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Communicating defects of the triangular fibrocartilage complex without disruption of the triangular fibrocartilage: A report of two cases
Communicating Defects of the Triangular Fibrocartilage Complex Without Disruption of the Triangular Fibrocartilage: A Report of Two Cases Marvin S. Arons, MD, Gerald Fishbone, MD, Jeffrey A. Arons, MD, New Haven, CT Perforations or communicating defects of the triangular fibrocartilage complex have been more commonly identified after Palmer published his classification system (J Hand Surg 1989;14A:594 – 606). To his variants of class 1B (traumatic) ulnar avulsion with or without distal ulnar fracture, a third category may be added: defects of the ulnar collateral ligament without any associated disruption of the triangular fibrocartilage. The ulnar collateral ligament can be defined as an ulnar capsular structure between the more discrete elements of the triangular fibrocartilage and the ulnar ligaments, with the defect or perforation being distal to the intact triangular fibrocartilage and exiting into the floor of the extensor carpi ulnaris sheath. We present 2 cases that illustrate the diagnosis, the use of both magnetic resonance imaging and arthrography to confirm the diagnosis, the associated dorsal ulnar cutaneous nerve pain distribution, and the open direct and retinacular flap repair. (J Hand Surg 1999;24A:148 –151. Copyright © 1999 by the American Society for Surgery of the Hand.) Key words: Ulnar collateral ligament, extensor carpi ulnaris, distal ulnar radial joint
Symptomatic communicating defects (perforations)1,2 of the triangular fibrocartilage complex (TFCC) are a common cause of ulnar wrist pain.3,4 These disruptions have been described and classified by Palmer.5 According to many reports concerning this subject, leaks of the ulnar capsule into the ulnar soft tissues are considered variants of class 1B in the From the Section of Plastic Surgery, Department of Surgery, and the Department of Radiology, Hospital of St Raphael, New Haven, CT; Yale–New Haven Hospital, New Haven, CT. Received for publication February 9, 1998; accepted in revised form August 4, 1998. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Marvin S. Arons, MD, Section of Plastic Surgery, Hospital of St Raphael, 205 Orchard Medical Bldg, 330 Orchard St, New Haven CT 06511. Copyright © 1999 by the American Society for Surgery of the Hand 0363-5023/99/24A01– 0021$3.00/0
148 The Journal of Hand Surgery
Palmer classification, ie, ulnar avulsion of the TFCC with or without distal ulnar fracture.6 – 8 We describe 2 cases of ulnar wrist pain due to a defect of the ulnar collateral ligament (UCL), which is defined as an ulnar capsular structure between the more discrete elements of the TFCC and the ulnar ligaments, with the defect or perforation distal to the intact triangular fibrocartilage (TFC) and exiting into the floor of the extensor carpi ulnaris (ECU) sheath. The TFCC consists of the radioulnar ligaments (dorsal and volar), the UCL, the meniscus homolog, and the ECU sheath.9 The TFC consists of the disk (central cartilaginous portion) surrounded by the radioulnar ligaments.10 These cases appear to be a separate subset of injuries that are only minimally discussed in the literature, although Palmer’s group7 tabulated 24 cases in which they demonstrated an “ulnar capsule leak” by arthrography. For our cases, both magnetic resonance imaging (MRI) (Fig. 1) and
The Journal of Hand Surgery / Vol. 24A No. 1 January 1999 149
Figure 1. T2-weighted MRI images of the wrist demonstrating fluid around the ECU tendon (arrow) consistent with ECU tenosynovitis. A small amount of fluid is also noted around the extensor digitorum communis tendons. The TFC is intact. At surgery, 2 tiny disruptions in the UCL (the posterior sheath of the ECU) were found with synovitis.
3-compartment (triple-injection) arthrography (Fig. 2) were performed.
Case Reports Case 1 Case 1 is a 50-year-old right-handed female teacher who presented with the chief complaint of exquisite right dorsal ulnar wrist pain associated with shooting electric sensations in the dorsal ulnar cutaneous nerve (DUCN) distribution. Her symptoms were aggravated by any type of wrist motion. Onset was 3 months previously when the patient attempted to turn a frozen ignition lock key. Hyperesthesia and dysesthesia in the DUCN distribution were confirmed on examination. Tinel’s sign was negative and sensory discrimination was normal. There was normal but painful motion of the wrist. There was neither crepitus nor clicking and the distal ulnar was stable. Exquisite tenderness was elicited over the ECU groove on the distal ulnar styloid and was
augmented with radial wrist deviation. Neither stenosis nor subluxation of the ECU was noted. Initial radiographs had negative findings of neutral ulnar variance. The MRI (Fig. 1) was consistent with ECU tenosynovitis.
