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Triangular Fibrocartilage Complex (TFCC) Of Wrist: Some Anatomico-clinical

Correlations

Article  in  Journal of the Anatomical Society of India · January 2007

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Triangular Fibrocartilage Complex (TFCC) Of Wrist: Some Anatomico-
clinical Correlations
Joshi S.S., Joshi S. D., Jadhav S. D., Athavale S. A., Waghmode P. S.
Rural Medical College, Loni

Abstract : Triangular fibrocartilage complex (TFCC) of wrist is a major ligamentous and cartilagenous structure that connects
the distal radius and ulnar carpus from the distal ulna. TFCC complex is interposed between the ulna and carpus. TFCC is an
arrangement of several structures, viz. triangular fibrocartilage (TFC), meniscal homologue (MH),
dorsal and palmar radiocarpal and ulnocarpal ligaments, sheath of extensor carpi ulnaris (ECU), the capsule of the distal
radioulnar joint (DRUJ) and the ulnar collateral ligament. The head of ulna is excluded from the formation of wrist joint and
there is interposed TFCC, which functions both as a cushion for ulnar carpus and a major stabilizer for DRUJ. Significant loads
are transmitted to the forearm unit through the distal ulna via the TFCC. Normal relationship of TFCC components is essential
for normal function of DRUJ. Tear, injury or degeneration of any one of these structures leads to patho-physiologic changes of
the DRUJ and an abnormal kinesis of the wrist and forearm. The incongruity between ulna and the triquetral is removed by
TFCC acting as a packing material. The MH, being compressible, allows for greater range of adduction at the wrist.
A total of one hundred and ten wrist joints (from 55 cadavers) were carefully dissected. The average length of
triangular fibrocartaligenous disc at the base and its height were almost equal (Base-12.4 mm & Height-12.2 mm) forming an
isosceles triangle. The average thickness of the disc in its central part was 1.45 mm on both the sides. Those discs that were
thick (Rt.-65.4%; Lt.-67.2%) looked opaque. Some of the discs were very thin (Rt.-27.4%; Lt.-25.6%) in the centre and looked
translucent. The disc perforation was seen in 7.2% cases on both the sides.

Key words: Triangular Fibrocartilage Complex (TFCC), Articular Disc, Meniscal Homologue (MH), Distal Radioulnar Joint
(DRUJ), Disc perforation

Introduction: or the ligamentum subcruetum, inserts into the fovea

Palmer and Werner (1981) coined the
term'Triangular Fibrocartilage Complex' (TFCC) to
describe the ligamentous and cartilagenous structure
that connects the distal radius and ulnar carpus from
the distal ulna. Palmer has pointed out that man is
differentiated from lower primates by a radiocarpal
joint with a TFCC complex interposed between the
ulna and the carpus. This TFCC complex improves
wrist functional stability and allows six degrees of
freedom at the wrist: flexion, extension, supination,
pronation, radial and ulnar deviation.
TFCC:
TFCC is formed by: Triangular fibrocartilage
(TFC), meniscal homologue (MH), dorsal and volar
radiocarpal ligaments, sheath of the extensor carpi
ulnaris (ECU), dorsal and palmar ulnocarpal
ligaments, the capsule of the DRUJ and ulnar
collateral ligament (James et al., 1995; Tulley, 1995;
James, 1996; Pfirrmenn et al., 2001; Dan et al., 2003;
Oatis, 2003). The TFCC is triangular in shape which
extends from the distal margin of the ulnar notch of
radius and courses towards the ulna, inserting into the
fovea at the base of the ulnar styloid process (Tulley,
1995).
There are superficial and deep layers of the
TFCC which attach separately at the base of ulnar
styloid (Benjamin et al., 1990; Dan et al., 2003; James
et al., 2007). The superficial component inserts into
the base of the styloid process and the deep portion,
near the axis (Fig.1, 2) of forearm rotation. When the
TFCC is viewed during wrist arthroscopy (James et
al., 2007) the styloid attachment appears folded.
Some of the blood vessels to the TFCC enter between
these folds. This folded part combined with the
vascular hilum is termed the ligamentum subcruetum
(Pfirrmenn et al., 2001; James et al., 2007). TFCC is 1-
2 mm thick at its centre and may thicken to 5 mm
where the TFCC inserts into fovea (James et al.,
2007). Only the peripheral 15-20% of the TFCC has
blood supply (Rama et al., 1986; Tulley, 1995;
Wheeless, 1996; Dan et al., 2003; Oatis, 2003).
Meniscus Homologue (MH) :
Brahme et al. (1995), Tulley (1995) and James
et al. (1996) have described Meniscus Homologue
(MH) as a triangular soft tissue structure located in the
space between proximal carpal row and the ulnar
styloid process and the articular disc. It becomes
smaller during pronation and supination as compared
with the neutral position (Pfirrmenn et al., 2001).
Functional significance of TFCC:
Pfirrmenn et al. (2001) have stated that TFCC
plays a key role in wrist biomechanics. Many workers
(Palmer et al., 1981; Reid, 1992; Boles et al., 1995;
Tulley, 1995, Oatis, 2003; James et al., 2007) have
shown that it is the main stabilizer of the ulnar carpus
and DRUJ providing a cushion or load bearing surface
at the wrist joint. It increases the articular surface for

