➢ The triangular fibrocartilage complex includes the articular disk, the meniscus homologue, the palmar and dorsal distal radioulnar ligaments, the sheath of the extensor carpi ulnaris, the ulnotriquetral ligament, the ulnolunate ligament, and the ulnar capsule. Together, these structures stabilize the ulnocarpal and distal radioulnar joints, transmit load from the carpus to the ulna, and assist with wrist mechanics.
➢ When injured, the triangular fibrocartilage complex can be a major contributor to ulnar-sided wrist pain and can be associated with damage of the carpal bones and instability of the distal radioulnar joint.
➢ Management of injuries of the triangular fibrocartilage complex includes nonoperative options and both open and arthroscopic operative techniques.
The triangular fibrocartilage complex is a multifaceted ligamentous structure providing support to the ulnocarpal articulation. Improved understanding of the complicated anatomy of the triangular fibrocartilage complex coupled with recent advances in surgical techniques will improve orthopaedic care.
The triangular fibrocartilage complex supports the ulnar side of the wrist, provides stability to the distal radioulnar joint, and is the most common source of ulnar-sided wrist pain when injured1-3. Knowledge of the anatomy, biomechanics, and pathology of the triangular fibrocartilage complex has increased greatly over the last three decades, leading to increased awareness of this structure among physicians4. In one cadaveric study, more than half (thirty-two) of sixty-one specimens had perforations of the triangular fibrocartilage complex5. All specimens with tears had evidence of damage to the lunate and/or distal ulnar cartilage, illustrating that damage to the triangular fibrocartilage complex and subsequent instability of the distal radioulnar joint can be associated with ulnolunate abutment5. This was reiterated by Lee et al., who found that the majority (fifty-eight) of ninety-six cadaveric specimens (average age at the time of death, seventy-five years) had disruption of the triangular fibrocartilage complex, which frequently resulted in arthrosis of the distal radioulnar joint6. Furthermore, in a study of distal radial fractures in fifty patients two to sixty years of age, the triangular fibrocartilage complex was torn in 78% (thirty-nine), making it the most frequent ligament tear in adults with a distal radial fracture7.
Anatomy and Histological and Biomechanical Characteristics
The triangular fibrocartilage complex is a complex arrangement of multiple structures, including the articular disk, the meniscus homologue, the palmar and dorsal distal radioulnar ligaments, the sheath of the extensor carpi ulnaris, the ulnotriquetral ligament, the ulnolunate ligament, and the ulnar capsule (Figs. 1, 2, and 3)1,8,9. Together, these structures stabilize the ulnocarpal and distal radioulnar joints, transmit load from the carpus to the ulna, and assist with wrist mechanics8-11.
The articular disk is triangular in shape, is made up of fibrocartilage, and lies between the dorsal and palmar distal radioulnar ligaments; its outer edge blends with their superficial fibers1,4,8,12. On histological sectioning, it transitions from the superficial zone of hyaline cartilage of the radius13. Distally, the disk is rich in chondrocytes and a chondroid matrix, suggesting that its function is to absorb pressure from the ulnar carpus11. Its center is avascular11. It has ulnar attachments to the styloid process, head of the ulna, extensor carpi ulnaris sheath, and meniscus homologue11,13. The extensor carpi ulnaris sheath attaches to the fovea, as does the articular disk via this connection12. If the triangular fibrocartilage complex is thought of as a hammock suspending the ulnar carpal bones, the disk would represent the center of this hammock8. It is partially responsible for load transmission from the carpal bones to the distal part of the forearm4. It exhibits very little if any distortion during pronation and supination of the wrist, allowing support of the ulnar carpus throughout wrist motion8. The outer 15% to 20% of the articular disk is vascularized while centrally it has no distinct blood supply (and poor healing potential) and is nourished by synovial fluid4,9,14,15.
