Acute blockage of forearm supination due to flap tear of the triangular fibrocartilage disc: A case report.

RATIONALE: Acute blockage of forearm supination has been reported in several studies. It is caused by loose bodies in the wrist joint, extensor carpi ulnaris tendon interposition, and distal radioulnar joint (DRUJ) injuries, including forearm bone fractures. Some studies have reported cases of DRUJ injuries caused by triangular fibrocartilage complex (TFCC) tears.We report a case of acute blockage of forearm supination after minor trauma and suggest a possible TFCC tear when a patient complains of forearm supination blocking. In addition, we present a comparison between our case and other reports on etiology, magnetic resonance imaging (MRI) findings, and arthroscopic findings, and show the specific characteristics of our case. PATIENTS CONCERNS: A 22-year-old male presented with left wrist pain as the chief complaint. He was injured 2 months prior to pushing his left hand on the floor during exercise. Physical examination showed a relative limitation of range of motion (ROM) in the left wrist of about 10° in flexion and about 15° in extension compared with the right side. The patient also complained of supination limitation and volar side wrist pain during supination. The patient showed tenderness in the axial compression test. DIAGNOSES: Plain radiographs showing no abnormalities. MRI showed a TFCC tear in the central portion. A torn flap of the TFCC was interposed on the volar side of the DRUJ. INTERVENTIONS: Arthroscopic surgery of the left wrist joint was performed. Arthroscopic examination revealed a tear in the TFCC on the radial side. A torn flap was interposed on the volar side of the DRUJ. We removed the flap from the DRUJ using an arthroscopic grasper and partially resected it. OUTCOMES: Intraoperative tests showed no locking and the forearm was well supinated. Two months after the surgery, the patient had no pain and showed full forearm supination. LESSONS: DRUJ blocking due to a TFCC tear should be suspected when acute blockage of forearm supination occurs after minor trauma. MRI is helpful for diagnosis; however, we suggest that the diagnosis should be confirmed through arthroscopy. Symptoms can be resolved by surgical treatment using arthroscopy.

Biomechanical Outcomes of Surgically Repaired TFCC Palmer Type 1B Tears: A Systematic Review of Cadaver Studies.

BACKGROUND: Palmer type 1B triangular fibrocartilage complex (TFCC) tears are a common cause of distal radioulnar joint (DRUJ) instability. Unfortunately, the best surgical technique for TFCC reinsertion is still unknown, and up to a quarter of patients report instability after repair. The purpose of this systematic review of cadaver studies was to compare the biomechanical outcomes of different surgical techniques used for Palmer 1B TFCC tears. METHODS: A systemic review of all cadaver studies published before January 2022 was performed using the PubMed and EMBASE databases. Only cadaver studies on reinsertion techniques for Palmer type 1B lesions were included. Biochemical outcome parameters evaluated were stability of the DRUJ and strength of the repair. RESULTS: A total of 248 articles were identified. Five articles fulfilled the inclusion criteria. Four different surgical techniques were identified. In 3 studies, transosseous tunnel repair was tested and resulted in the most stable DRUJ and strongest TFCC repair compared with the suture anchor repair, the peripheral capsular repair, and the outside-in repair. CONCLUSIONS: These results suggest that the transosseous tunnel repair might be a good technique for restoring DRUJ stability. However, more cadaver studies are needed to identify the most optimal technique.

COMPARATIVE RADIOLOGICAL DIAGNOSTICS OF ACUTE TRIANGULAR FIBROCARTILAGE COMPLEX INJURIES.

The aim was to analyze patients with clinical diagnosis of triangular fibrocartilage complex (TFCC) lesion using standard x-ray, ultrasound, conventional magnetic resonance imaging (MRI) and MR arthrography (MRA); to evaluate the accuracy of MRA compared with MRI in the diagnosis of this lesion; and to evaluate ultrasound as a method of diagnosing TFCC lesion. We analyzed 72 patients (46 female and 26 male; age range, 22-61 years; mean age 37 years; 50 right and 22 left wrists) with suspected TFCC lesion with clinical examination, standard x-rays, and ultrasound. We confirmed patients with traumatic TFCC injury on MRI and MRA. Ultrasound found 13 lesions in 72 patients with suspected TFCC lesions. Conventional MRI found 66 and MRA 68 TFCC lesions. Ultrasound is useful for visualizing intra-articular effusion, soft tissue, bone surface, and for early detection of occult fractures. MRI is a better diagnostic modality, fully able to visualize the TFCC cartilage and ligaments. MRA is consistently and accurately able to visualize structural abnormalities of TFCC.

