The Hook Test Is More Accurate Than the Trampoline

Test to Detect Foveal Tears of the Triangular

Fibrocartilage Complex of the Wrist
Andrea Atzei, M.D., Riccardo Luchetti, M.D., Daniele Carletti, M.D.,
Lucian Lior Marcovici, M.D., Lucia Cazzoletti, M.Sc., and Silvia Barbon, M.D.

Purpose: To evaluate the accuracy of the trampoline and hook tests, used in the arthroscopic assessment of triangular
fibrocartilage complex (TFCC) tears compared with arthroscopic direct visualization of the radiocarpal joint (RCJ) and of
the distal radial ulnar joint (DRUJ). Methods: In total, 135 patients (97 male, 38 female, mean age 43.5 years) were
divided into 2 groups: (1) 80 patients with chronic ulnar-sided wrist pain and positive fovea sign and (2) 55 patients with
other complaints. TFCC was assessed by RCJ and DRUJ arthroscopy and by the trampoline and hook tests to detect
rupture of distal and proximal components of the TFCC. Accuracy, specificity, sensitivity, and likelihood ratio of the 2
diagnostic methods were measured and compared, using RCJ and DRUJ arthroscopy as reference. Results: The tram-
poline and the hook tests showed an overall accuracy of 70.37% and 86.67%, respectively. The accuracy of the trampoline
test was similar for distal (69%), proximal (66%), and complete (73%) TFCC tears. The hook test was more accurate
when evaluating proximal (97%) and complete (98%) tears, rather than distal lesions (75%). Sensitivity for the tram-
poline and hook tests was 75.00% and 0.00% (P < .001) for distal tears and 78.85% and 100.00% (P < .001) and 58.33%
and 100.00% (P < .001) for complete or isolated proximal tears, respectively. Specificity for the trampoline and hook tests
was 67.27% and 96.36% (P < .001) respectively. Conclusions: The trampoline and hook tests can assure accurate
diagnosis of peripheral TFCC tear. The hook test shows greater specificity and sensitivity to recognize foveal TFCC tears.
Values of positive likelihood ratio suggest a greater probability to detect foveal laceration of peripheral TFCC for the hook
test than for the trampoline test. These findings suggest that DRUJ arthroscopy is not necessary to confirm foveal
incompetence of the TFCC, if the hook test is positive. Level of Evidence: Level II, retrospective diagnostic trial.

See commentary on page 1808

he triangular fibrocartilage complex (TFCC) was
T described by Palmer and Werner as the
3-dimensional structure that stretches between radius,
From the PRO-Mano, Hand Surgery and Rehabilitation Center, Treviso,
Italy; Hand Surgery Unit, Ospedale Koelliker, Torino (A.A.); Rimini Hand
Surgery and Rehabilitation Center, Rimini (R.L.); Orthopaedic Department,
Ospedale Mater Salutis, Legnago (D.C.); Hand & Microsurgery Unit, Jewish
Hospital of Rome, Rome (L.L.M.); Department of Diagnostics and Public
Health, Section of Epidemiology and Medical Statistics, University of Verona,
Verona (L.C.); and Department of Neurosciences, University of Padua, Padua
(S.B.), Italy.
The authors report that they have no conflicts of interest in the authorship
and publication of this article. Full ICMJE author disclosure forms are
available for this article online, as supplementary material.
Received October 7, 2020; accepted March 3, 2021.
Address correspondence to Andrea Atzei, M.D., PRO-Mano, Hand Surgery
and Rehabilitation Center, Treviso, Italy; Hand Surgery Unit, Ospedale
Koelliker, Torino, Italy. E-mail: andreatzei@gmail.com
Ó 2021 by the Arthroscopy Association of North America
0749-8063/201635/$36.00
https://doi.org/10.1016/j.arthro.2021.03.005
ulna, and the carpal bones.1 This complex plays a key
role in load transmission and stability of the wrist and
distal radioulnar joint (DRUJ).1,2 The most common
classification of disorders to the TFCC was presented by
Palmer in 1989, based on a tear’s location and patho-
mecanichs.3 In particular, 2 main classes can be
distinguished: class 1, traumatic lesions and class 2,
degenerative lesions. These classes are further divided
into 4 types (1A to 1D and 2A to 2D), depending on the
location of the tear and the presence or absence of
associated chondromalacic changes.3 Traumatic tears of
the TFCC commonly result in debilitating ulnar-sided
wrist pain and joint instability.4 In current clinical
practice, traumatic avulsions of the peripheral TFCC,
often associated with ulnar styloid fracture, represent
the commonest cause of ulnar-sided wrist pain and loss
of function that requires surgical treatment. Focusing
on anatomic and functional organization of the pe-
ripheral TFCC, Atzei5 proposed a treatment-oriented

