Clinical diagnosis
Case 65
【Treatment】He was given adhesive tapes including non-steroid anti-inflammatory drugs and supporter to immobilize wrist movement.
【Discussion】
Injury to triangular fibrocartilage complex (TFCC) is a main cause of ulnar wrist pain (1). TFCC injury is caused by trauma and repetitive sport activities such as golf, tennis and baseball. The triangular articular cartilage (disk) exists at the distal ends from radius to ulna and provides continuous gliding surface between carpal bones and ulna & radius (Fig. 5). It allows flexion-extention and translational movements of radius and ulna. The triangular articular cartilage of the distal end of ulna is a main component of TFCC. The articular cartilage of TFCC composes of triangular disk: triangular proper, fovea & styloid insertions and meniscus homologue (2 – 4) (Fig. 6-9).
TFCC indicates a space from the distal radius-sided ulna edge to base of ulna styloid (Figs. 5~9). Triangular cartilage is encompassed with palmer and dorsal radio-ulnar ligaments (Fig. 4). Further, other three ligaments are attached to TFCC: ulnotriquental ligament, ulnolunate ligament and ulnar carpal ligament (Fig. 5). Further, TFCC includes ulnocarpal ligament and extensor carpi ulnaris (ECU) (1 – 4) (Figs. 7, 8).
TFCC functions spacer, stabilizer and shock absorber. TFCC exists between ulna and os triquetrum & os linatum which prevents friction between ulna and these carpal bones. TFCC stabilizes to prevent dorsal or palmer displacement of ulnar head. Further, TFCC stabilizes radioulnar joint and proximal carpal row. TFCC plays a role of shock absorber when the load of the carpal bones was given to the distal ulna or when the load of the ulnar end was given to the carpal bone. The central portion of triangular cartilage (disk) is thin and consists of chondroid fibrocartilage (Figs 9, 10, 11). This type is often seen in structures that can bear compressive loads. The excess load beyond the ability of the shock absorber was given, resulting in injury of TFCC (Fig. 12).
Palmer classification for TFCC abnormalities is well accepted and based on the cause, location and degree of injury. It is mainly divided into two classes: Class 1, traumatic and Class 2, degenerative as shown in Table 1(5). Wrist radiograph and CT do not supply any information about TFCC abnormalities. MRI is increasingly attempted in the evaluation of TFCC injuries. The site of the triangular fibrocartilage disk and its attachments and relations with carpal bones are useful for imaging interpretation(6 - 9). A thorough understanding of TFCC anatomy is crucial in diagnostic accuracy and guiding patient treatment. In our patient who is thirty two-year-old, he incurred wrist traumatic damage and wrist MRI showed the injury of ulnotriquentral ligament and triangular disk, and bone marrow edema of os triquentrum, indicating to be corresponded to Class 1C (Table 1).
Irrespective of traumatic or degenerative TFCC lesions with a stable distal ulnar-radial joint, initial non-steroid anti-inflammatory drug (NSAID) is commonly given with wearing a temporary band, splint or cast to immobilize the wrist for approximately a month. Arthroscopic debridement or repair, or open surgery repair is given in TFCC lesions of resistant to conservative treatment or complex TFCC injury (10). In our case, he was given NSAIDs tape and supporter to immobilize the wrist joint.
【Summary】
We present a thirty two-year-old male with right ulna-sided wrist pain. Wrist MRI with fat suppression T2WI showed high signal intensity of ulnotriquentral ligament & triangular disk, and bone marrow edema of os triquentrum, indicating to the injury of TFCC: Class 1C, according to Palmer classification. We should keep in mind that TFCC functions shock absorber of loads from carpal bones to ulna or vice versa. Further, TFCC composes of seven factors: triangular articular cartilage (triangular proper, fovea & styloid insertions and meniscus homologue), palmer radioulnar ligament, dorsal radioulnar ligament, ulnotriquentral ligament, ulnolunate ligament, ulnocarpal ligament. Then, when reading MRI images, we have to check TFCC abnormalities based on these anatomical components.
【References】
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2017.8.2