J. Anat. Soc. India 56 (2) 8-13 (2007) 8

Triangular Fibrocartilage ...... Joshi S.S. , Joshi S. D., Jadhav S. D., Athavale S. A. & Waghmode P. S.
the carpus and distributes forces between ulna and
carpus enabling harmonic and smooth rotational
movements of the wrist and forearm.
Tulley (1995) and James et al. (2007) while
analyzing the transmission of forces through the wrist
have found that approximately 80% of forces
transferred to the wrist pass through the radius and
remaning 20% through ulna. Rotaional movements
during pronation and supination of the forearm produce
axial loading and yield a “drilling- like” effect of ulna at
the ulnar side of the carpus, which can cause
degenerative changes (Reid, 1992; Fabano et al., 2006).
As suggested by Werner et al. (1986) increasing the
ulnar variance to a positive 2.5 mm increases the load
transmission across the TFCC to 42% (18.4% to
41.9%) and shortening of the ulna by 2.5 mm
decreased axial load borne by ulna to 4.3%. These
results suggest that the biomechanics of the wrist joint
can be dramatically altered with relatively small (2.5
mm) changes in ulnar length and removal of the
articular disc of the TFCC.
TFCC is very frequently involved in wrist
injuries and a successful treatment of TFCC injuries
depends on its correct diagnosis. While clinical
literature is replete with TFCC derangements, the
anatomy literature and textbooks have underplayed
its significance. No comparable data being available
for Indian population a detailed study of this complex
has been carried out in our department.
Fig. 1: Showing inferior surface of the proximal articular
surface of wrist joint : A & B- Distal surface of radius;
c- TFC. The red point (green arrow) indicates the
axis of rotation of radius and TFC during pronation
and supination.
Fig. 1: In this fig. the same vertical axis of rotation (a-b) has
been shown.
J. Anat. Soc. India 56 (2) 8-13 (2007)
Material And Methods:
For the present study one hundred and ten
upper limbs ( Rt-55; Lt-55 ) were dissected over a
period of three years. None of these limbs showed any
evidence of abnormality, injury or operative
interference in or around the wrist joints studied. The
joints were opened by a transverse incision in such a
manner that intra-articular structures were clearly
visualized and various components of TFCC
confirmed. Presence of perforation in articular disc
was noted. Thickness and dimensions of base and
height of disc were measured carefully with the help of
sliding Vernier Caliper.
Observations:
After opening the cavity of wrist joint, the disc,
when viewed from inferior aspect was triangular in
shape and the surface was slightly concave. The base
is found to be attached to the distal margin of ulnar
notch of radius and apex to the base of styloid process
of ulna. After noting the length of the base and height
of the triangular disc the disc was incised at its base
and pulled inferiorly when one could easily visualize a
large area of attachment of its apex not only to the
base of styloid process but also to the fovea i.e.
ligament subcruetum (Fig. 3, 4) and soft cushion like
triangular projection MH could easily be visualized
within the medial part of the cavity deep to ulnar
collateral ligament (Fig. 3).
Fig. 3: Showing coronal section through the wrist joint
showing : TFC (black arrow); MH (red arrow);
Ligamentum Subcruetum (green arrow); Cavity of
DRUJ (blue arrow) T-Triquetral; L-Lunate; S-
Scaphoid; C-Capitate, R-Radius and U-Ulna.
9
Triangular Fibrocartilage ...... Joshi S.S. , Joshi S. D., Jadhav S. D., Athavale S. A. & Waghmode P. S.
Fig. 4: By a transverse wrist joint has been opened which
shows: The lower articular surface of the radius (a, b) and
the proximal articular surfaces of the scaphoid (c) and lunate
(d). Further a transverse cut has been made through the
base of styloid process of ulna and turning the cut part of
styloid process (e) and disc (f) inferiorly. Superior surface
disc has been exposed which shows a distinct perforation
and thining of central part. Lower articular surface of the
head of ulna (red arrow) is also seen.
Table: Showing measurements of base, height and
thickness of TFC (in mm):
Measurement of Right Left Combined Average
Average Range Average Range (Right+Left)
Base 12.4 9-6 12.1 9-17 12.25
Height 12 9-16 12.2 8-17 12.1