1800 Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 37, No 6 (June), 2021: pp 1800-1807
 ACCURACY OF ARTHROSCOPIC TESTS FOR TFCC TEAR
classification of Palmer 1B type peripheral tear, which
distinguishes repairable lesions of the single distal
component of TFCC (Atzei class 1) from those of the
proximal component of TFCC, which includes the
foveal insertions of the DRUJ ligaments. Ruptures of
the proximal component of TFCC may occur either in a
complete tear pattern (Atzei class 2: tear of distal and
proximal component) or isolated (Atzei class 3). Two
other categories also were described, which represent
nonrepairable lesions (Atzei class 4) and the variety of
tears associated to DRUJ arthritis (Atzei class 5). The
clinical relevance of this approach is that class 2 and 3
tears are associated with DRUJ instability and need to
be repaired by reattachment of the TFCC to its foveal
insertion, whereas class 1 tears benefit from simple
ligamentecapsular repair.5,6
Currently, wrist arthroscopy is considered as the gold
standard in the diagnosis of TFCC tears,7-9 as it permits
direct and accurate visualization of the damaged struc-
tures. However, the standard arthroscopy of the radio-
carpal joint (RCJ) has some relevant limitations, as it
cannot visualize the foveal attachments of the TFCC on
the ulnar head. DRUJ arthroscopy, a more demanding
procedure, is strongly recommended10,11 to detect rupture
of the proximal components of the TFCC at the fovea, as it
is the only approach able to visualize the foveal insertions.
The trampoline and hook tests have been introduced to
assess the competence of TFCC ligamentous structures.
TFCC compliance is examined by the trampoline test by
applying a compressive load with a probe ,thereby visu-
alizing TFCC bouncing.12 The hook test has been described
to assess integrity of peripheral TFCC by placing a probe
into the prestyloid recess and then applying a radially
directed traction force to the TFCC periphery.13 A positive
hook test, which occurs when the TFCC can be lifted off
the ulna head (i.e., distally and radially) by the probe, is
considered an accurate sign of incompetent foveal in-
sertions of the TFCC.14 Conversely, a negative hook test is
indicative of competent foveal attachments. In many
recent reports, the hook test was used as a reference test to
define the rupture of the proximal TFCC.15,16 However,
the diagnostic accuracy of trampoline and hook tests for
the arthroscopic assessment of type 1B TFCC lesions has
never been investigated. Therefore, arthroscopic explo-
ration of the DRUJ is still considered mandatory to com-
plete a thorough evaluation of the TFCC, due to its ability
to visualize and probe the proximal component of the
TFCC; i.e., the foveal insertions.
The purpose of this study was to evaluate the accuracy
of the trampoline and hook tests, used in the arthroscopic
assessment of TFCC tears, compared with arthroscopic
direct visualization of the RCJ and of the DRUJ. We
hypothesized a high sensitivity and specificity of the
trampoline test in identifying laceration of the distal
component of the peripheral TFCC and of the hook test
in detecting laceration of the proximal component.
1801
Methods
Patients
In this retrospective study, the clinical records of 178
consecutive patients who underwent wrist arthroscopy
in the period between February 2005 and January 2009
were reviewed. Our inclusion criterion was wrist pain
that showed no improvement after at least 3 months of
conservative treatment. As exclusion criteria, the
following were considered: radiographic evidence of
ulnar plus-variance; arthroscopic intraoperative find-
ings of lunotriquetral dissociation; arthroscopic intra-
operative findings of either central disc erosion or
perforation, or Palmer type 1 C split tear of the ulno-
carpal ligaments,17 or irreparable peripheral TFCC tear
(Palmer type 1B, Atzei class 4).
Based on clinical complaints and assessment, patients
were divided into 2 groups: group A comprised patients
who complained of pain in the ulnar compartment of
the wrist, showing a positive fovea sign,17 which is
assumed to be consistent with TFCC lesion (TFCC tear
group); and group B comprised patients who com-
plained of pain in a different site from the ulnar area of
the wrist (control group).
For the purposes of this study, the following parame-
ters were collected from patients’ clinical records pre-
operatively and at the 6-month follow-up visit: pain (0-
10 visual analog scale score); the Disabilities of the Arm,
Shoulder and Hand score; and DRUJ ballottement test.18
The DRUJ ballottement test was considered suggestive
for DRUJ instability when the increased anteroposterior
translation (compared with the contralateral side) was
associated to a soft end-point (positive DRUJ ballotte-
ment test).19 All surgeries were performed by a single
surgeon (A.A.) who was unaware of the patients’ clinical
investigation before conducing the arthroscopic
assessment.
Surgical Procedure
Standard wrist arthroscopy setup was applied.20 Wrist
distraction was achieved using a distraction tower via
finger straps on the index and ring finger. No saline was
insufflated into the joint (dry arthroscopy).21 System-
atic arthroscopic examination was performed routinely
on both RCJ and DRUJ using a standard 30
2.7-mm
scope. Small joint probe, motorized shavers, and su-
ture anchors were employed as necessary. For joint
exploration, at least the 3-4 and 6-R portals were used
on the RCJ, and the dorsal DRUJ and direct foveal
portals were used on the DRUJ.20
Diagnostic Arthroscopy
RCJ exploration was performed using the 3-4 and 6-R
portals. Laceration of the peripheral TFCC was searched
for on the dorsoulnar aspect of the RCJ, after local sy-
novitis was debrided as necessary. The trampoline and
1802 A. ATZEI ET AL.

