Relative Contributions of the Ulnar Attachments of the Triangular Fibrocartilage Complex to the Dynamic Stability of the Distal Radioulnar Joint

Haugstvedt, Jan Ragnar; Berger, Richard A.; Nakamura, Toshiyasu; Neale, Patricia G.; Berglund, Lawrence J.; An, Kai Nan

doi:10.1016/j.jhsa.2005.11.008

Cited by 209 publications

(171 citation statements)

References 24 publications

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Section: Historical Perspectivementioning

confidence: 99%

“…7 However, disruption of the TFCC at its foveal attachment can result in DRUJ instability. 3,5 Palmer 8 proposed a classification system for TFCC tears that divided them into traumatic and degenerative. Class I B tears are traumatic ulnar-sided peripheral tears that are more amendable to repair.…”

Section: Historical Perspectivementioning

confidence: 99%

“…As the ligaments extend ulnarly, they divide into a distal component that attaches to the ulnar styloid and a proximal component that attaches to the fovea. [3][4][5][6] The articular disk extends from the ulnar edge of the lunate fossa at the distal rim of the sigmoid notch and blends peripherally with the RUL.The foveal insertion of the TFCC contributes more to DRUJ stability than the styloid insertion because of its closer relationship to the rotational axis of the forearm. 4 In fractures of the ulnar styloid with disruption of the distal components of TFCC, patients may not experience DRUJ instability due to an intact foveal attachment.…”

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confidence: 99%

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Anatomic Foveal Reconstruction of the Triangular Fibrocartilage Complex With a Tendon Graft

Bain

McGuire

Lee

et al. 2014

Techniques in Hand &Amp; Upper Extremity Surgery

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An acute injury to the triangular fibrocartilage complex (TFCC) with avulsion of the foveal attachment can produce distal radioulnar joint (DRUJ) instability. The avulsed TFCC is translated distally so the footprint will be bathed in synovial fluid from the DRUJ and will become covered in synovitis. If the TFCC fails to heal to the footprint, then persistent instability can occur. The authors describe a surgical technique indicated for the treatment of persistent instability of the DRUJ due to foveal detachment of the TFCC. The procedure utilizes a loop of palmaris longus tendon graft passed through the ulnar aspect of the TFCC and into an osseous tunnel in the distal ulna to reconstruct the foveal attachment. This technique provides stability of the distal ulna to the radius and carpus. We recommend this procedure for chronic instability of the DRUJ due to TFCC avulsion, but recommend that suture repair remain the treatment of choice for acute instability. An arthroscopic assessment includes the trampoline test, hook test, and reverse hook test. DRUJ ballottement under arthroscopic vision details the direction of instability, the functional tear pattern, and unmasks concealed tears. If the reverse hook test demonstrates a functional instability between the TFCC and the radius, then a foveal reconstruction is contraindicated, and a reconstruction that stabilizes the radial and ulnar aspects of the TFCC is required. The foveal reconstruction technique has the advantage of providing a robust anatomically based reconstruction of the TFCC to the fovea, which stabilizes the DRUJ and the ulnocarpal sag.Key Words: triangular fibrocartilage complex, foveal tear, DRUJ instability, wrist arthroscopy, TFCC repair (Tech Hand Surg 2014;18: 92-97) HISTORICAL PERSPECTIVEThe triangular fibrocartilage complex (TFCC) is a complex 3-dimensional structure made up of the proximal triangular ligament or the radioulnar ligaments (RUL), the distal hammock structure, and the ulnar collateral ligaments. 1,2 The distal hammock structure and the ulnar collateral ligaments are distal components, inserting into the ulnar styloid. The palmar and dorsal portions of the RUL originate from the distal margin of the sigmoid notch and converge to attach to the ulna. As the ligaments extend ulnarly, they divide into a distal component that attaches to the ulnar styloid and a proximal component that attaches to the fovea. [3][4][5][6] The articular disk extends from the ulnar edge of the lunate fossa at the distal rim of the sigmoid notch and blends peripherally with the RUL.The foveal insertion of the TFCC contributes more to DRUJ stability than the styloid insertion because of its closer relationship to the rotational axis of the forearm. 4 In fractures of the ulnar styloid with disruption of the distal components of TFCC, patients may not experience DRUJ instability due to an intact foveal attachment. 7 However, disruption of the TFCC at its foveal attachment can result in DRUJ instability. 3,5 Palmer 8 proposed a classification syst...