The meniscus homologue extends from the dorsal-ulnar portion of the distal part of the radius to the palmar-ulnar portion of the triquetrum1. It blends into the ulnar capsule and the ulnar aspect of the superficial distal radioulnar ligament and lies between these two structures1. Histologically, it is not well defined and consists of irregular fibrous connective tissue13. It has a meniscal appearance on coronal section and contours distally, adding to the hammock-like shape of the distal triangular fibrocartilage complex11. It stretches during radial deviation and compresses during ulnar deviation11.
Distal Radioulnar Ligaments
The palmar and dorsal distal radioulnar ligaments appear as a thickened periphery around the articular disk with longitudinally oriented fibers1. These ligaments consist of both superficial and deep portions, which are combined at their attachment to the medial border of the distal part of the radius at the dorsal and palmar limits of the sigmoid notch and split as they travel ulnarly to their respective insertions1,4,9,11,12. Histologically, these ligaments are seen to attach directly to bone at both their origin on the radius and their insertion on the fovea via zones of calcified and uncalcified fibrocartilage11,13. The superficial portion inserts more distally around the periphery of the articular disk and the base of the ulnar styloid while the deep ligaments, or ligamentum subcruentum, insert more proximally on the fovea of the ulna1,4,8,10-12. The radioulnar ligaments are well vascularized at their periphery via branches of the anterior interosseous artery4,9.
The distal radioulnar ligaments are major stabilizers of the distal radioulnar joint, which is formed by the ulnar head and the sigmoid notch of the distal part of the radius4,9,16. During pronation and supination, the radius rotates about the fixed ulna with the center of rotation located in the fovea of the ulnar head4,16. The foveal insertion of the deep portion of the radioulnar ligaments makes it more mechanically advantageous than the superficial portion in terms of stabilizing the distal radioulnar joint throughout pronation and supination4,10,12.
In the neutral forearm position, the sigmoid notch accepts 60° to 80° of the convexity of the ulnar head, lending stability16. However, the sigmoid notch has a greater diameter than the ulnar head and, as a result, during extremes of pronation and supination the ulnar head translates dorsally and volarly, respectively, and becomes almost entirely uncovered16. In forearm pronation, the dorsal superficial fibers and palmar deep fibers of the radioulnar ligament tighten, providing stability to the distal radioulnar joint4. Conversely, in supination, the palmar superficial and dorsal deep fibers tighten4. At the limits of pronation and supination, during ulnar head translation, the superficial fibers of the radioulnar ligament become ineffective because of their less advantageous insertion point; thus, at these extremes, the deep portion of the ligament (ligamentum subcruentum) becomes the primary stabilizer of the distal radioulnar joint4.
Extensor Carpi Ulnaris Sheath and Ulnar Capsule
The ulnar capsule, or ulnar collateral ligament, arises from the tip of the styloid process and makes up the volar-ulnar, ulnar, and dorsal portions of the triangular fibrocartilage complex11. It borders the triangular fibrocartilage complex from the ulnotriquetral ligament volarly to the extensor carpi ulnaris sheath dorsally, where it makes up the floor of the sheath1,8. It is poorly defined histologically; however, distinct collagen fiber bundles have been identified in this structure13.
The extensor carpi ulnaris sheath attaches to the triquetrum and to the dorsal portion of the ulnar styloid1. It has a strong connection to the ulnar fovea and may be important to ulnocarpal stability12.
Ulnotriquetral and Ulnolunate Ligaments
The ulnotriquetral ligament originates on the volar-radial portion of the base of the ulnar styloid via the palmar radioulnar ligament and inserts at the palmar portion of the triquetrum dorsal to the volar lunotriquetral ligament1,12. Some sources suggest that its true origin is the ulnar fovea10. It widens proximally to distally from its origin on the ulna to its insertion on the triquetrum. It interweaves distally with the ulnotriquetral interosseous ligament, which also intertwines with the palmar ulnotriquetral ligament and the ulnolunate ligament1.
