J Korean Orthop Assoc.  2017 Apr;52(2):112-124. 10.4055/jkoa.2017.52.2.112.

Traumatic Triangular Fibrocartilage Complex Injuries and Instability of the Distal Radioulnar Joint

• Kim B
• Nho JH
• Jung KJ
• Yun K
• Kim YH
• Yoon HK

• KMID: 2438976
• DOI: http://doi.org/10.4055/jkoa.2017.52.2.112

Abstract

Traumatic triangular fibrocartilage complex (TFCC) injuries require multidisciplinary approach and plan. Trauma to TFCC can lead to instability of the distal radioulnar joint (DRUJ). Injury to TFCC is classified as a stable type that does not cause unstable lesions for DRUJ or unstable type that can cause instability of DRUJ. According to the location and severity of the injury, arthroscopic debridement or arthroscopic repair may be considered. In the ulnar side avulsion of TFCC, which could cause DRUJ instability, arthroscopic examination should be performed to identify an accurate location of the damaged structures, followed by arthroscopic debridement and repair. In the event of TFCC and DRUJ injuries with ulnar positive variance, arthroscopic TFCC repair or ulnar shortening osteotomy after arthroscopic debridement could be considered to solve the instability and ulnar side pain. However, if peripheral TFCC tear with ulnar impaction syndrome and DRUJ instability, it combined operation of ulnar shortening osteotomy and TFCC foveal fixation could be considered. An accurate classification of TFCC and DRUJ injuries is necessary. It is important to resolve and prevent recurrence of ulnar wrist pain caused by instability.

Keyword

triangular fibrocartilage complex; distal radioulnar joint; arthroscopy; joint instability

MeSH Terms

Arthroscopy
Classification
Debridement
Joint Instability
Joints*
Osteotomy
Recurrence
Tears
Triangular Fibrocartilage*
Wrist

Figure

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  Figure 1 Illustration of the triangular fibrocartilage complex.

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  Figure 2 (A) The Palmar classification of traumatic triangular fibrocartilage complex (TFCC) injury. (B) The Atzei classification of TFCC peripheral tears (class 1: reparable distal tear, class 2: reparable complete tear, class 3: reparable proximal tear, class 4: non-reparable tear, class 5: arthritic distal radioulnar joint). L, lunate; T, triquetrum; R, radius; U, ulna; D, distal; P, proximal.

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  Figure 3 Foveal sign is positive if patients feel pain when the examiner presses the ulnar snuff box between the extensor carpi ulnaris and flexor carpi ulnaris in triangular fibrocartilage complex tear with distal radioulnar joint instability.

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  Figure 4 (A) Press test can be performed by loading the wrist axially in ulnar deviation as the patient pushes up from a seated position. (B) Ulnar grind test; involves dorsiflexion of the wrist, axial load, and ulnar deviation or rotation which could cause wrist pain. (C) With the wrist in pronation, an unstable distal ulna may translate dorsally and can be manually reduced with dorsal thumb pressure (arrow).

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  Figure 5 Magnetic resonance imaging findings of triangular fibrocartilage complex injury in Palmer classification class 1B.

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  Figure 6 (A) Trampolin test: laxity and absence of rebound, imply detachment at one or more points of insertion. (B) Hook test: pulling cartilage disc toward radial side with a probe may help detect foveal avulsion.

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  Figure 7 Arthroscopic debridement of a Palmar classification class 1A tear lesion.

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  Figure 8 Arthroscopic examination of severe fraying of triangular fibrocartilage complex and debridement operation.

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  Figure 9 Arthroscopic assisted repair of a Palmer classification class 1B tear lesion using the direct foveal portal.

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  Figure 10 Magnetic resonance imaging finding of ulnar impaction syndrome and radiographs after ulnar shortening osteotomy.

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