Fig 1. The trampoline test. Artist’s rendering of a positive trampoline test (A). With a standard arthroscopic setting, the probe is
introduced in the 6-R portal (B) to exert a compressive force on the central disc of the TFCC, as seen through the arthroscope in
the 3-4 portal (C). In normal conditions, this maneuver produces a prompt bouncing of the disc (trampoline effect) when the
probe is released (negative trampoline test). In case of peripheral TFCC tear, release of the compressive force applied by the probe
on the central disc (D) is not able to elicit its prompt rebound (E: white arrows outline the depressed central disc). The loss of
trampoline effect defines the positive trampoline test. (TFCC, triangular fibrocartilage complex.)

hook tests were employed to assess TFCC. The tram-
poline test was considered positive when the
compressive force applied with the probe on the central
disc was not able to elicit its prompt rebound (loss of
trampoline effect), indicating a peripheral TFCC tear12
(Fig 1). In parallel, the hook test was performed by
applying traction to the ulnar-most border of the TFCC,
with the probe inserted into the prestyloid recess via the
6-R portal. Care was taken to introduce the tip of the
probe as close as possible to the foveal area of the ulnar
head, to “hook” as much as possible of the ulnar pe-
ripheral portion of the TFCC (Fig 2). The test was
considered positive when the TFCC could be lifted up
by the probe toward the center of the RCJ.13-16,19
Subsequently, to visualize the foveal insertions (prox-
imal component) of the TFCC, DRUJ exploration was
performed using the DRUJ portal.20 When a detach-
ment is present, the DRUJ is loose and a 2.7-mm
arthroscope can be easily introduced, then synovitis
and scar tissue are debrided using a motorized joint
synovial resector via the direct foveal portal. The status
of the foveal insertions (proximal component) of the
TFCC is diagnosed by direct visualization and probing of
the ligamentous fibers. When the proximal component
is competent, DRUJ exploration may be limited to the
joint space and ulnar head, so that a clear view of the
foveal area cannot be obtained. In these cases, integrity
of the proximal TFCC is assumed.11
Outcome Measures of Arthroscopic Assessment
On RCJ exploration, the arthroscopic findings taken
into consideration were as follows: (1) presence/
absence of central disc perforation; (2) integrity/rupture
of the distal periphery of the TFCC; (3) positive/nega-
tive trampoline test; (4) and positive/negative hook
test. On DRUJ exploration, the integrity/rupture of
foveal insertions of the TFCC was taken into consider-
ation. Accordingly, the outcome measures that were
taken into consideration to compare trampoline and
hook tests were accuracy, test sensitivity and specificity,
and the positive and negative likelihood ratio. There-
fore, a 2  2 table was created for the whole TFCC tears
group and also for each class that was detected (i.e.,
distal tear, complete tear, proximal tear)
Statistical Analysis
Statistically significant differences between the 2
diagnostic methods were assessed by performing the
mid-p version of the McNemar exact conditional test for
paired data.22 Differences were considered significant
with P < .05. Accuracy, sensitivity, specificity, and pos-
itive and negative likelihood ratio of the trampoline and
 ACCURACY OF ARTHROSCOPIC TESTS FOR TFCC TEAR 1803

