llTriangular Fibrocartilageand Ulnar Wrist PainGlenn A. Buterbaugh, MD

introduction

Ulnar wrist pain is considered by some as the low-back painof hand surgery. Multiple afflictions occur at this site, andthe hand surgeon must keep each in mind in the diagnosisof ulnar wrist pain. The triangular fibrocartilage complexhas been extensively studied over the last few years. Wehave come to better understand the anatomy and biome-chanics of the TFCC in the laboratory and have furtherrefined the diagnostic work-up. The disorders have beenidentified and classified in a pattern of injury.

Alternative lesions, as well, are considered in the diagno-

sis of ulnar wrist pain, including dislocation, subluxation,and arthritis of the distal radioulnar joint, medial carpal, andlunotriquetrat ligament instability, extensor carpi ulnarissubluxation and rupture, calcific extensor and flexor carpiulnaris tendonitis, hamate hook fractures and pisotriquetratsubluxation, and arthritis. The clinical findings for these¯ lesions help def’me the diagnostic work-up required in theevaluation of ulnar wrist pain.

In the diagnostic work-up, the general principles includea differentiation between acute and chronic injury. Also, thestability of the distal radioulnar joint and medial carpus bypalpation as well as the site of localized tenderness areimportant elements in the initial evaluation. Further exami-nation studies include wrist range of motion and pinch andgrip strength. The diagnostic Studies include standard PAradiographs of the wrist in neutral forearm rotation to assessulnar variance specifically as well as the articular surfaces.Other studies helpful in the evaluation of ulnar wrist paininclude three-compartment wrist arthrogram and MRI stud-ies for ligamentous and TFCC lesions, as well as CT scanstudies to evaluate distal radioulnar joint articulation, thepisotriquetral joint, and the hamate hook.

Anatomy

The term TFCC was introduced to describe the ligamentousand cartilage structure that suspends the distal radius andulnar carpus from the distal ulna (Fig. 11-1). The TFCCincorporates the poorly identifiable dorsal and volarradioulnar ligaments, the ulnar collateral ligament, themeniscus homologue, as well as the clearly definable artic-ular disk, extensor carpi ulnaris sheath, ulnolunate and luno-triquetral ligaments. The complex arises from the ulnaraspect of the lunate fossa of the radius. It courses toward theulna where it inserts about the fovea at the base of the ulnarstyloid. The fovea is an area rich in vascular foramen, whichprovides vascularity to the peripheral element of the TFCC,with a more central radial portion being relatively avascular.

Complex Injury

Figure 1. The anatomy of the TFCC is shown providing stability ofthe distal rac!ioulnar joint, Note the attachments of the TFCC to thefovea of the distal ul~’~a an(i a~icular edge of the radius. S, scaphoid;L. luna’:e: T, triquetrum.

TFCC Lesions: Injury Patterns and Treatment

A classification or TFCC abnormalities has been recentlydeveloped ba~cd on mechanism and site of inju~ (Table

Traumatic Ic~ions or the TFCC result from a fidl on theoutstretched upp,er extremitx or hyperrotation injuw to thefl~reama. These traumatic lesions occur fl’om the origin orinsertion or" th~ TFCC. Degenerative lesions of the TFCCresult from repetitive loading known as ulnar impaction syn-

105

106 Carpus and Distal Radius

Table 11-1. TFCC Abnormalities

Class 1 : TraumaticA. Central perforationB. Ulnar avulsion

With distal ulnar fractureWithout distal ulnar fracture

C. Distal avulsionD. Radial avulsion

With sigmoid notch fractureWithout sigmoid notch fracture

Class 2: Degenerative (ulnocarpal abutment syndrome)Stage:A. TFCC wearB. TFCC wear

+ lunate and/or ulnar chondromalaciaC. TFCC perforation

+ lunate and/or ulnar chondromalaciaD. TFCC perforation

+ lunate and/or ulnar chondromalacia+ L-T ligament perforation

E. TFCC perforation+ lunate and/or ulnar chondromalacia+ L-T ligament perforation+ ulnocarpal arthritis

A classification of triangular fibrocartilage complex injuries.

drome. A spectrum of injury results from early TFCC wearto TFCC perforation, lunate chondromalacia, LT ligamenttears, and ulnocarpal arthritis.

