AUTHOR AND EDITOR INFORMATION

Section 1 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

INTRODUCTION

Section 2 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

In 1981, Palmer and Werner introduced the term "triangular fibrocartilage complex" (TFCC) to describe the ligamentous and cartilaginous structures that suspend the distal radius and ulnar carpus from the distal ulna (see Image 1). The TFCC is the major ligamentous stabilizer of the distal radioulnar joint (DRUJ) and the ulnar carpus.

Functions of the TFCC are as follows:

• Provides a continuous gliding surface across the entire distal face of the 2 forearm bones for flexion-extension and translational movements (see Image 2)
• Provides a flexible mechanism for stable rotational movements of the radiocarpal unit around the ulnar axis
• Suspends the ulnar carpus from the dorsal ulnar face of the radius
• Cushions the forces transmitted through the ulnocarpal axis
• Solidly connects the ulnar axis to the volar carpus (see Image 3)

History of the Procedure

Since DeSault's original dissertation in 1777 describing DRUJ injuries, much has been written about the DRUJ and the TFCC complex. As Palmer (1981) has pointed out, humans are differentiated from lower primates by a radiocarpal joint with a TFCC complex interposed between the ulna and carpus. This TFCC complex improves wrist functional stability and allows 6° of freedom at the wrist—flexion, extension, supination, pronation, and radial and ulnar deviation. As interest in this structure evolved, open repair techniques for the TFCC were devised. With recent advances in small joint arthroscopy, the potential for arthroscopic debridement or repair of these structures now exists.

Problem

Injuries to the TFCC present with ulnar-sided wrist pain, frequently with clicking.

Torn TFCCs constitute 35% of intra-articular fractures and 53% of extra-articular fractures. There is no correlation between ulnar styloid fractures and TFCC injuries.

Patients with a torn TFCC display ulnar variance (radial shortening) that is on average 4.6 mm, versus 2.5 mm for no tear, and dorsal angulation of 24° versus 12° for no tear.

Frequency

Mikic (1978) looked at 180 wrist joints in 100 cadavers, ranging in age from fetuses to 94 years. He demonstrated that degeneration of the TFCC begins in the third decade of life and progressively increases in frequency and severity in subsequent decades. After the fifth decade of life, he noted no normal appearing TFCCs. Viegas and Ballantyne (1987) found similar results.

Etiology

Causative conditions for TFCC injuries include the following:

• Falls onto pronated hyperextended wrist
• Power drill injuries in which the drill binds and rotates the wrist instead of the bit
• Distraction force applied to the volar forearm or wrist
• Distal radius fractures

Pathophysiology

In 1983, Palmer and Werner looked at the axial load distribution through the distal radius and ulna. They demonstrated that with normal axial loading, 20% of the force is transmitted through the ulna and 80% is transmitted through the radius. Their data also illustrated that small changes in relative ulnar length can significantly alter load patterns across the wrist. For example, with a distal radius fracture that settles 2.5 mm, an increase in ulnar axial load of approximately 40% can be expected.

Palmer, Werner, Glisson, and Murphy (1988) demonstrated that the percentage of axial force transmitted through the ulna decreases by sequential removal of the horizontal portion of the TFCC. This percentage decrease is accentuated with more positive ulnar variance.

In a cadaver study, Adams (1993) demonstrated that no significant kinematic or structural changes resulted from an excision that did not violate the peripheral 2 mm of the disk and that constituted less than two thirds of the disk area.

TFCC tears are associated with a positive ulnar variance. Ulnar variance increases with pronation and grip and decreases with supination.

The floor of the extensor carpi ulnaris (ECU) tendon sheath broadly connects with the TFCC. After release of the TFCC from its distal ulna attachment, Tang (1998) demonstrated a 30% increase in ECU tendon excursion during wrist extension. This suggests the following:

• The TFCC is an important pulley for the ECU tendon.
• Disruption of the normal ECU excursion may contribute to abnormal loading and force transmission through the ulnar wrist and TFCC.

Clinical

The history of TFCC injuries includes ulnar-sided wrist pain (frequently accompanied with clicking), a fall or trauma, and/or mechanical symptoms that improve with rest and worsen with activity.