Fig 2. The hook test. Artist’s rendering of a positive hook test (A). With a standard arthroscopic setting, the probe is introduced in
the 6-R portal (B), then into the prestyloid recess (PSR), as seen through the arthroscope in the 3-4 portal (C: dotted line
represents probe’s profile under the TFCC). To “hook” as much as possible of the ulnar periphery of the TFCC, care is taken to
introduce the tip of the probe as close as possible to the foveal area of the ulnar head, then it is pulled radialwards and lifted up
towards the center of the RCJ (see arrows in B and C). When the foveal insertions are intact, the periphery of the TFCC cannot be
distorted by the pulling of the probe (negative hook test). The hook test is considered positive when the TFCC can be lifted up by
the probe (see arrows in D and E: dotted line represents probe’s profile under the TFCC). (TFCC, triangular fibrocartilage
complex.)

hook tests were measured and reported together with
95% confidence intervals (95% CIs). In particular, 95%
ClopperePearson CIs were determined for accuracy,
sensitivity, and specificity. Considering the 2 tests
together, the combined test was defined positive when
subjects were positive for at least 1 of the 2 tests.
Conversely, the combined test was defined negative
when subjects were negative for both tests. Accuracy,
sensitivity, specificity, and positive and negative likeli-
hood ratio were also measured and reported together
with 95% CIs. For positive and negative likelihood
ratios, 95% CIs were determined using the R package
‘PropCIs’ (https://cran.r-project.org/web/packages/
PropCIs/PropCIs.pdf, last accessed on August 5, 2020),
except for the negative likelihood ratios when sensitivity
estimate was 100%: in that case, we used the R package
‘bootLR’ to determine 95% CIs by means of a boot-
strapping method.23 Statistical analyses were performed
with STATA/IC 16.1 (StataCorp LLC, College Station,
TX) and RStudio 1.3.959 (RStudio, Boston, MA).
Results
Assessment of the Arthroscopic Tests
A total of 135 patients (97 male, 38 female, mean age
43.5 years) were included in the study. According to the
stated inclusion and exclusion criteria, from the initial
group, 43 patients were excluded because of the
following: (1) presence of ulnar plus variance (15 pa-
tients); (2) arthroscopic finding of central TFCC perfo-
ration (18 patients); (3) arthroscopic finding of Palmer
type 1 C split tear of the ulno-carpal ligaments 15
(9 patients); and (4) arthroscopic finding of irreparable
peripheral TFCC tear (Palmer type 1B, Atzei class 4)
(1 patient). Eighty patients were included in the TFCC
tear group and 55 patients in the control group. In the
TFCC tear group, rupture of the peripheral TFCC was
evident at RCJ arthroscopy in 68 cases. Of these cases,
DRUJ arthroscopy showed associated rupture of the
foveal insertion in 52 cases (complete TFCC tear e Atzei
class 2). Thus, the remaining 16 cases with arthroscopic
evidence of a torn peripheral TFCC were diagnosed as
suffering from an isolated distal tear of the TFCC (Atzei
class 1). In 12 cases, the TFCC showed a normal
appearance during RCJ exploration, but DRUJ
arthroscopy showed torn foveal insertions (Proximal
TFCC tear e Atzei class 3). The control group included
20 cases of ganglion cyst, 22 cases of carpometacarpal-1
and scaphotrapeziotrapezoid arthritism, and 13 diag-
nostic arthroscopies for miscellaneous wrist disorders
(scaphoid fracture/nonunion, midcarpal instability,
scapholunate/lunotriquetral instability). None of the 55
patients in the control group showed pathologic find-
ings on the peripheral TFCC in both RCJ and DRUJ
1804 A. ATZEI ET AL.

