Triangular Fibrocartilage Complex Injuries Treatment & Management
- Author: James R Verheyden, MD; Chief Editor: Harris Gellman, MD more...
Initial treatment of both symptomatic degenerative and traumatic triangular fibrocartilage complex (TFCC) tears is 8-12 weeks of conservative therapy consisting of the following:
Nonsteroidal anti-inflammatory drugs (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 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 TFCC abnormalities
Class 1: Traumatic
A - Central perforation (see the first, second, and third images below)
B - Ulnar avulsion (see the fourth, fifth, and sixth images below) with or without distal ulnar fracture
C - Distal avulsion
D - Radial avulsion with or without sigmoid notch fractureA Palmer class 1A tear of the triangular fibrocartilage complex after debridement, being treated with an electrothermal wand.Palmer class 1A tear of the triangular fibrocartilage complex after debridement with a shaver and thermal treatment.Palmer class 1B tear of the triangular fibrocartilage complex treated with an outside-in technique using 2-0 polydioxanone sutures and a wire loop.
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 lunotriquetral (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 distal radioulnar joint
Isolated TFCC disruptions may be associated with distal radioulnar (DRU) joint 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. 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 DRU joint 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 DRU joint instability is reduced with the forearm in supination. Palmar DRU joint instability is reduced with the forearm in pronation. If a congruent reduction can be achieved and the forearm is stable through a full range of motion, 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.
If the DRU joint remains unstable, open reduction is required to remove interposed structures. When instability persists with forearm range of motion, supplemental Kirschner wire (K-wire) stabilization just proximal to the DRU joint is recommended for 4-6 weeks.
Instability of the DRU joint is often associated with distal radius fractures and Galeazzi fracture -dislocations. Anatomic reduction of these fractures often stabilizes the joint. When fixation of these fractures does not stabilize the joint, stabilization can be obtained with either (1) long arm casting in a reduced position, open reduction, and TFCC repair or (2) supplemental K-wire fixation.
Rettig and Raskin noted a high association with Galeazzi fractures within 7.5 cm of the midarticular surface of the distal radius and with DRU joint instability after open reduction and internal fixation (ORIF) of the radial shaft fracture.
In individuals with radial head fracture and tenderness over the DRU joint, every attempt should be made to preserve the radial head to prevent proximal migration of the radius. DRU joint disruption associated with a displaced radial head fracture and proximal migration of the radius is termed the Essex-Lopresti fracture. Geel and Palmer noted good results in 18 of 19 patients with radial head fracture and pain at the DRU joint who were treated with ORIF of the radial head.
Arthroscopic compared with open repair
In a study of 16 competitive athletes with wrist TFCC injuries from 2001 through 2005, McAdams et al found that arthroscopic debridement or repair of TFCC injury provided pain relief and allowed patients to return to play. There was slower recovery in patients with concomitant ulnar-side wrist injuries.
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.[19, 20]
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 between the two approaches to repair. They did note an increased rate of postoperative superficial ulnar pain in patients who underwent open repair (14/39 patients with open technique vs 8/36 patients with arthroscopy). Females had a higher rate of reoperation.
Reiter et al performed a retrospective study of 46 patients who underwent arthroscopic repair of Palmer class IB tears to assess functional and subjective outcomes, as well as to determine 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.
Make a dorsal ulnar incision between the fourth and fifth extensor compartments. Carry the dissection down to the DRU ligament. Reflect the DRU ligament 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.
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.[18, 23, 24, 25]
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 DRU ligament, the palmar radioulnar (PRU) ligament, and the disk carpal ligaments
Traumatic central tears (Palmer class 1A)
Perform debridement as above.
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 extensor carpi ulnaris (ECU) tendon. Open the radial aspect of the ECU tendon sheath for 1 cm. Retract the ECU palmarly.
Under arthroscopic visualization, pass two 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 two to four sutures may be required.