The ulnolunate ligament originates on the volar portion of the articular disk and from the volar portion of the lunate fossa of the distal part of the radius1. Like the ulnotriquetral ligament, its true origin is the ulnar fovea according to some sources10. It blends proximally with the superficial fibers of the volar radioulnar ligament and inserts distally on the volar portion of the lunate1,12.
The ulnotriquetral ligament is taut during wrist extension and radial deviation and relaxed during wrist flexion and ulnar deviation10. The ulnolunate ligament is taut during wrist extension and ulnar deviation and relaxed during wrist flexion (it is unaffected by radial deviation)10. Both the ulnotriquetral and the ulnolunate ligaments become taut in wrist supination, suggesting that they act as a sling to resist carpal supination; attenuation of these ligaments in patients with inflammatory arthritis helps to explain the characteristic prominent ulna found with this disease spectrum (the carpus supinates away from the ulna)17.
Dorsal Cutaneous Branch of the Ulnar Nerve
The dorsal cutaneous branch of the ulnar nerve is a terminal branch that arises about 5.5 cm proximal to the head of the ulna and innervates the skin overlying the dorsal-ulnar aspect of the hand and the bases of the small finger and ulnar side of the ring finger18,19. It sits approximately 2.4 cm distal to the styloid on a line drawn from the styloid to the fourth dorsal web space and passes the ulnar side of the styloid at an average distance of 1.4 cm18,19. This puts the nerve at risk during placement of the 6-R portal for wrist arthroscopy (Table I)18. Damage to the nerve can be avoided by placing the portal in a so-called safe zone in the proximal fifth of a line drawn from the ulnar styloid to the fourth dorsal web space18. However, aberrant branches of the nerve that can be injured in the safe zone have been described18,19.
The triangular fibrocartilage complex is supplied by three main arterial branches: the ulnar artery and the palmar and dorsal branches of the anterior interosseous artery9. These vessels supply the periphery of the triangular fibrocartilage complex and the outermost 15% to 20% of the articular disk9,14,15. Tears in these areas of the triangular fibrocartilage complex have the potential to heal if they are repaired9,14.
The central aspect of the triangular fibrocartilage complex has no appreciable innervation. However, the volar and ulnar portions of the triangular fibrocartilage complex are innervated by branches of the ulnar nerve and the dorsal sensory branch of the ulnar nerve20. The dorsal portion of the triangular fibrocartilage complex has innervation from branches of the posterior interosseous nerve and the dorsal sensory branch of the ulnar nerve20. Whereas the volar innervation of the triangular fibrocartilage complex is relatively consistent, the innervation of the ulnar and dorsal portions of the triangular fibrocartilage complex is variable and not always present20.
Methods of Diagnosis
Multiple modalities are utilized to arrive at a correct diagnosis of injuries of the triangular fibrocartilage complex. A focused history followed by a thorough physical examination of the wrist should dramatically narrow the differential diagnosis (Table II). Subsequently, a final diagnosis may be confirmed with diagnostic imaging21.
The clinician should ascertain hand dominance; previous injuries and surgical procedures; and a detailed history of regular activities, focusing on those involving repetitive movements. The clinician should also focus on the onset of symptoms and the mechanism of injury9. The etiology of ulnar-sided wrist pain can be acute injury, overuse injury, or chronic degenerative conditions3. Symptoms may be acute or chronic and include loss of wrist rotation (instability of the distal radioulnar joint), a painful and limited range of motion at the wrist, and pain over the distal radioulnar joint and/or distal part of the ulna9.
Physical examination of the triangular fibrocartilage complex requires a systematic approach including observation, assessment of the range of motion, palpation, and provocative tests3,9,21. The examiner should compare the extremities, taking note of any asymmetry such as scars, erythema, cyanosis, swelling, or a prominent ulna (a sign of an injury of the distal radioulnar joint)3. Patients with ulnar-sided anatomic injury typically localize their pain to the ulnar side of the wrist3.