Design and Performance Analysis of a Dynamic Magnetic Resonance Imaging-Compatible Device for Triangular Fibrocartilage Complex Injury Diagnosis.

Pain and injury of the triangular fibrocartilage complex (TFCC) due to overuse or trauma are commonly diagnosed through static MRI scanning, while TFCC is always involved in radial and ulnar deviation of the wrist. To the best of our knowledge, a dynamic MRI diagnostic method and auxiliary tool have not been applied or fully developed in the literature. As such, this study presents the design and evaluation of a dynamic magnetic resonance imaging (MRI) auxiliary tool for TFCC injury diagnosis. First, 3D scanning and Python are used to measure and fit the radial and ulnar deviation trajectories of healthy participants and patients. 3D printing is then used to manufacture the auxiliary tool for dynamic MRI, and dynamic MRI diagnosis is then conducted to explore the clinical effect. The radial and ulnar deviation trajectory is presented as an asymmetric curve without an obvious circular centre, and the results indicate that the designed auxiliary device meets the requirements of the ulnar and radial movements of the human wrist. According to the MRI contrast test results, the image quality score of patients wearing the auxiliary device is higher than for those without. Such devices could assist clinicians in the diagnosis of TFCC damage, and our method could not only serve as the reference standard for clinical noninvasive diagnosis but also help in understanding the disease and improving the accuracy of TFCC diagnosis.

High-resolution magnetic resonance imaging of the triangular fibrocartilage complex using compressed sensing sensitivity encoding (SENSE).

PURPOSE: To evaluate the optimal sequence for high-resolution magnetic resonance imaging (MRI) of the triangular fibrocartilage complex (TFCC) using compressed sensing-sensitivity encoding (CS-SENSE). METHODS: Three-dimensional fast field echo T2-weighted images were obtained from 13 healthy volunteers using the original, high spatial resolution sequence with CS-SENSE [HR (CS-SENSE)] and without CS-SENSE (HR) and super-high spatial resolution sequence with CS-SENSE [S-HR (CS-SENSE)] and without CS-SENSE (S-HR). For qualitative analysis, the number of patients affected by motion artifacts in each sequence was counted, and the visualization of the TFCC anatomic structures and overall image quality were categorized. For the quantitative analysis, relative signal intensity (SI) and relative contrast of the lunate bone marrow, lunate cartilage, and disk proper in the wrist joint were all calculated. RESULTS: The HR (CS-SENSE) sequence showed better visualization scores than the original sequence in the triangular ligament at the ulnar styloid tip, dorsal radioulnar ligament, and ulnotriquetral ligament. Similarly, the S-HR (CS-SENSE) sequence showed better visualization scores than the original sequence in the triangular ligament at the ulnar styloid tip and dorsal radioulnar ligament. Overall image quality scores were not significantly different, and motion artifacts in the HR and S-HR sequences were observed in 3 of the 13 patients. In contrast, the original sequence showed higher values than those in the HR (CS-SENSE) and S-HR (CS-SENSE) sequences in relative SI of the bone marrow and relative contrast of the cartilage-bone marrow and cartilage-disk proper. CONCLUSIONS: Out of the three sequences, the HR (CS-SENSE) sequence provided the highest visualization score and diagnostically sufficient image quality score, although relative SI and relative contrast were low. The HR (CS-SENSE) sequence may be clinically useful for imaging TFCCs.

Diagnostic accuracy of wrist MRI in comparison to wrist arthroscopy regarding TFCC lesions in clinical practice.

