DEFINITION

The triangular fibrocartilage complex (TFCC) is a homogenous anatomic structure located on the ulnar aspect of the wrist that is responsible for distal radioulnar joint (DRUJ) stability and transfers load across

the wrist from the ulnar carpus to the distal ulna.21

Injury to the TFCC and subsequent synovitis is associated with ulnar-sided wrist pain, weakness of grip, and painful clicking about the DRUJ often resulting in patient disability.

Ulnocarpal abutment or ulnar impaction syndrome is characterized by ulnar-sided wrist pain associated with a TFCC tear and accompanying variable chondromalacia of the ulnar head, lunate, and triquetrum surfaces. The degenerative process typically occurs in ulnar positive or neutral variance from chronic compressive overloading of the ulnocarpal joint.

Arthroscopic TFCC débridement is indicated for centrally based lesions and may be combined with ulnar shortening in light of concomitant ulnocarpal abutment.

 

 

ANATOMY

 

The TFCC is a confluence of cartilaginous and ligamentous structures that span and support the DRUJ and ulnocarpal articulations. It arises from the distal aspect of the radial sigmoid notch and inserts into the base of the ulnar styloid and fovea (FIG 1).

 

 

The ulnocarpal complex, consisting of the ulnolunate ligament, ulnotriquetral ligament, and extensor carpi ulnaris (ECU) subsheath, spans the ulnocarpal joint.

 

 

 

FIG 1 • TFCC anatomy.

 

 

The superficial limbs of the dorsal and palmar radioulnar ligaments insert onto the base of the ulnar styloid, whereas the deep limbs insert into the fovea.11

 

The central articular disc is a thin fibrocartilage structure, spanning from the distal rim of the sigmoid notch and blends with the radioulnar ligaments.

 

PATHOGENESIS

 

Acute, Palmer I, TFCC injuries typically result from an axial load in ulnar deviation, combined with forearm rotation. Biomechanically, the TFCC becomes compressed and stretched between the ulna and lunate producing a tear.

 

 

These injuries typically occur in falls on a pronated outstretched hand or activities that require forceful ulnar deviation of the wrist (eg, golf and racquet sports).

 

Intra-articular distal radius fractures show a high incidence of concomitant tears of the triangular fibrocartilage, 50% to 84%.6,13 However, many of these tears are minimally symptomatic and do not require surgical intervention.16

 

Chronic degenerative tears of the TFCC are associated with ulnar positive variance and ulnar carpal impaction (FIG 2).

 

 

Ulnar positive variance occurs with any condition that causes a relative greater ulnar than radial length at the wrist. These include distal radius malunion, Essex-Lopresti lesion, developmental positive ulnar variance, and premature radial physeal closure.

 

 

 

FIG 2 • Ulnar abutment. The TFCC is compressed between the proximal ulnar lunate and the distal ulnar head.

 

 

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Degenerative tears result from chronic load to the ulnar side of the wrist. In an ulnar neutral wrist, the ulnar carpus absorbs 18% of axial load. This increases to 42% when ulnar variance is increased 2.5 mm and

decreases to 4.3% when ulnar variance is decreased 2.5 mm.20

 

NATURAL HISTORY

 

The natural history of Palmer type I TFCC tears is not well understood. Many type IA lesions without instability

respond to nonoperative management.22 In a long-term follow-up, Mrkonjic et al16 showed that distal radius fracture associated TFCC tears with a stable DRUJ showed some increased laxity and decreased grip strength but did not require routine surgical treatment.

 

 

Surgical débridement for failed conservatively treated type IA lesions showed excellent success.18 However, high failure rates were noticed when TFCC débridement alone was performed in the ulnar positive wrist.15

 

Types I B, C, and D tears may result in clinical instability of the DRUJ and require surgical intervention to restore stability.

 

Degenerative tears (type II) are nontraumatic with a natural history that shows TFCC attrition in more than half of patients older than 50 years of age.3 Also, after the fifth decade, 100% of TFCCs evaluated showed an abnormal appearance but usually asymptomatic.4

 

Symptomatic degenerative tears typically have progressive degenerative changes that involve the ulnocarpal joint surfaces, which may or may not strictly follow the progressive cascade in accordance with Palmer's classification: TFCC wear (IIA), ulnar or lunate chondromalacia (IIB), central TFCC perforation (IIC), lunotriquetral ligament tear (IID), and arthritic changes of the lunate and triquetrum (IIE).