In the physical examination, look for the following:

• Painful grinding or clicking with wrist range of motion (ROM)
• Weakness
• Ulnar deviation of the wrist with the forearm in neutral produces ulnar wrist pain and occasional clicking (Perform a TFCC compression test.)
• Instability of the DRUJ with shucking the distal radius and ulna between the examiner's fingers (Perform a DRUJ stress test; always compare this with the opposite wrist.)
• Piano key sign, which is a prominent and ballottable distal ulna with full pronation of the forearm
• Ulnar carpal sag
• Lunotriquetral (LT) interval tenderness
• Positive LT ballottement or shuck test
• ECU tendon subluxation

INDICATIONS

Section 3 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

If a congruent reduction cannot be achieved or if the dorsal instability is unstable in 30° of supination, then arthroscopic evaluation of the TFCC is recommended with repair as needed.

RELEVANT ANATOMY

Section 4 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

The TFCC is triangular in shape. Palmer (1984) found an inverse relationship between ulnar variance and the thickness of the TFCC; the TFCC is thicker in individuals who are ulnar minus. Generally, the TFCC is 1-2 mm thick at its center. This may thicken to 5 mm where the TFCC inserts into the eccentric concavity of the ulnar head and projecting styloid.

The TFCC extends ulnarly to insert into the base of the ulnar styloid (see Image 4). Distally, it inserts into the lunate via the ulnolunate (UL) ligament and the triquetrum via the ulnotriquetral (UT) ligament (see Image 5), hamate, and base of the fifth metacarpal. Radially, the TFCC arises from the ulnar margin of the lunate fossa of the radius (see Image 6).

Underneath the TFCC is the ulnar head. The seat, or the convex portion of the ulnar head, articulates with the sigmoid notch of the radius (see Image 7). The cartilage-covered nonarticular pole of the ulnar head is deep to the articular disk.

The ulnocarpal portion of the TFCC is composed of the discus articularis and the UL and UT ligaments (referred to by some as the disk carpal ligaments).

Embryologic studies have demonstrated that these ligaments arise from the disk and are critical to the carpal suspensory function of the TFCC.

The dorsal and palmar branches of the anterior interosseous artery and dorsal and palmar radiocarpal branches from the ulnar artery supply blood to the periphery of the TFCC. These vessels supply the TFCC in a radial fashion, with histologic sections demonstrating that the vessels penetrate the peripheral 10-40% of the disk. The central portion and radial attachment are avascular.

Mikic demonstrated that the percentage of the peripheral disk that is vascularized is reduced from one third in a young patient to one fourth in patients of advanced age.

Because the periphery of the TFCC has a good blood supply, tears in this region can be repaired. In contrast, tears in the central avascular area must be debrided, as they have no potential for healing.

The richly vascularized dorsal radioulnar ligament (DRUL) and palmar radioulnar ligament (PRUL) are composed of thick, longitudinally oriented collagen fiber bundles that blend in with the central avascular fibrocartilaginous portion.

Viewing the TFCC during wrist arthroscopy, the styloid attachment appears folded. Some of the blood vessels to the TFCC enter between these folds. This fold, combined with the vascular hilum, is termed the ligamentum subcruentum, which actually is the confluence of the TFCC and the V-shaped ligament (disk ligament) as it extends from the hilar area of the styloid to its twin insertions on the lunate and triquetrum.

From a distal perspective, the TFCC has 2 distinct insertions into the ulna—a superficial portion and a deep portion. The superficial components, the DRUL and PRUL, insert into the base of the styloid. The deep portion, or the ligamentum subcruentum, inserts into the fovea near the axis of forearm rotation.

CONTRAINDICATIONS

Section 5 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Repairing TFCC tears is contraindicated in the presence of infection or degeneration. Palmer class 2 (see the Palmer classification for triangular fibrocartilage complex abnormalities in Treatment, Medical therapy, below) degenerative TFCC tears represent a pathologic progression of disease associated with ulnar impaction syndrome. Degeneration of the TFCC is found with repetitive pronation and axial grip loading in association with ulnar positive variance and impaction between the ulnar head and the proximal pole of the lunate. Treatment of degenerative TFCC tears associated with ulnar impaction syndrome consists of nonoperative treatment first with immobilization, avoidance of aggravating activities, and nonsteroidal anti-inflammatory drugs (NSAIDs).

