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What happens to the triangular fibrocartilage complex during pronation and

supination of the forearm? Analysis of its morphology and diagnosic
assessment with MR arthrography

Article  in  Skeletal Radiology · January 2002

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Skeletal Radiol (2001) 30:677–685
DOI 10.1007/s002560100429
Christian W. A. Pfirrmann
Nicolas H. Theumann
Christine B. Chung
Michael J. Botte
Debra J. Trudell
Donald Resnick
Received: 27 March 2001
Revision accepted: 1 August 2001
Published online: 25 September 2001
© ISS 2001
This investigation was supported by the
Swiss National Science Foundation and the
Swiss Radiological Society
C.W.A. Pfirrmann (✉) · N.H. Theumann ·
C.B. Chung · D.J. Trudell · D. Resnick
Department of Radiology,
Veterans Administration Medical Center,
3350 La Jolla Village Drive, San Diego,
CA 92161, USA
e-mail: christian@pfirrmann.ch
Tel.: +41-1-3863305
Fax: +41-1-3863319
C.W.A. Pfirrmann
Department of Radiology,
Orthopedic University Hospital Balgrist,
Forchstrasse 340, 8008 Zurich,
Switzerland
N.H. Theumann
Service de Radiologie, CHUV,
1011 Lausanne, Switzerland
M.J. Botte
Division of Orthopedic Surgery,
Scripps Clinic and Research foundation,
N. Torrey Pines Road La Jolla,
CA 92037, USA
A RT I C L E
What happens to the triangular fibrocartilage
complex during pronation and supination
of the forearm?
Analysis of its morphology and diagnostic
assessment with MR arthrography
Abstract Objective: To evaluate the
dynamic morphologic changes of the
triangular fibrocartilage complex
(TFCC) during pronation and supi-
nation of the forearm using high-res-
olution MR arthrography in cadavers
and to evaluate the impact of these
changes on the diagnostic assess-
ment of the normal and abnormal
TFCC. Design and specimens: High-
resolution MR arthrography of 10
wrists of cadaveric specimens was
obtained in maximum pronation, in
the neutral position, and in maxi-
mum supination of the forearm. The
structures of the TFCC were evaluat-
ed by two musculoskeletal radiolo-
gists and correlated with anatomic
sections. The position of the forearm
that allowed the best visualization of
normal structures and lesions of the
TFCC was determined. Results: The
shape and extent of the articular disc
as well as the radial portions of the
radioulnar ligaments did not change
with pronation and supination. The
articular disc was horizontal in the
neutral position and tilted more dis-
tally to align with the proximal car-
pal row in pronation and supination.
The fibers of the ulnar part of the ra-
dioulnar ligaments (ulnar attachment
of the articular disc) revealed the
most significant changes: their orien-
tation was coronal in the neutral po-
sition and sagittal in positions of
pronation and supination. The ulno-
meniscal homologue was largest in
the neutral position and was reduced
in size during pronation and supina-
tion. The extensor carpi ulnaris ten-
don was centered in its groove in the
neutral position and pronation. In su-
pination this tendon revealed sublux-
ation from this groove. The dorsal
capsule of the distal radioulnar joint
was taut in pronation, and the palmar
capsule was taut in supination. The
preferred forearm position for analy-
sis of most of the structures of the
TFCC was the neutral position, fol-
lowed by the pronated position. The
neutral position was rated best for
the detection of ulnar and radial de-
tachments of the TFCC, followed by
the pronated position, except for two
central perforations of the TFCC
which were best seen with supina-
tion. Conclusion: The articular disc
and the surrounding radial portions
of the radioulnar ligaments form a
rigid, unified complex with the radi-
us without change in their shape in
positions of pronation and supination
of the forearm, while the ulnar at-
tachment of the TFCC shows impor-
tant dynamic changes. The neutral
forearm position is the best position
to analyze both the normal and the
abnormal TFCC.
Keywords Wrist, anatomy · Wrist,
injuries · Wrist, MR · Magnetic
resonance (MR), arthrography
678
Introduction
The distal radioulnar joint is important in function of
both the wrist and the entire upper extremity. Significant
loads are transmitted to the forearm through the distal
ulna by the triangular fibrocartilage complex (TFCC).