Traumatic Lesion (Class I Lesions---TFCC)

Traumatic lesions are classified as: 1A--a lesion of the hori-zontal portion of the TFCC (Fig. 11-2), 1B--an avulsion the complex from the distal ulna either with or without bone(Fig. 11-3), 1C--an avulsion of the complex from its inser-tion into the lunate or triquetrum (Fig. 11-4), 1D~an avulsion

Figure 11-2. The ligamentous supports of the ulnar aspect of thewrist (the triangular fibrocartilage complex) illustrating a Class perforation. The perforation is a dorsal palmar tear (arrow) justmedial to the radial origin of the TFCC. R, radius; U, ulna; L, lunate;T, triquetrum.

__.J

R

Class 1B

U

R

Class 1BU

Figure 11-3. (Top) The ligamentous supports of the ulnar aspecto17 the wrist (the triangular fibrocartilage complex) illustrating Class 1B lesion. In this instance, the TFCC is avulsed from the distalulna with an associated fragment of bone, i.e., the distal ulna. R,radius; U, ulna; L, lunate; T, triquetrum. (Bottom) The Iigamentoussupports of the ulnar aspect of the wrist (the triangular fibrocartilagecomplex) illustrating a Class 1 B lesion. In this case, the triangularfibrocartilage complex is torn free from the base of the ulnar styloidwithout an associated fracture arrow). R, radius; U, ulna; L, lunate;T, triquetrum/,(

Class 1C

U

Figure 11-4. The ligamentous supports of the ulnar aspect of thewrist (the triangular fibrocartilage complex) illustrating a Class lesion. The triangular fibrocartilage complex is avulsed distally fromits bony insertion to the lunate by the ulnolunate ligament and/or thet:iquetrum by the ulnotriquetral ligament (arrows). R, radius; U, ulna;L., lunate, T, triquetrum.

Triangular Fibrocartilage Complex Injury and Ulnar Wrist Pain 107

R

U

Class 1D

Figure 11-5. The ligamentous supports of the ulnar aspect of thewrist (the triangular fibrocartilage complex) illustrating a Class ~esion. Arrows indicate an avulsion of the TFCC from its radial origin.The avulsion can be with or without a fragment of bone. R, radius;U, ulna; L, lunate; T, triquetrum.

of the complex from the attachment to the distal aspect of thesigmoid notch of the radius (Fig. 11-5,~.

Evaluation and Treatment

Traumatic lesions of the TFCC generally occur secondary toa fall on an outstretched hand or are associated with hyper-rotation injuries to the foreama. Examination of the wristshould include the site of localized tenderness and range ofmotion of the wrist, including forearm rotation. Pain at theextremes of motion should be noted as well. Evidence ofinstability by manipulation of the distal ulna with attention towrist symptoms, clicks, and snaps are noted. Pinch and gripstrength as well as routine PA and lateral radiographs com-plete the exam.

All traumatic lesion,,; of the TFCC should be treated withimmobilization when seen acutely, if no instability pattern,subluxatio~., or fractures are noted. Complete disruption of

Class 1A

Figure 11-6. (Top) Arthrogramidentifying a traumatic, horizontaltear in the triangular fibroca#:ilage(arrows). (Bottom) The debridementof the torn portion of the triangularfibrocartilage utilizing a suctionpunch and the wrist arthroscope.R, radius; U, ulna; L, lunate; T,triquetrum; C, capitate; H, hamate.

108 Carpus and Distal Radius

the TFCC from the radius, carpus, or ulna is generally asso-ciated with a clinical or radiographically detectable insta-bility. In these cases, wrist arthrography and arthroscopyare indicated for evaluation and treatment. Witharthroscopy, if the lesion reduces closed, then four weeks ofimmobilization in ulnar deviation and slight flexion is usu-ally indicated. If positioning does not reduce the torn struc-tures, arthroscopic or open repair is indicated. When thelesion is in the centrum (the avascular portion of theTFCC), arthroscopic debridement has been shown biome-chanically and clinically to produce the desired effect.Enlargement of the tear preserving intact the volar and dor-sal ligaments frequently relieves the symptomatic clickingand does not disrupt the stability or the load-bearing char-acteristic of the TFCC. Osterman and associates reportedexcellent results with arthroscopic limited TFCC debride-ment for perforations in the avascular region. A relativecontraindication to TFCC debridement is an ulnar positivevariance.