INTRODUCTION: The purpose of this study was to arthroscopically verify MRI diagnostic accuracy for triangular fibrocartilage complex (TFCC) lesions in a regular clinical environment. METHODS: A total of 859 patients' data with both preoperative MRI of the wrist and additional wrist arthroscopy were retrospectively reviewed. Two board-certified hand surgeons and one orthopaedic surgeon executed wrist arthroscopy, whereas more than 100 radiologists examined the MRI of the wrist. The accordance of TFCC lesion classification using MRI in comparison to wrist arthroscopy and diagnostic precision of the former depending on technical details were evaluated. RESULTS: Diagnostic accuracy of MRI for TFCC lesions is poor in comparison to wrist arthroscopy as the reference standard. Technical specifications for MRI of the wrist are heterogeneous among the radiologists. These parameters have not improved accuracy of TFCC evaluation at large. CONCLUSION: The accuracy of MRI in a regular clinical environment still remains inferior to wrist arthroscopy for detection of TFCC lesions. Development of a standard MRI protocol may be implemented on a regular basis and application of the Palmer classification for TFCC lesion should be sought.

Degeneration of the articular disc in the human triangular fibrocartilage complex.

INTRODUCTION: Traumatic injuries of the triangular fibrocartilage complex (TFCC) are frequent reasons for ulnar wrist pain. The assessment of the extent of articular disc (AD) degeneration is important for the differentiation of acute injuries versus chronic lesions. MATERIALS AND METHODS: The AD of the TFCC of eleven human cadaver wrists was dissected. Degeneration was analyzed according to the grading of Krenn et al. Hematoxylin-eosin was used to determine the tissue morphology. Degeneration was evaluated using the staining intensity of alcian blue, the immunohistochemistry of the proteoglycan versican and the immunoreactivity of NITEGE, an aggrecan fragment. RESULTS: The staining homogeneity of HE decreased with higher degeneration of the AD and basophilic tissue areas were more frequently seen. Two specimens were characterized as degeneration grade 1, five specimens as grade 2, and four specimens as grade 3, respectively. Staining intensity of alcian blue increased with higher degeneration grade of the specimens. Immunoreactivity for NITEGE was detected around tissue fissures and perforations as well as matrix splits. Immunoreactivity for versican was found concentrated in the tissue around matrix fissures and lesions as well as loose connective tissue at the ulnar border of the AD. Specimens with degeneration grade 2 had the strongest immunoreactivity of NITEGE and versican. Cell clusters were observed in specimens with degeneration grade 2 and 3, which were stained by alcian blue and immunoreactive for NITEGE and versican. Increasing age of the cadaver wrists correlated with a higher degree of degeneration (p < 0.0001, r = 0.68). CONCLUSIONS: The fibrocartilage of degenerated ADs contains NITEGE and versican. The amount of the immunoreactivity of these markers allows the differentiation of degenerative changes into three grades. The degeneration of the AD increases with age and emphasizes its important mechanical function.

Relative Prevalence of and Factors Associated with Anxiety and Depression in Degenerative Triangular Fibrocartilage Complex Lesion Patients - a Casecontrol Study.

Triangular fibrocartilage complex (TFCC) lesions are a common cause of ulnar wrist pain. Data, including mental status assessment, were prospectively collected from patients who underwent arthroscopy. The HADS was used to assess the prevalence of depression and anxiety. Patients with degenerative TFCC lesions were at an increased risk of anxiety and depression. Early screening for anxiety and depression in degenerative TFCC lesions patients should be recommended.

Comparison between conventional MRI and MR arthrography in the diagnosis of triangular fibrocartilage tears and correlation with arthroscopic findings.

PURPOSE: The triangular fibrocartilage complex is one of the most important stabilizers of the wrist and a defect in its anatomical structure is a possible cause of ulnar sided wrist pain. The aim of this study is to compare the diagnostic accuracy between conventional MRI and MR arthrography (MRA) in the depiction of triangular fibrocartilage complex (TFCC) tears. METHODS-MATERIALS: A total of 60 patients with clinical findings that suggested TFCC tears underwent wrist MRI and MRA. All the MRI and MRA results were compared with the arthroscopic findings. RESULTS: 40 tears were confirmed by arthroscopy. 38/40 tears were identified by MRA while MRI identified 26/40 tears. There were also 8 false positives and 13 false negative results identified by MRI. Two false negative results were identified by MRA. No false positive results were identified. CONCLUSION: MR arthrography is more sensitive and specific method in terms of the diagnosis of TFCC tears compared to conventional wrist MRI. There was no difference in the diagnostic accuracy between wrist arthroscopy and MRA.

Biomechanical Analysis of Capsular Repair Versus Arthrex TFCC Ulnar Tunnel Repair for Triangular Fibrocartilage Complex Tears.