Palmer class 2A and 2B lesions that fail to respond to conservative treatment are treated with gentle debridement. If the patient is ulnar positive and symptomatic, a formal ulnar shortening is considered. An arthroscopic wafer is contraindicated, as this would require resection of intact TFCC to perform the procedure or require performing the procedure entirely through the DRUJ portals.

The surgical indications for an arthroscopic wafer procedure are a Palmer class 2C or 2D lesion in an ulnar positive variance of not more than 2 mm without evidence of lunate-triquetrum instability. If lunate-triquetrum instability is present, this is addressed with formal ulnar shortening in an attempt to tighten the ulnocarpal ligaments and decrease the motion between the lunate and triquetrum.

For patients with an ulnar positive variance of more than 2 mm, formal ulnar shortening is performed. For patients with ulnar neutral or negative variance and a Palmer class 2C lesion, an arthroscopic debridement is performed. Palmer class 2E lesions respond unpredictably to arthroscopic debridement. They are usually treated with a salvage procedure such as a limited ulnar head resection, Sauve-Kapandji procedure, or Darrach procedure that addresses the DRUJ and lunate-triquetrum joint pathology.

WORKUP

Section 6 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Imaging Studies

• X-rays: Obtain neutral forearm rotation posteroanterior (PA) and lateral x-rays of the wrist to allow assessment of ulnar variance and to assess for chondromalacia of the lunate or ulnar head, degenerative joint disease of the DRUJ, LT or scapholunate (SL) instability, dorsiflexed intercalated segment instability (DISI), or volar flexed intercalated segment instability (VISI).
• Wrist arthrograms
• • The accuracy and diagnostic capability of triple injection wrist arthrograms have been challenged over the past 5-10 years.
  • The test is not specific, with a high incidence of findings on the contralateral asymptomatic side.
  • Wrist arthrograms have poor diagnostic agreement with chronic wrist pain.
  • Positive findings are present in 27% of asymptomatic adults.
  • Palmer class 1B tears have positive arthrograms with a DRUJ injection but not with a radiocarpal injection.
  • Palmer class 1C tears have variable findings.
  • Palmer class 1D tears usually have positive arthrograms.
• MRI
• • MRI scans can predict TFCC lesions with 0.8 sensitivity and 0.7 specificity using a dedicated wrist coil.
  • Fat suppression MRI scans best exhibit the complex structure of the TFCC.

Diagnostic Procedures

• Wrist arthroscopy
• • Wrist arthroscopy is the criterion standard; it can be a diagnostic tool or a therapeutic tool.
  • When compared with other imaging studies, wrist arthroscopy is more accurate. It also allows for assessment of the size of the tear, for determining whether an unstable flap is present, and for detecting associated synovitis and chondral and ligamentous lesions.
  • With the trampoline test, normally a probe should bounce off of the TFCC. If a probe sinks into the TFCC as if it is on a feather bed, a tear is usually present.
  • Wrist arthroscopy is used in the diagnosis of TFCC tears associated with distal radius fractures. Richards (1997) examined 118 fractures. These fractures had wrist arthroscopy that required reduction and fixation because of a failure to obtain or maintain a reduction.

TREATMENT

Section 7 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Medical therapy

Initial treatment of both symptomatic degenerative and traumatic tears is 8-12 weeks of conservative therapy consisting of the following:

• NSAIDs
• Immobilization in slight flexion and ulnar deviation in a short arm cast for 4-6 weeks, followed by removable wrist splints and physical therapy
• Initial treatment with long arm casting for 4-6 weeks for traumatic tears and 3-4 weeks of short arm casting for degenerative tears recommended by some

The natural history of symptomatic tears according to Osterman's (1991) study of 133 patients is as follows:

• Traumatic tears with neutral ulnar variance did not worsen over time, and one third of patients were asymptomatic at 9.5 years of follow-up.
• In persons with traumatic tears with ulnar positive variance, two thirds of patients worsened over time both symptomatically and radiologically.