Thickness 1.4 0.5-2.5 1.5 0.5-2.7 1.45
As seen in table the average length of TFC at the base
was 12.25 mm (Rt.-12.4 mm; Lt.-12.1 mm) and its
height was 12.1 mm (Rt-12 mm; Lt- 12.2 mm), thus
forming an almost isosceles triangle. We had similar
findings for each disc examined.
The thickness at the centre of the TFC was
approximately 1.4 mm (range 0.5-2.5 mm) on the right
and 1.5 mm (range 0.5-2.7 mm) on the left, although
peripheral margins were thick and rigid.
Those discs that were thick looked opaque
(Rt-65.4%, Lt-67.2%). Very thin discs in the central
part were translucent (Rt-27.4%,Lt-25.6%). The
incidence of disc perforation was found to be 7.2% on
both sides. The majority of disc had concave superior
and inferior surfaces.
Meniscus Homologue as an entity was very
well defined and seen in all the limbs examined.
Sheath of ECU was confirmed as a thickening of the
fibrous capsule of wrist joint in its dorsimedial part,
being attched to the dorsal side of fovea of ulnar head.
This was also present in all wrist examined. Ulnar
collatral ligament in the form of separate fascicle was
not found.
J. Anat. Soc. India 56 (2) 8-13 (2007)
Discussion:
TFCC is ligamentous and cartilagenous
structure which stabilizes DRUJ and wrist. The
incongruity between the ulna and the triquetral is
removed by TFCC acting as a packing material.
Benjamin et al. (1990) have stated that the triangular
articular disc of the wrist joint and its associated
structures extend from the lower end of radius and
ulna to the base of fifth metacarpal. In 1981, Palmer
and Warner termed this as 'triangular fibrocartilage
complex' (TFCC). This name is now widely accepted
in clinical literature. It is frequently involved in wrist
injuries. Palmer (1987) stated that the anatomic
relationships between distal radius and ulna and ulnar
carpus is précise and even minor modification in these
relationships leads to significant load changes and
resultant pain syndromes.
Fornalski et al. (1999) have given a brief and
vivid account of evolution of the wrist. They state that
evolution of the wrist began some 400 million years
ago with the pectoral fins in a primitive fish; and
several hundred million years later, the primitive
amphibian appeared with a pentadactyl extremity, and
a syndesmotic DRUJ. Pronation and supination was
not present as the ulna was the primary weight-
bearing bone of the forearm. From the amphibians to
the reptiles, the anatomy of the upper extremity
remained realatively unchanged. It was not until
mammals first appeared about 230 million years ago
that the forearm began to change significantly. With
continued internal rotation and pronation of the
forearm, the mammal was able to place its extremity in
a more efficient position under its body. With the
development of bipedalism, hominids developed a
mobile wrist which was important for brachiation, food
gathering, self protection, and care of their young.
Complex motion including supination and pronation
developed with the evolution of three distinct
characteristics: i) proximal retreat of the ulna so that
there was no bony articulation between the ulna and
carpus, ii) development of the triangular fibrocartilage
complex (TFCC) and ulnocarpal meniscus, and iii) the
development of the DRUJ as a synovial joint.
The DRUJ is a part of an interconnected
forearm unit. Supination and pronation occur through
a complex interaction of bony articulations and soft
tissue structures including the radiocarpal joint, the
proximal radio ulnar joint (PRUJ), the introsseous
membrane, and the DRUJ.
Many workers (Mikic, 1978; Palmer, 1981;
James et al., 1995; Pfirrmenn, 2001 Dan et al., 2003;
Oatis, 2003; James, 2007) have shown that TFCC
plays a key role in wrist biomechanics and is an
arrangement of several structures:
 The primary structure is the triangular
10
Triangular Fibrocartilage ...... Joshi S.S. , Joshi S. D., Jadhav S. D., Athavale S. A. & Waghmode P. S.
fibrocartilagenous disc (TFC).
 The ulnocarpal meniscal homologue (MH).
 The dorsal and volar radio carpal ligaments.
 The sheath of the extensor carpi ulnaris tendon.
 The dorsal and palmar ulnocarpal ligaments.
 The capsule of the DRUJ.
 The ulnar collateral ligament.
From the functional point of view TFCC acts
as a major stabilizer of ulnar carpus and DRUJ. It