Reconstruct the ECU tendon as needed. Immobilize the wrist and elbow for 4 weeks in a splint or Muenster cast.
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.
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 DRU joint in neutral rotation with a single 0.062-in. 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
Degenerative tears (Palmer classes 2A and 2B)
Gently debride. If the patient is ulnar-positive and symptomatic, use open ulnar shortening.
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.
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.
Degenerative tears (Palmer class 2D)
Treatment is similar to that for Palmer class 2C tears. Carefully assess lunotriquetral (LT) instability. If the LT joint is stable, perform debridement. If it 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, because it leads to more laxity in the ulnar extrinsic and LT ligaments.
Degenerative tears (Palmer class 2E)
Degenerative tears have an unpredictable response to arthroscopic debridement. These tears usually require a salvage operation. The DRU and LT joints must be addressed. A limited ulnar head excision can be performed. The Sauve-Kapandji procedure involves radioulnar joint arthrodesis and proximal ulnar pseudarthrosis. The Darrach procedure is a resection of the distal end of the ulna.
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:
It is extra-articular
It maintains the mechanical integrity of the DRU joint
It maintains the origins and insertions of the ligamentous tissue and capsule forming the peripheral aspect of the TFCC; it may result in tightening of the ulnocarpal complex, including the LT ligament, with shortening
It is potentially less painful than an arthroscopic resection
See the list below:
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 triangular fibrocartilage complex (TFCC) repairs.
Complications include the following:
Wrist arthroscopy complications
Nonunion (in cases of nonunion, perform an ulnar shortening osteotomy)
Outcome and Prognosis
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; one patient was not satisfied. At 16-24 months' follow-up, 70% of the patients were satisfied.
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.
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.
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 TFCC was intact in 12 of 15 patients.
Corso et al reviewed 44 patients (average age, 32.5 years) and 45 wrists with zone-specific repair and follow-up of 37 months and found excellent results in 29 patients, good results in 12, fair results in one, and poor results in three.
In a study from 2001 through 2005 of 16 competitive athletes with wrist TFCC, McAdams et al found that arthroscopic debridement or repair of TFCC injury provided pain relief and allowed patients to return to play, with slower recovery in patients with concomitant ulnar-sided wrist injuries. .
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.[33, 34]
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.
In a cadaveric study comparing the biomechanical strength of knotless suture anchor repair and the traditional outside-in repair of peripheral TFCC tears, Desai et al concluded that the all-arthroscopic suture anchor TFCC repair was biomechanically stronger than the outside-in repair and that the former allowed repair of both superficial and deep layers of the articular disk directly to bone, thereby restoring native TFCC anatomy. They suggested that the absence of knots might prevent irritation to the surrounding soft tissues.
Minami et al reviewed 16 patients (average age, 30 years) 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 reviewed 28 patients (average age, 30 years) 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.
De Smet et al conducted a retrospective survey of 46 patients who underwent debridement with or without wafer distal ulna resection. Patients were sent a questionnaire on pain, disability, and time off from work. Mean scores on the Disabilities of the Arm, Shoulder, and Hand (DASH) scale decreased from 42 to 28. The pain was considered severe in 12 patients; 32 patients were satisfied. There were significant differences in the outcome between use of debridement only and use of debridement with wafer resection of the distal ulna.
Minami and Kato reviewed 25 patients (average age, 32 years) 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.
Trumble et al reviewed 21 patients with treatment delays 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. Treatment delays longer than 6 months from the time of injury resulted in a higher recurrence of symptoms; in these situations, the authors recommended combining arthroscopic repair with ulnar shortening.
Hulsizer et al reviewed 97 patients (average age, 34 years; average ulnar variance, 0.4 mm) 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. . 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.
In a retrospective study involving 256 patients, Yamanaka et al compared preoperative and postoperative TFCC thickness and TFCC angle, using magnetic resonance imaging (MRI) to quantitatively evaluate the effect of ulnar shortening osteotomy on disk regeneration and the suspension effect on the TFCC. They found that ulnar shortening osteotomy yielded a high residual potential for regeneration in the disk proper. There was no correlation between disk regeneration or the suspension effect on the TFCC and the Mayo wrist score.