The technique of wrist arthroscopy is generally per-formed under regional or general anesthesia with distrac-tion of the wrist in finger traps (Fig. 11-6). The anatomiclandmarks on the dorsum of the wrist are identified, includ-ing the intervals between the extensor pollicis longus andextensor digitorum communis (three to four portal), exten-sor digitorum communis and the extensor digiti quinti (fourto five portal), and the intervals radial and ulnar to theextensor carpi ulnaris (6R and 6U portals). After the wristis distended, the arthroscope is carefully introduced by ini-tially using a blunt trochar through the three to four portal.Inspection of the radiocarpal joint begins in sequential fash-ion with examination of the articular surfaces of the radius,scaphoid, lunate, and triquetrum, as well as the interosseousligaments, the volar carpal ligament and the TFCC. TheTFCC is specifically examined with a probe to "feel" thetriangular fibrocartilage perforations if present, as well as toassess the integrity of the TFCC by its "trampolining."

Following careful assessment of all pathology,if partial excision of the TFCC is elected, the perforationshould be enlarged to the point where there are no redun-dant margins. This usually requires removal of the centraltwo-thirds of the triangular fibrocartilage. The instrumentsgenerally required are a suction punch, a banana bladeor hook knife, and a motorized shaver utilized to "trimup" the margins of the debridement. The wrist is then copi-ously irrigated with normal saline, and the wounds areclosed.

Early motion is encouraged. Patients are allowed toresume activity as symptoms permit. One can expectpatients who undergo partial excision of a perforated trian-gular fibrocartilage to improve markedly within three to sixweeks following the procedure for Type I A and 2C lesions.If the procedure has been done for degenerative lesions withassociated chondromalacic changes, particularly in patientswith an ulnar positive variance, symptoms may not be com-pletely relieved, but merely improved.

For peripheral tears of the TFCC, arthroscopic or openrepair is indicated in lesions that do not reduce closed.Hermansdorfer and Kleinman have identified the trampo-

line lest on arthroscopic evaluation in the identification operipheral tears. Since there is good vascutarity or" th~ |TFCC in tlhe peripheral regions, suture repair is POssible ~either through an arthroscopic or open technique. Theyhave reported good results in a series of these patients.

Degenera,~._..From Mikic s study in 1978, the TFCC has been shown toundergo changes with age. The term ulnar impaction svn.drome has frequently been used to describe the pathol@c:sequence (Fig. 1 I-7). Individuals more than 50 years .have degenerative TFCC changes (many with perforati(~r~l.Based on this work and the clinical experience of othersdegenerative lesions of the TFCC are defined in the fo12]lowing classes: 2A--wear of the TFCC without cartila,,,eabnormality (Fig. I 1-8), 2B~wear of the TFCC with eitherulnar head or lunate chondromalacia (Fig. 11-9), 2C~degenerative perforation of the TFCC with associatedlunate and ulnar head chondromalacia (Fig. I 1-10),the addition of lunotriquetral ligament tear with the find-ings of 2C (Fig. 11-11), 2E---degenerative arthritis of the

U

2

R

Fi!gure 11-7. The ulnar impaction syndrome with evidence ofchondromalacic changes on the ulnar head and lunate. U, ulna;R, radius; TQ, Iriquetrum; L, lunate; S, scaphoid; H, hamate;C, capitate; TZ. trapezium; TP, trapezoid; 2, 3, 4, 5, metacarpals.

L

R

Class 2A

U

Figure 11-8. The ligamentous supports of the ulnar aspect ofthe wrist (the triangular fibrocartilage complex) illustrating Class 2A lesion. Both the proximal and distal aspects of the TFCChistologically and at times, grossly, evidence degenerative changesas illustrated by the stippling on this illustration (arrow). R, radius;U, ulna; L, lunate; T, triquetrum.

ClaFigure 11-9. The ligamentous supports of the ulnar aspect of thewrist (the triangular fibrocartilage complex) illustrating a Class lesion. In addition to the degenerative changes of the TFCC seen ina Class 2A lesion (stippling), cartilage erosion of the ulnar headbeneath the TFCC is seen (arrow), or of the kissing area of themedial border of the lunate distal to the TFCC (arrow). R, radius;U, ulna; L, lunate; T, triquetrum.

Tdangt~lar Fibrocartilage Complex Injury and Ulnar Wrist Pain 109

Class 2C

Figure 11-10. The Iigarnentous supports of the ulnar aspect of thewrist (the triangular fibrocartilage complex) illustrating a Class lesion. Further progression of the Class 2 degenerative lesions of theTFCC evidences now a large central perforation of the TFC (proximalarrow), as well as the underlying cartilage abnormality of the ulnarhead and distally, the medial aspect of the lunate. R, radius; U, ulna;L, lunate; T, triquetrum.