The anatomic relationships between the distal radius,
ulnar head, and carpus are precise, and even minor modi-
fications in these relationships lead to significant chang-
es in load and resultant pain [1]. The TFCC consists of
the articular disc (also called the triangular fibrocarti-
lage, TFC), the dorsal and palmar radioulnar ligaments,
the ulnocarpal meniscal homologue, the dorsal and pal-
mar ulnocarpal ligaments, the sheath of the extensor
carpi ulnaris tendon, and the capsule of the distal radio-
ulnar joint. Some authors include the ulnar collateral lig-
ament as a component of the TFCC [2], although the
existence of this ligament has been disputed by others
[3].
Fig. 1A, B Schematic display of the distal radioulnar joint in pro-
nation, neutral position, and supination of the forearm. A The tra-
ditional understanding of the radioulnar ligament function. B The
changes seen with MR imaging and anatomic analysis. The radial
portions (r) of the radioulnar ligaments surround the articular disc.
These two structures form a stable unit with the radius. The
changes in the triangular fibrocartilage complex (TFCC) in prona-
tion and supination of the forearm occur in its ulnar attachment
(u). RUL radioulnar ligament, ECU extensor carpi ulnaris tendon
Significant controversy relates to the dynamic chang-
es that occur in the TFCC during pronation and supina-
tion of the forearm. The role of the dorsal and palmar ra-
dioulnar ligaments has been investigated by numerous
authors with inconsistent results. Some authors believe
that the dorsal radioulnar ligament is taut in maximum
supination of the forearm and the palmar radioulnar liga-
ment is taut in maximum pronation [4, 5]. Others indi-
cate that the dorsal radioulnar ligament becomes tighter
than the palmar radioulnar ligament during pronation
whereas the palmar radioulnar ligament is more taut dur-
ing supination (Fig. 1A) [6, 7, 8]. However, the radius
rotates an average of 150°–160° around the ulnar head
during maximum pronation and maximum supination.
This rather large range of motion supposedly leads to
major changes in morphology and orientation of the in-
terposed soft tissue structures of the TFCC.
The purpose of this study was to evaluate the dynam-
ic morphologic changes of the TFCC during pronation
and supination of the forearm using high-resolution MR
arthrography in cadavers and to evaluate the impact of
these changes on the diagnostic assessment of the normal
and abnormal TFCC.
Materials and methods
Specimens
Ten upper extremities were harvested from non-embalmed cadav-
ers (four women, six men; age range at death, 61–79 years, aver-
age age 71.3 years). The specimens were derived from arms cut
through the midportion of the humerus. The elbow and proximal
radioulnar joint remained intact. The specimens were immediately
deep frozen at –40 °C (Forma Bio-Freezer, Forma Scientific,
Marietta, Ohio). Standard radiographs in two projections were ob-
tained to confirm the absence of traumatic or articular disorders of
the distal radioulnar joint and the radiocarpal joint. The specimens
were allowed to thaw for 24 h at room temperature prior to MR
imaging.
Image acquisition
Prior to MR imaging, the radiocarpal joint and the distal radioul-
nar joint were each injected with a solution of 2 ml gadolinium di-
meglumine (Magnevist, Schering, Berlin, Germany) diluted in
250 ml of saline that was mixed with an equal amount of iodinated
contrast agent (Omnipaque 350, Nycomed Amersham, Princeton,
N.J.). Approximately 4 ml of solution was injected in the radiocar-
pal joints and 2 ml in the distal radioulnar joint under fluoroscopic
observation.
MR images were acquired with a 1.5 T MR scanner (Signa,
GE Medical Systems, Milwaukee, Wis.) using a dedicated receive-
only wrist coil. The wrists were placed palm down longitudinal to
the gantry table in a neutral position (no ulnar or radial deviation),
and the elbow joint was flexed 90°. Flexion of the elbow was nec-
essary to determine the exact degree of pronation and supination.
The hand was fixed in the wrist coil to allow free pronation and
supination of the forearm. Images were acquired in the neutral po-
sition and in maximum pronation and maximum supination of the
forearm. A neutral position of the forearm was defined as follows:
The elbow joint was flexed to 90° and the humerus was parallel to
 679