Table 1. 2  2 Table Showing the Results of Trampoline Test and Hook Tests and of the Combination of Both Tests (Combined
Tests) for Each Class of TFCC Lesions on Enrolled Patients

All Tears (n ¼ 80) Test Torn TFCC Control Group

Trampoline test Positive 58 18
Negative 22 37
Hook test Positive 64 2
Negative 16 53
Combined tests Positive 76 18
Negative 4 37

Distal Tear (n ¼ 16) Test Torn TFCC Control Group

Trampoline test Positive 12 18

Negative 4 37
Hook test Positive 0 2
Negative 16 53
Combined tests Positive 12 18
Negative 4 37

Complete Tear (n ¼ 52) Test Torn TFCC Control Group

Trampoline test Positive 41 18

Negative 11 37
Hook test Positive 52 2
Negative 0 53
Combined tests Positive 52 18
Negative 0 37

Proximal Tear (n ¼ 12) Test Torn TFCC Control Group

Trampoline test Positive 7 18

Negative 5 37
Hook test Positive 12 2
Negative 0 53
Combined tests Positive 12 18
Negative 0 37

Control group (n ¼ 55) Test Torn TFCC Intact TFCC

Trampoline test Positive 18

Negative 37
Hook test Positive 2
Negative 53
Combined tests Positive 18
Negative 37

D, distal component of peripheral TFCC; P, proximal component of peripheral TFCC; TFCC, triangular fibrocartilage complex.