 

It is possible to have components of a type I traumatic tear in a wrist with a preexisting degenerative TFCC, in

which an acute flap causes mechanical symptoms. In this case, arthroscopic débridement alone may not improve symptoms and ulnocarpal decompression is warranted.

 

PATIENT HISTORY AND PHYSICAL EXAMINATION

 

Patients often report ulnar-sided wrist pain occurring after a fall. They may also complain of clicking, catching, weakness, localized swelling, and a sense of instability.

 

Physical examination reveals swelling over the ulnar wrist, with focal tenderness over the TFCC and distal ulna.

 

 

Fovea sign—direct pressure applied to the fovea region that reproduces their pain had 95.2% sensitivity and 86.5% specificity for TFCC foveal disruption and/or ulnotriquetral ligament injury.24

 

Ulnocarpal palpation—pain at the ulnocarpal joint suggests synovitis or TFCC pathology.

 

TFCC stress test—ulnar deviation and axial loading of wrist reproduces a painful click with forearm rotation.

 

Ulnocarpal stress test—pain reproduced during pronation and supination of the forearm with the wrist in ulnar deviation

 

Pisiform boost test—increased pain of passive and active ulnar deviation with dorsally directed pressure applied over the palmar aspect of the pisiform, resulting in a lifting of the carpus

 

The DRUJ must be assessed for instability with shuck or “piano key” test. The distal radius is held in one hand and the other hand stresses the distal ulna volarly and dorsally in neutral rotation, pronation, and supination.

This must be compared to the contralateral side.

 

 

Instability suggests disruption of the radioulnar ligaments.

 

IMAGING AND OTHER DIAGNOSTIC STUDIES

 

The radiographic evaluation of a patient with ulnar abutment should include a standard wrist series, a Palmer 90

× 90 neutral rotation view19 and a fully pronated grip stress view.25

 

 

The Palmer 90 × 90 view places the forearm in neutral rotation while the elbow is flexed to 90 degrees and the shoulder is abducted to 90 degrees. The static ulnar variance is calculated from this view (FIG 3).

 

The fully pronated grip stress view has the shoulder adducted to the patient's side and slightly externally rotated, the forearm is pronated, and the patient is asked to make a fist of maximum intensity. An increase ulnar variance indicates dynamic variance.

 

Ulnar impaction is suspected in a patient with an ulnarzero or ulnar-plus variance. Subchondral cystic and sclerotic joint changes in the lunate indicate probable ulnar impaction (FIG 4).

 

Magnetic resonance imaging (MRI) evaluation of the triangular fibrocartilage can aid in diagnosis especially in central tears. Magnetic resonance (MR) arthrogram has been shown to be more sensitive than standard MR imaging but can have higher false positives.12,23

 

On T2 imaging, an intact TFCC has a homogenous low signal.

 

An MRI should be considered for ulnar impaction syndrome in the absence of clear radiographic findings. Characteristic early findings include bone hyperemia in the lunate, triquetrum, and ulnar head, which has low

signal intensity on T1-weighted images and high signal intensity on T2-weighted images (FIG 5A,B).9

 

Computed tomography (CT) arthrography has been shown to have high sensitivity and specificity in diagnosing central TFCC tears and can be used when MRI is contraindicated.12,17,23

 

 

 

FIG 3 • Ulnar-plus variance is shown on a 90 × 90 neutral rotation view.

 

 

P.1038

 

 

 

FIG 4 • PA radiograph of a wrist with ulnar abutment showing positive ulnar variance and cystic changes within the lunate.

 

DIFFERENTIAL DIAGNOSIS

TFCC tear Ulnocarpal impaction Ulnocarpal synovitis

Ulnar extrinsic ligament tear Lunotriquetral joint instability

 

 

 

 

FIG 5 • A. T1-weighted MRI of a wrist with ulnar abutment demonstrating low signal intensity at the proximal lunate. B. T2-weighted MRI of a wrist showing increased signal intensity within the proximal lunate and TFCC demonstrating ulnar abutment.

