Terry L. Whipple, MD
The triangular fibrocartilage complex (TFCC) serves both as a stabilizer of the radioulnar joint and as an axial load-bearing structure. Tears of the TFCC are a common cause of ulnar-sided wrist pain in persons who, in the present or past, have been subjected to significant upper extremity weight bearing. With advancements in diagnostic capabilities, traumatic and degenerative TFCC abnormalities are becoming common findings in persons who complain of wrist pain. Similar to the situation with the arthroscopic removal of displaced menisci in the knee, the arthroscopic management of TFCC tears has been refined and offers relief to patients with chronic, debilitating wrist pain.
Anatomy, Biomechanics, Mechanism of Injury
The TFCC is composed of cartilage and ligament. The structure originates from the radius and inserts into the distal ulna and ulna carpus. The function of the TFCC is to provide an articular sling for the lunate and triquetrum as the cartilage rotates over the head of the ulna. Recent studies have demonstrated that the TFCC is not, as once believed, the predominant stabilizer of the distal radioulnar joint. The mechanism of injury to the TFCC is generally compression between the lunate and the ulna. Traumatic injury can occur with acute rotational force, for example, a fall on the outstretched hand, or due to an axial compression/distraction force to the ulnar carpus. Degenerative lesions may develop a repetitive loading of the TFCC secondary to forearm rotation. A spectrum of injuries to the TFCC may result, beginning with changes caused by wear and progressing to perforation, lunotriquetral instability, and ulnocarpal arthritis.
The most common site of tears in the TFCC is parallel to the sigmoid notch of the radius; second most common, central perforation of the triangular fibrocartilage (TFC) disk proper; third, parallel to the dorsal capsular attachment; and the fourth, parallel to the volar capsular attachment. In general, traumatic lesions of the avascular centrum do not heal, become symptomatic, and require treatment. Undisplaced peripheral lesions may heal without treatment because of the adequate blood supply; however, displaced peripheral lesions usually require surgical repair. Tears at the periphery which constitute a separation of the TFC from the dorsal capsule, require repair. In the repair, a suture is used to reattach the TFC to the capsule.
Dr. Whipple has conducted extensive arthroscopic laboratory research to examine the effect of distal radial ulnar stability after sequential detachments of the TFC disk, transection of the dorsal and volar radioulnar TFCC margins, and the volar ulnocarpal ligament complex without compromising the other inherent stabilizing structures. Arthroscopy provides a means of detaching isolated portions of the TFCC without compromising other stabilizing structures as has been necessary in previous investigations. The results of this experimentation have led Dr. Whipple to conclude that the TFCC is not the predominant stabilizer of the distal radioulnar joint. Through his research, he has been instrumental in the development of unique instrumentation and equipment that facilitates the arthroscopic approach for the treatment of TFCC abnormalities.
- Palmer AK Triangular fibrocartilage complex lesions: A classification J Hand Surg 1989;14A:594-606
- Whipple TL Clinical application of wrist arthroscopy In: Lichtman, EM, ed. The Wrist and its Disorders Philadelphia: W.B. Saunders 1998:118-28
- Whipple TL, Marotta JJ, Powell JH Techniques of wrist arthroscopy Arthroscopy 1986;2:244-52
- Total Run Time: 31:20 minutes
- Catalog Number: 7013
- VJO Publication Date: October, 1991