the plane of the gantry table. Maximum supination was achieved

by rotating the forearm about 90° until the longitudinal axis of the
humerus faced downward to the gantry table, perpendicular to the
gantry table. In maximum pronation the longitudinal axis of the
humerus faced up, almost perpendicular plane of the gantry
table. Coronal, sagittal, and axial T1-weighted spin echo MR se-
quences (TR=500 ms, TE=12 ms, slice thickness=2 mm, inter-
space=0.1 mm, NEX=2, FOV=6×6 cm, 512×256 matrix) were ac-
quired in all three forearm positions.

Simulated injuries

Three of the specimens had central communicating defects of the

TFC. These lesions served as model for type 1A injuries according
to the Palmer classification [9]. Ulnar detachment injuries (type
1B injury, n=4) and radial detachment injuries (type 1D injury,
n=3) were created surgically with a scalpel by an experienced
hand surgeon. Longitudinal 5 cm incisions were made over the
dorsal aspect of the ulnar head. The extensor retinaculum was in-
cised ulnarly and reflected. Access to the distal radioulnar joint
was at a point ulnar to the extensor carpi ulnaris tendon, allowing
creation of type 1B lesions and was radial to the extensor carpi ul-
naris tendon, allowing creation of type 1D lesions. To minimize
artifacts from air introduced in the soft tissues, the incisions were
irrigated and filled with saline. After careful approximation of the
dissected tissues, skin closure was performed with the specimens
entirely submerged in saline using a single layer of 4-0 monofila-
ment sutures in a running, locking fashion. After this surgical pro-
cedure, all specimens underwent MR arthrography in the three
forearm positions as described previously.
Anatomic section preparation
After imaging, all cadaveric specimens were immediately posi-
tioned with the forearm in neutral position (n=4), in maximum
pronation (n=3), and in maximum supination (n=3), and then were
frozen at –40 °C for at least 24 h. Subsequently, they were sec-
tioned with a band saw into 3-mm-thick sections that correspond-
ed to the imaging planes used for MR arthrography: coronal sec-
tions (n=4), sagittal sections (n=3), and axial sections (n=3). Pho-
tographs of each section were obtained with the specimen thawed.
Fig. 2 Schematic display of the measurements of the articular disc
performed in the coronal (distance x, A) and in the sagittal plane
(distance y, B). Distance z displays the measurement of the ulno-
meniscal homologue
In a second step, the radiologists were asked to rate each of the
three forearm positions (pronation, neutral position or supination)
with regard to the identification of a particular structure of the
TFCC. They had to decide which position was best (3 points),
which was the second choice (2 points), and which was the worst
(1 point). This decision had to be made for each component of the
TFCC separately: the dorsal and palmar radioulnar ligaments, ul-
nomeniscal homologue, ulnotriquetral ligament, ulnolunate liga-
ment, extensor carpi ulnaris tendon sheath, and the dorsal and pal-
mar portions of the distal radioulnar joint capsule.
In a third step the radiologists had to decide in which forearm
position the lesions of the TFCC were best seen. The same scores
as in the second step were used.
Results