Future and Controversies
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 may have solved this question by using a custom-made surface coil allowing complete freedom of wrist motion. From MRI scans of the wrist in coronal and sagittal planes at maximal pronation and neutral and maximal supination, he showed that during pronation and supination, the TFCC twists at its origin. This should result in friction between the proximal side of the disk proper and the ulnar head during rotation. The friction may increase in ulnocarpal abutment syndrome because of ulnar variance, potentially explaining the degeneration seen in Palmer class 2 TFCC tears.
Palmer AK, Werner FW. The triangular fibrocartilage complex of the wrist--anatomy and function. J Hand Surg [Am]. 1981 Mar. 6(2):153-62. [Medline].
Palmer AK. Triangular fibrocartilage complex lesions: a classification. J Hand Surg [Am]. 1989 Jul. 14(4):594-606. [Medline].
Palmer AK, Glisson RR, Werner FW. Relationship between ulnar variance and triangular fibrocartilage complex thickness. J Hand Surg [Am]. 1984 Sep. 9(5):681-2. [Medline].
Mikic ZD. Age changes in the triangular fibrocartilage of the wrist joint. J Anat. 1978 Jun. 126(Pt 2):367-84. [Medline].
Viegas SF, Ballantyne G. Attritional lesions of the wrist joint. J Hand Surg [Am]. 1987 Nov. 12(6):1025-9. [Medline].
Palmer AK, Werner FW. Biomechanics of the distal radioulnar joint. Clin Orthop Relat Res. 1984 Jul-Aug. 26-35. [Medline].
Palmer AK, Werner FW, Glisson RR, Murphy DJ. Partial excision of the triangular fibrocartilage complex. J Hand Surg [Am]. 1988 May. 13(3):391-4. [Medline].
Adams BD. Partial excision of the triangular fibrocartilage complex articular disk: a biomechanical study. J Hand Surg [Am]. 1993 Mar. 18(2):334-40. [Medline].
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]. 1998 Nov. 23(6):986-91. [Medline].
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. 2007 Sep. 26(3):714-9. [Medline].
Zlatkin MB, Rosner J. MR imaging of ligaments and triangular fibrocartilage complex of the wrist. Radiol Clin North Am. 2006 Jul. 44(4):595-623, ix. [Medline].
Iordache SD, Rowan R, Garvin GJ, Osman S, Grewal R, Faber KJ. Prevalence of triangular fibrocartilage complex abnormalities on MRI scans of asymptomatic wrists. J Hand Surg Am. 2012 Jan. 37(1):98-103. [Medline].
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]. 1997 Sep. 22(5):772-6. [Medline].
Lee Master D, Yao J. The wrist insufflation test: a confirmatory test for detecting intercarpal ligament and triangular fibrocartilage complex tears. Arthroscopy. 2014 Apr. 30(4):451-5. [Medline].
Osterman AL, Terrill RG. Arthroscopic treatment of TFCC lesions. Hand Clin. 1991 May. 7(2):277-81. [Medline].
Rettig ME, Raskin KB. Galeazzi fracture-dislocation: a new treatment-oriented classification. J Hand Surg [Am]. 2001 Mar. 26(2):228-35. [Medline].
Geel CW, Palmer AK. Radial head fractures and their effect on the distal radioulnar joint. A rationale for treatment. Clin Orthop Relat Res. 1992 Feb. 79-84. [Medline].
McAdams TR, Swan J, Yao J. Arthroscopic Treatment of Triangular Fibrocartilage Wrist Injuries in the Athlete. Am J Sports Med. 2008 Dec 4. [Medline].
Yao J, Dantuluri P, Osterman AL. A novel technique of all-inside arthroscopic triangular fibrocartilage complex repair. Arthroscopy. 2007 Dec. 23(12):1357.e1-4. [Medline].
