eMedicine Specialties > Orthopedic Surgery > Hand & Upper Extremity

Triangular Fibrocartilage Complex Injuries: Follow-up

Author: James R Verheyden, MD, Consulting Surgeon, Department of Orthopedic Surgery, The Orthopedic and Neurosurgical Center of the Cascades
Coauthor(s): Andrew K Palmer, MD, Chair, Professor, Department of Orthopedics, State University of New York-Upstate Medical University
Contributor Information and Disclosures

Updated: Jun 23, 2009

Outcome and Prognosis

Palmer class IB tears and arthroscopic repair

A review by de Araujo et al 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.25

Reiter et al performed a retrospective study of 46 patients who underwent arthroscopic repair of Palmer class IB tears to determine patients' functional and subjective outcomes, as well as whether clinical outcomes were related to ulnar length. Good to excellent results were achieved in 63% of the patients, including increased range of motion and grip strength and pain relief. Ulnar neutral or positive variance was not a contraindication for repair and did not necessitate simultaneous ulnar shortening.6

Palmer class ID tears and arthroscopic repair

Sagerman and Short 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.26

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

Trumble et al 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 range of motion was 89%, and grip strength was 85%. Thirteen of 19 patients returned to their original jobs or sports. Follow-up studies demonstrated that the triangular fibrocartilage complex (TFCC) was intact in 12 of 15 patients.27

Arthroscopic repair

Corso et al 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.28

In a study from 2001 through 2005 of 16 competitive athletes with wrist triangular fibrocartilage injuries, McAdams et al found that arthroscopic debridement or repair of TFC injury provided pain relief and allowed patients to return to play, with slower recovery in patients with concomitant ulnar-sided wrist injuries.13 .

Yao et al compared an all-arthroscopic TFCC repair technique with an outside-in technique in 10 matched pairs of fresh-frozen cadaveric wrists and found that the all-arthroscopic technique resulted in decreased operative time; reduced postoperative immobilizations; and decreased irritation from suture knots below the skin.53,55

In a study of 75 patients with TFCC repair by arthroscopic or open technique between 1997 and 2006, Anderson et al found that there was no statistical difference in clinical outcome for arthroscopic and open techniques for TFCC repair. They did note an increased rate of postoperative superficial ulnar pain in patients who underwent open repair (14 of 39 patients with open technique, vs 8 of 36 patients with arthroscopy). Females had a higher rate of reoperation.57

Arthroscopic debridement

Minami et al 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.32

Westkaemper et al 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.33

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

Minami and Kato reviewed 25 patients (average age, 32 y) with follow-up of 35 months. Ulnar variance averaged more than 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.34

Ulnar shortening for delayed treatment of triangular fibrocartilage complex tears

Trumble et al 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%; range of motion 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.35

Ulnar shortening after failed debridement

Hulsizer et al 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.36

Future and Controversies

A large controversy exists concerning the biomechanical changes of the triangular fibrocartilage complex (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 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.37

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.

 


More on Triangular Fibrocartilage Complex Injuries

Overview: Triangular Fibrocartilage Complex Injuries
Workup: Triangular Fibrocartilage Complex Injuries
Treatment: Triangular Fibrocartilage Complex Injuries
Follow-up: Triangular Fibrocartilage Complex Injuries
Multimedia: Triangular Fibrocartilage Complex Injuries
References
Further Reading
[ CLOSE WINDOW ]

References

  1. Palmer AK, Werner FW. The triangular fibrocartilage complex of the wrist--anatomy and function. J Hand Surg [Am]. Mar 1981;6(2):153-62. [Medline].

  2. McAdams TR, Swan J, Yao J. Arthroscopic Treatment of Triangular Fibrocartilage Wrist Injuries in the Athlete. Am J Sports Med. Dec 4 2008;[Medline].

  3. Yao J, Dantuluri P, Osterman AL. A novel technique of all-inside arthroscopic triangular fibrocartilage complex repair. Arthroscopy. Dec 2007;23(12):1357.e1-4. [Medline].

  4. Yao J. All-arthroscopic triangular fibrocartilage complex repair: safety and biomechanical comparison with a traditional outside-in technique in cadavers. J Hand Surg [Am]. Apr 2009;34(4):671-6. [Medline].

  5. Anderson ML, Larson AN, Moran SL, Cooney WP, Amrami KK, Berger RA. Clinical comparison of arthroscopic versus open repair of triangular fibrocartilage complex tears. J Hand Surg [Am]. May-Jun 2008;33(5):675-82. [Medline].