Image analysis Dynamic morphologic changes of the TFCC during

MR images were reviewed by two musculoskeletal radiologists in
consensus. In a first step, all structures of the TFCC were analyzed
for changes in morphology, orientation and size in each of the
three forearm positions. All sequences were viewed simultaneous-
ly, and findings were correlated with those derived from inspec-
tion of the anatomic sections: The articular disc was analyzed for
morphologic changes in shape and position (position in relation to
the first carpal row). The disc was measured in the coronal plane
(middle slice of all slices in which the TFC was visible; Fig. 2A)
and in the sagittal plane (second slice ulnar to the slice in which
the radius was last visible; Fig. 2B). The dorsal and palmar radio-
ulnar ligaments were analyzed for changes in orientation and ap-
pearance throughout their course from their radial insertion to
their ulnar insertion. The (ulnoradial) size of the ulnomeniscal ho-
mologue was measured on that coronal scan in which this size was
longest (Fig. 22). The ulnotriquetral and ulnolunate ligaments
were analyzed for changes in orientation. The anatomic position
of the extensor carpi ulnaris tendon in relation to the ulna was ana-
lyzed in the axial plane. Finally, the dorsal and palmar portions of
the capsule of the distal radioulnar joint were analyzed in the three
forearm positions.
pronation and supination
The articular disc, defined by its homogeneous hypoin-
tense appearance, showed no changes in its shape during
pronation and supination of the forearm (Figs. 11, 3, 4, 5).
There was no measurable change in its sagittal and coro-
nal size (mean coronal size: 10.0 mm, SD: 1.2 mm;
mean change in size: 0.35 mm, SD: 0.4 mm; mean sagit-
tal size: 14.0 mm, SD: 0.8 mm; mean change in size:
0.4 mm, SD:0.5 mm). The coronal orientation of the disc
was horizontal in the neutral position. A slight change in
this orientation to a more oblique orientation with ap-
proximation of the articular disc to the proximal carpal
row was noted in pronation (n=7) and supination (n=8)
(Fig. 4A). In three and two cases respectively, there was
no change in its orientation in pronation and supination.
The sagittal orientation was parallel to the palmar tilt of
the distal radial articular surface.
680
Fig. 3 Axial T1-weighted (TR/TE 500 ms/12 ms) MR arthro-
graphic images (A) at the level of the triangular fibrocartilage in
pronation (left), neutral position (center), and supination (right) of
the forearm and corresponding axial anatomic section in the neu-
tral position (B). Note the dorsal (black curved arrow) and the pal-
mar (white curved arrow) radial portions of the radioulnar liga-
ments forming a ring around the articular disc. The ulnar portions
of the radioulnar ligaments (white arrowheads) change direction.
The prestyloid recess (black straight arrow) is most distended in
pronation. The extensor carpi ulnaris tendon is demonstrated by
the white straight arrow
Both the dorsal and palmar radioulnar ligaments
showed two fundamentally different parts in static and
dynamic appearance in all cases: The radial part com-
prised about two thirds of both ligaments. Distinct thick-
enings in the dorsal and palmar borders of the articular
discs were evident, and the dorsal band was thicker than
the palmar band (Fig. 5). The signal intensity of this part
of the ligament was homogeneously hypointense, and the
borders were inseparable from the articular disc. The
thickening could be followed around the entire periphery
of the articular disc (Figs. 3A, 4A, 5A). The dorsal and
ventral radioulnar ligaments joined each other at the ul-
nar side of the articular disc, forming a complete ring
around the articular disc (Fig. 3B). This radial part of the
radioulnar ligaments did not show any change in shape
or appearance during pronation and supination of the
forearm.
The ulnar part of the radioulnar ligaments extended
from ulnodorsal margin of the articular disc to the ulnar
styloid process and the ulnar notch (Fig. 4B). This part
had intermediate signal intensity and, sometimes, inter-
Fig. 4 A Coronal T1-weighted (TR/TE 500 ms/12 ms) MR arthro-
graphic images through the triangular fibrocartilage complex
(TFCC) in pronation (left), neutral position (center), and supina-
tion (right) of the forearm. Note the approximation of the articular
disc to the proximal articular surface of the proximal carpal row in
pronation and supination (arrowheads). The ulnomeniscal homo-
logue (black curved arrow) is smaller in pronation and supination
compared with the neutral position. B Corresponding coronal ana-
tomic section through the TFCC in the neutral position. Note the
two laminae (arrowheads) of the ulnar portions of the radioulnar
ligaments connecting the TFC (curved arrow) to the ulna. The dis-
tal lamina is almost horizontal and connects the TFC to the ulnar
styloid (white arrowhead), the proximal lamina is more vertical in
orientation and connects the TFC to the fovea of the distal ulna
(black arrowhead). The two laminae are separated by the ligamen-
tum subcruentum (black arrow). The ulnomeniscal homologue
(white arrow) is interposed between the TFC and ulnar styloid
proximally and the proximal carpal row distally
nal striations were present. There were two distinct lami-
nae (Fig. 4B): The distal lamina was orientated horizon-
tally and extended between the articular disc and the sty-
loid process of the ulna. The proximal lamina was orien-
tated vertically and curved from the undersurface of the
articular disc to the ulnar fovea. This ulnar part of the ra-
dioulnar ligaments changed its orientation in different
positions of the forearm: in the neutral position the distal
lamina was oriented in the coronal plane; in maximum
pronation and supination, the orientation was sagittal
(Figs. 1B, 3A).
The ulnomeniscal homologue was a triangular soft
tissue structure with inhomogeneous intermediate signal
intensity located in the space between the proximal car-
pal row and the ulnar styloid process and articular disc
 681

