1) The triangular fibrocartilage complex (TFC) provides stability to the distal radioulnar joint (DRUJ) and allows for forearm pronation and supination. Injuries to the TFC can cause ulnar-sided wrist pain and DRUJ instability. 2) Clinical examination of TFC injuries may reveal DRUJ instability on tests like the ulnar fovea sign and distal ulna ballottment test. MRI or arthroscopy can help diagnose the specific type of TFC tear. 3) Surgical treatment depends on the type and location of the TFC tear. Debridement is used for central perforations while suture repair or foveal

3. Acute Triangular Fibrocartilage Complex Injuries
Treatment & Management
Ivan Tami
Centro manoegomito
Clinica Ars Medica – Gravesano
Switzerland

4. anatomyatlases.org
Introduction

5. Introduction

6. Introduction

7. Anatomy
of the DRUJ
- mobility (forearm pronosupination)
- stability (load and force trasmission)
Anatomy

8. • N-sigmoid notch
• L-lunate art. surface
• S-scaphoid art. surface
Anatomy

9. Anatomy
• DRUJ congruity
– 60% in neutral position
– 10% during maximal P/S

10. Anatomy
• DRUJ congruity
– 60% in neutral position
– 10% during maximal P/S
Arthroscopic Management of
Ulnar Pain, F. del Piñal et al.

11. Anatomy
• The dorsal capsule
– extended in P
– folded in S
• The palmar capsule
– extended in S
– folded in P
Arthroscopic Management of
Ulnar Pain, F. del Piñal et al.

12. Anatomy
• TFCComplex
– triangular fibrocartilage
– meniscus homologue
– RU ligaments
– UL and UT ligaments
– sheat floor of ECU
– ulnar joint capsule
Arthroscopic Management of
Ulnar Pain, F. del Piñal et al.

13. Clinical Presentation
• Ulnar-sided
– wrist pain
– snapping
– clunking
•  grip strength
• Impaired function
–  P/S

14. Clinical Examination
• DRUJ instability
– ulnar fovea sign
• DRUJ instability
– ulnar fovea sign
Atzei A et al. Foveal TFCC Tear Classification
and Treatment. Hand Clin 2011

15. Clinical Examination
• DRUJ instability
– ulnar fovea sign
Arthroscopic Management of
Ulnar Pain, F. del Piñal et al.
• DRUJ instability
– ulnar fovea sign
– distal ulna ballottment test

16. Clinical Examination
• DRUJ instability
– ulnar fovea sign
– distal ulna ballottment test
Functional Evaluation of the
Distal Radioulnar Joint, N.
Badur and M. Garcia-Elias

17. Clinical Examination
• DRUJ instability
– ulnar foveal sign
– distal ulna ballottment test
– piano key sign
Functional Evaluation of the
Distal Radioulnar Joint, N.
Badur and M. Garcia-Elias

18. Imaging for TFCC

19. aging: MRI ”floating styloid”
Courtesy of F. Del Grande,
EOC CH-Lugano

20. Imaging: MRI
”complete TFCC tear”
Courtesy of F. Del Grande,
EOC CH-Lugano

21. Imaging: MRI
”non repairable TFCC tear”
Courtesy of F. Del Grande,
EOC CH-Lugano

22. Diagnosis: arthroscopy
Gold standard

23. Diagnosis: arthroscopy

24. Diagnosis: arthroscopy

25. Diagnosis: arthroscopy
• Hook test
– positive  TFCC tear
– negative  No tear
Arthroscopic Management of Ulnar
Pain. F. del Piñal et al.

26. Diagnosis: arthroscopy
• Hook test1, 2
– positive  TFCC tear
– negative  No tear
1
Atzei A et al. New trends in
arthroscopic management of
type 1-B TFCC injuries with
DRUJ instability. JHS Eur
2009
2
Atzei A et al. Foveal TFCC
tear classification and
treatment. Hand Clin 2011
Video: https://www.youtube.com/watch?v=EO8VR5XUF2g

27. Diagnosis: arthroscopy
Arthroscopic Management of Ulnar
Pain. F. del Piñal et al.
• Trampoline test
– positive  TFCC tear
– negative  No tear

28. Diagnosis: arthroscopy
• Trampoline test1
– positive  TFCC tear
– negative  No tear
1
Hermansdorfer JD et al.
Management of chronic
peripheral tears of the TFCC.
JHS Am 1991
Video: https://www.youtube.com/watch?v=u2zC5DgFUFA

29. Palmer Classification of TFCC Lesions1
• I Traumatic injury
– A: central perforation
– B: ulnar avulsion
– C: distal avulsion
– D: radial avulsion
• II Degenerative injury
1
Palmer AK. Triangular fibrocartilage complex
lesions: a classification. JHS Am 1989