 

 

 

DRUJ instability DRUJ arthritis

 

 

 

Ulnar styloid nonunion Pisotriquetral arthritis Kienböck disease

 

 

NONOPERATIVE TREATMENT

Nonoperative management is indicated for the initial treatment of TFCC tears in the absence of DRUJ instability.

Immobilization of the wrist and forearm with a sugar-tong or long-arm splint for 4 weeks, combined with a course of nonsteroidal anti-inflammatories

Intra-articular steroid injection can be helpful in patients who present acutely. Activity modifications are used to avoid movements that exacerbate the pain.

Postimmobilization therapy includes gradual range of motion and strengthening, but avoid torque or forceful grasp for 8 weeks.

Three to 4 months of nonoperative treatment is a reasonable plan prior to surgical intervention.

 

SURGICAL MANAGEMENT

 

Surgical treatment is indicated in the symptomatic patient after failure of nonoperative management.

 

 

Wrist arthroscopy is performed to evaluate the TFCC, ulnocarpal articular surfaces, and intercarpal ligaments.

 

Type IA tears have been shown to respond well to arthroscopic débridement in the absence of ulnar positive variance. Types I B to D tears are often treated with repair and discussed elsewhere in this text.

 

Treatment of degenerative fibrocartilage complex tears begins with arthroscopic TFCC débridement and includes ulnar shortening in the ulnar positive or neutral patient (IIA to IIC). Additional lunotriquetral ligament débridement and possible pinning along with diaphyseal ulnar shortening osteotomy are indicated for IID and IIE TFCC tears.

 

 

Mechanical débridement of the triangular fibrocartilage with a 2.5- or 2.7-mm shaver has been successful,

 

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although it can be challenging, particularly in regard to the débridement of the ulnar and dorsal aspects of the triangular fibrocartilage tear.

 

Radiofrequency ablation probes have become increasingly popular for TFCC débridement and are useful for removal of torn fragments of fibrocartilage.5

 

Arthroscopic ulnar shortening by burr excision of the ulnar dome is indicated in patients with a TFCC tear who have ulnar impaction with less than 4 mm ulnar-plus variance that do not respond to nonoperative treatment.

 

 

The goal of the surgery is to create an ulnar neutral to minus variance of 2 mm.

 

Preoperative Planning

 

Preoperative radiographic evaluation is paramount to determine ulnar variance and evidence of ulnar impaction.

 

 

The patient must be informed that an arthroscopically assisted ulnar shortening may not be possible should there be laxity of the ulnocarpal ligaments, a peripheral TFCC tear, or lunotriquetral laxity.

 

The amount of shortening should be calculated preoperatively, with no more than 4 mm resection possible for arthroscopic shortening.

 

The surgeon should verify that the operating room is equipped with a mini C-arm to confirm intraoperatively the amount of ulna resected.

 

Positioning

 

 

The patient is placed supine, using the hand table, with the arm in a position accessible to fluoroscopic imaging. A well-padded pneumatic tourniquet is placed on the proximal arm.

 

The involved extremity is prepared and draped in the usual fashion.

 

The wrist is distracted (10 to 12 pounds) using a commercially available wrist traction device.

TECHNIQUES

• Triangular Fibrocartilage Complex Débridement

Portals and Arthroscopic Examination

The standard dorsal 3-4, 4-5, 6R, and midcarpal radial portals are used. Incision is made just through skin.

 

A hemostat is used for blunt dissection and penetration through capsule into the joint to reduce the risk of nerve or tendon injury.

 

A diagnostic arthroscopic examination of the radiocarpal, ulnocarpal, and midcarpal joints is performed to assess the intrinsic and extrinsic ligaments, the articular surfaces, and synovium for potential pathology and causes of symptoms that could affect the treatment plan.

 

Perform a synovectomy to ensure clear visualization of the joint.

 

 

 

TECH FIG 1 • A. Arthroscopic evaluation of ulnar carpal impaction from 3-4 portal with lunate chondromalacia and degenerative TFCC tear. B. Arthroscopic ulnar impaction with degenerative TFCC tear and exposed ulnar head with chondromalacia.

