Anatomy of Triangular Fibrocartilage complex

Anatomy and biomechanics of tfcc

1. The Distal Radioulnar
Joint and TFCC

Anatomy and Clinical Significance

Rafael E. Salazar Il, OTR/L

2. Distal Radioulnar Joint:

= Articulation of the ulnar
notch of radius and its
ulnar axis.

Articulation of the proximal
carpal row and the distal
ends of the radius
= Scaphoid
Lunate
(LaStayo, 2006)

Proximal Row
Carpal Bones

Palmar
Vel
AY
Lrriquetrum

Lunate
ocala =>

Lunate facet

3. Extrinsic Soft Tissue Stabilizers of i
DRUJ

= Pronator Quadratus
= Interosseous Ligament

= Tendon of Extensor Carpi
Ulnaris (ECU)
= Tendon sheath blends with
the TFCC

4. Joint Capsule

= Continuous with RU
Ligaments of TFCC and ECU
Sheath

Ligamentous Attachments

ı TFCC
Ulnocarpal Ligaments

(Wijffles, 2012)

5. 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
(Wijffles, 2012)

6. Radio- Short Triquetrum Ulnolunate
scapho- radiolunate
capitate nt
ligament Long

radiolunate

Ulnotriquetral
ligament

ligament
Meniscus
homologue

Ulnar styloid

Ulnar capsule
Prestyloid

recess

Ligamentum

subcruentum
E) Triangular I}

Deep portion of
articular dorsal DRUL
disc

Superficial portion of

dorsal DRUL
Radius

7. Functions of the TFCC =

= Provides gliding surface across distal face of both radius and
ulna

= Stabilizing mechanism of the DRUJ during rotational movement
= supination/pronation

= Suspends the ulnar carpus from contacting the distal ulna/radius

= Cushions forces that are transmitted through the ulnocarpal axis

= Connects the ulna to the volar carpus

(Coker, 2010)

8. Importance of TFCC =

Stability: TFCC Injuries:
= Prevents dislocation of the = Instability of the DRUJ
radius as it rotates around its = Dislocation of ulna
ulnar axis .
= Decreased rotational
= Suspends the ulnar carpus movement
over ulna

= Ulnar Impingement
= Causes a (+) ulnar variance

= Pain with ulnar deviation &
supination

9. "Resting position"
(midway between

_- pronation and
O Supination) so that
palm faces trunk
180 Degrees of Rotational
Movement :
Pronation
Supination

Translational Movement of
Ulna During Pronation and
Supination

Pronation: Dorsal

Supination: Palmar
(Wijffles, 2012) Supination Pronation

10. Biomechanics Cont.

= TFCC: Radioulnar Pronation
Ligaments Tighten and
Loosen During Rotational Neutral
Movement

= Pronation - $)

= Dorsal Superficial & Deep
Palmar Fibers Tighten

Supination

= Supination
= Palmar Superficial & Deep
Dorsal Fibers Tighten

11. TFCC Injuries

Etiology:
= Traumatic Injuries/Lesions
(Class 1)

= Falls on outstretched,
pronated hand

= Acute rotational injury
= Distraction Force

= Degenerative
Injuries/Lesions (Class 2)
= Repetitive movement
= Hypovascularity and poor
nutrition
= Central portion of TFCC
= Anatomical Variation
= + Ulnar variance (Wijffles, 2012)

12. Symptoms of TFCC Injury

= Ulnar sided wrist pain

= Popping/clicking with
pronation/supination

= Decreased rotational
movement

= Decreased grip strength

= Instability of the DRUJ

(Coker, 2010)

14. Diagnosis of TFCC Injuries

= DRUJ Stability Tests

= Piano Key Test: Tests Static
DRUJ stability

= Rule Out Alternative
Causes:
= Radius Pull Test
= Interosseous Membrane
= Clunk Test
= Interosseous Membrane
= ECU Test

= Extensor Carpi Ulnaris
Tendon
(Wijffles, 2012)

Distal Radioulnar Joint (DRUJ) Subluxation
Radius

Distal Radioulnar \
Joint NY

KT Una

15. Diagnosis of TFCC Injuries Cont. IM

= Physical Assessment of the
TFCC

= Palpable tenderness over
the TFCC

= Combined ulnar deviation
and pronation/supination
may cause pain and
popping/clicking sounds
= Ulnar Impingement Sign

= TFCC Stress Test

= “Press Test”: has been
shown to have 100%

sensitivity for TFCC tears
(Wijfles, 2012)

16. “Press Test” for TFCC

= Patient is asked to lift
himself/herself out of a
chair while bearing weight
on extended wrists

= Pain at the wrist indicates
TFCC tear/lesion

17. Radiological Assessment =

= X-ray
= Ulnar Variance Is Calculated

= (+) Is Associate With TFCC
Tears

= 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 (Thomas, 2012)

18. Conservative Treatment for TFCC IT
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.) (Baek, 2012)

19. Surgical Interventions

Central Debridement Peripheral Repair
= As 80% of the central TFCC is = Ligaments are directly
avascular with poor healing repaired

Een en en. area = Avulsed portion of TFCC is
Bay Leelee WI debrided and the torn

debridement. border is sutured to the
= Arthroscopic or Open fovea
= Common for Type Il = Usually open

Lesions

Open
TFCC Repair

Drill holes for
lod

Lucio et al, 1991

20. Postoperative Therapeutic
Management

= Wound care/Scar
managemnet

= Edema Control

= Splinting
= To protect the integrity of
the repair
= Per protocol/surgeon’s
recommendations

(Coker, 2010)

21. Postoperative Management Cont.

= Maintain and improve ROM

= Digits/ Uninvolved Joints
initially

= Goal is to maximize pain-
free wrist and forearm
AROM
= Follow protocol/surgeons
guidelines for when to
initiate wrist PROM/AROM
and strengthening

(Coker, 2010)

22. Outcome Measures

= Grip Strength
= Dynamometer

= ROM Measurements From
Wrist
= Goniometer

= ***Patient Specific
Goals/Outcomes

23. References

= Baek G, Kato H, Romanowski, L. Distal radioulnar joint instability.
IFSSH Scientific Committee on Bone and Joint Injuries. 2012.

Coker D. Anatomy and dysfunction of the DRUJ and TFCC. South
County Hand Center. 2010.

LaStayo P, Lee M. The forearm complex: anatomy, biomechanics and
clinical considerations. J Hand Ther. 2006.

Lucio BT, Stokes HM, Phoehling GG, Lemoine-Smith S, Crook E.
Management of isolated triangular firbrocartilage complex perforations
of the wrist. J Hand Ther. 1991; 162-168.

Snell C. (2012) Triangular fibrocartilage complex tears: evidence based
assessment and management. The Sports Physiotherapist. Retrieved
from http://www.thesportsphysiotherapist.com/triangular-fibrocartilage-
complex-tears-evidence-based-assessment-and-management/
Thomas B, Sreekanth, R. Distal radioulnar joint injuries. Indian J
Orthop. 2012; 493-504.

Wijffels M, Brink P, Schipper I. Clinical and non-clinical aspects of distal
radioulnar joint instability. The Open Orthopaedic J. 2012; 204-210.