Case 2 Case 2 is a 32-year-old ambidextrous female teacher who presented with the chief complaint of right dorsal ulnar wrist pain and tenderness aggravated by any motion of the wrist and associated with shooting pain in the DUCN distribution. Onset was 3 months previously during a twisting incident with severe torquing of the wrist. During examination, cutaneous hypersensitivity was noted in the DUCN distribution. Tinel’s sign was negative and sensory discrimination was normal. The range of motion of the wrist was normal but painful. There was neither crepitus nor clicking and the distal ulna was stable. Severe tenderness was elicited over the ECU groove
150 Arons, Fishbone, and Arons / Communicating Defects of the TFCC
Figure 2. Radiocarpal joint injection demonstrates contrast passing into soft tissues ulnar to the distal ulna (arrow) consistent with disruption of the UCL (the posterior sheath of the ECU). (The contrast in the distal radioulnar joint is from a prior injection.) The TFC is intact. At surgery, a tiny disruption in the UCL was found.
on the distal styloid and was augmented with radial wrist deviation. There was neither stenosis nor subluxation of the ECU. Routine x-rays and stress views were negative and there was neutral ulnar variance. The arthrogram (Fig. 2) was consistent with disruption of the UCL (the posterior sheath of the ECU).
Treatment and Results Surgical repair was performed in both cases. (A third unreported case with similar history, signs, symptoms, and radiologic examination results underwent surgery elsewhere.) The DUCN was dissected and protected and demonstrated no visual intrinsic pathology or extrinsic compression. An ulnar-based retinacular flap was created and the ECU tendon was released on the dorsal radial surface of the sixth compartment. The ECU tendon, which appeared normal, was retracted, thereby revealing the perforations at the level of the distal ulnar styloid process in the ECU sheath. (In case 1, discolored brownish synovium from 2 small perforations was biopsied and
showed hyperplastic synovium. In case 2, only 1 defect was noted without related visual synovitis. The perforations or tears were tiny [2–3 mm].) The disruptions were directly sutured and then reinforced by imbrication with the retinacular flap, which also was used as a stabilizing sling for the ECU. In neither case was the TFC visualized by additional surgery. The wrist was immobilized for 3 weeks with a splint and an additional 3 weeks with a hinged flexion-extension wrist orthoplast splint. Radial and ulnar deviation motions were protected for 6 weeks. Full painless motion returned and the ulnar hypersensitivity in both cases disappeared.
Discussion The UCL with associated structures is a controversial topic. Osterman11 states that there is no true UCL, while Green12 quotes Taleisnik and Mayfield, who both list 2 collateral ligaments of the wrist: the “radial collateral ligament” and the “ulnar collateral ligament.” Kleinman13 describes an ulnocarpal me-
The Journal of Hand Surgery / Vol. 24A No. 1 January 1999 151
niscus homolog and a vestigial ulnar collateral ligament and Buterbaugh14 states that “The triangular fibrocartilage complex is further defined by the ulnar collateral ligament which is the floor of the extensor carpi ulnaris tendon sheath and the articular portion of the triangular ligament.” Berger15 reported that the “dorsal and palmar radioulnar ligaments . . . provide an anchor for a multitude of ligaments including . . . the extensor carpi ulnaris subsheath.” In further searching the literature concerning this nomenclature controversy, we noted a significant reference from 1970 by Spinner and Kaplan,16 who basically defined the UCL as a periosteum/ECU fibro-osseous sheath. Our 2 cases are examples of perforations (or tears) of the UCL structures without associated injury of the TFC disk. At surgery, these disruptions were visualized and repaired and the perforations were associated with synovitis only in case 1. In each case, the signs and symptoms disappeared after surgery, including the apparent referred pain in the DUCN distribution.17 We wish to draw attention to this subset of traumatic Palmer class 1B TFCC abnormalities5 causing ulnar wrist pain. It does not fall exactly within the Palmer classification of TFCC injuries, which may be diagnosed arthrographically, as proposed by Palmer’s group,7 or by MRI.6,18 Dalinka et al18 stated that an MRI was comparable to an arthrogram in diagnosing TFCC pathology. However, Oneson et al6 championed the MRI in diagnosing wrist pathology. Surgery confirmed the clinical and radiologic diagnosis in our 2 cases. We found no mention in the literature of the DUCN distribution pain associated with these ECU sheath findings.