Palmer classification for triangular fibrocartilage complex abnormalities

Class 1: Traumatic

• A - Central perforation (see Images 8-10)
• B - Ulnar avulsion (see Images 11-13) with or without distal ulnar fracture
• C - Distal avulsion
• D - Radial avulsion with or without sigmoid notch fracture

Class 2: Degenerative (ulnocarpal abutment syndrome) stage

• A - TFCC wear
• B - TFCC wear with lunate and/or ulnar chondromalacia
• C - TFCC perforation with lunate and/or ulnar chondromalacia
• D - TFCC perforation with lunate and/or ulnar chondromalacia and LT ligament perforation
• E - TFCC perforation with lunate and/or ulnar chondromalacia, LT ligament perforation, and ulnocarpal arthritis

Acute isolated TFCC disruption with dislocation or instability of the distal radioulnar joint

Isolated TFCC disruptions may be associated with DRUJ instability. These injuries are often associated with distal radius and forearm fractures. Forced hyperpronation usually results in dorsal dislocation. On physical examination, the ulnar head is prominent dorsally and the patient has limited forearm supination. Less commonly, volar dislocation results from forced supination. On physical examination, dorsal skin dimpling is often observed and pronation is limited. The volarly displaced ulnar head is often not felt because of the overlying soft tissues. When dislocation of the ulnar head is not present, subluxation and instability are more difficult to diagnose. Subluxation and instability of the DRUJ are assessed on physical examination by shucking the radius and ulna past each other to determine the amount of dorsal/palmar laxity. This should be performed in neutral, pronation, and supination and compared to the opposite side.

The more common dorsal DRUJ instability is reduced with the forearm in supination. Palmar DRUJ instability is reduced with the forearm in pronation. If a congruent reduction can be achieved and the forearm is stable through a full ROM, then the forearm is immobilized in a long arm cast in the position of stability for 4-6 weeks. With a dorsal dislocation, the preferred position of immobilization is in approximately 30° of supination for 4 weeks, followed by gradual reduction to neutral over the next 2 weeks. If a congruent reduction cannot be achieved or if the dorsal instability is unstable in 30° of supination, then arthroscopic evaluation of the TFCC is recommended with repair as needed.

Surgical therapy

If the DRUJ remains unstable, open reduction is required to remove interposed structures. When instability persists with forearm ROM, supplemental Kirschner wire (K-wire) stabilization just proximal to the DRUJ is recommended for 4-6 weeks.

Instability of the DRUJ is often associated with distal radius fractures and Galeazzi fractures-dislocations. Anatomic reduction of these fractures often stabilizes the DRUJ. When fixation of these fractures does not stabilize the DRUJ, stabilization can be obtained with either long arm casting in a reduced position, open reduction and TFCC repair, or supplemental K-wire fixation. Retting and Raskin (2001) noted a high association with Galeazzi fractures within 7.5 cm of the midarticular surface of the distal radius and with DRUJ instability after open reduction and internal fixation of the radial shaft fracture.

In individuals with radial head fracture and tenderness over the DRUJ, every attempt should be made to preserve the radial head to prevent proximal migration of the radius. DRUJ disruption associated with a displaced radial head fracture and proximal migration of the radius is termed the Essex-Lopresti fracture. Geel and Palmer (1992) noted good results in 18 of 19 patients with radial head fracture and pain at the DRUJ, who were treated with open reduction and internal fixation of the radial head.

Intraoperative details

Open repair

• Make a dorsal ulnar incision between the fourth and fifth extensor compartments.
• Carry the dissection down to the DRUL.
• Reflect the DRUL and the periosteum over the lunate fossa.
• Place horizontal mattress sutures in the TFCC through drill holes placed in the dorsoulnar aspect of the distal radius.

Wrist arthroscopy

Indications for wrist arthroscopy include acute unstable tears, acute tears that fail to respond to conservative management, and chronic tears for which conservative management fails.

General arthroscopic principles are as follows:

• Debride to a stable smooth rim of tissue.
• Maintain a 2-mm peripheral rim.
• Excise less than two thirds of the central portion of the TFCC.
• Maintain the integrity of the DRUL, PRUL, and disk carpal ligaments.