 

 

The TFCC is evaluated for injury. All joint surfaces are assessed for evidence of ulnar impaction including the lunotriquetral ligaments (TECH FIG 1A,B).

 

The TFCC is probed to assess the integrity of its peripheral attachments.

Triangular Fibrocartilage Complex Débridement

 

With the scope in the 3-4 portal, a working 6R portal is used to débride the radial, palmar, and a portion of the dorsal aspect of the TFCC tear (TECH FIG 2).

 

Alternating working portals between 6R and 4-5 may provide easier access to the tear.

 

Placing scope in 6R or 4-5 allows visualization and débridement of ulnar aspect of TFCC with instrumentation in the 3-4 portal.

 

P.1040

 

 

 

TECH FIG 2 • Mechanical débridement of the TFCC. The arthroscope is in the 3-4 portal looking ulnar while the suction punch enters through the 6R portal to débride the TFCC.

 

 

Use small joint punches (straight and angled), graspers, or an 18-gauge needle to débride the TFCC. The suction punch is particularly useful.

 

 

Take care not to injure the underlying ulnar head and overhanging lunate and triquetrum. Keep three points in mind while débriding the ulnar aspect of the TFCC:

 

Avoid injuring the attachment of the triangular fibrocartilage at its insertion on the base of the ulnar styloid.

 

Avoid injuring the dorsal or palmar radioulnar ligaments. If the ulnar attachment of the TFCC is transected, or if the dorsal and palmar radioulnar ligaments are injured, DRUJ instability could result.

 

 

 

TECH FIG 3 • A. The arthroscope is in the 3-4 portal and the shaver is passed through the 6R portal to smooth the edges of the débrided central TFCC tear. B. The débridement of the TFCC is complete. The ulnar head is visible and ready for shortening if indicated.

 

 

Avoid scuffing the articular surfaces while passing the cutting and grasping instruments from the 3-4 portal across the radiocarpal joint into the ulnocarpal joint.

 

After the TFCC has been mechanically débrided, the edges are smoothed using a shaver or radiofrequency ablator. If done appropriately, ablation of the tissue is also thought to cause shrinkage,

 

which could tighten the peripheral edge of the TFCC and prevent unstable flaps.14 A 2.0- or 2.9-mm shaver can be used to smoothen the TFCC rim (TECH FIG 3A).

 

The end point of TFCC débridement is reached when the ulnar head is visible through the TFCC and a stable, smooth TFCC rim remains (TECH FIG 3B).

 

Typically, a central defect measuring approximately 1 cm in diameter is created and up to 80% of substance can be resected without creating iatrogenic instability.1

 

After confirming that ulnar recession is not necessary, the wrist is removed from traction and a TFCC stress test is performed (ulnarly deviate, axially load, and repeatedly supinate and pronate the wrist).

 

The presence of popping or clicking is a sign that further débridement might be needed or that some other pathology is present.

 

One source of such postdébridement popping is thickened synovium in the DRUJ just proximal to the TFCC.

 

Wounds are closed with 4-0 nylon in simple or mattress fashion and a well-padded short-arm volar splint is applied.

• Laser-Assisted Triangular Fibrocartilage Complex Débridement

   

  The technique of laser-assisted TFCC débridement is similar to that of mechanical débridement, with the exception that the arthroscope can be left in the 3-4 portal, whereas the laser probe is kept in the 4-5 portal.

   

  The laser is set to 1.4 to 1.6 joules at a frequency of 15 pulses per second. With the help of a side-firing 70-degree laser tip, the triangular fibrocartilage can be rapidly and precisely débrided.

   

  The 70-degree laser tip permits ablation of not only the radial and palmar portions of the TFCC tear but also the ulnar and dorsal components.

   

  There is no need to bring the laser probe in through the 3-4 portal.

   

   

  P.1041

   

  During the débridement, take care not to injure the ulnar head by firing the laser tangentially to the head of the ulna or passing the probe beneath the triangular fibrocartilage and firing distally (TECH FIG 4).

   

  This latter technique presents minimal danger to the lunate or triquetrum, as the fluid used to expand the joint acts as a heat sink and absorbs the laser energy as it emerges from beneath the triangular fibrocartilage.

   

   

   

  TECH FIG 4 • Laser-assisted débridement of a TFCC tear. The laser probe is placed 1 mm from the TFCC.