arthroscopy. The arthroscopic findings in the TFCC tear
group were summarized in the following classes of
TFCC lesions: (1) distal TFCC tear (with intact foveal
insertion, n ¼ 16), (2) complete TFCC tear (n ¼ 52),
and (3) proximal TFCC tear (n ¼ 12). For each class of
detected TFCC lesions, data from both the trampoline
and hook test were presented as a 2  2 table, identi-
fying true and false positives, false and true negatives
(Table 1).
Outcome measures defining test accuracy, sensitivity,
specificity, and the positive and negative likelihood ratio
with their 95% CIs are described in Table 2 for all classes
of TFCC tears and for each class of TFCC tear. Measured
as the proportion of patients correctly identified by each
diagnostic method, the overall accuracy of the trampo-
line test was 70.37%. Similar values were found for the
different types of TFCC tears: 69.01%, 65.67%, and
72.90% for distal, proximal, and complete lesions,
 ACCURACY OF ARTHROSCOPIC TESTS FOR TFCC TEAR
Table 2. Outcome Measures (95% CIs) Considered to Compare Diagnostic Performance of the Trampoline Test and Hook Test
and the Combination of Both (Combined Test) for Peripheral TFCC Tears
Performance Measure (95% CI)
Test Accuracy Sensitivity
All tears (n ¼ 80)
Trampoline test 70.37% (61.9%-77.9%) 72.50% (61.4%-81.9%)
Hook test 86.67% (79.7%-91.9%) 80.00% (69.6%-88.1%)
Combined tests 86.67% (79.7%-91.9%) 80.00% (69.6%-88.1%)
Distal tear (n ¼ 16)
Trampoline test 69.01% (56.9%-79.5%) 75.00% (47.6%-92.7%)
Hook test 74.65% (62.9%-84.2%) 0.00% (0.0%-20.6%)*
Combined tests 69.01% (56.9%-79.5%) 75.00% (47.6%-92.7%)
Complete tear (n ¼ 52)
Trampoline test 72.90% (63.5%-81.0%) 78.85% (65.3%-88.9%)
Hook test 98.13% (93.4%-99.8%) 100.00% (93.2%-100%)*
Combined tests 83.18% (74.7%-89.7%) 100.00% (93.2%-100%)*
Proximal tear (n ¼ 12)
Trampoline test 65.67% (53.1%-76.9%) 58.33% (27.7%-84.8%)
Hook test 97.01% (89.6%-99.6%) 100.00% (73.5%-100.0%)* 96.36% (87.5%-99.6%) 27.5 (8.11-99.71) 0.00 (0.00-0.23)y
Combined tests 73.13% (60.9%-83.2%) 100.00% (73.5%-100%)*
CI, confidence interval.
*One-sided 97.5% (97.5% CI).
y
95% CIs were determined by means of a bootstrapping method according to Marill et al.23
respectively. In contrast, the hook test showed to be
more accurate when evaluating all tears (86.67%), and
particularly proximal (97.01%) and complete (98.13%)
tears, rather than distal lesions (74.65%). Comparing the
2 methods, we found that the hook test proved to be
more accurate than the trampoline test when we eval-
uated the proximal and complete lesions, whereas the 2
tests had a similar accuracy in distal lesions (Table 2).
Interestingly, statistical analyses on collected data
demonstrated significant differences between the 2
evaluation tests. The hook test had significantly greater
sensitivity than the trampoline test in the case of both
complete TFCC tear (P < .001) and isolated proximal
lesion (P ¼ .031). Regarding distal TFCC tear, the hook
test was found to be significantly less sensitive than the
trampoline test (P < .001). In particular, the hook test
was negative in all patients showing a distal tear,
revealing its low sensitivity in detecting this class of
lesions. Furthermore, specificity for the hook test
(96.36%) was significantly greater than for the tram-
poline test (67.27%) (P < .001). Overall positive like-
lihood ratio for the trampoline and hook test was 2.22
(95% CI 1.53-3.39) and 22 (95% CI 6.46-80.04),
respectively. In the case of isolated distal TFCC tear
(Atzei class 1), the positive likelihood ratio for the
trampoline test and for hook test was 2.29 (95% CI
1.37-3.65) and 0.00 (95% CI 0.00-6.10), respectively.
Conversely, the negative likelihood ratio for the tram-
poline test and the hook test was 0.37 (95% CI
0.15-0.76) and 1.04 (95% CI 0.84-1.14), respectively.
In the case of rupture of the foveal insertions of the
TFCC, the positive likelihood ratio for the trampoline
1805
Positive Negative
Specificity Likelihood Ratio Likelihood Ratio
67.27% (53.3%-79.3%) 2.22 (1.53-3.39) 0.41 (0.27-0.60)
96.36% (87.5%-99.6%) 22.0 (6.46-80.04) 0.21 (0.13-0.31)
67.27% (53.3%-79.3%) 2.86 (2.05-4.37) 0.07 (0.03-0.18)
67.27% (53.3%-79.3%) 2.29 (1.37-3.65) 0.37 (0.15-0.76)
96.36% (87.5%-99.6%) 0.00 (0.00-6.10) 1.04 (0.84-1.14)
67.27% (53.3%-79.3%) 2.29 (1.37-3.65) 0.37 (0.15-0.76)
67.27% (53.3%-79.3%) 2.41 (1.65-3.69) 0.31 (0.18-0.53)
96.36% (87.5%-99.6%) 27.5 (8.11-99.71) 0.00 (0.00-0.06)y
67.27% (53.3%-79.3%) 3.06 (2.18-4.58) 0.00 (0.00-0.08)y
67.27% (53.3%-79.3%) 1.78 (0.89-3.09) 0.62 (0.28-1.07)
67.27% (53.3%-79.3%) 3.06 (2.12-4.58) 0.00 (0.00 0.32)y
test was 2.41 (95% CI 1.65-3.69) and 1.78 (95% CI
0.89-3.09) for complete (Atzei class 2) and proximal
