The Wrist

Essential Components of a Diagnostic or Preoperative Imaging Evaluation of the Wrist: 1. Status of the Osseous Structures 2. The Triangular Fibrocartilage Complex 3. The Ligaments 4. Carpal Instabilities 5. The Tendons 6. The Carpal Tunnel & Guyons Canal 7. The Articular Surfaces & Joint Capsule 8. Nerves/Entrapment Neuropathies 9. Collateral Ligaments of the 1st MCP Joint 10. Arthritis

TFCC
Thickened pad of

connective tissue that functions as a cushion for ulnar axial loads

Articular disc

Meniscus
Ulnar collateral ligament

Anatomy
Consists Of:

The Wrist

The TFC Complex

TFC Meniscus homologue attachment Attachment to UCL & subsheath of ECU Ulno-lunate/Ulno-triquetral ligaments Radioulnar ligs (dorsal & ventral)

The Triangular Fibrocartilage Complex

Functions to: Stabilize DRUJ and ulno-carpal

articulation Distribute forces during axial loading

Component Function TFC is an asymmetric biconcave

fibrocartilagenous disk that articulates with the distal ulna and the triquetrum

Anatomy
Is positioned between the ulna & triquetrum and attaches to the Ulna via 2 bands (fovial attachment and ulnar styloid attachment) Attaches laterally to the Radius The TFC is thinner in patients with + ulnar variance and vice versa Low on all pulse sequences Best assessed on Coronal MR Images

The TFC

Anatomy
The TFC
Most commonly injured component of the TFCC High T2 signal intensity extending to an articular surface is a tear
May be partial thickness (ulnar or carpal side) or full thickness

TFCC Injuries may be divided into 2 classes

Class 1 Traumatic Tears Class 2 Degenerative Injuries

Acute TFC Tear

Chronic Degenerative TFC Tear

Anatomy
The TFC
Location Of Tear Is Important The vascular supply to the TFC is peripheral periphery is well vascularized
Tears of outer 20% may heal Central tears may require surgery

Avulsion from ulnar attachments may result in TFC interposition between radius & ulna and dysfunction of the DRUJ

Anatomy
Signal Abnormalities Without Sxs TFC May have increased signal due to myxoid degeneration Asymptomatic TFC peforations
Due to normal variant perforations or asymptomatic degenerative tears (~50% of patients by the sixth decade of life)

The TFC

Central tears commonly degenerative Peripheral Tears - traumatic Correlate With Clinical Symptoms!

Anatomy
The TFC

The Wrist

Accuracy of MRI in Diagnosing TFC Tears Accuracy Rate of 89 95% Highly Variable Depending on Technique

TFC Tear With Ulnolunate Abutment and Lunotriquetral Tear

Anatomy
The TFC Complex
Meniscal Homologue Attachment Dorsal Portion More WellDefined Forms Distal Border of Prestyloid Recess (Prox Border is Styloid Attachment of TFC) Continuous with
Medial Capsule, ECU Sheath, & Dorsal Radioulnar Ligament

The Wrist
Anatomy
The TFC Complex
Attachment to UCL and ECU Sheath

The TFC Also Attaches to the UCL/Medial Capsule The TFC Attaches to the Sheath of the ECU Tendon Dorsomedially

The Wrist
Anatomy
The TFC Complex
Ulnolunate & Ulnotriquetral Ligaments

Origniate From Volar Aspect of the Volar Radioulnar Ligament Ligaments are Thickenings of the Capsule and are Extrinsic Ligaments

Ulnolunate and Ulnotriquetral Ligaments

Volar Radioulnar Ligament

Anatomy
The TFC Complex
Dorsal & Ventral Radioulnar Ligament - The peripheral thickening of the
TFC give rise to the DRUL and the VRUL - Attach to the medial ulnar styloid process and the lateral distal radius

The Wrist
Anatomy
The TFC Complex
Dorsal & Ventral Radioulnar Ligaments

The Ligaments are Flat Superiorly & Inferiorly and Can Be Distinguished From the TFC by This Feature Disruption of the Dorsal & Ventral RULs Seen with DRUJ Instability

TFCC tear:

Examination (cont)
Rule out injury to distal radio-ulnar joint (DRUJ) Squeeze radius/ulna together and passively rotate forearm
Painful in DRUJ injury No pain in isolated

TFCC tear

TFCC tear:

Examination (cont)
Tenderness just distal to ulnar styloid

TFCC load test

Pain is a + test

TFCC tear:

Examination (cont)
Press test
Patient presses

arms of chair to lift body off seat

100% sensitive

Traumatic TFCC Tear

Linear radial tears respond well to debridement Return to sport as symptoms resolve
Peripheral tears amenable to repair Splinted for 4-6 weeks then return-to-sport program

Wrist pain
Floor Exercises

Distal Radioulnar Joint Disorders

Class I traumatic
A - perforation of horizontal TFC

B - TFC avulsed from distal ulnar insertion

C - TFC avulsed from lunate

D - TFC avulsed from radius

TFC Tear

B, 33 ani, tenismen - fractura de scafoid

- leziune TFCC

Distal radioulnar joint disorders Class II degeneration A - wear of central TFC without tear B - wear of TFC & chondromalacia of ulnar C - perforation of horizontal TFCC D - perforation of TFC, tear of LTL &degenerative changes lunate E - complete abscence of horizontal TFCC, tear of LTL, osteoarthritis distal RU joint

Degenerative tears of the TFCC (A)Palmer class IIB lesion (ulnar impaction syndrome). Coronal T2*-weighted MR arthrogram image revealing a degenerative partial tear of the proximal surface of the central portion of the TFC and thinning without perforation (arrow). Note the existence of positive ulnar variance (B) Palmer class IIC lesion (ulnar impaction syndrome). Coronal fat-suppressed T1weighted MR arthrogram image showing a central TFC perforation

TFC tear and ganglion cyst adjacent to FCU

TFCC Degeneration

Scapholunate Ligament Tear

Scapholunate ligament tear and degenerative tear of TFC

Scapholunate ligament tear and AVN of proximal pole of scaphoid

Scapholunate Ligament Tear and TFC Tear

Scapholunate Ligament Tear and TFC Tear

SLAC wrist & cystic degenerative change

Wrist pain
Balance Beam