provides a cushion or load bearing surface at the wrist
joint, increasing the articular surface for the carpus,
allowing axial loading of the ulnar aspect of the
forearm. Thus it is important in loading of DRUJ and
also acts as a buttress to support proximal carpal row
(Wheeless, 1996). During axial loading, radius carries
majority of load (80%), and the ulna a smaller load
(20%)(Brahme et al., 1990; Tulley, 1995; Oatis, 2003;
James et al., 2007). The head of ulna is excluded from
the formation of wrist joint and there is interposed
TFCC which functions both as cushion for ulnar
carpus, and a major stabilizer for DRUJ. Although
DRUJ is not a part of wrist joint proper, it is important
to the normal functioning of the wrist and is frequently
implicated in wrist pathology. The DRUJ has been
described as a part of compound joint with PRUJ.
Together these joints are the source of pronation and
supination of forearm.
Pfirrmann et al. (2001) have analyzed the
morphology of TFCC during pronation and supination
of forearm by MR arthrography and have emphasized
that: i) The disc is horizontal in neutral position and
tilted more distally to align with proximal carpal row in
pronation and supination, ii) the ulnar attachement of
the articular disc revealed the most significant
changes: their orientation was coronal in neutral
position and sagittal in positions of pronation and
supination. Nakamura (1995) after thorough
investigation of the wrist from the fresh cadavers,
proposed a functional model of TFCC and described
the dynamic changes in TFCC during pronation and
supination. During pronation and supination, little
deformity of disc proper was observed; while the ulnar
insertion of the triangular ligament was twisted. He
has proposed a suspension theory to account for the
stability and mobility of TFCC during pronation and
supination, when these three components ( Disc
proper, MH, Ulnar collateral ligament ) suspend each
other.
The disc is usually two to three times thicker
ulnarly than radially and is vascularized by branches
of the ulnar and posterior interosseous arteries. The
central and radial aspects of the disc are relatively
avascular. MH is a structure that resides between the
ulna and triquetrum, having a common origin with the
J. Anat. Soc. India 56 (2) 8-13 (2007)
triangular ligament, and inserting on the ulnar border
of the triquetrum (Joseph et al., 2006).
Nakamura et al. (2001) after examining the
serially sectioned fresh-frozen cadaveric wrists have
shown that medially TFCC is attached to a broad area
in the ulnar fovea through vertically oriented
Sharpey's fibres and attached to the base of ulnar
styloid by horizontally directed fibres. Floor of the
sheath of ECU is firmely attached to the dorsal part of
the ulnar fovea. Much of the ulnar attachment is via
zones of calcified and uncalcified fibrocartilage which
blend with the adjacent cartilages. Such an
arrangement of tissues prevents undue wear and tear
at the ulnar attachment zone during pronation and
supination of forearm.
Pfirrmann et al. (2001) have also described
by analysis of MR arthrography two laminae of which
distal was oriented horizontally and extended
between TFCC and styloid process of ulna. The
proximal lamina was oriented vertically and curved
from the undersurface of articular disc to the ulnar
fovea. They have stated that the ulnar part of the
radioulnar ligament changed its orientation in different
positions of forearm: rotation of radius about the ulna
is accompanied by translation of ulna so that in
supination the ulna is somewhat palmar, and in
pronation the ulna is more dorsal relative to the radius.
In the neutral position, the distal surface of the ulna is
completely covered by the articular disc. In pronation
and supination, the ulnar head swings outside this
covering roof so that the disc is no longer completely
supported by distal ulna. This might be an explanation
of the higher vulnerability of TFCC in these forearm
positions.
De Smet L (1994) in a review article 'ulnar
variance: facts and fiction' has stated that the relative
length of ulna compared to the radius or 'ulnar
variance', appears to be an important element in wrist
pathology. Positive ulnar variance is harmful for the
ulnar compartment of the wrist and causes
degeneration and perforation of TFCC and