Figure 11-’11. ~he ligamentous supports of the ulnar aspect of thewrist (the triangular fibrocartilage complex) illustrating a Class 2D lesion.Further progression of the degenerative TFCC abnormalities reveals athrough and through pertoration of the horizontal portion of the TFC(proximal arrow), cartilage abnormalities of the ulnar head and of adjacent area of the medial border of the lunate (distal radial arrow),and a disruption of the lunotriquetral ligament (distal ulna arrow).R, radius; U, ulna; L, lunate; T, triquetrum.

sigmoid, notch, ulnar head, and ulnar carpus with a largeperforation of the TFCC (Fig. 11-12).

Evaluation and Treatment

The evaluation of Class 2 lesions is similar to Class 1lesions with particular attention to ulnar variance on the

neutral PA radiograph. Triple-injection wrist arthrographyfurther defines the pathology and helps determine the lesionclass.

The treatment of .Class 2 lesions or ulnar impaction syn-drome begins with a conservative program of nonsteroidalanti-inflammatory agents, a trial of immobilization untilsymptorns resolve, and steroid injections into the distal

110 Carpus and Distal Radius

Class 2E \ Figure 11-12. The ligamentous supports of the ulnar aspect of thewrist (the triangular fibrocartilage complex) illustrating a Class lesion. The final progression of degenerative TFCC abnormalitiesreveals the findings of a Class 2D lesion, the additional changes ofcartilage abnormalities involving the seat of the ulna, and the sigmoidnotch of the radius. R, radius; U, ulna; L, lunate; T, triquetrum.

radioulnar joint and ulnar carpus. If conservative care isunsuccessful after a three-month trial, then treatment todecompress the ulnar impaction is indicated.

Surgical treatment for the ulnar positive patient is a for-mal ulnar shortening with application of plate fixation(Fig. 11-13) for Class 2A through 2D lesions. Otheroptions include an open-wafer procedure (Fig. 11-14)described by Feldon for Class 2A, 2B, and 2C lesions withthe alternative of an arthroscopic wafer procedure for theClass 2C lesions as described by Buterbaugh. In the ulnarneutral patient, Class 2 lesions are treated with arthroscop-ic limited debridement. Class 2D lesions with TFCC per-foration and lunotriquetral ligament tear are treated withan ulnar shortening (with or without lunotriquetral fusion)based on the stability of the lunotriquetral complex aftershortening. Alternatives in the treatment of this lesion haveincluded the open-wafer procedure with dorsal capsulor-rhaphy of the wrist or combined with lunotriquetral fusion.

Class 2E lesions are best treated with limited ulnar headresection as described by Bowers or Watson, a Suave-Kapandji syndrome, i.e. a distal radioulnar joint arthrode-sis with a proximal pseudo-arthrosis popularized byTaleisnik, or a formal Darrach procedure. The choice ofthe appropriate procedure is based on surgeon preference,the integrity of the complete triangular fibrocartilage com-plex, and the stability of the distal ulna. The advantages ofthe limited ulnar-head resection and the Suave-Kapandjiprocedure are primarily related to maintaining the liga-mentous supports of the distal radioulnar joint as well asthe biomechanical advantage of maintaining the ulnar col-umn of the wrist. The Darrach procedure, described byDingman, is a useful salvage procedure, although radiout-nat impingement at the resection site and distal tip insta-bility can be problematic. Multiple procedures have beendescribed to reconstruct the unstable distal ulna followinga Darrach procedure.

Dislocations of the Distal Radiounlar Joint

Coincident wi~:h TFCC injuries, more severe ulnar patholo-gy can occur with major wrist trauma. Isolated dislocationsoccur involving the distal ulna with the ulna volar or dorsalrelative to the distal radius.

Dislocation Distal Radioulnar Joint--Ulna Dorsal

This injury results from hyperpronation with disruption ofthe dorsal distal radioulnar joint ligaments in partial orcomplete TFCC injury,. Clinically, a dorsal prominenceover the wrist is noted with the forearm locked in pronation.Attempts at supination are painful. CT scan of the distal..radioulnar joint confirms the diagnosis. Closed reductionwith cast immobilization for four weeks in supination is thetreatment of choice. Open reduction is required in late casesor when closed reduction is unsuccessful.