• Arthroscopic Ulnar Shortening

   

  The objective is to create a smooth and level distal ulna with neutral to 2 mm negative variance.

   

  Small irregularities, however, tend to flatten out with the passage of time.

   

  After TFCC débridement, arthroscopic ulnar shortening is accomplished by placing the scope in the 3-4 portal and introducing the instruments through the 4-5 portal.

   

  Occasionally, the 6R portal can be used, as can the DRUJ portal.

   

  The small joint arthroscopic burr abrader (2.9 mm) is placed in the 4-5 portal (TECH FIG 5).

   

  Alternating the burr between portals enables access to the entire ulnar head.

   

  The distal ulnar cartilage is then removed through the defect in the central TFCC.

   

  A 3 to 4 mm of distal ulna is then removed with the burr; however, sufficient ulnar head must remain for proper joint loading to avoid arthritis from excessive contact stress.

   

  During burring, the forearm is fully supinated and pronated by the assistant to ensure circumferential débridement of distal ulna.

   

  The burr should be removed intermittently from the wrist and irrigated to cleanse the ulnocarpal joint of bone fragments.

   

   

  Frequent fluoroscopic imaging is used to confirm the level of resection. Avoid burring at the ulna fovea to prevent injury to deep TFCC attachment.

   

  After completing the resection, there should be neutral to 2 mm negative ulnar variance.

   

  The wrist is removed from the traction tower and examined with ulnar deviation, axial load, and supination and pronation to ensure no crepitance or clicking is felt which require further ulnar leveling or TFCC débridement.

   

  The holmium:YAG laser can be used for ulnar resection. It is introduced through the 4-5 portal and the cartilage and subchondral bone of the ulnar seat of the distal ulna are rapidly vaporized, using similar technique as burring (TECH FIG 6A,B). The laser is set to 1.4 to 1.6 joules at a frequency of 15 pulses per

  second.

   

  The laser becomes less efficient once the trabeculae of the distal ulna are visible (TECH FIG 6C). At that point, the 2.9-mm arthroscopic burr is brought in to finish the shortening.

   

   

  Frequent fluoroscopic monitoring is again used to ensure appropriate resection. Saline inflow must be adequate to prevent thermal injury.

   

  Wounds are closed with 4-0 nylon in simple or mattress fashion, and a well-padded short-arm volar splint is applied.

   

   

   

  TECH FIG 5 • Arthroscopic 2.9-mm burr in the 4-5 portal débriding articular cartilage and subchondral bone of ulnar head.

   

   

  P.1042

   

   

   

  TECH FIG 6 • A. The 70-degree side-firing laser probe easily vaporizes the hyaline cartilage and subchondral bone of the ulnar head. B. The laser has cleared the ulnar head of its cartilage and subchondral plate. C. The spacing of the bony trabeculae of the ulnar head decreases the laser's efficiency. The final leveling of the ulnar head is achieved with the small joint burr.

   

  PEARLS AND PITFALLS
  	TFCC débridement     Indication ▪ Symptomatic Palmer types IA and IIA tears without evidence of static or dynamic ulnar impaction that failed nonoperative management     Pearls ▪ All portals should be made by incising only the skin (avoid plunging blade beneath skin). Once the skin is cut, a small hemostat should be used to bluntly dissect through the subcutaneous tissue and penetrate the wrist joint capsule.

  • Excise only unstable central TFCC, leaving the periphery intact (at least 2 mm).

  • Assess lunate and triquetrum articular surfaces and ulnar head for evidence of chondromalacia.

  • Reevaluate wrist after débridement for absence of preoperative TFCC click.

   

   

  Technical points

  • Scope viewing in 3-4 portal with a 6R working portal (but can adjust for needed visualization)

  • Cauterize synovitis with thermal probe.

  • Use suction punch and 2.0-3.0-mm shaver to remove unstable TFCC flap.

     

    Pitfalls ▪ Injury to dorsal ulnar sensory nerve

    • Injury to the peripheral attachments of the TFCC and the dorsal and palmar radioulnar ligaments

    • Failure to recognize unstable DRUJ with repairable TFCC tear

    • Traumatic central tear with positive ulnar variance may need ulnar shortening.