Fig. 5 A Three consecutive sagittal T1-weighted (TR/TE 500 ms/

12 ms) MR arthrographic images through the TFCC from radial
(right) to ulnar (left) aspects in neutral position of the forearm.
The dorsal (black arrow) and the palmar (white arrow) radial ra-
dioulnar ligaments are clearly outlined. The palmar ulnolunate
(white arrowheads) and ulnotriquetral (white curved arrows) liga-
ments and the tendon sheath (black over white arrowheads) of the
extensor carpi ulnaris tendon (black curved arrow) connect the
articular disc and the radioulnar ligaments (straight black and
white arrows) to the carpus. B Sagittal T1-weighted (TR/TE
500 ms/12 ms) MR arthrographic images through the TFCC in
pronation (left), neutral position (center), and supination (right) of
the forearm. Note the ulnar head swinging dorsally in pronation
and palmarly in supination (curved arrow). The ulnolunate liga-
ment (arrowheads) is clearly visualized. C Corresponding sagittal
Fig. 6 Axial T1-weighted (TR/TE 500 ms/12 ms) MR arthro-
anatomic section. The palmar (white arrow) and dorsal (black
graphic images through the level of the ulnar head in pronation
arrow) radioulnar ligaments are clearly visible as thickenings in
(left), neutral position (center), and supination (right) of the fore-
the periphery of the articular disc. Both radioulnar ligaments are
arm. Note that the extensor carpi ulnaris tendon (curved arrow) is
slightly darker than the articular disc. They are connected by the
centered in its groove in pronation and the neutral position. The
radiolunate ligament (white arrowheads) palmarly and by the ten-
tendon subluxes out of the groove in supination, and the radial ret-
don sheath (black arrowheads) of the extensor carpi ulnaris tendon
inaculum (arrowheads) is stretched
(curved arrow) dorsally to the carpus

Table 1 Visibility scores for

the structures of the TFCC in Structure Score
pronation, neutral position and
supination of the forearm (the Pronation Neutral Supination
best rating is displayed in bold
characters) Mean SD Mean SD Mean SD

Dorsal radioulnar ligament (radial part) 1.7 0.8 2.8 0.4 1.5 0.5
Palmar radioulnar ligament (radial part) 1.6 0.7 2.9 0.3 1.5 0.5
Radioulnar ligament (ulnar part) 1.7 0.8 2.8 0.4 1.5 0.5
Ulnotriquetral ligament 1.7 0.5 3.0 0.0 1.3 0.5
Ulnolunate ligament 1.5 0.5 3.0 0.0 1.5 0.5
Meniscal homologue 1.6 0.5 3.0 0.0 1.4 0.5
Tendon sheath of the extensor carpi ulnaris 2.6 0.5 2.4 0.5 1.0 0.0
Dorsal capsule of the distal radioulnar joint 2.2 0.4 2.8 0.4 1.0 0.0
Palmar capsule of the distal radioulnar joint 1.0 0.0 2.4 0.4 2.6 0.5
682