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Section: Historical Perspectivementioning

confidence: 99%

Section: Historical Perspectivementioning

confidence: 99%

mentioning

confidence: 99%

See 1 more Smart Citation

Anatomic Foveal Reconstruction of the Triangular Fibrocartilage Complex With a Tendon Graft

Bain

McGuire

Lee

et al. 2014

Techniques in Hand &Amp; Upper Extremity Surgery

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“…[15][16][17][18][19] As each palmar and dorsal radioulnar ligament extends toward the ulna, it divides into two limbs: the deep limb attaches to the fovea on the ulna, and the superficial limb attaches to the base and midportion of the ulnar styloid. [15][16][17][18][19] Thus, the TFCC has four insertions on the ulna, which can be termed the deep palmar limb, deep dorsal limb, superficial palmar limb, and superficial dorsal limb 2 (►Fig. 1).…”

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confidence: 99%

Open Repair of the Triangular Fibrocartilage Complex from Palmar Aspect

Moritomo

2015

Jnl Wrist Surg

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Instability of the distal radioulnar joint (DRUJ) caused by a traumatic foveal tear of the triangular fibrocartilage complex (TFCC) can produce significant disability, which could present as pain, weakness, and a restricted range of motion. Several surgical procedures to repair TFCC foveal tear have been proposed, including open 1-4 and arthroscopic 5-9 TFCC repairs. Several surgical approaches have also been proposed, including a dorsal 10-12 or a palmar 3,10,13,14 approach. However, the ideal procedure and approach for TFCC foveal tear remain controversial.Over the past few decades, a considerable number of studies of the anatomy of the TFCC have been undertaken. [15][16][17][18][19] As each palmar and dorsal radioulnar ligament extends toward the ulna, it divides into two limbs: the deep limb attaches to the fovea on the ulna, and the superficial limb attaches to the base and midportion of the ulnar styloid. [15][16][17][18][19] Thus, the TFCC has four insertions on the ulna, which can be termed the deep palmar limb, deep dorsal limb, superficial palmar limb, and superficial dorsal limb 2 (►Fig. 1).Regarding the direction of DRUJ instability, palmar radius instability, in which the distal radius is unstable in a palmar direction with respect to the ulna, is a much more common form of DRUJ instability than dorsal radius instability. 20 A biomechanical study showed that the deep palmar limb has a Keywords ► DRUJ instability ► TFCC foveal tear ► open repair ► CT arthrography ► surgical approach AbstractBackground Although foveal tears of the triangular fibrocartilage complex (TFCC) can be surgically reattached to the fovea via a dorsal approach, the foveal lesion is difficult to visualize from the dorsal side because the extensor carpi ulnaris (ECU) sheath floor and the superficial dorsal limb of the radioulnar ligament hinders the view of the fovea. Materials and Methods Twenty-one patients with foveal tears were treated by an open repair method from the palmar aspect. Pain, instability, motion, and grip strength were evaluated after a mean follow-up period of 26 months, and each patient was rated according to the Mayo Modified Wrist Score (MMWS). Description of Technique A 4-cm skin incision is made on the palmar aspect of the ulnar fovea. The ulnar fovea is exposed through a transverse capsulotomy of the distal radioulnar joint. The distal aspect of the TFCC is also exposed between the ECU tendon sheath and the ulnotriquetral ligament. After curettage of the scar tissue in the fovea, the deep palmar and dorsal limbs of the TFCC are sutured back to the fovea using a suture anchor technique. Results Foveal TFCC tears could be repaired via a palmar surgical approach without violating the floor of the ECU tendon sheath and the superficial dorsal limb. Excellent results were achieved in 18 patients, and a good result was achieved in three. Conclusions Our result compared favorably with those reported for dorsal approach. The palmar surgical approach facilitates the inspection and repair of the TFCC foveal tears. L...