       

      Rehabilitation ▪ Avoid early heavy loading of the wrist for at least 4 weeks. Arthroscopic ulnar shortening

      Indications ▪ Symptomatic TFCC tear with ulnar carpal impaction (Palmer types IIA to IIC)

       

      Pearls ▪ Preoperative neutral posteroanterior (PA) and pronated grip x-rays to determine ulnar variance

    • Resect only 3-4 mm of bone.

    • Midcarpal arthroscopy is used to evaluate lunotriquetral joint stability.

       

      Technical points

  • Pronate and supinate the wrist during distal ulnar resection to ensure complete resection.

  • Preserve peripheral attachment of TFCC and radioulnar ligaments.

  • Avoid resection into the ulnar fovea.

  • Use 2.9-mm burr for ulnar head resection (can use burr size as guide for resection).

  • Intermittent fluoroscopic evaluation to assess resection

     

    Pitfalls ▪ Injury to dorsal ulnar sensory nerve

    • Destabilization of the DRUJ with detachment of TFCC or radioulnar ligaments

    • Excessive head resection that disrupts loading across sigmoid notch

    • Failure to recognize lunotriquetral ligament perforation (IID and IIE) which require débridement and/or pinning with ulnar shortening osteotomy to tighten ulnocarpal ligaments

 

 

P.1043

POSTOPERATIVE CARE

Triangular Fibrocartilage Complex Débridement

 

Postoperative care includes immediate immobilization in volar short-arm splint with digital range of motion.

 

 

Active wrist and forearm range of motion is begun at 2 weeks.

 

Strengthening exercises are initiated at 6 weeks; avoid repetitive rotation or wrist loading.

 

Premature return to activities can lead to ulnocarpal synovitis and associated pain.

 

Return to normal activities and lifting can resume at 3 months.

 

 

 

FIG 6 • A. Preoperative radiograph showing ulnar abutment. B. Postoperative radiograph after arthroscopically assisted ulnar shortening.

 

Arthroscopic Ulnar Shortening

 

Similar protocol is used for patients undergoing ulnar shortening with brief immobilization followed by early active range of motion.

 

OUTCOMES

The results of arthroscopic débridement of type IA TFCC tears have a very good prognosis, revealing 80% to 85% good to excellent results.8,15

However, multiple studies have shown that simple TFCC débridement alone, in the setting of ulnar positive variance and in particular ulnar impaction, has inferior outcomes.2,7,10

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Arthroscopic TFCC débridement, when combined with an arthroscopically assisted ulnar shortening, has been shown to provide excellent and good results in over 80% of patients.18,26,27

This technique offers comparable results with ulnar shortening osteotomy, without the risk of hardware irritation or ulnar nonunion (FIG 6A,B).2

 

COMPLICATIONS

TFCC débridement

Injury to the dorsal branch of the ulnar nerve

Instability secondary to excessive débridement of the TFCC (dorsal and palmar radioulnar ligaments, attachment in the ulnar fovea)

Continued symptoms due to unrecognized ulnar impaction Arthroscopic ulnar shortening

Continued symptoms due to inadequate or uneven resection Disruption of the DRUJ from excessive resection Detachment of the TFCC from the ulnar fovea

Loss of forearm rotation

 

 

REFERENCES

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2. Bernstein MA, Nagle DJ, Martinez A, et al. A comparison of combined arthroscopic triangular fibrocartilage complex debridement and arthroscopic wafer distal ulna resection versus arthroscopic triangular fibrocartilage complex debridement and ulnar shortening osteotomy for ulnocarpal abutment syndrome. Arthroscopy 2004;20(4):392-401. doi:10.1016/j.arthro.2004.01.013.

    

    

3. Brown JA, Janzen DL, Adler BD, et al. Arthrography of the contralateral, asymptomatic wrist in patients with unilateral wrist pain. Can Assoc Radiol J 1994;45(4):292-296.

    

    

4. Culp RW, Osterman AL, Kaufmann RA. Wrist arthroscopy. In: Green DP, Hotchkiss RN, Pederson WC, et al, eds. Green's Operative Hand Surgery, ed 5. Philadelphia: Elsevier, 2005:781-803.