The active and passive ranges of motion should be compared between the affected and contralateral extremities. Wrist flexion (normal: 80°) and extension (normal: 70°) and forearm supination and pronation with the elbow flexed to 90° (normal: 90° each) should be documented9,21.
The triangular fibrocartilage complex can be palpated distal to the ulnar head in the depression between the pisiform, flexor carpi ulnaris, and ulnar styloid9. Tenderness in this anatomic area, termed the fovea, represents a positive ulnar fovea sign, which may indicate a tear of the ulnotriquetral ligament, foveal disruption of the triangular fibrocartilage complex, or chondromalacia on the ulnar aspect of the lunate suggestive of ulnocarpal impaction3,21,22. This sign is 95.2% sensitive and 86.5% specific for such pathological conditions3,22.
The ulnocarpal stress test (ulnar deviation with axial loading of the wrist in alternating supination and pronation) is a useful tool for screening for ulnar-sided, intra-articular pathological conditions3,9,23. However, it is not as specific as the foveal sign for pinpointing pathological involvement of the triangular fibrocartilage complex and may also indicate ulnotriquetral ligament injuries, ulnocarpal abutment syndrome, arthritis, and loose bodies3. A positive grind test—signified by audible clicking, a feeling of crepitus, or pain on passive manipulation of the wrist with alternating pronation and supination—may also suggest a tear of the triangular fibrocartilage complex21. A positive lunotriquetral shuck test—pain and laxity when the examiner grasps the pisotriquetral unit between the thumb and index finger of one hand and grasps the lunate with the other hand and applies alternating dorsal and volar forces—can help rule in a concomitant lunotriquetral ligament injury3,24,25. In addition, pain over the pisotriquetral joint elicited by compression or shuck can be secondary to a pisotriquetral pathological condition rather than injury of the triangular fibrocartilage complex26.
After a thorough history has been obtained and physical examination has been performed, diagnostic imaging can narrow a differential diagnosis and direct an appropriate treatment plan3. Conventional radiographs, including neutral rotation posteroanterior views, posteroanterior views in radial and ulnar deviation, lateral views, and pronated posteroanterior clenched-fist stress views, help determine ulnar variance, carpal alignment, fractures, and degenerative changes27-29. In addition, axial computed tomography of both wrists in neutral, pronation, and supination may detect subluxation of the distal radioulnar joint3,27. Furthermore, conventional arthrography can elucidate complete or partial tears of the triangular fibrocartilage complex3,27. However, because of a lack of sensitivity and specificity with conventional arthrography, that technique has largely been supplanted by magnetic resonance imaging (MRI) and MR arthrography, which are presently the diagnostic tests of choice for triangular fibrocartilage complex injuries29-31. MRI is especially useful for evaluation of ligament disruptions, cartilage defects, tendon abnormalities, occult fractures, and osteonecrosis3,27. Moreover, MR arthrography and high-resolution MRI with dedicated wrist coils offer the best images of the small structures of the wrist and full-thickness tears of the triangular fibrocartilage complex27,32. Standard MRI has only a 44% sensitivity for tears of the triangular fibrocartilage complex; thus, dedicated wrist coils should be used when an injury of the triangular fibrocartilage complex is suspected32,33. However, asymptomatic individuals have a high prevalence of abnormal MRI findings in the triangular fibrocartilage complex, and an unresolved challenge is differentiating a mechanically unimportant perforation from a tear34. This is also true for wrist arthroscopy, which is the standard of care for diagnosis of intra-articular wrist lesions but may also detect clinically irrelevant lesions23. Therefore, MRI and wrist arthroscopy findings should be considered in the context of symptoms and physical examination findings.