(Fig. 4B). There was a reduction in the maximum medio-

lateral size of the ulnomeniscal homologue in pronation
(mean size: 6.8 mm, SD: 1.4 mm) and supination (mean
size: 5.8 mm, SD: 1.6 mm) when compared with its size
in the neutral position (mean size: 9.5 mm, SD: 1.3 mm)
(Fig. 4B).
The palmar ulnocarpal ligaments (ulnotriquetral and
ulnolunate ligaments) were best seen in the sagittal scans
(Fig. 5). Both ligaments inserted proximally at the pal-
mar border of the articular disc, which corresponded to
the location of the radial part of the palmar radioulnar
ligament (Fig. 4A). No significant changes in the appear-
ance of the insertion or course of the ligament during
maximum pronation and supination could be observed.
The distal portion of the tendon of the extensor carpi
ulnaris muscle was located in a groove between the radial
articular surface of the ulnar head and the styloid process
of the ulna. In pronation and neutral position, the tendon
was centered in this groove. In supination the tendon sub-
luxed in an ulnar direction out of the groove (Figs. 1, 6).
However, the degree of subluxation in an ulnar direction
was never more than 2 mm from a sagittal midline drawn
through the center of the ulnar head in an axial image.
The ulnar head shifted dorsally in pronation and palmarly
in supination. The dorsal and palmar portions of the joint
capsule were redundant in the neutral position. In maxi-
mum pronation, the joint capsule was taut dorsally and, in
maximum supination, it was taut palmarly.

Preferred forearm position for the analysis

of the structures of the TFCC

The scores for the detectability of the structures of the
TFCC in the three forearm positions are displayed in
Table 1. The articular disc was seen equally well in all
forearm positions. The neutral position was almost al-
ways the first or second choice with regard to visualiza-
tion of the structures of the TFCC. The supinated posi-
tion was rated last for observation of most structures of
the TFCC, except for the palmar capsule of the distal ra-
dioulnar joint, which was taut in the supinated position
and well seen.
Preferred forearm position for detection of lesions
of the TFCC
All lesions were well detected in all forearm positions.
Two of three type 1A lesions were best seen in the sup-
inated position because the margins of the tear were at
different levels in the coronal plane (Fig. 7A). In supina-
tion, the ulnar side of the tear was located at a slightly
distal level when compared with the corresponding radi-
al side. In the neutral and pronated positions the margins
of the tear were better aligned. The third type 1A lesion
Fig. 7 A Type 1A lesion of the TFCC. Coronal T1-weighted
(TR/TE 500 ms/12 ms) MR arthrographic images through the
TFCC in pronation (left), neutral position (center), and supination
(right) of the forearm. The type 1A lesion (curved arrow) is clear-
ly visible as a slit-like interruption of the center of the articular
disc in all three forearm positions. In supination, however, this le-
sion becomes even more evident: the two margins of the lesion do
not align and a step (black straight arrow) is visible. B Type 1B
lesion of the TFCC. Coronal T1-weighted (TR/TE 500 ms/12 ms)
MR arthrographic images through the TFCC in pronation (image),
neutral position (center), and supination (right) of the forearm.
The detachment of the TFC (arrow) is best seen in the neutral po-
sition. C Type 1D lesion of the TFCC. Axial T1-weighted (TR/TE
500 ms/12 ms) MR arthrographic images through the TFCC in
pronation (image), neutral position (center), and supination (right)
of the forearm. The dorsal radioulnar ligament and the dorsal part
of the articular disc are detached (curved white arrow) from the
radius. Note the changes in the position of the ulnar styloid (white
straight arrow) and the extensor carpi ulnaris tendon (black
curved arrow)
was best seen in the neutral position. For three of the
four type 1B lesions, the neutral position was believed to
be optimal (Fig. 7B). In one type 1B lesion, the pronated
position was preferred. The supinated position was rated
least useful for all four lesions. The preferred position