    

    

5. Darlis NA, Weiser RW, Sotereanos DG. Arthroscopic triangular fibrocartilage complex debridement using radiofrequency probes. J Hand Surg Br 2005;30(6):638-642. doi:10.1016/j.jhsb.2005.06.016.

    

    

6. Geissler WB, Freeland AE, Savoie FH, et al. Intracarpal soft-tissue lesions associated with an intra-articular fracture of the distal end of the radius. J Bone Joint Surg Am 1996;78(3):357-365.

    

    

7. Hulsizer D, Weiss AP, Akelman E. Ulna-shortening osteotomy after failed arthroscopic debridement of the triangular fibrocartilage complex. J Hand Surg Am 1997;22(4):694-698. doi:10.1016/S0363-5023 (97)80130-X.

    

    

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9. Imaeda T, Nakamura R, Shionoya K, et al. Ulnar impaction syndrome: MR imaging findings. Radiology 1996;201(2):495-500. doi:10.1148/radiology.201.2.8888248.

    

    

10. Kim BS, Song HS. A comparison of ulnar shortening osteotomy alone versus combined arthroscopic triangular fibrocartilage complex debridement and ulnar shortening osteotomy for ulnar impaction syndrome. Clin Orthop Surg 2011;3(3):184-190. doi:10.4055/cios.2011.3.3.184.

     

     

11. Kleinman WB. Stability of the distal radioulna joint: biomechanics, pathophysiology, physical diagnosis, and restoration of function what we have learned in 25 years. J Hand Surg Am 2007;32(7):1086-1106. doi:10.1016/j.jhsa.2007.06.014.

     

     

12. Lee RK, Ng AW, Tong CS, et al. Intrinsic ligament and triangular fibrocartilage complex tears of the wrist: comparison of MDCT arthrography, conventional 3-T MRI, and MR arthrography. Skeletal Radiol 2013;42(9):1277-1285. doi:10.1007/s00256-013-1666-8.

     

     

13. Lindau T, Adlercreutz C, Aspenberg P. Peripheral tears of the triangular fibrocartilage complex cause distal radioulnar joint instability after distal radial fractures. J Hand Surg Am 2000;25(3):464-468. doi:10.1053/jhsu.2000.6467.

     

     

14. Medvecky MJ, Ong BC, Rokito AS, et al. Thermal capsular shrinkage: basic science and clinical applications. Arthroscopy 2001;17(6):624-635.

     

     

15. Minami A, Ishikawa J, Suenaga N, et al. Clinical results of treatment of triangular fibrocartilage complex tears by arthroscopic debridement. J Hand Surg Am 1996;21(3):406-411.

     

     

16. Mrkonjic A, Geijer M, Lindau T, et al. The natural course of traumatic triangular fibrocartilage complex tears in distal radial fractures: a 13-15 year follow-up of arthroscopically diagnosed but untreated injuries. J Hand Surg Am 2012;37(8):1555-1560. doi:10.1016/j.jhsa.2012.05.032.

     

     

17. Omlor G, Jung M, Grieser T, et al. Depiction of the triangular fibrocartilage in patients with ulnar-sided wrist pain: comparison of direct multi-slice CT arthrography and direct MR arthrography. Eur Radiol 2009;19(1):147-

    151. doi:10.1007/s00330-008-1118-3.

     

     

18. Osterman AL. Arthroscopic debridement of triangular fibrocartilage complex tears. Arthroscopy 1990;6(2):120-124.

     

     

19. Palmer AK, Glisson RR, Werner FW. Ulnar variance determination. J Hand Surg Am 1982;7(4):376-379.

     

     

20. Palmer AK, Werner FW. Biomechanics of the distal radioulnar joint. Clin Orthop Relat Res 1984;(187):26-35.

     

     

21. Palmer AK, Werner FW. The triangular fibrocartilage complex of the wrist—anatomy and function. J Hand Surg Am 1981;6(2):153-162. doi:10.1016/S0363-5023(81)80170-0.

     

     

22. Park MJ, Jagadish A, Yao J. The rate of triangular fibrocartilage injuries requiring surgical intervention. Orthopedics 2010;33(11):806. doi:10.3928/01477447-20100924-03.

     

     

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