Background: This study compares the effectiveness of a peripheral capsular repair with a knotless arthroscopic transosseous ulnar tunnel repair (TR) in restoring distal radioulnar joint (DRUJ) stability and stiffness in the setting of a massive triangular fibrocartilage complex (TFCC) tear. Methods: Eight matched pairs of fresh-frozen cadaveric forearms were tested. Each forearm was tested in supination and pronation using 3-dimensional (3D) optical tracking devices prior to any intervention. Each specimen then underwent a diagnostic wrist arthroscopy and sectioning of the TFCC's deep and superficial fibers. All specimens were then retested to assess instability secondary to the tear. The TFCC was repaired with either a peripheral capsular repair (CR) using three 2-0 polydioxanone sutures or a transosseous ulnar TR using a 2-0 FiberWire, and then retested (statistical significance; P < .05). Results: After TFCC arthroscopic sectioning, all specimens were unstable with a significant increase in translation and a significant decrease in stiffness. TFCC repair with TR resulted in displacement and stiffness similar to the native tissue. CR specimens were found to have significantly greater displacement and significantly decreased stiffness compared with the intact state. Conclusions: Arthroscopic sectioning of the TFCC resulted in DRUJ instability, as measured by stiffness and ulnar translation. TR effectively restored DRUJ stability and demonstrated no significant difference in postoperative stiffness or maximal displacement when compared with the intact specimen in pronation and supination. This study provides biomechanical evidence that an arthroscopic ulnar tunnel technique can restore stability to the DRUJ after a massive TFCC tear.

High-resolution 3 T MRI of traumatic and degenerative triangular fibrocartilage complex (TFCC) abnormalities using Palmer and Outerbridge classifications.

AIM: To investigate the usefulness of high-resolution 3 T magnetic resonance imaging (MRI) for the evaluation of traumatic and degenerative triangular fibrocartilage complex (TFCC) abnormalities among three groups: patients presenting with wrist pain who were (a) younger than age 50 years or (b) age 50 or older (PT<50 and PT≥50, respectively), and (c) asymptomatic controls who were younger than age 50 years (AC). MATERIALS AND METHODS: High-resolution 3 T MRI was evaluated retrospectively in 96 patients, including 47 PT<50, 38 PT≥50, and 11 AC. Two board-certified radiologists reviewed the MRI images independently. MRI features of TFCC injury were analysed according to the Palmer classification, and cartilage degeneration around the TFCC was evaluated using the Outerbridge classification. Differences in MRI findings among these groups were detected using chi-square test. Cohen's kappa was calculated to assess interobserver and intra-observer reliability. RESULTS: The incidence of Palmer class 1A, 1C and 1D traumatic TFCC injury was significantly (p<0.05) higher in PT≥50 than in PT<50 (class 1A: 47.4% versus 27.7%, class 1C: 31.6% versus 12.8%, and class 1D: 21.1% versus 2.1%). Likewise, MRI findings of TFCC degeneration were observed more frequently in PT≥50 than in PT<50 (p<0.01). Outerbridge grade 2 or higher cartilage degeneration was significantly (p<0.01) more frequently seen in PT≥50 than in PT<50 (55.3% versus 17% in the lunate, 28.9% versus 4.3% in the triquetrum, 73.7% versus 12.8% in the ulna). CONCLUSION: High-resolution wrist MRI at 3 T enables detailed evaluation of TFCC traumatic injury and degenerative changes using the Palmer and Outerbridge classifications, with good or excellent interobserver and intra-observer reliability.

Can the Diagnostics of Triangular Fibrocartilage Complex Lesions Be Improved by MRI-Based Soft-Tissue Reconstruction? An Imaging-Based Workup and Case Presentation.