Dislocation Distal Radioulnar Joint--Ulna Volar

Vo]iar dislocations of the distal radioulnar joint are associat-ed with forced supination of the forearm or can be sec-ondary to a direct blow. Pathomechanics may require com-plete disruption of the TFCC. Clinically, the forearm islocked in supination with pain over the distal radioulnarjoint. A furrow or iffdentation is noted on the ulnar side ofthe distal extensor aspect of the forearm, and there is aprominence on the anterior aspect of the wrist. Evaluationby CT scan will show the volar position of the distal ulna..Treatment, as in dorsal dislocations, consists of a closedreduction with direct pressure over the ulna volarly withgentle forearm pronation. The arm is immobilized in prona-tion for four v,c,eeks. In late cases or in unsuccessful closedreductions, open reduction is required.

Distal Radio~ulnar Joint DislocationAssociated with Radial Head Fractures(E,,~se~-Lopresti Lesion)

Injuries to the distal radioulnar joint associated with radialhead fractures can occur at the time of injury (Type 1) result from proximal migation following excision of theradial head (Type 2). Migration generally occurs within thefirst two years: following radial head excision.

Treatment recommendations for Type 1 injuries includean open reduction of the radial head or neck fracture withclosed reduction and pinning of the distal radioulnar joint.If the radial head is not reconstructable, then a radial headsilastic implant with distal radioulnar joint pinning is pet-formed. In Type 2 injuries, a formal ulnar shortening withplate fixation is done to reduce the distal radioulnar join!.and a radial head implant is added to prevent further proxi-mal migration of the radius. Problems associated withsilastic radial head implants are recognized, and theimplants may require removal at a future time. This area is

Triangular Fibrocartilage Complex In.iury and Ulnar Wrist Pain 111

Figure 11-13. An ulna shortening osteotomy with application of a seven-hole dynamic compression plate is shown. Note the obliqueosteotomy and the compression lag screw applied. Note the decompression of the ulnar impaction at the distal radioulnar joint.

being intensely studied for possible attempts at reconstruc-tion of the interosseous membrane. If the distal radiounlari~:int shows significant degenerative changes, then recon-’i~.~cti’v’e options including a hemiresection arthroplastywith ulnar shortening, distal radioulnar joint fusion withproximal pseudarthrosis (Suave-Kapandji procedure), distal ulna excision may be required. A final salvage tech-nique may be conversion to a one-bone forearm.

Subluxation of the Extensor Carpi Ulnaris Tendon

Spinner and Kaplan have described the anatomy of the sixthdorsal compartnaent and a fiberosseous tunnel overlying1.5 cm to 2.0 cm of distal ulna. The extensor carpi ulnarisalone occupies this compartment. It is held tight to theulnar group by the extensor carpi ulnaris tendon sheath. Theextensor retinaculum, a separate structure from the ECU

112 Carpus and Distal Radius

Figure 11-14. Wafer procedure is diagrammed with excisionof the distal 2mm of ulnar head. This can be performed as anopen technique or arthroscopically.

tendon sheath, passes around the ulna to insert on the palmaraspect of the carpus and soft tissues.

With forced supination, palmar flexion, and ulnar devia-tion, the ECU tendon can rupture or attenuate the extensorcarpi ulnaris tendon sheath to dislocate in a palmar andulnar direction (Fig. 11-15). The tendon relocates on fore-arm pronation. This change in position of the extensor carpiulnaris with forearm rotation produces a clicking or snap-ping, and in some instances causes pain. Cases have beenreported, as well, of partial rupture of the extensor carpiulnaris associated with subluxation over a prominent por-tion of the distal ulna causing an abrasion to the undersur-face of the extensor carpi ulnaris. Treatment in acute casesshould include immobilization in a long-arm plaster splintin pronation with the wrist in slight dorsiflexion and radialdeviation. For chronic cases, operative reconstruction usu-

Figure 11-15. Subluxated ECU tendon with extensor retinaculumreflected above shows tendon’s fiberosseous sheath attenuatedyet intact.

ally is required and involves the medial wall of the exten-sor carpi ulnaris tendon sheath.

Calcific Tendonitis

The sudden onset of pain without history of trauma to theulnar aspect of the wrist, particularly associated with repeti-tive ulnar deviation, can occur. Clinical presentation includesswelling over the extensor carpi ulnaris or flexor carpi ulnaristendon sheatlas with occasional crepitation on range ofmotion. Radiographs may show calcific deposits within thetendon sheath consistent with calcific tendonitis. Most casesgenerally respond to oral nonsteroidal anti-inflammatoryagents or steroid injection with splinting.

