
D. Radial avulsion
With sigmoid notch fracture
Without sigmoid notch fracture

26. Classification of Injury
Class 2: Degenerative (ulnocarpal abutment syndrome)
TFCC Wear
TFCC Wear, plus lunate &/or ulnar chondromalacia

27. Classification of Injury
Class 2: Degenerative
(ulnocarpal abutment syndrome)
C. TFCC perforation
plus lunate &/or ulnar chondromalacia
plus lunotriquetral ligament perforation
D. TFCC perforation
plus ulnocarpal arthritis

28. Contribution of age Age related changes begin as early as 3rd decade
Increase rapidly by age 50
Virtually all wrists have significant degenerative changes and 50% or more will have arthrographically demonstrable “lesions”

29. Symptoms Ulnar-sided wrist pain
Frequently with clicking
May be a history of a fall on a pronated wrist, traction or twisting injury
Improved by rest, worsened by load activity
Often assoc’d w/ tendonitis of ECU

30. Physical Exam
Swelling w/ a reversal of normal convex shape at ulnar border of wrist
Tenderness along soft region of ulnar border of wrist between ulnar styloid and triquetrum
Bring hand into UD compresses TFCC
RD can apply pressure to peripheral tissues
Dimpling along dorsal surface, particularly in supination—indicative of volar sublux of ulna
Ask pt to duplicate motion that causes symptoms

31. Physical Exam: provocative tests
Only meaningful if they reproduce pt’s symptoms
TFC compression test
Examiner axially load the wrist then add UD or rotatory motion
Painful click that reproduces symptoms
Always compare to the other side
Piano key sign: test for DRUJ stability
Grasp distal ulna and attempt to passively move the ulna volarly and dorsally in various degrees of pronation and supination.
Pain and tenderness w/ inc’d motion suggest DRUJ involvement
Gross laxity represents significant TFCC disruption

32. Physical Exam: provocative tests
Test LT ligament w/ Ballottement test
Examiner hold lunate between thumb and IF of one hand and triquetrum in thumb and IF of the other. Move triquetrum volar and dorsal to appreciate instability or elicit pain.

33. Physical Exam: provocative tests
Check ECU tendon for subluxation
on supination w/ wrist-ulnar deviation, tendon displaces, often w/ audible snap, when moved in the ulnar and palmar directions
on pronation, it relocates into its normal sulcus

34. Physical Exam: provocative tests
Articular Disc Shear
Examiner stabilizes the distal radius while thumb is positioned dorsally over distal ulnar head
Grasp pisotriquetral complex w/ other thumb and IF
Produce a dorsal glide of pisotriquetral complex on the ulnar head producing a shearing of the articular disc
Positive if produces patient’s pain &/or laxity

35. Physical Exam: provocative tests
Measure grip strength
Will see decrease grip w/ TFCC injury
Pain w/ tight grip
Testing ligamentum subcruentum
In supination: pressure to distal ulna volarly should cause pain
In pronation: pressure to distal ulna dorsally should cause pain

36. Differential Diagnosis
ECU subluxation
LT ligament injury
Pisotriquetral arthritis
Chondral lesions of lunate or midcarpal jt
Ulnar artery thrombosis
Ulnar neuropathy at wrist

37. Objective testing
Differential anesthetic injection may be helpful to localize symptomatic source of pain
X-ray
Carpal alignment
Ulnar styloid morphology
Ulnar variance
MRI: to differential soft tissues
Arthrography: evaluation of integrity of intercarpal and capsular wrist ligaments
Arthroscopy

38. Management Immobilization x 2 weeks (normal xray)
Reexamine after 2 weeks, continue immob if still tender
Still painful after 6 weeks then MRI
Arthroscopic evaluation
Surgical debridement
Central or peripheral tears
Repair of peripheral tear
Distal ulna resection / ulnar osteotomy

39. Post-operative Care: Central Debridement
Wrist Immob Orthosis and begin AROM at 3-5 days
Scar mgt once sutures removed
3-4 weeks add resistance, PROM and dynamic splinting if needed
6 weeks progressive strengthening

40. Post-operative Care Peripheral Repair
Long arm cast at 10 days when sutures removed. Short arm cast at 3 weeks.
6 weeks: cast removed, wrist immob orthosis. Initiate AROM and scar mgt. PROM to elbow if needed.
8 weeks: PROM & dynamic splinting if needed.
10-12 weeks: begin strengthening.

41. References Green’s Operative Hand Surgery 5th Ed
Review of Hand Surgery
Beredjiklian & Bozentka
Examination of the Hand and Wrist
Tubiana, Thomine, Mackin
Principles of Hand Surgery and Therapy
Trumble
Anatomy, Biomechanics and Pathomechanics
Handout from Drexel University, 3 Mar 07
Atlas of the Hand Clinics: Disorders of the Lunotriquetral Joint, March 2004
The Wrist: Diagnosis and Operative Treatment
Cooney, Linscheid, Dobyns
Rehabilitation of the Hand and Upper Extremity
Hunter, Mackin, Callahan