Wrist and ulnar joint anatomy

1. TRIANGULAR FIBROCARTILAGE COMPLEX
FAILAGAO, NEL JOHN ROY B
WVMC-ORTHO

2. 1. ANATOMY
2. FUNCTION
3. BIOMECHANICS
4. MECHANISM OF
INJURIES
5. CLASSIFICATIONS
6. SPECIAL TESTS
7. TREATMENT
TRIANGULAR FIBROCARTILAGE COMPLEX

3. BONY ANATOMY OF THE DRUJ
Distal Radioulnar Joint:
 Articulation of the ulnar notch of
radius and it’s ulnar axis.
 Articulation of the proximal carpal row
and the distal ends of the radius
 Scaphoid
 Lunate

4. EXTRINSIC SOFT TISSUE STABILIZERS OF
DRUJ
 PRONATOR
QUADRATUS
 INTEROSSEOUS
LIGAMENT
 TENDON OF
EXTENSOR CARPI
ULNARIS (ECU)
 TENDON SHEATH
BLENDS WITH
THE TFCC

5. INTRINSIC SOFT TISSUE
STABILIZATION
JOINT CAPSULE
Ligamentous
Attachments
TFCC
Ulnocarpal Ligaments

6. ANATOMY OF THE TFCC
THE TRIANGULAR
FIBROCARTILAGE COMPLEX
 The Five Parts:
 Triangular Fibrocartilage Disc
(articular disc)
 Volar and Dorsal Radioulnar
Ligaments (Superficial & Deep)
 Meniscus Homologue
 Ulno-colateral & Ulno-carpal
Ligaments
 Tendon Sheath of ECU
TFCC attaches to the fovea at the
base of the ulnar styloid

7. MENISCUS HOMOLOGUE
SUPERFICIAL (DISTAL) LIMBS THAT
ATTACH TO THE ULNAR STYLOID AND
DEEP (PROXIMAL) LIMBS
TFCC COMPONENTS

8. TFCC COMPONENTS
ARTICULAR
DISC
VRUL
DRUL
UL, UTr ECU sub sheath

9. • SIGMOID NOTCH
• RADIOULNAR
LIGAMENTS
ANATOMY

10. IMPORTANCE OF TFCC
STABILITY:
Prevents dislocation of
the radius as it rotates
around its ulnar axis
Suspends the ulnar
carpus over ulna
TFCC Injuries:
Instability of the DRUJ
 Dislocation of ulna
 Decreased rotational
Movement
Ulnar Impingement
 Causes a (+) ulnar variance
 Pain with ulnar deviation &
supination

11. 180 Degrees of Rotational
Movement
 Pronation
 Supination
Translational Movement of
Ulna During Pronation and
Supination
 Pronation: Dorsal
 Supination: Palmar
BIOMECHANICS & MOVEMENT

12. Pronation
Supination
BIOMECHANICS
 TFCC: Radioulnar Ligaments Tighten and Loosen During Rotational
Movement
PRONATION
Dorsal Superficial &
Deep
Palmar Fibers
Tighten
SUPINATION
Palmar Superficial &
Deep Dorsal Fibers
Tighten
Neutral

13. TFCC INJURIES
ETIOLOGY:
Traumatic Injuries/Lesions
(TYPE 1)
• Most common is fall on extended wrist
with forearm pronation
• Traction injury to ulnar side of wrist
• Traction injury to ulnar wrist
Degenerative Injuries/Lesions
(TYPE 2)
• Associated with positive ulnar
variance
• Associated with ulnocarpal
impaction

14. Ulnar sided wrist pain
Popping/clicking with
pronation/supination
Decreased rotational movement
Decreased grip strength
Instability of the DRUJ
SYMPTOMS OF TFCC INJURY

15. DIAGNOSIS OF TFCC INJURIES
 DRUJ Stability Tests
 Piano Key Test
 Rule OutAlternative
Causes:
 Radius Pull Test
 Clunk Test
 ECU Test

16. Physical Assessment of the
TFCC
 Palpable tenderness over the
TFCC
TFCC Stress Test
DIAGNOSIS OF TFCC INJURIES

17. “PRESS TEST” FOR TFCC
Patient is asked to lift
himself/herself out of a
chair while bearing weight
on extended wrists

18. RADIOLOGICAL ASSESSMENT
MRI
 The radioulnar ligaments, ulnocarpal
ligaments and the TFCC with it foveal
attachment to ulna can be visualized
 86% Sensitivity for detection of TFCC tears
RADIOGRAPHS
⚫ Posteroanterior (PA)
⚫ True lateral X-ray
⚫ Pronation and supination views.
⚫ Aclenched fist PAview in
pronation.

19. MRI
A.MRI t2-weighted fat suppression image
B.Proton density-weighted MRI

20. CONSERVATIVE TREATMENT FOR
TFCC LESIONS
 Splinting for a period of time to
reduce symptoms
 Followed by progressive ROM and
strengthening exercises
 If patient’s symptoms have not been
resolved in 4-6 weeks, surgical repair
or debridement should be considered.
 Conservative treatment is thought to be
ineffective for chronic (>6 mo.)

21. SURGICAL INTERVENTIONS
CENTRAL DEBRIDEMENT
 As 80% of the central TFCC is
avascular with poor healing
potential, damage to this area is
usually treated with debridement
 Arthroscopic or Open
 Common for Type II
Lesions
PERIPHERAL REPAIR
 Ligaments are directly repaired
 Avulsed portion of TFCC is debrided
and the torn border is sutured to the
fovea
 Usually open

22. CLINICAL EVALUATION
 Trauma, eg, a fall on the outstretched hand
(FOOSH)
 Ulnar-sided wrist pain (USWP), especially on loading
the hand and rotating the forearm
 Persistence of USWP and stiffness following distal
radius fractures (DRF)
 Clicking sounds
 Obvious instability

23.  Impingement
sign
 The ulna fovea
sign
 The piano-key
test
 The table top test
 The Grind test
SPECIAL TESTS

24.  Useful to delineate sigmoid notch fractures and DRUJ
Injuries
 Ligament injuries can be assessed indirectly by assessing
the radioulnar articulation in various positions and also by
loading views
 Three-dimensional (3D) reconstructions are helpful in
assessing spatial relationship between the radius and
ulna
COMPUTED TOMOGRAPHY

25. ARTHROSCOPY IS THE GOLD STANDARD FOR
EVALUATION OF TFCC INJURIES
1. Central TFCC tear
2. Foveal detachment of
the TFCC
3. Reattachment of TFCC
4. Degenerative tears of
TFCC.

26. PALMER’S CLASSIFICATION OF TFCC INJURIES

27.  Class 1ATFCC
(central perforation)
lesions
 Class 1B lesions
 Class 1C lesions
TFCC INJURIES - MANAGEMENT

28. POSTOPERATIVE THERAPEUTIC
MANAGEMENT
 Wound care/Scar managemnet
 Edema Control
 Splinting

29. POSTOPERATIVE MANAGEMENT
Maintain and improve
ROM
 Digits/ Uninvolved
Joints initially
Goal is to maximize
pain- free wrist and
forearm AROM

30. OUTCOME MEASURES
Grip Strength
Dynamometer
ROM Measurements
From Wrist
Goniometer
Patient Specific
Goals/Outcomes

31. TREATMENT OF TFCC INJURIES
Non operative
splinting or AE
cast Pharmacological
NSAIDS
Steroid
injections
modification of
activity
occupational
therapy
Operative
arthroscopic
Open
techniques