Lunotriquetral Instability

Pain over the: ulnar aspect of the wrist distal to the distalradioulnar joint may be associated with disruption of thelunotriquetral ligament. In cases not associated with theulnar impaction syndrome, well-localized tenderness overthis site as well as pain is associated with manipulation ofthe lunate and triquetrum and/or pain associated with stressat the midcarpal joint. Further progression of these symp-toms may lead to a volar carpal instability or VISI patternor an associated dynamic midcarpal instability. In isolatedlunotriquetral instability, with a lunotriquetral ligamenttear, ulnar variance is carefully examined for ulnarimpaction syndrome (i.e., an ulnar positive variance). cases of ulnar negative variance, multiple procedures forlunotriquetral instability have been attempted. Wrist dorsalcapsulorrhaphy, ligament reconstruction, and lunotriquetralfusion have been tried with mixed results.

Pisotriquetral Subluxation, Dislocation,a~td Osteoarthritis

Subluxation and dislocation of the pisotriquetral joint havebeen studied by Vasilas and associates on the radiographicasl?ec~ of the pisotriquetral joint. A pisotriquetral view ofthe joint is required with the forearm positioned 30°

supinated off the neutral position. Loss of symmetUbetween the pisiform and triquetrum is examined andrequired for ~:he diagnosis. A carpal tunnel view may behelpful in fu~Iher assessment of this joint.

Pisotriquetral osteoarthritis is more a common problemassociated with localized tenderness over the pisotriquetraljoint. Frequently on clinical exam, manipulation ,of the pisi-form over the,’ triquetrum causes intense pain. Local anes-thetic injection into the pisotriquetral joint confirms thediagnosis. The radiographic views as described above, the30° supinated view, as well as carpal tunnel views, will fre-quently show loss of joint space and osteophyte forma-tion (Fig. 11-16).

]initial treatment of pisotriquetral pathology involves rest.nonsteroidal anti-inflammatory agents, and steroid injec-

Triangular Fibrocartilage Complex Injury. and Ulnar Wrist Pain 113

Figure 11-16. Thirty-degree supinated view identifying thepi~c:r~quetral joint. Note the degenerative changes present.

tions into the pisotri.quetral joint. If conservative therapyfails, then operative treatment is required with pisiformexcision from the flexor carpi ulnaris tendon sheath.

Other Causes of Ulnar Wrist Pain

The complete evaluation of the ulnar aspect of the wristmust include a careful neurologic and vascular exam of thehand. A c.areful sensory exam as well as motor exam isrequired for all patients with ulnar wrist pain. Specificattention to the evaluation of the ulnar nerve in Guyon’scanal as well as the dorsal cutaneous branch of the ulnarnerve and its anatomic variations are important in thisanalysis. ’The vascular status, as well, must be carefullyevaluated with an Allen’s test to evaluate the patency of theulnar artery. Other conditions can be referred to the ulnaraspect of the wrist, such as hamate hook fractures,Kienbrck’s disease, intraosseous and extraosseous gan-glions, tumors of the: carpal bones, distal ulna and radius,and medial facet artbxitis of the lunate.

Conclusiion

In the evaluation of the patient with a TFCC injury or ulnarwrist pain secondary to other causes, the clinician must becomplete in the evaluation process to confm-n the diagnosis.As a general rule, conservative options should be tried inmost instances of TFCC injury with operative treatment pre-served for patients unresponsive to conservative care orwhen instability is present. ,One will frequently see thepatient who has undergone multiple procedures for ulnarwrist pain with continued disability. Care must be taken toidentify the cause of the problem as well as the subsequentgoals of the patient in the rehabilitation of this wrist injury.

Annotated Bibliography

TFCC Lesion: Injury Patterns and TreatmentBicbcr W, Linscheid RL, Dobyns JH. Beckenbaugh RD: Faileddistal ulna resections. J Hand Stui~,. 113A:l 91-200, 1988.

Study of 20 patients with failed distal ulna resections suggestedthut the procedure should be avoided in yotltlg patients zttad those~ ith ligamcntous laxity.

[~il.~ Z J, Chamberland D: Distal ulnar head shortening for~r,’:m~cnt of triangular fibrocartilage complex tears with ulna...... :li~c variance. J HandStog. 16A:I 115-9, 1991.

