Daniel J. Nagle
DEFINITION
A tear of the triangular fibrocartilage complex (TFCC) is one of the most common causes of ulnar wrist pain. The treatment of TFCC tears and the associated synovitis is one of the primary indications for operative wrist arthroscopy.
Ulnar-sided wrist pain associated with a TFCC tear in the presence of ulnar-neutral or ulnar-plus variance constitutes ulnar abutment syndrome. Successful treatment of an ulnar abutment syndrome requires not only the débridement of the TFCC tear but also shortening of the ulna.
Patients with Palmer type IA8 TFCC tears are prime candidates for TFCC débridement.
Patients with Palmer type II (degenerative central tears) can also benefit from TFCC débridement. For the more advanced degenerative tears associated with lunatotriquetral ligament tears (Palmer type IID and E), other procedures such as an ulnar shortening osteotomy must be considered.
ANATOMY
The triangular fibrocartilage is the primary stabilizer of the distal radioulnar joint. It attaches radially on the distal lip of the sigmoid notch (FIG 1). Ulnarly, the triangular fibrocartilage inserts at the base of the ulnar styloid via a continuation of the dorsal and palmar radioulnar ligaments and the fibers of the ligamentum subcruentum.4
FIG 1 • Triangular fibrocartilage anatomy.
PATHOGENESIS
Tears of the triangular fibrocartilage are typically the result of a fall on the outstretched upper extremity. The ulna is driven distally and compresses the TFCC between itself and the lunate, producing a central or radial tear of the articular disc. This same mechanism can result in lunatotriquetral tears and peripheral TFCC tears (reviewed elsewhere).
Forceful ulnar deviation, such as noted in racquet sports and golf, can lead to TFCC tears. Gymnastics, with its significant axial loading of the wrist, can also lead to a TFCC tear.
The combination of ulnar axial load and torque noted during these sports can be sufficient to tear the triangular fibrocartilage.
At least 50% of intra-articular distal radius fractures are associated with tears of the triangular fibrocartilage.1 Many of these tears remain asymptomatic and require no surgical treatment.
An ulnar abutment (impaction) syndrome can develop as a result of shortening after a distal radius fracture (FIG 2). Radial collapse of the articular platform leads to a relative lengthening of the ulna.
Palmer et al9 have demonstrated an increase in the ulnocarpal load with increasing ulnar variance.
Repetitive axial loading of the wrist in a patient with an ulnar-zero or ulnar-plus variance can lead to an attritional tear of the triangular fibrocartilage and ulnar abutment syndrome.
NATURAL HISTORY
The natural history of TFCC tears is not well established. Many asymptomatic TFCC tears are noted on routine wrist arthroscopy. If left untreated one could assume that a TFCC tear could lead to chondromalacia of the lunate, triquetrum, and distal ulnar head. This in turn could lead to painful ulnocarpal synovitis.
FIG 2 • Ulnar abutment. The triangular fibrocartilage complex is compressed between the proximal ulnar lunate and the distal ulnar head.
The increase in the force transmitted through the ulnocarpal joint noted in an ulnar abutment syndrome can lead to a degenerative tear of the triangular fibrocartilage, chondromalacia of the lunate, triquetrum, and distal ulna, and a triquetrolunate ligament tear.
PATIENT HISTORY AND PHYSICAL EXAMINATION
Physical examination includes the following:
Ulnocarpal compression test: Pain at the ulnocarpal joint with or without popping and grinding is suggestive of a TFCC tear and possible ulnar abutment syndrome.
Lester press test: Pain at the ulnocarpal joint is suggestive of a TFCC tear and possible ulnar abutment syndrome.
Ulnocarpal palpation: Pain at the ulnocarpal joint suggests the presence of TFCC pathology as well as ulnocarpal synovitis.
IMAGING AND OTHER DIAGNOSTIC STUDIES
The radiographic evaluation of a patient with an ulnar abutment should include a standard wrist series and a Palmer 90 × 90 neutral rotation view.10
The Palmer 90 × 90 view places the forearm in neutral rotation while the elbow is flexed to 90 degrees and the shoulder is abducted to 90 degrees. The ulnar variance is calculated from this view (FIG 3A). Ulnar abutment is suspected in a patient with an ulnar-zero or ulnar-plus variance.
The ulnar aspect of the lunate should be carefully examined for subchondral cysts.
An MRI should be considered when evaluating the patient for ulnar abutment syndrome. The MRI will demonstrate increased signal in the lunate on the T2 images (FIG 3B,C). This corresponds to either a cyst or intraosseous edema.
The triangular fibrocartilage can also be evaluated on the MR images. Whether an MR arthrogram is needed is a function of the MR resolution. The accuracy of lower-resolution MR is increased with the addition of an intra-articular gadolinium injection.