tear (Atzei class 3), respectively. The positive likelihood
ratio for the hook test was 27.50 (95% CI 8.11-99.71)
in both cases of complete tear and proximal tear (Atzei
class 2 and 3). In parallel, the overall negative likeli-
hood ratio was calculated to be 0.41 (95% CI 0.27-0.60)
for the trampoline test and 0.21 for the hook test (95%
CI 0.13-0.31).
Outcome measures of accuracy, sensitivity, specificity
also were obtained by combining the results of the
trampoline and hook tests (Table 2). The overall accu-
racy of the combined test was 86.67%. For the distal
lesion, the combined test showed the same diagnostic
performance as the trampoline test. For complete and
proximal lesions, the sensitivity of the combined test had
the same sensitivity values as the hook test (100%). The
specificity of the combined test had the same values as
the specificity of the trampoline test (67%); however,
the positive likelihood ratio showed less satisfactory
values compared with those of the hook test alone.
Discussion
This study pointed out that the trampoline and hook
arthroscopic tests are accurate to make a diagnosis of
peripheral TFCC tear, with the hook test showing
greater sensitivity and specificity in recognizing foveal
lesions (Atzei class 2 and 3). In particular, the positive
hook test is strongly indicative of proximal and com-
plete TFCC lesions (Atzei class 2 and 3) with lacerated
foveal insertion (sensitivity: 100%). Notably, in patients
with distal tears, its sensitivity decreases up to 0.00%.
1806 A. ATZEI ET AL.
This highlights that the hook test cannot identify
whether the distal TFCC is torn (Atzei class 1) or intact.
Its high sensitivity in the diagnostic evaluation of the
proximal ligaments is confirmed by the constant finding
of the negative hook test in case of competent foveal
attachments of the TFCC. Further evidence of the
scarce ability of the hook test to distinguish between an
intact TFCC and one with a distal tear arises from the
analysis of the diagnostic performance of the combi-
nation of both tests. In fact, for such a lesion (Atzei class
1), the combined test shows the same diagnostic per-
formance indices as the trampoline test. Conversely, the
diagnostic performance of the combined test for foveal
lesions (Atzei class 2 and 3) relies entirely on the
optimal values of the sensitivity of the hook test, and
yet it is rather limited by the low specificity of the
trampoline test. Very useful information on test accu-
racy arises also from the analysis of the values of like-
lihood ratios. From a practical standpoint, the positive
likelihood ratio of 27.5 for the hook test in patients with
ruptured foveal insertion of the peripheral TFCC (Atzei
class 2 and 3) correlates with the probability that the
hook test is found positive 27.5 times more often than
in patients without ruptures, i.e., with competent foveal
insertion (Atzei class 1), whereas the trampoline test is
found positive only 2.41 times more often than in pa-
tients without ruptures. In parallel, the trampoline test
and the hook test are found negative respectively 0.37
and 0.0 times as often as in patients without ruptures.
In contrast, in patients with distal peripheral TFCC tear
(Atzei class 1), the trampoline test and the hook test are
found positive, respectively, 2.29 and 0.0 times and
negative 0.37 and 1.04 times as often as in patients
without ruptures. Although in the literature no reports
have been published that quantify the clinical impact of
likelihood ratios, it is assumed that tests with a positive
likelihood ratio greater than 10 or a negative likelihood
ratio less than 0.1 have the potential to alter clinical
decisions.24 Yet, clinical information provided by tests
with likelihood ratios between 5 and 10 or 0.1 and 0.2
may be still considered at least as useful.24 The combined
use of the trampoline and hook test provides greater
accuracy than the trampoline test alone to recognize any
class of tears from the whole group. However, for foveal
lesions, the combined test seems less accurate than the
hook test alone, due to the low specificity of the tram-
poline test. In this respect, it should be considered that in
clinical practice, these tests are performed after preop-
erative clinical assessment and imaging studies. Conse-
quently, when the preoperative work-up is suggestive of
foveal rupture of the TFCC with subsequent DRUJ
instability, the surgeon is advised to privilege the infor-
mation provided by the hook test alone.
Reviewing the literature, we found no clinical trials
reporting on the comparison between the trampoline and
hook tests for arthroscopic TFCC diagnosis. Nevertheless,
Trehan et al.25 assessed the trampoline and hook arthro-
scopic tests to evaluate TFCC foveal tear on cadaveric