Background of Injuries of the Triangular Fibrocartilage Complex
Tears of the triangular fibrocartilage complex are classified as acute (less than three months from the time of injury), subacute (three months to one year), or chronic (greater than one year)3,35. They are further categorized as traumatic or degenerative3. Traumatic tears typically occur in the setting of falls on an outstretched hand, violent traction of the wrist, and twisting injuries to the forearm3,36. Activities with rapid forearm rotation and ulnar-sided loading, such as swinging a tennis racquet, baseball bat, or golf club, can lead to injury, particularly in patients with ulnar positive wrists37,38.
Triangular fibrocartilage complex injury occurred in 53% (sixteen) of thirty extra-articular distal radial fractures and 35% (thirty-one) of eighty-eight intra-articular distal radial fractures in the study by Richards et al., and they are often accompanied by an ulnar styloid fracture37,39. When patients with a distal radial fracture are noted to have instability of the distal radioulnar joint, disruption of the distal radioulnar ligaments of the triangular fibrocartilage complex is often the cause; in fact, seventeen of nineteen of such patients had a partial or complete triangular fibrocartilage complex tear in the study by Lindau et al.40,41. Severe bidirectional instability occurs when both the dorsal and the palmar radioulnar ligament are disrupted40. When triangular fibrocartilage complex injuries are combined with instability of the distal radioulnar joint, patients can experience pain, decreased grip strength, and mechanical symptoms42.
While most tears of the triangular fibrocartilage complex associated with a distal radial fracture are not treated acutely, an unhealed tear of the triangular fibrocartilage complex can lead to chronic ulnar-sided wrist pain and instability of the distal radioulnar joint with arthrosis32,40,43,44. However, there are no definitive guidelines regarding acute repair of the triangular fibrocartilage complex at the time of distal radial fixation.
Classification and Diagnosis of Injuries of the Triangular Fibrocartilage Complex
The Palmer classification has been historically used to classify tears of the triangular fibrocartilage complex. Palmer class-1 tears are traumatic, whereas class-2 tears are degenerative; the tears are further categorized by their anatomic location and the degree of chondromalacia or arthritic change (Table III)36,45-48. Recently, as the understanding of the three-dimensional anatomy of the triangular fibrocartilage complex has improved, there has been more emphasis on treatment based on the diagnosis of a tear of the distal or proximal component of the triangular fibrocartilage complex36. The proximal component is made up of the distal radioulnar ligaments and the strong foveal attachment of the ligamentum subcruentum, which lend stability to the distal radioulnar joint, whereas the distal component describes the ulnar collateral ligament and the distal hammock structure that suspends the carpus8,49. When the proximal component of the triangular fibrocartilage complex is torn, the distal radioulnar joint becomes unstable36,49.
A Palmer class-1B lesion may or may not include an ulnar styloid fracture at its base50. This is important because such a fracture typically represents some degree of instability of the distal radioulnar joint50. Furthermore, a fleck fracture off the ulnar head represents a probable avulsion of one or both deep radioulnar ligaments (ligamentum subcruentum) from their foveal attachment, which is also indicative of instability42.
If arthroscopic assessment is performed, the two most important tests are the trampoline and hook tests (Table IV). With the trampoline test, the examiner assesses the tautness of the triangular fibrocartilage complex by applying a compressive load across it with a probe36. The test is positive when the triangular fibrocartilage complex is soft and compliant, indicating a likely peripheral tear. The hook test is performed by applying traction to the ulnar-most aspect of the triangular fibrocartilage complex with a probe through the 4-5 or 6-R portal (Table I). A triangular fibrocartilage complex that can be pulled upward and radially toward the center of the radiocarpal joint suggests disruption of the foveal attachment of the posterior component of the triangular fibrocartilage complex36.
Injuries of the Distal Radioulnar Joint
Instability (abnormal translation) of the distal radioulnar joint is categorized as slight (<5 mm), mild (5 to 10 mm), or severe (>10 mm)36. Abnormal translation in full supination suggests rupture or stretching of the dorsal limb of the posterior component of the triangular fibrocartilage complex. Abnormal translation in full pronation suggests injury to the palmar limb of the posterior component of the triangular fibrocartilage complex36.