cartilagenous wear of the carpal bones-'ulnar
impaction syndrome'.
Benjamin et al. (1990) have shown that the
styloid process of ulna is covered by articular cartilage
and is associated with a prestyloid recess (a
diverticulum of the radiocarpal joint).
James (2007) mentioned that the disc is 1-2
mm thick in the centre. In the present series average
thickness found to be 1.45 mm. Pfirrmann et al. (2001)
have given the height of the disc as 10 mm and the
base 14 mm whereas in the present series it was
found to be 12.1 mm and 12.25 mm respectively.
Wheeless' (1996) has given the ulnar attachement of
the disc as 5 mm and in the present series it was found
11
Triangular Fibrocartilage ...... Joshi S.S. , Joshi S. D., Jadhav S. D., Athavale S. A. & Waghmode P. S.
to be 5.6 mm.
The presence of MH as a well defined entity
and confirmation of thickening of sheath of ECU lend
further support to the view that TFCC beside its
supportive and stabilizing role also act as a cushion to
make the ulnar part of radiocarpal joint more
congruent.
Going through the literature one comes
across wide range of variations in the incidence of
perforation of the discs. The variability may be
accounted for its dependence upon age, working
condition or ulnar variance and an important factor
being the avascularity of the central part of the disc.
Palmer (1981) has given its incidence in 53% TFC
examined. The highest incidence of the perforation
has been shown amongst the Japanes in the mean
age group of 74 years as 65% (Uchiyama et al., 1994).
Mikic (1978) while reviewing the age changes
in the TFC of wrist has quoted the incidence of
perforation given by Poirier and Charpy (1911) as
40.3%; Lanz and Wachsmuth (1935) - 25%, and
Grant (1944) - 30%. Liebolt (1950) found perforation
in 30.6%, Kessler and Silberman (1961) in age
groups of 14-76 years found perforation in 7%. In the
age group of 18-72 years, Ranawat et al. (1969) found
a perforation in 16% of discs obtained.
Following is the incidence found by Mikic
(1978) decade wise: first and second decades-no
perforation; third decade-7.6%; fourth decade-
18.1%; fifth decade- 40%; sixth decade - 40.8%; and
above 60 years it was 60%. While in the present
series, although the cadavers were in the fourth to
sixth decade there was a lower incidence of
perforartion i.e 7.2%.
Most of TFCC injuries are caused by a fall on
outstretched hand, rotational injuries or repetitive
axial loading. In TFCC lesions patients complain of
ulnar sided wrist pain and clicking and often
crepitation with forearm rotation, gripping, or ulnar
deviation of the wrist. Provocative maneuvers are
often helpful in differentiating TFCC injuries from
lunotriquetral pathology. Lester and colleagues
(1995) described a 'press test' to diagnose TFCC
tears: in this patient grasps both sides of a chair seat
while sitting in the chair. He then presses the body
weight directly upward, and if the pain replicates the
ulnar sided pain, the test is considered positive. Potter
and associates (1997) reported that MRI had a
sensitivity of 100%, specificity of 90% and accuracy of
97% in the wrists with arthroscopically verified TFCC
lesions.
Summary & Conclusion:
Present work has been carried out in one
hundred and ten (Rt.55; Lt.55) wrists. Observations
were made on TFCC. A well defined MH was found in
J. Anat. Soc. India 56 (2) 8-13 (2007)
all the wrist examined, so also the thickening of
sheath of ECU. An important feature which normally is
not appreciated by anatomist is the complex nature of
attachments of ulnar part of TFC. This divides into a
horizontal lamina getting attached to the base of
styloid process and a vertical lamina of connective
tissue (which is vascular) getting attached to the ulnar
fovea- ligamentum subcruetum. The height (12.1
mm) and width (12.2 mm) at the base of TFC have
been measured. The disc was found to be very thin in
the central part (1.45 mm) and this happens to be an
avascular zone below the head of ulna. The incidence
of perforation of TFC in the present series was found
to be 7.2%. The functional significance of TFCC as a
stabilizer of ulnar part of wrist, and acting as a
cushion, transmission of forces and its important role
in pronation and supination of forearm have been
discussed .
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