3.
4. 5. 6.
7.
8.
9.
10. 11. 12.
13.
14. 15. 16.
References 1. Gilula LA, Palmer AK. Is it possible to diagnose a tear at arthrography or MR imaging? Radiology 1993;187:582 (letter). 2. Gilula LA, Palmer AK. Is it possible to call a “tear” on
17. 18.
arthrograms or magnetic resonance imaging scans? J Hand Surg 1993;18A:547 (letter). Ireland DCR. Management of ulnar-sided wrist pain. In: Boswick JA Jr, ed. Advances in upper extremity surgery and rehabilitation. Rockville, MD: Aspen Publishers, 1986:51–57. Taleisnik J. Pain on the ulnar side of the wrist. Hand Clin 1987;3:51– 68. Palmer AK. Triangular fibrocartilage complex lesions: a classification. J Hand Surg 1989;14A:594 – 606. Oneson SR, Timins ME, Scales LM, Erickson SJ, Chamoy L. MR imaging diagnosis of triangular fibrocartilage pathology with arthroscopic correlation. AJR Am J Roentgenol 1997;168:1513–1518. Levinsohn EM, Rosen ID, Palmer AK. Wrist arthrography: value of the three-compartment injection method. Radiology 1991;179:231–239. Kleinman WB. Repair of chronic peripheral tears/avulsion of the triangular fibrocartilage. In: Blair WF, ed. Techniques in hand surgery. Baltimore: Williams & Wilkins, 1996:555–564. Palmer AK, Werner FW. The triangular fibrocartilage complex of the wrist—anatomy and function. J Hand Surg 1981;6:153–162. Nathan R, Schneider LH. Classification of distal radioulnar joint disorders. Hand Clin 1991;7:239 –247. Osterman AL. Atlas of right wrist arthroscopy. Hand Clin 1995;11:103–113. Green DP. Carpal dislocations and instabilities. In: Green DP, ed. Operative hand surgery. Vol. 2. 2nd ed. New York: Churchill Livingstone, 1988:875–938. Kleinman WB. Scapho-trapezio-trapezoid joint arthrodesis. In: Blair WF, ed. Techniques in hand surgery. Baltimore: Williams & Wilkins, 1996:835– 848. Buterbaugh GA. Radiocarpal arthroscopy portals and normal anatomy. Hand Clin 1994;10:567–576. Berger RA. The anatomy and basic biomechanics of the wrist joint. J Hand Ther 1996;9:84 –93. Spinner M, Kaplan EB. Extensor carpi ulnaris: its relationship to the stability of the distal radio-ulnar joint. Clin Orthop 1970;68:124 –129. Dawson DM, Hallett M, Millender LH. Entrapment neuropathies. 2nd ed. Boston: Little, Brown, 1990:196 –197. Dalinka MK, Meyer S, Kricun ME, Vanel D. Magnetic resonance imaging of the wrist. Hand Clin 1991;7:87–98.
Symptomatic communicating defects (perforations)1,2 of the triangular fibrocartilage complex (TFCC) are a common cause of ulnar wrist pain.3,4 These disruptions have been described and classified by Palmer.5 According to many reports concerning this subject, leaks of the ulnar capsule into the ulnar soft tissues are considered variants of class 1B in the From the Section of Plastic Surgery, Department of Surgery, and the Department of Radiology, Hospital of St Raphael, New Haven, CT; Yale–New Haven Hospital, New Haven, CT. Received for publication February 9, 1998; accepted in revised form August 4, 1998. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Marvin S. Arons, MD, Section of Plastic Surgery, Hospital of St Raphael, 205 Orchard Medical Bldg, 330 Orchard St, New Haven CT 06511. Copyright © 1999 by the American Society for Surgery of the Hand 0363-5023/99/24A01– 0021$3.00/0
148 The Journal of Hand Surgery
Palmer classification, ie, ulnar avulsion of the TFCC with or without distal ulnar fracture.6 – 8 We describe 2 cases of ulnar wrist pain due to a defect of the ulnar collateral ligament (UCL), which is defined as an ulnar capsular structure between the more discrete elements of the TFCC and the ulnar ligaments, with the defect or perforation distal to the intact triangular fibrocartilage (TFC) and exiting into the floor of the extensor carpi ulnaris (ECU) sheath. The TFCC consists of the radioulnar ligaments (dorsal and volar), the UCL, the meniscus homolog, and the ECU sheath.9 The TFC consists of the disk (central cartilaginous portion) surrounded by the radioulnar ligaments.10 These cases appear to be a separate subset of injuries that are only minimally discussed in the literature, although Palmer’s group7 tabulated 24 cases in which they demonstrated an “ulnar capsule leak” by arthrography. For our cases, both magnetic resonance imaging (MRI) (Fig. 1) and
The Journal of Hand Surgery / Vol. 24A No. 1 January 1999 149
Figure 1. T2-weighted MRI images of the wrist demonstrating fluid around the ECU tendon (arrow) consistent with ECU tenosynovitis. A small amount of fluid is also noted around the extensor digitorum communis tendons. The TFC is intact. At surgery, 2 tiny disruptions in the UCL (the posterior sheath of the ECU) were found with synovitis.