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“…Of late, biomechanical studies have highlighted the importance of the deep attachment of the TFCC for maintaining stability of the distal radioulnar joint. 10 Moritomo recently described a palmar repair method of the foveal insertion of the TFCC through an open volar ulnar (VU) approach using a suture anchor (International Wrist Investigator's Workshop; September 2006; Washington, DC). As attention has shifted toward the multitudinous causes of ulnar-sided wrist pain, the indication for the judicious use of a volar ulnocarpal portal and volar DRUJ portal have emerged.…”

Section: Historical Perspectivementioning

confidence: 99%

Distal Radioulnar Joint Arthroscopy and the Volar Ulnar Portal

Slutsky

2007

Techniques in Hand &Amp; Upper Extremity Surgery

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Pain on the ulnar side of the wrist remains poorly understood. As attention has shifted toward the myriad causes of ulnar-sided wrist pain, the utility of viewing the wrist from a volar ulnar (VU) perspective has emerged. Lunotriquetral ligament tears have been implicated in the pathogenesis of volar intercalated segmental instabilities. They often originate in the palmar subregion, which is most important for maintaining stability. These tears are difficult to visualize through the 4, 5, or 6R portals. They are well seen through a VU portal, and the direct line of sight facilitates debridement. The VU portal has potential use in the arthroscopic diagnosis and treatment of patientswith injuries tothe ulnarslingmechanism.Itaidsin triangular fibrocartilage repairs especially those involving the dorsal aspect between the ulnar styloid and the radial insertion, because the proximity of the 4, 5, and 6R portals makes triangulation of the instruments difficult.Although arthroscopy of the dorsal aspect of the distal radioulnar joint has been well described, it has largely remained a curiosity, with few clinical indica-tions. Recent biomechanical studies have highlighted the importance of the deep attachment of the triangular fibrocartilage complex in maintaining distal radioulnar joint stability. The volar distal radioulnar portal is useful for assessing the foveal attachment. It may be used where there is the suspicion of a peripheral triangular fibrocartilage detachment due to a loss of its normal tension despite the lack of a visible tear during radio-carpal arthroscopy. The judicious use of these portals deserves consideration for inclusion as part of a thorough arthroscopic examination of selected patients with ulnarsided wrist pain. Keywords: arthroscopy, DRUJ, volar, portal | HISTORICAL PERSPECTIVEThe indications for wrist arthroscopy have steadily grown from a mostly diagnostic tool to a valuable adjunctive procedure in the treatment of myriad wrist disorders. The ulnocarpal joint has been the proverbial ''black box^ of the wrist pain. Instability of the distal radioulnar joint (DRUJ) is a hotbed for research, with new and innovative techniques appearing monthly. Although the new generation of 3-T magnetic resonance imaging scanners holds promise for the future, many of the causes of ulnar-sided wrist pain are revealed only at the time of arthroscopy. Establishing the diagnosis of a peripheral detachment of the triangular fibrocartilage complex (TFCC) or a tear of the ulnar sling mechanism remains an exacting challenge even for the experienced arthroscopist.The clinical utility of volar portals has been recently elucidated. 1 As kinematic and biomechanical studies have shed light on the role of the dorsal capsular structures and palmar subregions of the interosseous ligaments in maintaining carpal stability, it has become prudent to view the wrist from a palmar perspective. Volar portals for wrist arthroscopy have certain advantages over the standard dorsal portals for visualizing dorsal capsular struct...

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Relative Contributions of the Ulnar Attachments of the Triangular Fibrocartilage Complex to the Dynamic Stability of the Distal Radioulnar Joint

Cited by 209 publications

References 24 publications

Anatomic Foveal Reconstruction of the Triangular Fibrocartilage Complex With a Tendon Graft

Anatomic Foveal Reconstruction of the Triangular Fibrocartilage Complex With a Tendon Graft

Open Repair of the Triangular Fibrocartilage Complex from Palmar Aspect

Distal Radioulnar Joint Arthroscopy and the Volar Ulnar Portal

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