~.~ ~ to 4ram of cartilage and subchondral bone ~as excised fromfi~c ulnar head ii~ seven patients with a TFCC tear and ulna positivex ariancc. Six patients had either complete or marked improvementill ~3 rlll~[ollls"

Boulas H J, Milek MA: Ulnar shortening for tears of thetriangular fibrocartilaginous complex. J Hand Surg,15A:415-420, 1990.

The ulna was shortened an average of 2ram in l0 consecutivepatients with ulnar wrist pain associated with TFCC tears. Sixpatients had ulnolunate abutment and/or cartilage degeneration. ~Pain relief and grip strength were excellent, but flexion decreased anaverage of 25.8° postoperatively.

Buck-Gramcko D: On the priorities of publication of someoperative procedures on the distal end of the ulna. J HandSurg, 15B:416-420, 1’990.

A literature review of distal ulna procedures for the treatment ofposttraumatic conditions of the distal radioulnar joint. Options are

114 Carpus and Distal Radius

outlined, and included in the discussion are the origins of the namesof the procedures attributed to certain authors.

Darrow JC, Linscheid RL, Dobyns JH, Mann JM, WoodMB, Beckenbaugh RD: Distal ulnar recession for disordersof the distal radioulnar joint. J Hand Surg, 10A:482--491,1985.

Thirty-six wrists in 35 patients were treated with an ulnarshortening osteotomy to stabilize or decompress the distal radioulnarjoints. Twenty-eight of the 36 wrists had good to excellent results at a24.5-month follow-up.

Hermansdorfer JD, Kleinman WB: Management of chronicperipheral tears of the triangular fibrocartilage complex.J HandSurg, 16A:340-6, 1991.

In 13 patients with traumatic peripheral separation of the TFCC,reattachment was done with nonabsorbable sutures passed throughdrill holes at the medial base of the ulnar styloid. Eight of the I ipatients returned to painless activities. Two of the three otherpatients did well after additional surgery (distal ulna resection inone and ulnar shortening osteotomy in the other).

Minami A, Kaneda K, Itoga H: Hemiresection-interpositionarthroplasty of the distal radioulnar joint associated withrepair of triangular fibrocartilage complex lesions. J HandSurg, 16A:1t20-5, 1991.

Hemiresection-interposition arthroplasty with repair of the tomTFCC was performed in 16 wrists to prevent ulnar headimpingement on the TFCC. There was complete pain relief in I0wrists. Grip strength and range of motion improved in all wrists.

Osterman AL: Arthroscopic debridement of triangularfibrocartilage complex tears. Arthroscopy, 6(2); 120-4, 1990.

A prospective study of 52 consecutive patients showed that 86%had a positive initial arthrogram and 66% had a positive bone scanat the time of diagnostic arthroscopy; 34% of the tears were linear,46% central perforation, and 20% ulnar or peripheral perforation.Eleven patients had no visible tear. The author concluded thatarthroscopic debridement reduced symptoms without increasingclinical ulnar instability,.

Palmer AK: Triangular fibrocartilage complex lesion: aclassification. J Hand Surg, 14A:594-606, t989.

TFCC injuries were classified into traumatic and degenerativelesions after analysis of anatomic, biomechanical, and clinicalstudies.

Palmer AK, Wemer FW: The triangular fibrocartilagecomplex of the wrist anatomy and function. J Hand Surg,6A:153-162, 1981.

The TFCC is anatomically described as the homogeneousstructure composed of the articular disk, the dorsal and volarradioulnar ligaments, the meniscus homologue, the ulnarcollateral ligament, and the sheath of the extensor carpi ulnaris.Biomechanical studies suggested that the TFCC functions as acushion and a major stabilizer of the distal radioulnar joint.

Palmer AK, Glisson RR, Wemer FW: Ulnar variancedetermination. J Hand Sm~. 7A:376-379, 1982.

The technique of ulnar variance determination is describedplacing the forearm in a neutral tbrearm rotation position withthe elbow flexed and obtaining a PA radiograph of the wrist. A

template is utilized to measure accurately the variance betweenthe length of the radius and ulna.

Palmer AK, Glisson RR, Wemer FW: Relationship betweenulnar variance and triangular fibrocartilage complexthickness. J Hand Surg, 9A:681-683, 1984.

Anatomic data is presented showing an inverse relationshipbetween positive ulnar variance and TFCC thickness.

