An anatomic study of the ligamentous structure of the triangular fibrocartilage complex

Ishii, Soh; Palmer, Andrew K.; Werner, Frederick W.; Short, Walter H.; Fortino, Maria D.

doi:10.1016/s0363-5023(98)80003-8

Cited by 125 publications

(129 citation statements)

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“…[15][16][17][18][19] As each palmar and dorsal radioulnar ligament extends toward the ulna, it divides into two limbs: the deep limb attaches to the fovea on the ulna, and the superficial limb attaches to the base and midportion of the ulnar styloid. [15][16][17][18][19] Thus, the TFCC has four insertions on the ulna, which can be termed the deep palmar limb, deep dorsal limb, superficial palmar limb, and superficial dorsal limb 2 (►Fig. 1).…”

mentioning

confidence: 99%

Open Repair of the Triangular Fibrocartilage Complex from Palmar Aspect

Moritomo

2015

Jnl Wrist Surg

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Instability of the distal radioulnar joint (DRUJ) caused by a traumatic foveal tear of the triangular fibrocartilage complex (TFCC) can produce significant disability, which could present as pain, weakness, and a restricted range of motion. Several surgical procedures to repair TFCC foveal tear have been proposed, including open 1-4 and arthroscopic 5-9 TFCC repairs. Several surgical approaches have also been proposed, including a dorsal 10-12 or a palmar 3,10,13,14 approach. However, the ideal procedure and approach for TFCC foveal tear remain controversial.Over the past few decades, a considerable number of studies of the anatomy of the TFCC have been undertaken. [15][16][17][18][19] As each palmar and dorsal radioulnar ligament extends toward the ulna, it divides into two limbs: the deep limb attaches to the fovea on the ulna, and the superficial limb attaches to the base and midportion of the ulnar styloid. [15][16][17][18][19] Thus, the TFCC has four insertions on the ulna, which can be termed the deep palmar limb, deep dorsal limb, superficial palmar limb, and superficial dorsal limb 2 (►Fig. 1).Regarding the direction of DRUJ instability, palmar radius instability, in which the distal radius is unstable in a palmar direction with respect to the ulna, is a much more common form of DRUJ instability than dorsal radius instability. 20 A biomechanical study showed that the deep palmar limb has a Keywords ► DRUJ instability ► TFCC foveal tear ► open repair ► CT arthrography ► surgical approach AbstractBackground Although foveal tears of the triangular fibrocartilage complex (TFCC) can be surgically reattached to the fovea via a dorsal approach, the foveal lesion is difficult to visualize from the dorsal side because the extensor carpi ulnaris (ECU) sheath floor and the superficial dorsal limb of the radioulnar ligament hinders the view of the fovea. Materials and Methods Twenty-one patients with foveal tears were treated by an open repair method from the palmar aspect. Pain, instability, motion, and grip strength were evaluated after a mean follow-up period of 26 months, and each patient was rated according to the Mayo Modified Wrist Score (MMWS). Description of Technique A 4-cm skin incision is made on the palmar aspect of the ulnar fovea. The ulnar fovea is exposed through a transverse capsulotomy of the distal radioulnar joint. The distal aspect of the TFCC is also exposed between the ECU tendon sheath and the ulnotriquetral ligament. After curettage of the scar tissue in the fovea, the deep palmar and dorsal limbs of the TFCC are sutured back to the fovea using a suture anchor technique. Results Foveal TFCC tears could be repaired via a palmar surgical approach without violating the floor of the ECU tendon sheath and the superficial dorsal limb. Excellent results were achieved in 18 patients, and a good result was achieved in three. Conclusions Our result compared favorably with those reported for dorsal approach. The palmar surgical approach facilitates the inspection and repair of the TFCC foveal tears. L...

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confidence: 99%

Open Repair of the Triangular Fibrocartilage Complex from Palmar Aspect

Moritomo

2015

Jnl Wrist Surg

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“…3 The DRULs are defined as palmar and dorsal components each with a superficial and deep part blending with the cartilage of the TFC. [4][5][6] This arrangement is illustrated in the human cadaver dissection demonstrating the proximal or deep surface of the TFC complex (Fig 1). These ligament pairs work as a functional couple to stabilise the radius on the ulna head with the deep pair acting as the more powerful stabilisers.…”