Yao J. All-arthroscopic triangular fibrocartilage complex repair: safety and biomechanical comparison with a traditional outside-in technique in cadavers. J Hand Surg [Am]. 2009 Apr. 34(4):671-6. [Medline].
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]. 2008 May-Jun. 33(5):675-82. [Medline].
Reiter A, Wolf MB, Schmid U, Frigge A, Dreyhaupt J, Hahn P, et al. Arthroscopic repair of Palmer 1B triangular fibrocartilage complex tears. Arthroscopy. 2008 Nov. 24(11):1244-50. [Medline].
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. 2008 Jun. 90(6):778-85. [Medline].
Wysocki RW, Richard MJ, Crowe MM, Leversedge FJ, Ruch DS. Arthroscopic Treatment of Peripheral Triangular Fibrocartilage Complex Tears With the Deep Fibers Intact. J Hand Surg Am. 2012 Feb 1. [Medline].
Geissler WB. Arthroscopic knotless peripheral triangular fibrocartilage repair. J Hand Surg Am. 2012 Feb. 37(2):350-5. [Medline].
Chen AC, Hsu KY, Chang CH, Chan YS. Arthroscopic suture repair of peripheral tears of triangular fibrocartilage complex using a volar portal. Arthroscopy. 2005 Nov. 21(11):1406. [Medline].
Wnorowski DC, Palmer AK, Werner FW, Fortino MD. Anatomic and biomechanical analysis of the arthroscopic wafer procedure. Arthroscopy. 1992. 8(2):204-12. [Medline].
Henry MH. Management of acute triangular fibrocartilage complex injury of the wrist. J Am Acad Orthop Surg. 2008 Jun. 16(6):320-9. [Medline].
de Araujo W, Poehling GG, Kuzma GR. New Tuohy needle technique for triangular fibrocartilage complex repair: preliminary studies. Arthroscopy. 1996 Dec. 12(6):699-703. [Medline].
Sagerman SD, Short W. Arthroscopic repair of radial-sided triangular fibrocartilage complex tears. Arthroscopy. 1996 Jun. 12(3):339-42. [Medline].
Trumble TE, Gilbert M, Vedder N. Isolated tears of the triangular fibrocartilage: management by early arthroscopic repair. J Hand Surg [Am]. 1997 Jan. 22(1):57-65. [Medline].
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. 1997 Feb. 13(1):78-84. [Medline].
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.
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]. 1999 Feb. 24(1):22-6. [Medline].
Skie MC, Mekhail AO, Deitrich DR, Ebraheim NE. Operative technique for inside-out repair of the triangular fibrocartilage complex. J Hand Surg [Am]. 1997 Sep. 22(5):814-7. [Medline].
Desai MJ, Hutton WC, Jarrett CD. Arthroscopic repair of triangular fibrocartilage tears: a biomechanical comparison of a knotless suture anchor and the traditional outside-in repairs. J Hand Surg Am. 2013 Nov. 38(11):2193-7. [Medline].
Minami A, Ishikawa J, Suenaga N, Kasashima T. Clinical results of treatment of triangular fibrocartilage complex tears by arthroscopic debridement. J Hand Surg [Am]. 1996 May. 21(3):406-11. [Medline].
Westkaemper JG, Mitsionis G, Giannakopoulos PN, Sotereanos DG. Wrist arthroscopy for the treatment of ligament and triangular fibrocartilage complex injuries. Arthroscopy. 1998 Jul-Aug. 14(5):479-83. [Medline].
De Smet L, Van Nuffel M, Koorneef P, Degreef I. Arthroscopic debridement with and without distal ulnar resection in the treatment of triangular fibrocartilage complex tears. Acta Orthop Belg. 2014 Mar. 80(1):112-5. [Medline].
Minami A, Kato H. Ulnar shortening for triangular fibrocartilage complex tears associated with ulnar positive variance. J Hand Surg [Am]. 1998 Sep. 23(5):904-8. [Medline].