DIFFERENTIAL DIAGNOSIS
TFCC tear
Distal radioulnar ligament injury
Distal radioulnar joint instability
Ulnocarpal ligament injury
Lunotriquetral joint instability
Ulnocarpal synovitis
Lunate chondromalacia
Triquetral chondromalacia
Distal ulnar chondromalacia
Kienböck disease
FIG 3 • A. Ulnar-plus variance noted on 90 × 90 neutral rotation view. B,C. T1and T2-weighted MRIs of a wrist with an ulnar abutment demonstrating the change in signal at the ulnar proximal lunate.
NONOPERATIVE TREATMENT
Immobilization of the involved wrist with either a Munster splint or long-arm cast for 4 weeks, combined with a course of nonsteroidal anti-inflammatories or an intra-articular steroid injection (or both), can be helpful in patients who present acutely.
A TFCC tear that is exacerbated by specific activities can occasionally respond to activity modification.
SURGICAL MANAGEMENT
The failure of nonoperative treatment (splinting, rest, nonsteroidal anti-inflammatory medications, activity modification, and therapy) leads the surgeon and patient to choose surgical débridement of a TFCC tear.
Mechanical débridement of the triangular fibrocartilage has been successful although it can be challenging, particularly in regard to the débridement of the ulnar and dorsal aspects of the triangular fibrocartilage tear.
There are two potential problems with mechanical TFCC débridement:
Passage of the instruments across the radiocarpal joint places those joints at risk of scuffing.
The proximity of the scope to the operative site (TFCC) can distort the operator’s perception of the ulnocarpal joint.
Radiofrequency devices have become increasingly popular for TFCC débridement because of the small probe size and relatively low cost. Monopolar and bipolar radiofrequency devices are currently in use. The instrument settings vary with the device.
Arthroscopic ulnar shortening is indicated in patients with a TFCC tear who have longstanding or acute exacerbation of ulnar abutment syndrome and who do not respond to nonoperative treatment.
It is generally thought that an arthroscopically assisted ulnar shortening is indicated if the ulnar-plus variance is less than 4 mm.
The goal of the surgery is to create an ulnar-minus variance of 2 mm.
Preoperative Planning
TFCC débridement: Preoperative evaluation should include wrist radiographs: a “wrist series” and a “90 × 90” view described by Palmer.10 An MRI with or without an arthrogram can also be helpful.
Arthroscopic ulnar shortening
The patient must be informed that an arthroscopically assisted ulnar shortening may not be possible should there be laxity of the ulnocarpal ligaments, a peripheral TFCC tear, or lunatotriquetral laxity.
The amount of shortening should be calculated preoperatively.
The surgeon should verify that the operating room is equipped with a mini C-arm to permit intraoperative assessment of the amount of ulna resected.
Positioning
The patient is placed in the supine position.
A pneumatic tourniquet is placed on the proximal arm.
The involved extremity is prepared and draped in the usual fashion.
The wrist is distracted using a commercially available wrist traction device.
TECHNIQUES
MECHANICAL TFCC DÉBRIDEMENT
Portals and Arthroscopic Examination
The standard dorsal 3-4 and 4-5 or 6R wrist arthroscopy portals are used for TFCC débridement (TECH FIG 1). These portals should be wide enough to permit the easy passage of instruments.
Before débriding the TFCC, perform a thorough and systematic arthroscopic examination of the radiocarpal, ulnocarpal, and midcarpal joints because associated intrinsic and extrinsic ligament injury and articular and synovial pathology could affect the treatment plan.
Perform ulnocarpal synovectomy to ensure clear visualization of that joint.
TECH FIG 1 • Wrist arthroscopy portals.
Radial and Palmar Débridement
The initial débridement of the radial and palmar and a portion of the dorsal aspects of the TFCC tear is accomplished with a scope in the 3-4 portal while the instruments enter through the 4-5 portal.
Use small joint punches (straight and angled), graspers, mini-banana blades, and mini-hook knives to débride the TFCC. The suction punch is particularly useful.
Take care not to injure the underlying ulnar head and overhanging lunate and triquetrum (TECH FIG 2).
Ulnar Débridement
Once the radial and palmar aspects of the TFCC have been débrided, move the arthroscope to the 4-5 portal.
TECH FIG 2 • Mechanical débridement of the TFCC. The arthroscope is in the 3-4 portal looking ulnar, while the suction punch enters through the 4-5 portal to débride the palmar aspect of the TFCC.
Débride the ulnar aspect of the triangular fibrocartilage by passing the instruments through the 3-4 portal.
Keep three points in mind while débriding the ulnar aspect of the TFCC:
Avoid injuring the attachment of the triangular fibrocartilage at its insertion at the base of the ulnar styloid.