Introduction. The triangular fibrocartilage complex (TFCC) provides both mobility and stability of the radiocarpal joint. TFCC lesions are difficult to diagnose due to the complex anatomy. The standard treatment for TFCC lesions is arthroscopy, posing surgery-related risks onto the patients. This feasibility study aimed at developing a workup for soft-tissue reconstruction using clinical imaging, to verify these results in retrospective patient data. Methods. Microcomputed tomography (µ-CT), 3 T magnetic resonance imaging (MRI), and plastination were used to visualize the TFCC in cadaveric specimens applying segmentation-based 3D reconstruction. This approach further trialed the MRI dataset of a patient with minor radiological TFCC alterations but persistent pain. Results. TFCC reconstruction was impossible using µ-CT only but feasible using MRI, resulting in an appreciation of its substructures, as seen in the plastinates. Applying this approach allowed for visualizing a Palmer 2C lesion in a patient, confirming ex postum the arthroscopy findings, being markedly different from MRI (Palmer 1B). Discussion. This preliminary study showed that image-based TFCC reconstruction may help to identify pathologies invisible in standard MRI. The combined approach of µ-CT, MRI, and plastination allowed for a three-dimensional appreciation of the TFCC. Image quality and time expenditure limit the approach's usefulness as a diagnostic tool.

Diagnostic Wrist Arthroscopy for Nonspecific Wrist Pain.

Background: This study addresses the prevalence of discrete pathophysiology accounting for patients' symptoms during diagnostic wrist arthroscopy in individuals with wrist pain without a specific preoperative diagnosis. Secondarily, we determined the number and type of surgeries subsequent to diagnostic wrist arthroscopy. Methods: Between January 2000 and January 2015, 135 diagnostic wrist arthroscopies were performed by 12 surgeons in 3 urban academic hospitals. We recorded the diagnostic findings of diagnostic wrist arthroscopy and any subsequent surgeries. Results: One hundred and five patients had synovitis or a normal wrist (78%), 17 had likely age-appropriate changes (eg, central triangular fibrocartilage complex defects scapholunate changes) (13%), 8 (6%) were given uncommon diagnoses, and 5 (4%) had osteochondral defects. Sixteen patients (12%) had subsequent wrist surgery: 2 were for adverse events, 2 were carpal tunnel releases, and 12 were other surgeries. Conclusion: Diagnostic arthroscopy performed in the setting of an unclear preoperative diagnosis yielded limited diagnostic benefit.

High-Resolution 3T MR Imaging of the Triangular Fibrocartilage Complex.

This study is intended as a review of 3Tesla (T) magnetic resonance (MR) imaging of the triangular fibrocartilage complex (TFCC). The recent advances in MR imaging, which includes high field strength magnets, multi-channel coils, and isotropic 3-dimensional (3D) sequences have enabled the visualization of precise TFCC anatomy with high spatial and contrast resolution. In addition to the routine wrist protocol, there are specific techniques used to optimize 3T imaging of the wrist; including driven equilibrium sequence (DRIVE), parallel imaging, and 3D imaging. The coil choice for 3T imaging of the wrist depends on a number of variables, and the proper coil design selection is critical for high-resolution wrist imaging with high signal and contrast-to-noise ratio. The TFCC is a complex structure and is composed of the articular disc (disc proper), the triangular ligament, the dorsal and volar radioulnar ligaments, the meniscus homologue, the ulnar collateral ligament (UCL), the extensor carpi ulnaris (ECU) tendon sheath, and the ulnolunate and ulnotriquetral ligaments. The Palmer classification categorizes TFCC lesions as traumatic (type 1) or degenerative (type 2). In this review article, we present clinical high-resolution MR images of normal TFCC anatomy and TFCC injuries with this classification system.

Effect of Electrothermal Treatment on Nerve Tissue Within the Triangular Fibrocartilage Complex, Scapholunate, and Lunotriquetral Interosseous Ligaments.