  6. Reiter A, Wolf MB, Schmid U, Frigge A, Dreyhaupt J, Hahn P, et al. Arthroscopic repair of Palmer 1B triangular fibrocartilage complex tears. Arthroscopy. Nov 2008;24(11):1244-50. [Medline].

  7. Palmer AK. Triangular fibrocartilage complex lesions: a classification. J Hand Surg [Am]. Jul 1989;14(4):594-606. [Medline].

  8. Palmer AK, Glisson RR, Werner FW. Relationship between ulnar variance and triangular fibrocartilage complex thickness. J Hand Surg [Am]. Sep 1984;9(5):681-2. [Medline].

  9. Mikic ZD. Age changes in the triangular fibrocartilage of the wrist joint. J Anat. Jun 1978;126(Pt 2):367-84. [Medline].

  10. Viegas SF, Ballantyne G. Attritional lesions of the wrist joint. J Hand Surg [Am]. Nov 1987;12(6):1025-9. [Medline].

  11. Palmer AK, Werner FW. Biomechanics of the distal radioulnar joint. Clin Orthop Relat Res. Jul-Aug 1984;26-35. [Medline].

  12. Palmer AK, Werner FW, Glisson RR, Murphy DJ. Partial excision of the triangular fibrocartilage complex. J Hand Surg [Am]. May 1988;13(3):391-4. [Medline].

  13. Adams BD. Partial excision of the triangular fibrocartilage complex articular disk: a biomechanical study. J Hand Surg [Am]. Mar 1993;18(2):334-40. [Medline].

  14. Tang JB, Ryu J, Kish V. The triangular fibrocartilage complex: an important component of the pulley for the ulnar wrist extensor. J Hand Surg [Am]. Nov 1998;23(6):986-91. [Medline].

  15. Yoshioka H, Tanaka T, Ueno T, Carrino JA, Winalski CS, Aliabadi P, et al. Study of ulnar variance with high-resolution MRI: correlation with triangular fibrocartilage complex and cartilage of ulnar side of wrist. J Magn Reson Imaging. Sep 2007;26(3):714-9. [Medline].

  16. Zlatkin MB, Rosner J. MR imaging of ligaments and triangular fibrocartilage complex of the wrist. Radiol Clin North Am. Jul 2006;44(4):595-623, ix. [Medline].

  17. Richards RS, Bennett JD, Roth JH, Milne K Jr. Arthroscopic diagnosis of intra-articular soft tissue injuries associated with distal radial fractures. J Hand Surg [Am]. Sep 1997;22(5):772-6. [Medline].

  18. Osterman AL, Terrill RG. Arthroscopic treatment of TFCC lesions. Hand Clin. May 1991;7(2):277-81. [Medline].

  19. Rettig ME, Raskin KB. Galeazzi fracture-dislocation: a new treatment-oriented classification. J Hand Surg [Am]. Mar 2001;26(2):228-35. [Medline].

  20. Geel CW, Palmer AK. Radial head fractures and their effect on the distal radioulnar joint. A rationale for treatment. Clin Orthop Relat Res. Feb 1992;79-84. [Medline].

  21. Varitimidis SE, Basdekis GK, Dailiana ZH, Hantes ME, Bargiotas K, Malizos K. Treatment of intra-articular fractures of the distal radius: fluoroscopic or arthroscopic reduction?. J Bone Joint Surg Br. Jun 2008;90(6):778-85. [Medline].

  22. Chen AC, Hsu KY, Chang CH, Chan YS. Arthroscopic suture repair of peripheral tears of triangular fibrocartilage complex using a volar portal. Arthroscopy. Nov 2005;21(11):1406. [Medline].

  23. Wnorowski DC, Palmer AK, Werner FW, Fortino MD. Anatomic and biomechanical analysis of the arthroscopic wafer procedure. Arthroscopy. 1992;8(2):204-12. [Medline].

  24. Henry MH. Management of acute triangular fibrocartilage complex injury of the wrist. J Am Acad Orthop Surg. Jun 2008;16(6):320-9. [Medline].

  25. de Araujo W, Poehling GG, Kuzma GR. New Tuohy needle technique for triangular fibrocartilage complex repair: preliminary studies. Arthroscopy. Dec 1996;12(6):699-703. [Medline].

  26. Sagerman SD, Short W. Arthroscopic repair of radial-sided triangular fibrocartilage complex tears. Arthroscopy. Jun 1996;12(3):339-42. [Medline].

  27. Trumble TE, Gilbert M, Vedder N. Isolated tears of the triangular fibrocartilage: management by early arthroscopic repair. J Hand Surg [Am]. Jan 1997;22(1):57-65. [Medline].