wrists, as 3 blinded observers interpreted the video re-
cordings of the two arthroscopic tests. They demonstrated
that the hook test assured for significantly greater sensi-
tivity (90%), specificity (90%), and reliability (Cohen
kappa 0.87 and 0.81 for inter- and intraobserver,
respectively) than the trampoline test (sensitivity: 43%,
specificity: 83%, reliability: Cohen kappa 0.16 and 0.63
for inter- and intraobserver, respectively).25
The analysis of TFCC lesions involves several prob-
lems that make their resolution still incomplete. Painful
symptoms can be highly limiting in most cases. How-
ever, some cases might show mild symptoms so that an
acute and reparable lesion may become chronic and, in
most cases, not repairable. Furthermore, current diag-
nostic strategies turn out to be incomplete and not
satisfactory. Actually, in terms of precision and accu-
racy, no investigation (i.e., radiography, nuclear mag-
netic resonance) can yet compete with arthroscopy,
which, however, suffers from high invasiveness as its
main limit. Another important limit is that the surgeon
is required to be highly experienced in small joint
arthroscopy, which needs a dedicated learning curve.
Considering that, once the pathology has been sus-
pected by a thorough clinical assessment,26 the patient
needs to be confirmed with a precise and early diagnosis
to be directed to the most suitable treatment. In this
context, the present work focuses on the evaluation of
TFCC lesions by wrist arthroscopy, to contribute to the
consolidation of this technique as a diagnostic modality.
The TFCC consists of 2 components, the proximal and
distal parts. The distal part includes the so-called
hammock structure and plays a role in supporting the
carpus, whereas the proximal part is formed by the volar
and dorsal component and functions as a true ligament.2
According to the novel “iceberg” theory,6 during
arthroscopy of the RCJ joint the TFCC shows its
“emerging” tip, which is the distal component (dc-TFCC),
mainly functioning as a shock absorber. The “submerged”
part of the TFCC is represented by the proximal foveal
insertions (proximal components of the TFCC, i.e., pc-
TFCC), which play the most relevant role for the biome-
chanical support and stabilization of the DRUJ and the
ulnar carpus. The latter part results to be the most difficult
to examine by RCJ arthroscopy, and requires DRUJ
arthroscopy, a more technically demanding procedure,
for a thorough assessment.10,11 Consequently, the
development of a simple and precise diagnostic test that
assesses the rupture of the foveal insertions appears to be a
worthwhile opportunity.
The results of this study highlight that the hook test can
serve to specifically evaluate the proximal foveal in-
sertions, becoming a consistent indicator of TFCC foveal
lesions (Atzei class 2 and 3). This implies that, even if RCJ
exploration only is not sufficient for a thorough
 ACCURACY OF ARTHROSCOPIC TESTS FOR TFCC TEAR
arthroscopic assessment of TFCC tears, use of the hook
test makes DRUJ exploration no longer necessary for
these diagnostic purposes. As DRUJ arthroscopy is a more
advanced procedure, requiring greater skills and experi-
ence, understanding the value of the hook test gives one
the prospect of avoiding routine DRUJ exploration. The
critical issue raised by the aforementioned “iceberg”
concept, which explains how the assessment of TFCC
functions, relevance and lesions depend not only on the
observation of the emerging part (i.e., dc-TFCC), but even
primarily on the examination of the submerged portion of
the iceberg (i.e., pc-TFCC), corresponding to the greater
functional importance of this anatomical structure.6
Clinically, this translates into the need of adopting the
hook test as a standard evaluation method for a precise
assessment of the competence of the foveal (proximal)
attachments of the TFCC.
Limitations
Some limitations to this study can be acknowledged.
First of all, performing the diagnostic test needs relevant
surgical experience and sensibility. Second, sample size
was limited. Third, the time frame during which this
pathology can be detected and treated is limited.
Conclusions
The trampoline and hook tests can assure accurate
diagnosis of peripheral TFCC tear. The hook test shows
greater specificity and sensitivity to recognize foveal
TFCC tears. Values of positive likelihood ratio suggest a
greater probability to detect foveal laceration of pe-
ripheral TFCC for the hook test than for the trampoline
test. These findings suggest that DRUJ arthroscopy is
not necessary to confirm foveal incompetence of the
TFCC if the hook test is positive.
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