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]. 1997 Sep. 22(5):807-13. [Medline].
Hulsizer D, Weiss AP, Akelman E. Ulna-shortening osteotomy after failed arthroscopic debridement of the triangular fibrocartilage complex. J Hand Surg [Am]. 1997 Jul. 22(4):694-8. [Medline].
Yamanaka Y, Nakamura T, Sato K, Toyama Y. How does ulnar shortening osteotomy influence morphologic changes in the triangular fibrocartilage complex?. Clin Orthop Relat Res. 2014 Nov. 472(11):3489-94. [Medline]. [Full Text].
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. 2004 Jun. 8(2):116-23. [Medline].
Baehser-Griffith P, Bednar JM, Osterman AL, Culp R. Arthroscopic repairs of triangular fibrocartilage complex tears. AORN J. 1997 Jul. 66(1):101-2, 105-11, quiz 112, 115, 117-8. [Medline].
Bednar JM. Arthroscopic treatment of triangular fibrocartilage tears. Hand Clin. 1999 Aug. 15(3):479-88, ix. [Medline].
Bowers WH. The distal radioulnar joint. In: Green's Operative Hand Surgery. Vol 1. New York, NY: Churchill Livingstone;. 1999: 989-95.
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]. 1994 Nov. 19(6):945-53. [Medline].
Chidgey LK, Dell PC, Bittar ES, Spanier SS. Histologic anatomy of the triangular fibrocartilage. J Hand Surg [Am]. 1991 Nov. 16(6):1084-100. [Medline].
Cooney WP. Evaluation of chronic wrist pain by arthrography, arthroscopy, and arthrotomy. J Hand Surg [Am]. 1993 Sep. 18(5):815-22. [Medline].
Cooney WP, Linscheid RL, Dobyns JH. Triangular fibrocartilage tears. J Hand Surg [Am]. 1994 Jan. 19(1):143-54. [Medline].
De Smet L, De Ferm A, Steenwerckx A, et al. Arthroscopic treatment of triangular fibrocartilage complex lesions of the wrist. Acta Orthop Belg. 1996 Mar. 62(1):8-13. [Medline].
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. 1997 Jun. 13(3):370-4. [Medline].
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.
Ishii S, Palmer AK, Werner FW, et al. Pressure distribution in the distal radioulnar joint. J Hand Surg [Am]. 1998 Sep. 23(5):909-13. [Medline].
Jantea CL, Baltzer A, Ruther W. Arthroscopic repair of radial-sided lesions of the triangular fibrocartilage complex. Hand Clin. 1995 Feb. 11(1):31-6. [Medline].
Kihara H, Short WH, Werner FW, et al. The stabilizing mechanism of the distal radioulnar joint during pronation and supination. J Hand Surg [Am]. 1995 Nov. 20(6):930-6. [Medline].
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. 1995 Aug. 77(8):1207-9. [Medline].
Kleinman WB, Graham TJ. The distal radioulnar joint capsule: clinical anatomy and role in posttraumatic limitation of forearm rotation. J Hand Surg [Am]. 1998 Jul. 23(4):588-99. [Medline].
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]. 1999 Jun. 24(3):338-41. [Medline].
Nakamura T, Yabe Y, Horiuchi Y. Functional anatomy of the triangular fibrocartilage complex. J Hand Surg [Br]. 1996 Oct. 21(5):581-6. [Medline].
Osterman AL. Wrist arthroscopy: Operative procedures. In: Green's Operative Hand Surgery. Vol 1. New York, NY: Churchill Livingstone;. 1999: 209-16.
Schers TJ, van Heusden HA. Evaluation of chronic wrist pain. Arthroscopy superior to arthrography: comparison in 39 patients. Acta Orthop Scand. 1995 Dec. 66(6):540-2. [Medline].
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]. 1992 May. 17(3):423-8. [Medline].