  28. Corso SJ, Savoie FH, Geissler WB, et al. Arthroscopic repair of peripheral avulsions of the triangular fibrocartilage complex of the wrist: a multicenter study. Arthroscopy. Feb 1997;13(1):78-84. [Medline].

  29. Nakamura T, Yabe Y, Horiuchi Y. Functional anatomy of the triangular fibrocartilage complex. J Hand Surg [Br]. Oct 1996;21(5):581-6. [Medline].

  30. Schers TJ, van Heusden HA. Evaluation of chronic wrist pain. Arthroscopy superior to arthrography: comparison in 39 patients. Acta Orthop Scand. Dec 1995;66(6):540-2. [Medline].

  31. Werner FW, Palmer AK, Fortino MD, Short WH. Force transmission through the distal ulna: effect of ulnar variance, lunate fossa angulation, and radial and palmar tilt of the distal radius. J Hand Surg [Am]. May 1992;17(3):423-8. [Medline].

  32. Minami A, Ishikawa J, Suenaga N, Kasashima T. Clinical results of treatment of triangular fibrocartilage complex tears by arthroscopic debridement. J Hand Surg [Am]. May 1996;21(3):406-11. [Medline].

  33. Westkaemper JG, Mitsionis G, Giannakopoulos PN, Sotereanos DG. Wrist arthroscopy for the treatment of ligament and triangular fibrocartilage complex injuries. Arthroscopy. Jul-Aug 1998;14(5):479-83. [Medline].

  34. Minami A, Kato H. Ulnar shortening for triangular fibrocartilage complex tears associated with ulnar positive variance. J Hand Surg [Am]. Sep 1998;23(5):904-8. [Medline].

  35. Trumble TE, Gilbert M, Vedder N. Ulnar shortening combined with arthroscopic repairs in the delayed management of triangular fibrocartilage complex tears. J Hand Surg [Am]. Sep 1997;22(5):807-13. [Medline].

  36. Hulsizer D, Weiss AP, Akelman E. Ulna-shortening osteotomy after failed arthroscopic debridement of the triangular fibrocartilage complex. J Hand Surg [Am]. Jul 1997;22(4):694-8. [Medline].

  37. Nakamura T, Nakao Y, Ikegami H, et al. Open repair of the ulnar disruption of the triangular fibrocartilage complex with double three-dimensional mattress suturing technique. Tech Hand Up Extrem Surg. Jun 2004;8(2):116-23. [Medline].

  38. Baehser-Griffith P, Bednar JM, Osterman AL, Culp R. Arthroscopic repairs of triangular fibrocartilage complex tears. AORN J. Jul 1997;66(1):101-2, 105-11, quiz 112, 115, 117-8. [Medline].

  39. Bednar JM. Arthroscopic treatment of triangular fibrocartilage tears. Hand Clin. Aug 1999;15(3):479-88, ix. [Medline].

  40. Bowers WH. The distal radioulnar joint. In: Green's Operative Hand Surgery. Vol 1. New York, NY: Churchill Livingstone;. 1999: 989-95.

  41. Cantor RM, Stern PJ, Wyrick JD, Michaels SE. The relevance of ligament tears or perforations in the diagnosis of wrist pain: an arthrographic study. J Hand Surg [Am]. Nov 1994;19(6):945-53. [Medline].

  42. Chidgey LK, Dell PC, Bittar ES, Spanier SS. Histologic anatomy of the triangular fibrocartilage. J Hand Surg [Am]. Nov 1991;16(6):1084-100. [Medline].

  43. Cooney WP. Evaluation of chronic wrist pain by arthrography, arthroscopy, and arthrotomy. J Hand Surg [Am]. Sep 1993;18(5):815-22. [Medline].

  44. Cooney WP, Linscheid RL, Dobyns JH. Triangular fibrocartilage tears. J Hand Surg [Am]. Jan 1994;19(1):143-54. [Medline].

  45. De Smet L, De Ferm A, Steenwerckx A, et al. Arthroscopic treatment of triangular fibrocartilage complex lesions of the wrist. Acta Orthop Belg. Mar 1996;62(1):8-13. [Medline].

  46. Fellinger M, Peicha G, Seibert FJ, Grechenig W. Radial avulsion of the triangular fibrocartilage complex in acute wrist trauma: a new technique for arthroscopic repair. Arthroscopy. Jun 1997;13(3):370-4. [Medline].

  47. Fernandez DL, Palmer AK. Fractures of the distal radius. In: Green's Operative Hand Surgery. Vol 1. New York, NY: Churchill Livingstone;. 1999: 930-3.