Treatment of traumatic central tears (Palmer class 1A)

• Debridement as above

Treatment of traumatic ulnar-side tears (Palmer class 1B) with outside-in technique

• Debride the synovitis and the edges of the tear.
• Make a 1-cm incision just radial to the ECU tendon.
• Open the radial aspect of the ECU tendon sheath for 1 cm.
• Retract the ECU palmarly.
• Under arthroscopic visualization, pass 2 needles through the capsule and across the tear using a meniscus mender or similar TFCC repair device.
• Use a wire loop passed through one needle to retrieve a 2-0 polydioxanone suture (PDS) passed through the other needle. This creates a loop.
• Tie the suture over the dorsal wrist capsule, approximating the tear.
• From 2 to 4 sutures may be required.
• Reconstruct the ECU tendon as needed.
• Immobilize the wrist and elbow for 4 weeks in a splint or Muenster cast.

Treatment of ulnar extrinsic ligament tears (Palmer class 1C)

• Perform a mini open or arthroscopic repair using zone-specific cannulas.
• Stay between the ECU and flexor carpi ulnaris (FCU) to avoid the neurovascular bundle.

Treatment of traumatic radial side tears (Palmer class 1D)

Debride as with a Palmer class 1A tear, or repair as follows:

• Debride the edge of the sigmoid notch with a shaver down to bleeding bone.
• Make drill holes through the distal radius with a K-wire passed percutaneously into the joint from the sigmoid notch across the distal radius.
• Pass a 2-0 PDS double-ended suture on long needles through the TFCC and into the drill holes.
• Tie the suture on the surface of the radius through a small incision while protecting the superficial radial nerve.
• Pin the DRUJ in neutral rotation with a single 0.062-inch K-wire.
• Immobilize the wrist and elbow for 8 weeks in a splint or Muenster cast.
• Transosseous suture anchors can be used in place of drill holes.

Treatment of degenerative tears (Palmer classes 2A and 2B)

• Gently debride.
• If the patient is ulnar positive and symptomatic, use open ulnar shortening.

Treatment of degenerative tears (Palmer class 2C)

• Gently debride in patients who are ulnar neutral or ulnar negative.
• For patients who are ulnar positive, consider the arthroscopic wafer procedure. The arthroscopic wafer procedure is performed as follows:
  • Wnorowski demonstrated almost a 50% unloading of the ulnar side of the wrist after excision of the central portion of the TFCC and resection of the radial two thirds of the width of the ulnar head to a depth of subchondral bone.
  • Patients with an arthroscopic wafer procedure may have a more prolonged postoperative course than those with open ulnar shortening.

Treatment of degenerative tears (Palmer class 2D)

• Treatment is similar to that for Palmer class 2C tears.
• Carefully assess LT instability.
• If the LT is stable, perform debridement.
• If the LT is unstable, consider an open shortening osteotomy to unload the ulnar head and tighten the ulnar extrinsic ligaments. Then, consider an LT fusion or pinning or an LT ligament repair.
• An arthroscopic wafer procedure is contraindicated, as it leads to more laxity in the ulnar extrinsic and LT ligaments.

Treatment of degenerative tears (Palmer class 2E)

• Degenerative tears have an unpredictable response to arthroscopic debridement.
• These tears usually require a salvage operation.
• Address the DRUJ and LT joint.
• A limited ulnar head excision can be performed.
• The Sauve-Kapandji procedure involves radioulnar joint arthrodesis and proximal ulnar pseudoarthrosis.
• The Darrach procedure is a resection of the distal end of the ulna.

Ulnar-shortening osteotomy

Consider ulnar-shortening osteotomy for patients with ulnar positive variance, patients in whom debridement fails, and/or patients who present with a delay in treatment of longer than 6 months.

Advantages of an ulnar-shortening osteotomy are as follows:

• Extra-articular
• Maintains the mechanical integrity of the DRUJ
• Maintains the origins and insertions of the ligamentous tissue and capsule forming the peripheral aspect of the TFCC; may result in tightening of the ulnocarpal complex, including the LT ligament, with shortening
• Potentially less painful than an arthroscopic resection

Postoperative details

• All patients are immobilized immediately following surgery.
• If debridement alone is performed, patients are placed in a bulky dressing and started on motion exercises at 5-7 days.
• All other patients are placed in a sugar-tong splint.
• Skin sutures are removed at 7-10 days.
• A Muenster-style cast is used for 2 weeks, followed by a short arm cast for 3 weeks for patients who have undergone TFCC repairs.