3-compartment (triple-injection) arthrography (Fig. 2) were performed.
Case Reports Case 1 Case 1 is a 50-year-old right-handed female teacher who presented with the chief complaint of exquisite right dorsal ulnar wrist pain associated with shooting electric sensations in the dorsal ulnar cutaneous nerve (DUCN) distribution. Her symptoms were aggravated by any type of wrist motion. Onset was 3 months previously when the patient attempted to turn a frozen ignition lock key. Hyperesthesia and dysesthesia in the DUCN distribution were confirmed on examination. Tinel’s sign was negative and sensory discrimination was normal. There was normal but painful motion of the wrist. There was neither crepitus nor clicking and the distal ulnar was stable. Exquisite tenderness was elicited over the ECU groove on the distal ulnar styloid and was
augmented with radial wrist deviation. Neither stenosis nor subluxation of the ECU was noted. Initial radiographs had negative findings of neutral ulnar variance. The MRI (Fig. 1) was consistent with ECU tenosynovitis.
Case 2 Case 2 is a 32-year-old ambidextrous female teacher who presented with the chief complaint of right dorsal ulnar wrist pain and tenderness aggravated by any motion of the wrist and associated with shooting pain in the DUCN distribution. Onset was 3 months previously during a twisting incident with severe torquing of the wrist. During examination, cutaneous hypersensitivity was noted in the DUCN distribution. Tinel’s sign was negative and sensory discrimination was normal. The range of motion of the wrist was normal but painful. There was neither crepitus nor clicking and the distal ulna was stable. Severe tenderness was elicited over the ECU groove
150 Arons, Fishbone, and Arons / Communicating Defects of the TFCC
Figure 2. Radiocarpal joint injection demonstrates contrast passing into soft tissues ulnar to the distal ulna (arrow) consistent with disruption of the UCL (the posterior sheath of the ECU). (The contrast in the distal radioulnar joint is from a prior injection.) The TFC is intact. At surgery, a tiny disruption in the UCL was found.
on the distal styloid and was augmented with radial wrist deviation. There was neither stenosis nor subluxation of the ECU. Routine x-rays and stress views were negative and there was neutral ulnar variance. The arthrogram (Fig. 2) was consistent with disruption of the UCL (the posterior sheath of the ECU).
Treatment and Results Surgical repair was performed in both cases. (A third unreported case with similar history, signs, symptoms, and radiologic examination results underwent surgery elsewhere.) The DUCN was dissected and protected and demonstrated no visual intrinsic pathology or extrinsic compression. An ulnar-based retinacular flap was created and the ECU tendon was released on the dorsal radial surface of the sixth compartment. The ECU tendon, which appeared normal, was retracted, thereby revealing the perforations at the level of the distal ulnar styloid process in the ECU sheath. (In case 1, discolored brownish synovium from 2 small perforations was biopsied and
showed hyperplastic synovium. In case 2, only 1 defect was noted without related visual synovitis. The perforations or tears were tiny [2–3 mm].) The disruptions were directly sutured and then reinforced by imbrication with the retinacular flap, which also was used as a stabilizing sling for the ECU. In neither case was the TFC visualized by additional surgery. The wrist was immobilized for 3 weeks with a splint and an additional 3 weeks with a hinged flexion-extension wrist orthoplast splint. Radial and ulnar deviation motions were protected for 6 weeks. Full painless motion returned and the ulnar hypersensitivity in both cases disappeared.