  48. Ishii S, Palmer AK, Werner FW, et al. Pressure distribution in the distal radioulnar joint. J Hand Surg [Am]. Sep 1998;23(5):909-13. [Medline].

  49. Jantea CL, Baltzer A, Ruther W. Arthroscopic repair of radial-sided lesions of the triangular fibrocartilage complex. Hand Clin. Feb 1995;11(1):31-6. [Medline].

  50. Kihara H, Short WH, Werner FW, et al. The stabilizing mechanism of the distal radioulnar joint during pronation and supination. J Hand Surg [Am]. Nov 1995;20(6):930-6. [Medline].

  51. Kirschenbaum D, Sieler S, Solonick D, et al. Arthrography of the wrist. Assessment of the integrity of the ligaments in young asymptomatic adults. J Bone Joint Surg Am. Aug 1995;77(8):1207-9. [Medline].

  52. Kleinman WB, Graham TJ. The distal radioulnar joint capsule: clinical anatomy and role in posttraumatic limitation of forearm rotation. J Hand Surg [Am]. Jul 1998;23(4):588-99. [Medline].

  53. Lucey SD, Poehling GG. Arthroscopic treatment of triangular fibrocartilage complex tears. In: Techniques in Hand and Upper Extremity Surgery. Vol 1. Philadelphia, Pa: Lippincott Williams & Wilkins;. 1997: 228-36.

  54. Nakamura T, Yabe Y, Horiuchi Y. Dynamic changes in the shape of the triangular fibrocartilage complex during rotation demonstrated with high resolution magnetic resonance imaging. J Hand Surg [Br]. Jun 1999;24(3):338-41. [Medline].

  55. Nakamura T, Yabe Y, Horiuchi Y. Fat suppression magnetic resonance imaging of the triangular fibrocartilage complex. Comparison with spin echo, gradient echo pulse sequences and histology. J Hand Surg [Br]. Feb 1999;24(1):22-6. [Medline].

  56. Osterman AL. Wrist arthroscopy: Operative procedures. In: Green's Operative Hand Surgery. Vol 1. New York, NY: Churchill Livingstone;. 1999: 209-16.

  57. Skie MC, Mekhail AO, Deitrich DR, Ebraheim NE. Operative technique for inside-out repair of the triangular fibrocartilage complex. J Hand Surg [Am]. Sep 1997;22(5):814-7. [Medline].

[ CLOSE WINDOW ]

Further Reading

Related eMedicine topics
Wrist Arthroscopy

Carpal Ligament Instability: eMedicine - Orthopedic Surgery

Ulnar-Sided Wrist Pain: eMedicine - Orthopedic Surgery

Hand, Fractures and Dislocations: Wrist: eMedicine - Plastic Surgery

Fractures, Wrist: eMedicine - Emergency Medicine

Clinical guidelines
Forearm, wrist, & hand (acute & chronic), not including carpal tunnel syndrome. Work Loss Data Institute - Public For Profit Organization.  2004 (revised 2008 May 29).  128 pages.  NGC:006557

ACR Appropriateness Criteria® chronic wrist pain. American College of Radiology - Medical Specialty Society.  1998 (revised 2005).  7 pages.  NGC:004619

[ CLOSE WINDOW ]

Keywords

triangular fibrocartilage, triangular fibrocartilage complex, triangular fibrocartilage complex injury, triangular fibrocartilage injuries, TFCC, TFC, carpal articular disk, discus articularis, triangular ligament, triangular cartilage, triangular disk, meniscus

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

James R Verheyden, MD, Consulting Surgeon, Department of Orthopedic Surgery, The Orthopedic and Neurosurgical Center of the Cascades
James R Verheyden, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, and American Society for Surgery of the Hand
Disclosure: Nothing to disclose.

Coauthor(s)

Andrew K Palmer, MD, Chair, Professor, Department of Orthopedics, State University of New York-Upstate Medical University
Andrew K Palmer, MD is a member of the following medical societies: American Osteopathic College of Physical Medicine and Rehabilitation
Disclosure: Del Palma Orthopedics Salary Board membership

Medical Editor

Joseph E Sheppard, MD, Associate Professor of Clinical Orthopedic Surgery, Chief of Hand and Upper Extremity Service, Department of Orthopedic Surgery, University of Arizona Health Sciences Center, University Physicians Healthcare
Joseph E Sheppard, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Society for Surgery of the Hand, Clinical Orthopaedic Society, and Western Orthopaedic Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

N Ake Nystrom, MD, PhD, Associate Professor of Orthopedic Surgery and Plastic Surgery, University of Nebraska Medical Center
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD, Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine
Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.