COMPLICATIONS

Section 8 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Complications include the following:

• Infection
• Stiffness
• Repair failure
• Wrist arthroscopy complications
• Continued pain
• Decreased strength
• Hardware failure
• Nonunion (In cases of nonunion, perform an ulnar shortening osteotomy.)

OUTCOME AND PROGNOSIS

Section 9 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Palmer class IB tears and arthroscopic repair

A review by de Araujo et al (1996) of 17 patients after arthroscopic repair of Palmer class IB tears, with an average patient age of 33 years, showed that at 8 months follow-up, 16 patients (48%) were satisfied or very satisfied; 1 patient was not satisfied. At 16-24 months' follow-up, 70% of the patients were satisfied.

Palmer class ID tears and arthroscopic repair

Sagerman and Short (1996) reviewed 12 patients after arthroscopic repair of Palmer class ID tears, with an average follow-up of 17 months, and found good or excellent results in 67% of patients.

Palmer classes IB, IC, and ID tears and arthroscopic repair

Trumble et al (Jan 1997) reviewed 24 patients after arthroscopic repair of Palmer classes IB, IC, and ID tears. The average patient age was 31 years. Treatment occurred within 4 months after injury, with a follow-up of 34 months. Postoperative ROM was 89%, and grip strength was 85%. Thirteen of 19 patients returned to their original jobs or sports. Follow-up studies demonstrated that the TFCC was intact in 12 of 15 patients.

Arthroscopic repair

Corso et al (1997) reviewed 44 patients (average age, 32.5 y) and 45 wrists with zone-specific repair and follow-up of 37 months and found excellent results in 29 patients, good results in 12 patients, fair results in 1 patient, and poor results in 3 patients.

Arthroscopic debridement

Minami et al (1996) reviewed 16 patients (average age, 30 y) with a follow-up of 35 months. Palmer class 1 tears were found in 11 patients, and Palmer class 2 tears were found in 5 patients. Of the 16 patients, 13 returned to their previous jobs. Ulnar positive and LT tears were associated with a poor outcome; Palmer class 1 tears were associated with excellent results; and Palmer class 2 tears were associated with poor results.

Westkaemper et al (1998) reviewed 28 patients (average age, 30 y) with a follow-up of 15.4 months. Excellent results were found in 13 patients, with good results in 8 patients, fair results in 2 patients, and poor results in 5 patients.

Ulnar shortening for triangular fibrocartilage complex tears associated with ulnar positive variance

Minami and Kato (1998) reviewed 25 patients (average age, 32 y) with follow-up of 35 months. Ulnar variance averaged >3.5 mm. Ulnar shortening osteotomies of 3 mm, fixed with a 6-hole 3.5-mm dynamic compression plate (DCP), were performed. Twenty-three patients also had arthroscopy. Palmer class 1 tears were found in 15 patients; only the flap was removed. Palmer class 2 tears were found in 8 patients; no debridement was performed. Complete relief or only occasional mild pain was found in 23 patients. Of the 25 patients, 23 returned to their original work. Osteotomies healed at an average of 7 weeks. This research suggests that ulnar shortening is indicated in both traumatic and degenerative tears associated with ulnar positive variance.

Ulnar shortening for delayed treatment of triangular fibrocartilage complex tears

Trumble et al (Sep 1997) reviewed 21 patients (average age 32 y) with delay in treatment longer than 6 months and follow-up of 29 months. Palmer class 1 tears were repaired. Ulnar shortening osteotomies of 2-3 mm fixed with 6-hole 3.5-mm DCPs were performed. Complete pain relief was found in 19 of 21 patients. Grip strength was 83%; ROM was 81% of normal. Authors noted that delays in treatment of over 6 months from the time of injury resulted in a higher recurrence of symptoms; in these situations, they recommended combining arthroscopic repair with ulnar shortening.

Ulnar shortening after failed debridement

Hulsizer et al (1997) reviewed 97 patients with central or nondetached ulnar peripheral tears initially treated with debridement. Persistent pain more than 3 months after surgery was reported by 13 patients. A 2-mm ulnar shortening osteotomy, fixed with a 6-hole 3.5-mm DCP, was performed on these 13 patients. The average age of the patients was 34 years, and average ulnar variance was 0.4 mm. Complete pain relief at 2.3-year follow-up was reported by 12 of the 13 patients. An ulnar shortening osteotomy of 2 mm was recommended for patients in whom arthroscopic debridement failed.