Avoid injuring the dorsal or palmar radioulnar ligaments. If the ulnar attachment of the TFCC is transected, or if the dorsal and palmar radioulnar ligaments are injured, distal radioulnar joint instability will result.
Avoid scuffing the articular surfaces while passing the cutting and grasping instruments from the 3-4 portal across the radiocarpal joint into the ulnocarpal joint.
Dorsal Débridement
The dorsal aspect of the TFCC tear can usually be débrided using the 3-4 and 4-5 portals. Occasionally, however, the instruments need to be passed through the 6U portal while the scope is placed in the 3-4 portal.
Injury to the dorsal sensory branch of the ulnar nerve is avoided when establishing the 6U portal by using a longitudinal portal incision and blunt dissection to reach the ulnocarpal joint capsule.
Completion
Once the TFCC has been débrided with the punches and knives, smooth the rough edges of the débrided TFCC using a full radius cutter.
The 2.0-mm cutters are small but relatively ineffective, while the 2.9-mm cutters are effective but must be controlled so as to avoid collateral damage to the adjacent articular surfaces (TECH FIG 3A).
The end point of the TFCC débridement is reached when the ulnar head is visible through the TFCC and a stable TFCC perimeter is created (TECH FIG 3B).
Typically, a central defect measuring at least 1 cm in diameter is created.
Before declaring the surgery complete, remove the instruments from the wrist, release the traction, and ulnarly deviate, axially load, and repeatedly supinate and pronate the wrist.
The presence of popping or clicking is a sign that further débridement might be needed or that some other pathology is causing the popping and clicking.
One source of such post-débridement popping is thickened synovium in the distal radioulnar joint just proximal to the TFCC.
Close wounds using subcuticular sutures of 4-0 Prolene and apply a volar splint.
TECH FIG 3 • A. The arthroscope is in the 3-4 portal and the full radius cutter is passed through the 4-5 portal to smooth the edges of the débrided central TFCC tear. B. The débridement of the TFCC is complete. The ulnar head is clearly visible and ready for shortening.
LASEROR RADIOFREQUENCY-ASSISTED TFCC DÉBRIDEMENT
TECH FIG 4 • Laser-assisted débridement of a TFCC tear. The laser probe is placed 1 mm from the TFCC.
The technique of laser-assisted TFCC débridement is similar to that of mechanical débridement, with the exception that the arthroscope can be left in the 3-4 portal while the laser probe is kept in the 4-5 portal.
The laser is set to 1.4 to 1.6 joules at a frequency of 15 pulses per second. With the help of a side-firing 70-degree laser tip, the triangular fibrocartilage can be rapidly and precisely débrided.
The 70-degree laser tip permits ablation of not only the radial and palmar portions of the TFCC tear but also the ulnar and dorsal components.
There is no need to bring the laser probe in through the 3-4 portal.
During the débridement, take care not to injure the ulnar head. This is avoided by firing the laser tangentially to the head of the ulna or passing the probe beneath the triangular fibrocartilage and firing distally (TECH FIG 4).
This latter technique presents minimal danger to the lunate or triquetrum as the fluid used to expand the joint acts as a heat sink and absorbs the laser energy as it emerges from beneath the triangular fibrocartilage.
Radiofrequency-assisted débridement is similar to laserassisted débridement.
Monopolar probes have a theoretical disadvantage compared to bipolar probes in that the energy imparted to the TFCC flows through the adjacent tissue in the direction of the grounding pad. This could lead to tissue damage beyond the TFCC.
The flow of irrigation fluid must be sufficient to cool the joint when using the radiofrequency devices.
ARTHROSCOPIC ULNAR SHORTENING
The goal of the surgery is to create an ulnar-minus variance of 2 mm without any irregularities of the remaining distal ulna.
Small irregularities, however, tend to flatten out with the passage of time.
Arthroscopic ulnar shortening is accomplished by placing the scope in the 3-4 portal and introducing the instruments through the 4-5 portal.
Occasionally the 6U portal can be used, as can the distal distal radioulnar joint portal.
While the holmium:YAG laser is useful for ulnar shortening, the barrel abrader can also be used alone or in combination with the laser.
If the holmium:YAG laser is used, it is introduced through the 4-5 portal and the cartilage and subchondral bone of the ulnar seat of the distal ulna are rapidly vaporized (TECH FIG 5A,B).
The laser becomes less efficient once the trabeculae of the distal ulna are visible (TECH FIG 5C). At that point, the 2.9-mm barrel abrader is brought in to finish the shortening (TECH FIG 5D).
It is important to avoid injury to the sigmoid notch, and frequent fluoroscopic monitoring of the amount of bone resected is mandatory.
Take care to fully supinate and pronate the wrist to adequately débride the ulnar head.
Remove all instruments at the end of the procedure, and ulnarly deviate, axially load, and supinate and pronate the wrist to be sure no clicking or popping is noted. If any clicking or popping is noted and it appears to be emanating from the area of the surgery, further ulnar leveling may be required.