30. Central perforation
Oneson SR., Chamoy L. et al. MR
Interpretation of the Palmer Classification of
TFCC Lesions. RadioGraphic 1996
• Palmer Class IA Lesions
– perforation of TFC proper
– sagittally oriented
– avascular portion
– debridement
Nakamura T. et al. Repair of foveal
detachment of the triangular fibrocartilage
complex: open and arthroscopic
transosseous techniques. Hand Clin 2011

31. Surgical Treatment: debridement
Video: https://www.youtube.com/watch?v=Or4rw_tTUP0

32. Distal (Volar) avulsions
• Palmer Class IC Lesions
– avulsion volar attachments
– sagittally oriented
– ulnocarpal instability
– surgical repair
– debridement
– ulnar shortening
Oneson SR., Chamoy L. et al. MR
Interpretation of the Palmer Classification of
TFCC Lesions. RadioGraphic 1996

33. Radial avulsions
• Palmer Class ID Lesions
– radial avulsion
– less common than IA/B
– by distal radius fractures
– avascular
– surgical repair
– debridement
Oneson SR., Chamoy L. et al. MR
Interpretation of the Palmer Classification of
TFCC Lesions. RadioGraphic 1996

34. Radial avulsions

35. Radial avulsions
Video: https://www.youtube.com/watch?v=jJNLUiYwxJM

36. Radial avulsions

37. Ulnar avulsions
• Palmer Class IB Lesions
– well-vascularized
– ulnar lesions
– capsule tear
– foveal tear
– surgical repair by instability
Oneson SR., Chamoy L. et al. MR
Interpretation of the Palmer Classification of
TFCC Lesions. RadioGraphic 1996

38. Ulnar avulsions
• Palmer Class IB Lesions
– well-vascularized
– ulnar lesions
– capsule or distal tear
– foveal or proximal tear
– complete tear
– surgical repair by instability
Nakamura T. et al. Functional anatomy of the
triangular fibrocartilage complex. JHS Br 1996

39. Ulnar avulsions
• Palmer Class IB Lesions
– well-vascularized
– ulnar lesions
– capsule or distal tear
– foveal or proximal tear
– complete tear
– surgical repair by instability
Nakamura T. et al. Functional anatomy of the
triangular fibrocartilage complex. JHS Br 1996

40. Atzei-EWAS Classification of TFCC1
1
Atzei A. New Trends in arthroscopic
management of 1-B TFCC injuries with
DRUJ instability. JHS Eur 2009

41. Atzei-EWAS Classification of TFCC1
Palmer Class IB
1
Atzei A. New Trends in arthroscopic
management of 1-B TFCC injuries with
DRUJ instability. JHS Eur 2009

42. Atzei-EWAS Classification of TFCC1
Palmer Class II
1
Atzei A. New Trends in arthroscopic
management of 1-B TFCC injuries with
DRUJ instability. JHS Eur 2009

43. Atzei-EWAS Classification of TFCC
Acute injuries

44. Atzei-EWAS Classification of TFCC
Acute injuries
Atzei Class I:
suture ligament-to-capsule

45. Surgical Treatment: suture (ligament-to-capsule)
• Repair: suture ligament-to-capsule

46. Surgical Treatment: suture (ligament-to-capsule)
Video: https://www.youtube.com/watch?v=kBJcpmQNZMs

47. Atzei-EWAS Classification of TFCC
Atzei Class II and III:
foveal refixation

48. Surgical Treatment: foveal refixation
• Repair: foveal refixation
Nakamura T. et al. Repair of foveal
detachment of the triangular fibrocartilage
complex: open and arthroscopic
transosseous techniques. Hand Clin 2011

49. Surgical Treatment: foveal refixation
Video: https://www.youtube.com/watch?v=1gWL0JvBTic

50. Open versus Arthroscopic Repair
Marc Garcia-Elias
Institut Kaplan, Barcelona

51. Open versus Arthroscopic Repair
Lucchetti R. Comparison between open and arthroscopic-
assisted foveal triangular fibrocartilage complex repair for post-
traumatic distal radio-ulnar joint instability. JHS Eur 2014

52. Rehabilitation
• 1-3° weeks
– long-arm cast
– neutral rotation
– elbow F/E
• 4-6° weeks
– short cast
– start wrist F/E
– assisted forearm rotation
• 7-10° weeks
– short cast at night
– resume daily activities
Sport and heavy works tasks > 3 months

53. • 1-3° weeks
– short cast
– start wrist F/E
– assisted forearm rotation
• 4-6° weeks
– wrist widget during the day
– short cast at night
– active E/F and P/S
• 7-10° weeks
– resume daily activities
– progressive forceful loading
Partial lesion: treatment

54. The author declares that the research for and communication
of this independent body of work does not constitute any
financial or other conflict of interest.
Take home message
• Clinical assessment
• MRI +/- arthrography
• Arthroscopic repair
• 3-6 months rehabilitation

55. Thank you for your attention!

56. www.manoegomito.ch