PURPOSE: To evaluate the effect of thermal treatment on neural tissue in the triangular fibrocartilage complex (TFCC), scapholunate interosseous ligament (SLIL), and lunotriquetral interosseous ligament (LTIL). METHODS: The intact TFCC, SLIL, and LTIL were harvested from cadaveric specimens and treated with a radiofrequency probe as would be performed intraoperatively. Slides were stained using a triple-stain technique for neurotrophin receptor p75, pan-neuronal marker protein gene product 9.5 (PGP 9.5), and 4',6-diamidino-2-phenylindole for neural identification. Five TFCC, 5 SLIL, and 4 LTIL specimens were imaged with fluorescence microscopy. Imaging software was used to measure fluorescence signals and compare thermally treated areas with adjacent untreated areas. A paired t test was used to compare treated versus untreated areas. P < .05 was considered significant. RESULTS: For the TFCC, a mean of 94.9% ± 2.7% of PGP 9.5-positive neural tissue was ablated within a mean area of 11.7 ± 2.5 mm(2) (P = .02). For the SLIL treated from the radiocarpal surface, 97.4% ± 1.0% was ablated to a mean depth of 2.4 ± 0.3 mm from the surface and a mean horizontal spread of 3.4 ± 0.5 mm (P = .01). For the LTIL, 96.0% ± 1.5% was ablated to a mean depth of 1.7 ± 0.7 mm and a mean horizontal spread of 2.6 ± 1.0 mm (P = .02). Differences in the presence of neural tissue between treated areas and adjacent untreated areas were statistically significant for all specimens. CONCLUSIONS: Our study confirms elimination of neuronal markers after thermal treatment of the TFCC, SLIL, and LTIL in cadaveric specimens. This effect penetrates below the surface to innervated collagen tissue that is left structurally intact after treatment. CLINICAL RELEVANCE: Electrothermal treatment as commonly performed to treat symptomatic SLIL, LTIL, and TFCC tears eliminates neuronal tissue in treated areas and may function to relieve pain through a denervation effect.

MR morphology of triangular fibrocartilage complex: correlation with quantitative MR and biomechanical properties.

OBJECTIVE: To evaluate pathology of the triangular fibrocartilage complex (TFCC) using high-resolution morphologic magnetic resonance (MR) imaging, and compare with quantitative MR and biomechanical properties. MATERIALS AND METHODS: Five cadaveric wrists (22-70 years) were imaged at 3 T using morphologic (proton density weighted spin echo, PD FS, and 3D spoiled gradient echo, 3D SPGR) and quantitative MR sequences to determine T2 and T1rho properties. In eight geographic regions, morphology of TFC disc and laminae were evaluated for pathology and quantitative MR values. Samples were disarticulated and biomechanical indentation testing was performed on the distal surface of the TFC disc. RESULTS: On morphologic PD SE images, TFC disc pathology included degeneration and tears, while that of the laminae included degeneration, degeneration with superimposed tear, mucinous transformation, and globular calcification. Punctate calcifications were highly visible on 3D SPGR images and found only in pathologic regions. Disc pathology occurred more frequently in proximal regions of the disc than distal regions. Quantitative MR values were lowest in normal samples, and generally higher in pathologic regions. Biomechanical testing demonstrated an inverse relationship, with indentation modulus being high in normal regions with low MR values. The laminae studied were mostly pathologic, and additional normal samples are needed to discern quantitative changes. CONCLUSION: These results show technical feasibility of morphologic MR, quantitative MR, and biomechanical techniques to characterize pathology of the TFCC. Quantitative MRI may be a suitable surrogate marker of soft tissue mechanical properties, and a useful adjunct to conventional morphologic MR techniques.

The Traumatized TFCC: An Illustrated Review of the Anatomy and Injury Patterns of the Triangular Fibrocartilage Complex.

The triangular fibrocartilage complex (TFCC) plays an important role in wrist biomechanics and is prone to traumatic and degenerative injury, making it a common source of ulnar-sided wrist pain. Because of this, the TFCC is frequently imaged, and a detailed understanding of its anatomy and injury patterns is critical in generating an accurate report to help guide treatment. In this review, we provide a detailed overview of TFCC anatomy, its normal appearance on magnetic resonance imaging, the spectrum of TFCC injuries based on the Palmer classification system, and pitfalls in accurate assessment.

The Function of the Distal Interosseous Membrane and its Relevance to the Stability of the Distal Radioulnar Joint: An Anatomical and Biomechanical Review.

The purpose of this article is to review functional anatomy and biomechanics of the distal interosseous membrane (DIOM) and its relevance to the stability of the distal radioulnar joint. The intact DIOM constrained dorsal dislocation of the radius, but it seldom constrained palmar dislocation. A residual ulnar translation deformity of the radial shaft in distal radius fractures has the potential to cause the distal radioulnar joint instability when the triangular fibrocartilage complex injury is also present, because it may result in detensioning of DIOM. Ulnar shortening with the osteotomy performed proximal to the attachment of the DIOM had a more favorable effect on stability of the DRUJ compared with the effect of distal osteotomy, especially in the presence of the distal oblique bundle (DOB). The longitudinal resistance to ulnar shortening was significantly greater in proximal shortening than in distal shortening.