Palmer AK, Werner FW, Glisson RR, Murphy D J: Partialexcision of the triangular fibrocartilage complex. J HandSurg, 13A;403-406, 1988.

Excision of less than two thirds of the horizontal part of theTFCC cadavers did not alter axial load transmission.

Shaw JA, Bruno A, Paul EM: Ulnar stytoid fixationin the treatment of posttraumatic instability of the radioulnarjoint; A biomechanical study with clinical correlation.J Hand Surg, 15A:712-720, 1990.

Biomechanical testing of nine cadaver specimens showed that theTFCC was the: main stabilizer of the radioulnar joint. Internalfixation of the ulnar styloid avulsion fractures restores stability inall forearm rotation positions.

Viegas SF, Pogue DJ, Patterson RN, Peterson PD: Effects ofradioulnar instability on the radiocarpal joint: Abiomechanical study. J Hand Surg, 15A:728-32, 1990.

Computerized analysis of pressure-sensitive film measurement ofEve cadaver specimens was used to analyze three stages ofradioulnar instability. In forearm supination, all stages of radioulnarinstability resulted in-decreased lunate contact area. In neutralforearm rotation, stage 3 instability demonstrated decreased lunatecontact area. In stage 3 instability the lunate high pressure wasslhifted volar.

r)islocations of the Distal Radioulnar JointButerbaugh GA, Palmar AK: Fractures and dislocations ofthe distal radioulnar joint. Hand Clin, 4(3):361-75, 1988.

A systemic ~:~view is presented of the mechanism, presentation.and treatment of fractures and dislocations of the distal radioulnarjoint. These injuries included ulna dorsal and ulna volar dislocationsas well as lesions associated with fractures of the radial head(Essex-Lopresti lesion) and dislocations of the distal radioulnarjoint associated with radial shaft fractures (Galleazzi fractures).

Extensor Ca~rpi Ulnaris SubluxationEckhardt WA, Palmer AK: Recurrent dislocation of extensorcarpal ulnari:~ tendon. J Hand Surg, 6A:629-631, 1981

Four cases of extensor carpal ulnaris subluxation secondary, tosheath attenuation are presented. Sheath reconstruction wass~accessful in relieving symptoms.

Lunotriquetra! Instability tI-torii E, Garcia-Elias M, An KN, et al: A Kinematic study oflunotriquetral dissociations. J Hand Surg, 16A:355-62, 1991.

Stereoradiographic analysis of five cadaver specimens showedthat the essential lesion to produce a static palmar flexed intercalatedsegmented insl:ability was transection of the dorsal radiotriquetralaad dorsal scaphotriquetral ligaments in addition to the division ofthe lunotriquetral ligament and interosseous membrane.

Pin PG, Young VL, Gilula LA, Weeks PM: Management ofchronic lunotriquetral ligament tears. J Hand Surg, 14A:77-

83, 1989.Eleven patients with chronic lunotriquetral ligament tears were

t~ated with lunotriquetral fusion using a compression screw. Allpatients had fusion achieved at two to five months. Only threepatients had persistent pain postoperatively.

Viegas SF, Patterson RM, Peterson PD, et al: Ulnar-sidedpedlunate instability; an anatomic and biomechanic study.J Hand Surg, 15A;268,78, 1990.

The spectrum of ulnar-sided perilunate instability is described inthree stages based on anatomic disruption and instability. Stage I:lunotriquetral ligament tearing without instability. Stage 1I:lunotriquetral ligament tear and palmar ligamentous tears withdynamic VISI deformity. Stage llI: Complete lunotriquetraldisruptions with palmar and dorsal disruption with static VISIdeformity.

Triangular Fibrocartilage Complex Injury and Ulfiar Wrist Pain

Pisotriquetral Joint DisordersPaley D, McMurtry RY, Cruickshank B: Pathologicconditions of the pisiform and pisotriquetral joint.J Hand Surg,. 12A: 110-119, 1987.

This paper reviewed 216 reported cases of p isotriquetraldisease in the last 65 years. The authors’ experience with16 cases of pisotriquetral joint disease is described.Pathologic study suggests repetitive trauma leads todysfunction of the pisotriquetral joint, then to instability,followed by degenerative changes.

Seradge H, Seradge E: Pisotriquetral pain syndromeafter carpal tunnel release. J Hand Surg, 14A;858-862, 1989.

Pain from the pisotriquetrai joint was present in 1. 1% of500 patients s:.ix months postoperatively following carpaltunnel release. Pisiform excision was curative.

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