for all three type 1D lesions was the neutral position, fol-
lowed by the pronated position in two cases and the sup-
inated position in one case (Fig. 7C).
Discussion
The palmar and dorsal radioulnar ligaments connect the
radius to the styloid process of the ulna and stabilize the
articular disc. The concept of two individual ligaments
has led to difficulties and controversies with regard to
understanding the dynamic biomechanics during prona-
tion and supination of the forearm (Fig. 1A). There has
been significant dispute as to which ligament lengthens
and which shortens during pronation and supination of
the forearm and which of these ligaments is more impor-
tant for the stability of the distal radioulnar joint [4, 5, 6,
7, 8, 10] (Fig. 1A).
Our results suggest that the radioulnar ligaments have
two separate parts with different MR morphology and
signal intensity and different behavior during supination
and pronation (Fig. 1B). The radial portions of the radio-
ulnar ligaments represent a thickening in the periphery
of the articular disc with the same homogeneous hypoin-
tense signal characteristics as the disc itself (Fig. 5A).
The palmar and dorsal radial radioulnar ligament join
each other and form a ring around the articular disc
(Fig. 5A, B). This ring configuration has been previously
described by other investigators [11]. The dorsal liga-
ment is thicker than the palmar ligament. Histologically
the radial portions of the radioulnar ligaments consist of
highly ordered, parallel collagen fibers, and they have a
strong radial attachment at the palmar and dorsal ulnar
edge of the radius [2, 12, 13].
The ulnar portions of the radioulnar ligaments con-
nect the articular disc with the ulna. The MR appearance
and the histologic structure as well as the function of the
ulnar portions of the radioulnar ligaments are different
from the radial portions. This part of the TFCC has also
been named the triangular ligament [14]. There are two
laminae – a distal and a proximal – separated by a vascu-
larized zone of fatty tissue, the so-called ligamentum
subcruentum [15] (Fig. 4B). Histologically, the ulnar part
of the radioulnar ligaments consists of much less ordered
collagen bundles, and the histologic appearance has been
described as loose-knit connective tissue with blood ves-
sels and scattered areas of fat [12]. This histologic pat-
tern explains the intermediate signal intensity noted in
T1- and T2weighted MR images.
The articular disc and the surrounding radioulnar liga-
ments appear to be rigidly connected to the radius with-
out changes in shape during pronation and supination of
the forearm, while major changes occur in the ulnar part
of the radioulnar ligaments (Fig. 1B). These findings are
consistent with the results of a report by Nakamura and
coworkers, who investigated the functional anatomy of
683
the TFCC in dissected cadaveric specimens [14] and dy-
namic MR imaging in volunteers [16]. The distal lamina,
which has a horizontal orientation, changes from a me-
diolateral direction in the neutral position to a more sag-
ittal direction in positions of pronation and supination,
while the lower lamina, which has a more vertical orien-
tation and inserts in the fovea of the ulna, is twisted in
both pronation and supination. The fovea of the ulna cor-
responds to the geometric rotation center for pronation
and supination [17].
Our results show that the articular disc tilts slightly
in the coronal plane during maximum pronation and su-
pination and aligns with the proximal joint surface of
the carpal row (Fig. 4A). In the neutral position, the ar-
ticular disc is more horizontal in orientation. The impor-
tance of this movement is not clear. It has been empha-
sized previously that the ulnocarpal ligaments, which
insert proximally in the articular disc, tighten during
pronation and supination of the forearm and may be re-
sponsible for this distal movement of the articular disc
[18]. Another possible explanation is the relative length-
ening of the ulna during pronation [19]. However, this
does not explain the tilting of the articular disc that oc-
curs in supination.
The ulnar collateral ligament was not included in the
analysis because we were not able to identify this liga-
ment as a distinct structure. Only a few scattered hypoin-
tense fibers were identifiable, these fibers blending with
the thick tendon sheath of the extensor carpi ulnaris ten-
don dorsoulnarly. The tendon sheath of the extensor
carpi ulnaris continues radiodorsally with the dorsal ul-
nocarpal ligaments, which are thinner than their ventral
counterparts (Fig. 5). The ulnomeniscal homologue is a
triangular soft tissue structure that occupies the space be-
tween the proximal carpal row and both the styloid pro-
cess of the ulna and the articular disc (Fig. 4B). This
structure is of variable size but constantly reduces in me-
diolateral length during both supination and pronation of
the forearm (Fig. 4A).
Abnormalities of the extensor carpi ulnaris tendon
and its tendon sheath are important causes of ulnar-sid-
ed wrist pain [20]. Subluxation and dislocations of
these structures may occur following injury or in cases
of chronic inflammatory diseases [21]. In the neutral
position and in pronation, the extensor carpi ulnaris
tendon was centered in the groove in all our specimens.
In supination, ulnar subluxation of the extensor carpi
ulnaris tendon appears to be a physiologic finding
(Fig. 6).
Rotation of the radius about the ulna is accompanied
by translation of the ulna so that in supination the ulna is
somewhat palmar, and in pronation the ulna is more dor-
sal relative to the radius [17]. In the neutral position, the
distal (discal) joint surface of the ulna is completely cov-
ered by the articular disc. In pronation and supination,
the ulnar head swings outside this covering roof so that
684