Discussion The UCL with associated structures is a controversial topic. Osterman11 states that there is no true UCL, while Green12 quotes Taleisnik and Mayfield, who both list 2 collateral ligaments of the wrist: the “radial collateral ligament” and the “ulnar collateral ligament.” Kleinman13 describes an ulnocarpal me-
The Journal of Hand Surgery / Vol. 24A No. 1 January 1999 151
niscus homolog and a vestigial ulnar collateral ligament and Buterbaugh14 states that “The triangular fibrocartilage complex is further defined by the ulnar collateral ligament which is the floor of the extensor carpi ulnaris tendon sheath and the articular portion of the triangular ligament.” Berger15 reported that the “dorsal and palmar radioulnar ligaments . . . provide an anchor for a multitude of ligaments including . . . the extensor carpi ulnaris subsheath.” In further searching the literature concerning this nomenclature controversy, we noted a significant reference from 1970 by Spinner and Kaplan,16 who basically defined the UCL as a periosteum/ECU fibro-osseous sheath. Our 2 cases are examples of perforations (or tears) of the UCL structures without associated injury of the TFC disk. At surgery, these disruptions were visualized and repaired and the perforations were associated with synovitis only in case 1. In each case, the signs and symptoms disappeared after surgery, including the apparent referred pain in the DUCN distribution.17 We wish to draw attention to this subset of traumatic Palmer class 1B TFCC abnormalities5 causing ulnar wrist pain. It does not fall exactly within the Palmer classification of TFCC injuries, which may be diagnosed arthrographically, as proposed by Palmer’s group,7 or by MRI.6,18 Dalinka et al18 stated that an MRI was comparable to an arthrogram in diagnosing TFCC pathology. However, Oneson et al6 championed the MRI in diagnosing wrist pathology. Surgery confirmed the clinical and radiologic diagnosis in our 2 cases. We found no mention in the literature of the DUCN distribution pain associated with these ECU sheath findings.
3.
4. 5. 6.
7.
8.
9.
10. 11. 12.
13.
14. 15. 16.
References 1. Gilula LA, Palmer AK. Is it possible to diagnose a tear at arthrography or MR imaging? Radiology 1993;187:582 (letter). 2. Gilula LA, Palmer AK. Is it possible to call a “tear” on
17. 18.
arthrograms or magnetic resonance imaging scans? J Hand Surg 1993;18A:547 (letter). Ireland DCR. Management of ulnar-sided wrist pain. In: Boswick JA Jr, ed. Advances in upper extremity surgery and rehabilitation. Rockville, MD: Aspen Publishers, 1986:51–57. Taleisnik J. Pain on the ulnar side of the wrist. Hand Clin 1987;3:51– 68. Palmer AK. Triangular fibrocartilage complex lesions: a classification. J Hand Surg 1989;14A:594 – 606. Oneson SR, Timins ME, Scales LM, Erickson SJ, Chamoy L. MR imaging diagnosis of triangular fibrocartilage pathology with arthroscopic correlation. AJR Am J Roentgenol 1997;168:1513–1518. Levinsohn EM, Rosen ID, Palmer AK. Wrist arthrography: value of the three-compartment injection method. Radiology 1991;179:231–239. Kleinman WB. Repair of chronic peripheral tears/avulsion of the triangular fibrocartilage. In: Blair WF, ed. Techniques in hand surgery. Baltimore: Williams & Wilkins, 1996:555–564. Palmer AK, Werner FW. The triangular fibrocartilage complex of the wrist—anatomy and function. J Hand Surg 1981;6:153–162. Nathan R, Schneider LH. Classification of distal radioulnar joint disorders. Hand Clin 1991;7:239 –247. Osterman AL. Atlas of right wrist arthroscopy. Hand Clin 1995;11:103–113. Green DP. Carpal dislocations and instabilities. In: Green DP, ed. Operative hand surgery. Vol. 2. 2nd ed. New York: Churchill Livingstone, 1988:875–938. Kleinman WB. Scapho-trapezio-trapezoid joint arthrodesis. In: Blair WF, ed. Techniques in hand surgery. Baltimore: Williams & Wilkins, 1996:835– 848. Buterbaugh GA. Radiocarpal arthroscopy portals and normal anatomy. Hand Clin 1994;10:567–576. Berger RA. The anatomy and basic biomechanics of the wrist joint. J Hand Ther 1996;9:84 –93. Spinner M, Kaplan EB. Extensor carpi ulnaris: its relationship to the stability of the distal radio-ulnar joint. Clin Orthop 1970;68:124 –129. Dawson DM, Hallett M, Millender LH. Entrapment neuropathies. 2nd ed. Boston: Little, Brown, 1990:196 –197. Dalinka MK, Meyer S, Kricun ME, Vanel D. Magnetic resonance imaging of the wrist. Hand Clin 1991;7:87–98.