Close wounds using subcuticular sutures of 4-0 Prolene and apply a volar splint.
TECH FIG 5 • A. The 70degree side-firing laser probe easily vaporizes the hyaline cartilage and subchondral bone of the ulnar head. B. The laser has cleared the ulnar head of its cartilage and subchondral plate. C. The spacing of the bony trabeculae of the ulnar head decreases the laser’s efficiency. The final leveling of the ulnar head is achieved with the small joint burr. D. The small joint burr is brought in through the 4-5 or 6R portal to finish the ulnar shortening.
POSTOPERATIVE CARE
Postoperative care includes early range of motion and suture removal at 2 weeks.
Early range of motion is critical as it leads to a more supple scar and a better range of motion.
Strengthening exercises are initiated at 6 weeks if needed.
Premature resumption of heavy lifting or repetitive activities will lead to ulnocarpal synovitis.
Some patients are pain-free after as little as 2 weeks, and the surgeon must temper the patient’s desire to return to full activity.
The patient is instructed to avoid heavy lifting for 3 months.
Typically patients are able to return to unrestricted activities in 12 weeks, although they may experience some discomfort for 6 to 12 months.
Patients who undergo a simple TFCC débridement will recover more rapidly than those who undergo an arthroscopic ulnar shortening.
OUTCOMES
The results of arthroscopic débridement of traumatic triangular fibrocartilage tears have been very good.2,3
Minami et al5 noted, however, that degenerative tears (Palmer type II) have a less favorable prognosis due to the associated ulnar wrist pathology noted in these patients.
Our results11 and those reported by Osterman7 and Palmer8 suggest that arthroscopically assisted ulnar shortening in properly selected patients provides excellent and good results in over 80% of patients (FIG 4).
COMPLICATIONS
TFCC débridement
Infection and injury to the dorsal branch of the ulnar nerve are rare.
Excessive débridement of the TFCC (dorsal and palmar radioulnar ligaments, attachment in the ulnar fovea) can lead to instability.
Formation of portal site cysts (very rare)
Arthroscopic ulnar shortening
Inadequate bony resection can lead to a nonresolution of the patient’s symptoms.
Uneven resection of the distal ulna can lead to catching of any significant residual bony prominence on the overlying triangular fibrocartilage.
We have seen one patient reconstitute his triangular fibrocartilage and require repeat débridement. This phenomenon has been anecdotally reported by others.
The surgeon must remain vigilant and avoid injury to the sigmoid notch.
The surgeon must avoid excessive ulnar débridement, which could lead to the detachment of the triangular fibrocartilage from the fovea.
FIG 4 • Six-month postoperative radiograph after arthroscopic ulnar shortening in patient in Techniques Figure 5.
REFERENCES
1. Bombaci H, Polat A, Deniz G, et al. The value of plain X-rays in predicting TFCC injury after distal radial fractures. J Hand Surg Br 2008;33B:322–326.
2. Husby T, Haugstvedt JR. Long-term results after arthroscopic resection of lesions of the triangular fibrocartilage complex. Scand J Plast Reconstr Surg Hand Surg 2001;35:79–83.
3. Infanger M, Grimm D. Meniscus and discus lesions of triangular fibrocartilage complex (TFCC): treatment by laser-assisted wrist arthroscopy. J Plast Reconstr Aesthet Surg 2009;62:466–471 [Epub 2008 May 12].
4. Kleinman WB. Stability of the distal radioulnar joint: biomechanics, pathophysiology, physical diagnosis, and restoration of function what we have learned in 25 years. J Hand Surg Am 2007;32A: 1086–1106.
5. Minami A, Ishikawa J, Suenaga N, et al. Clinical results of treatment of triangular fibrocartilage complex tears by arthroscopic debridement. J Hand Surg Am 1996;21A:406–411.
6. Nagle DJ, Bernstein MA. Laser-assisted arthroscopic ulnar shortening. Arthroscopy 2002;18:1046–1051.
7. Osterman AL. Arthroscopic debridement of triangular fibrocartilage complex tears. Arthroscopy 1990;6:120–124.
8. Palmer AK. Triangular fibrocartilage disorders: injury patterns and treatment. Arthroscopy 1990;6:125–132.
9. Palmer AK, Glisson RR, Werner FW. Relationship between ulnar variance and triangular fibrocartilage complex thickness. J Hand Surg Am 1984;9A:681–682.
10. Palmer AK, Glisson RR, Werner FW. Ulnar variance determination. J Hand Surg Am 1982;7A:376–379.
11. Wnorowski DC, Palmer AK, Werner FW, et al. Anatomic and biomechanical analysis of the arthroscopic wafer procedure. Arthroscopy 1992;8:204–212.