A tear of the triangular fibrocartilage complex associated with an injury to the distal radioulnar joint may require reconstruction of the distal radioulnar joint if the triangular fibrocartilage complex cannot be repaired to the fovea40,42. There are three categories of distal radioulnar joint reconstruction: (1) a direct radioulnar tether that is extrinsic to the joint, (2) an indirect radioulnar link through a tenodesis or an ulnocarpal sling, or (3) reconstruction of the distal radioulnar ligaments42. The best option is currently thought to be reconstruction of the distal radioulnar ligament since there are concerns about the stability and biomechanics of the other repairs42.
Salvage of the distal radioulnar joint is recommended if there is substantial arthrosis or cartilage injury36,51. Options for salvage include the Bowers procedure (hemiresection arthroplasty of the distal part of the ulna with preservation of the styloid and triangular fibrocartilage complex), Darrach procedure (distal ulnar resection), and Sauvé-Kapandji technique (fusion of the distal radioulnar joint with resection of a distal portion of the ulnar shaft to preserve forearm rotation)29,51.
Management (Table V)
Initial management of most triangular fibrocartilage complex tears is nonoperative, including immobilization in a cast or splint followed by hand therapy; in one study, 57% (forty-eight) of eighty-four patients with a triangular fibrocartilage complex tear had enough improvement after four weeks of immobilization to avoid an operation3,37,52. Some physicians also have success using corticosteroid injections3,37,43,52,53. Given the adequate ulnar-sided peripheral blood supply of the triangular fibrocartilage complex, Palmer class-1B and 1C injuries may heal without an operation if they are immobilized properly35.
Contraindications to repairs of triangular fibrocartilage complex lesions include severe osteoarthritis, previous soft-tissue infection or osteomyelitis, or severe osteoporosis of the ulnar head36. Relative contraindications are unaddressed positive ulnar variance with secondary ulnar impaction, carpal chondromalacia, and hypoplasia of the sigmoid notch (unless osteoplasty of the sigmoid notch is also performed)36,54.
Injuries of the triangular fibrocartilage complex with a potential for being treated successfully with surgery should be addressed within three to six months after they are sustained55. Open repair of the triangular fibrocartilage complex, including the dorsal and volar approaches described by Hermansdorfer and Kleinman and by Moritomo, respectively, was the standard treatment historically; however, today there is more emphasis on arthroscopic methods43,56,57. Anderson et al. reported no statistical difference in clinical outcomes between open and arthroscopic repairs of the triangular fibrocartilage complex58. Open repair remains a good surgical option for surgeons who are not as comfortable with arthroscopy or those who recognize a tear of the triangular fibrocartilage complex while fixing the distal part of the radius59.
The commonly used portals are the 3-4, 6-U, 6-R, distal radioulnar joint, and direct foveal portals (Table I)36,50. The direct foveal portal is 1 cm proximal to the 6-U portal and made with the forearm in full supination to displace the ulnar styloid and extensor carpi ulnaris tendon; it allows access to the ulnar head volar to the triangular fibrocartilage complex36. The distal radioulnar joint portal can be used to inspect the posterior component of the triangular fibrocartilage complex for undersurface, partial-thickness lacerations that cannot be seen from the radiocarpal joint or for avulsions from the fovea36. Some surgeons perform a volar approach through the tendon sheath of the flexor carpi radialis to further visualize dorsal structures60. A volar-ulnar portal has also been described61.
The edges of any torn tissue and any exposed bone surface should be debrided to cause bleeding and thereby improve blood flow to the tissues prior to performance of the repair62. Central (Palmer class-1A) and degenerative tears do not heal well when repaired and are best treated with simple tear debridement with or without an ulnar shortening osteotomy45,53. Palmer class-1B, 1C, and 1D lesions are commonly amenable to arthroscopic repair53.