the disc is no longer completely supported by the distal
ulna (Fig. 5B). This might be an explanation of the high-
er vulnerability for the TFCC in these forearm positions.
The value of conventional arthrography, MR imaging,
and arthroscopy in the diagnosis of lesions of the TFCC
has been evaluated extensively [22, 23, 24, 25, 26, 27,
28]. Arthroscopy is still considered the only standard of
reference for the assessment of the structures of the
TFCC [29, 30, 31]. MR arthrography has proved to be
superior to standard MR imaging in this assessment [32].
The importance of forearm position with regard to MR
imaging of the TFCC has not been emphasized. In our
limited series, most of the structures of the TFCC were
best seen in the neutral forearm position. Furthermore,
most lesions were best seen in this same forearm posi-
tion. The neutral position is most frequently used in rou-
tine clinical MR imaging studies of the wrist. The prona-
ted position was rated second best in the visualization of
the TFCC. The so-called Superman position is a fre-
quently used position in which the patient lies prone with
the arm stretched above the head, and the palm of the
wrist parallel to the gantry table. In this position the fore-
arm is pronated. On the basis of our data the supinated
position is not recommended for the analysis of the
TFCC.
There are some limitations of our study. For optimal
delineation of all the structures of the TFCC we used
high-resolution MR arthrography in cadavers instead of
standard MR imaging in volunteers or patients. The dis-
tension of the joints by contrast material may have some
effect on the physiologic movements of the soft tissues.
The use of cadavers, however, enabled us to use anatom-
ic-MR imaging correlation and surgically produced le-
sions of the TFCC. Second, active pronation and supina-
tion of the forearm may have different effects on the
structures of the TFCC compared with passive move-
ment only. However, every effort was made to provide
natural and unlimited pronation and supination of the
forearm. Also the numbers of specimens available for
our analysis and the number of injuries of the TFCC
were small.
In conclusion, the articular disc and the surrounding
radial portions of the radioulnar ligaments form a rigid
unified complex with the radius and do not change in
shape in pronation and supination of the forearm, while
the ulnar attachment of these structures is that portion of
the TFCC that changes dramatically during these fore-
arm movements. The neutral forearm position is optimal
in the analysis of the normal and abnormal TFCC using
MR arthrography as the investigative method.

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