FUTURE AND CONTROVERSIES

Section 10 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

A large controversy exists concerning the biomechanical changes of the TFCC during pronation and supination. A number of authors claim that the dorsal RUL tightens during pronation and relaxes with supination. Others claim the exact opposite.

Nakamura (Jun 1999) may have solved this conundrum by using a custom-made surface coil that allows complete freedom of wrist motion. He obtained MRI scans of the wrist in the coronal and sagittal planes at maximal pronation and neutral and maximal supination.

He demonstrated that during pronation and supination, the triangular ligament twists at its origin. This should result in friction between the proximal side of the disk proper and the ulnar head during rotation, much like the windshield wiper on a car. Nakamura theorized that this friction may increase in ulnocarpal abutment syndrome because of ulnar variance and may explain the degeneration observed in Palmer class 2 TFCC tears.

MULTIMEDIA

Section 11 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Media file 1:  The triangular fibrocartilage complex suspends the distal radius and ulnar carpus from the distal ulna. T=triquetrum; L=lunate; S=scaphoid. (Reprinted with permission from Palmer AK and Werner FW: The Triangular Fibrocartilage Complex of the Wrist - Anatomy and Function. J Hand Surg; 1981; 6:153)
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Media file 2:  The triangular fibrocartilage complex provides a continuous gliding surface across the entire distal face of the radius and ulna to allow for flexion-extension and translational movements.
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Media file 3:  Distally, the triangular fibrocartilage complex inserts into the lunate and triquetrum via the ulnolunate and ulnotriquetral ligaments. The triangular fibrocartilage complex solidly connects the ulnar axis to the volar carpus. The unlabeled arrow points to the prestyloid recess. (Reprinted with permission from Palmer AK and Werner FW: The Triangular Fibrocartilage Complex of the Wrist - Anatomy and Function. J Hand Surg; 1981; 6:153)
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Media file 4:  Relation of the triangular fibrocartilage complex to the distal radius and ulnar styloid.
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Media file 5:  The ulnocarpal portion of the triangular fibrocartilage complex is composed of the discus articularis, the ulnolunate (ULL), and the ulnotriquetral (UTL) ligaments. Distally, the triangular fibrocartilage complex inserts into the lunate via the ulnolunate ligament and into the triquetrum via the ulnotriquetral ligament.
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Media file 6:  Sigmoid notch of the distal radius with distinct dorsal, palmar, and distal margins and an indistinct proximal margin; the triangular fibrocartilage complex arises from the ulnar margin of the lunate fossa of the radius. (Reprinted with permission from Fernandez D and Palmer AK. Fractures of the Distal Radius. In: Green's Operative Hand Surgery. Vol 1. 1999)
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Media file 7:  The seat of the ulnar head articulates with the sigmoid notch of the distal radius. Radially, the triangular fibrocartilage complex arises from the ulnar margin of the lunate fossa of the radius. Ulnarly, the triangular fibrocartilage complex inserts into the base of the ulnar styloid. (Reprinted with permission from Fernandez D and Palmer AK. Fractures of the Distal Radius. In: Green's Operative Hand Surgery. Vol 1. 1999)
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Media file 8:  A Palmer class 1A tear of the triangular fibrocartilage complex that is being probed.
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Media file 9:  A Palmer class 1A tear of the triangular fibrocartilage complex after debridement, being treated with an electrothermal wand.
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Media file 10:  Palmer class 1A tear of the triangular fibrocartilage complex after debridement with a shaver and thermal treatment.
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Media file 11:  A traumatic, ulnar side Palmer class 1B tear of the triangular fibrocartilage complex.
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Media file 12:  Palmer class 1B tear of the triangular fibrocartilage complex treated with an outside-in technique using 2-0 polydioxanone sutures and a wire loop.
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Media file 13:  Completion of an outside-in repair for a Palmer class 1B tear of the triangular fibrocartilage complex.
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REFERENCES

Section 12 of 12

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

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Article Last Updated: Feb 9, 2007