Radial tears (Palmer class 1D) are repaired by passing suture through the radial triangular fibrocartilage complex and then through bone tunnels (or an anchor/biotenodesis screw) to secure the structure to the distal part of the radius35,63. Multiple arthroscopic techniques to suture the torn triangular fibrocartilage complex to the dorsal ulnocarpal joint capsule and extensor carpi ulnaris tendon sheath have been described3. The aim of these techniques is to restore the distal component of the triangular fibrocartilage complex36. When the posterior component of the triangular fibrocartilage complex is involved, the repair may fail if the foveal attachments are not repaired. A good technique for securing the attachments of the posterior component of the triangular fibrocartilage complex (Palmer class 1B) includes the use of transosseous sutures or bone anchors to anchor the tissue back to the fovea; this is usually done with arthroscopically assisted techniques36,64. All-inside repairs can be done with a meniscal repair device or with a Tuohy needle3,43,65. Some arthroscopic methods utilize a mini-open approach designed to protect the dorsal branch of the ulnar nerve65.
Ulnar Positive Wrists
Success rates of triangular fibrocartilage complex debridement in ulnar neutral wrists approach 66% to 87%, whereas failure rates in ulnar positive wrists are up to 60%53. Thus, some surgeons advocate using ulnar shortening with repair or debridement of the triangular fibrocartilage complex if the patient has positive ulnar variance; the ulnar shortening is performed with either an ulnar shaft osteotomy or a wafer procedure to remove a portion of the distal part of the ulna3,38,66. An ulnar shaft osteotomy of 2.5 mm has been shown to decrease axial load on the distal part of the ulna from 18% to 4%3,67,68. Tatebe et al. showed that ulnar shaft osteotomy alone led to healing of a triangular fibrocartilage complex tear in ten of thirteen patients with a painful ulnar positive wrist69. Hulsizer et al. found that ulnar shaft osteotomy led to pain relief in twelve of thirteen patients in whom triangular fibrocartilage complex debridement alone had failed70.
Most surgeons prescribe two to six weeks of immobilization in either a long arm cast or a sugar-tong splint, depending on their preference, after repair or reconstruction of a triangular fibrocartilage complex. Some advocate immobilization in full supination to avoid stress on the dorsal part of the triangular fibrocartilage complex50. Patients in whom the triangular fibrocartilage complex tear was secured over a button usually have the button removed at around five weeks; it is important to place a non-adherent dressing or cast padding under the button to protect the skin prior to removal37. Athletes sixteen to forty-two years of age can return to play at an average of 3.3 months after arthroscopic debridement or repair71.
Reconstruction of the distal radioulnar joint is typically followed by strict immobilization for four to six weeks followed by placement of an ulnar gutter splint42. It can take four to six months to regain supination and pronation. Heavy lifting and impact loading are discouraged for the first six months following surgery42. Full activity is allowed once the patient has recovered nearly full wrist motion and grip strength42.
Complications of operative management of triangular fibrocartilage complex tears include sensitivity and pain from subcutaneous knots, extensor carpi ulnaris tendinitis, and septic arthritis43,58. There is also the risk of skin breakdown and entrapment of the dorsal branch of the ulnar nerve with sutures tied over a button65. Furthermore, any attempt at fixing a radial-sided triangular fibrocartilage complex tear with suture secured on the radial aspect of the distal part of the radius places the radial sensory nerve at risk of injury62.
The triangular fibrocartilage complex is a fascinating and complicated structure with critical importance to distal radioulnar joint stability and ulnar carpal support. Understanding the anatomy of the triangular fibrocartilage complex is important to understanding its function, a prerequisite for appropriate treatment. While the triangular fibrocartilage complex has been studied extensively over the last thirty years, we have much to learn about this complicated structure.
Source of Funding: No external sources of funding were used.
Investigation performed at the Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
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