Section: Leesmentioning

confidence: 91%

Functional anatomy of the distal radioulnar joint in health and disease

Lees

2013

annals

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The distal radioulnar joint (DRUJ) is critical to the function of the forearm as a mechanical unit. This paper is concerned with the concepts and observations that have changed understanding of the function of the DRUJ, notably with respect to the biomechanics of this joint. The DRUJ has been shown to be important in acting to distribute load and removal of the ulna head leads to the biomechanical equivalent of a one-bone forearm. The soft tissues with topographical relations to the distal forearm and DRUJ have also been investigated in our experimental series with findings including the description of a clinical disorder termed subluxation-related ulna neuropathy syndrome.A working knowledge of the applied anatomy and biomechanics of the forearm and wrist is useful for any practitioner treating traumatic, developmental and degenerative disorders of the distal radioulnar joint (DRUJ), hand and forearm. The elbow, forearm and wrist act as a unified structure to provide a stable, strong and highly mobile strut for positioning the hand in space and for conducting load-bearing tasks. This paper is concerned with illuminating current concepts regarding the DRUJ and defining its place in the function of the forearm as a mechanical unit. What follows is a personal view and details some of our own experiments that have built on the contributions of other authors working in this field. Comparative anatomy of the DRUJThe DRUJ facilitates forearm rotation. During evolution the development of the DRUJ was probably as important as development of the opposable thumb in allowing human beings to manipulate their environment, facilitating development as hunter-gatherers. The human DRUJ is recognisable in that of the great apes whereas 'lower' mammals have a syndesmosis for a DRUJ. Mobility of the forearm allows apes to place the hand in three-dimensional (3D) space and enables them to swing through the tree branches, an action known as brachiation. Mobility of the hand and forearm in hominids that developed an upright stance was instability owing to ligament injury sustained as a result of falls on the outstretched hand. Applied anatomy of the DRUJ, TFC complex and osseoligamentous structures of the forearmThe DRUJ is one of a pair of hemijoints (uniaxial pivot joints) that function simultaneously permitting the movement of the forearm through the range of pronosupination, the other being the proximal radioulnar joint (PRUJ). The articulations occur between the head of the ulna on the sigmoid notch of the radius (DRUJ) and the head of the radius on the radial notch of the ulna (PRUJ). The key concept in understanding the pathophysiology of the DRUJ is to appreciate that one of its components, namely the ulna head, is essentially a fixed structure about which the specially adapted radius bone rotates.The ulna is essentially a straight bone with a dense, strong condensation of stabilising ligaments known as the triangular fibrocartilage (TFC) complex attaching the distal ulna to the hand and the ulna to the radius. The TFC...

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“…It consists of the articular disk, meniscus homologue, palmar radioulnar ligament (PRUL), DRUL, ECUS, ulnar capsule, and the ulnolunate and ulnotriquetral ligaments. 11,12 The PRUL and DRUL contain a superficial and a deep portion that are conjoined at the radius attachment. The superficial portion surrounds the articular disk but has no clear definable insertion into the ulnar styloid.…”

Section: Relevant Anatomymentioning

confidence: 99%

Distal Radioulnar Joint Arthroscopy and the Volar Ulnar Portal

Slutsky

2007

Techniques in Hand &Amp; Upper Extremity Surgery

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Pain on the ulnar side of the wrist remains poorly understood. As attention has shifted toward the myriad causes of ulnar-sided wrist pain, the utility of viewing the wrist from a volar ulnar (VU) perspective has emerged. Lunotriquetral ligament tears have been implicated in the pathogenesis of volar intercalated segmental instabilities. They often originate in the palmar subregion, which is most important for maintaining stability. These tears are difficult to visualize through the 4, 5, or 6R portals. They are well seen through a VU portal, and the direct line of sight facilitates debridement. The VU portal has potential use in the arthroscopic diagnosis and treatment of patientswith injuries tothe ulnarslingmechanism.Itaidsin triangular fibrocartilage repairs especially those involving the dorsal aspect between the ulnar styloid and the radial insertion, because the proximity of the 4, 5, and 6R portals makes triangulation of the instruments difficult.Although arthroscopy of the dorsal aspect of the distal radioulnar joint has been well described, it has largely remained a curiosity, with few clinical indica-tions. Recent biomechanical studies have highlighted the importance of the deep attachment of the triangular fibrocartilage complex in maintaining distal radioulnar joint stability. The volar distal radioulnar portal is useful for assessing the foveal attachment. It may be used where there is the suspicion of a peripheral triangular fibrocartilage detachment due to a loss of its normal tension despite the lack of a visible tear during radio-carpal arthroscopy. The judicious use of these portals deserves consideration for inclusion as part of a thorough arthroscopic examination of selected patients with ulnarsided wrist pain. Keywords: arthroscopy, DRUJ, volar, portal | HISTORICAL PERSPECTIVEThe indications for wrist arthroscopy have steadily grown from a mostly diagnostic tool to a valuable adjunctive procedure in the treatment of myriad wrist disorders. The ulnocarpal joint has been the proverbial ''black box^ of the wrist pain. Instability of the distal radioulnar joint (DRUJ) is a hotbed for research, with new and innovative techniques appearing monthly. Although the new generation of 3-T magnetic resonance imaging scanners holds promise for the future, many of the causes of ulnar-sided wrist pain are revealed only at the time of arthroscopy. Establishing the diagnosis of a peripheral detachment of the triangular fibrocartilage complex (TFCC) or a tear of the ulnar sling mechanism remains an exacting challenge even for the experienced arthroscopist.The clinical utility of volar portals has been recently elucidated. 1 As kinematic and biomechanical studies have shed light on the role of the dorsal capsular structures and palmar subregions of the interosseous ligaments in maintaining carpal stability, it has become prudent to view the wrist from a palmar perspective. Volar portals for wrist arthroscopy have certain advantages over the standard dorsal portals for visualizing dorsal capsular struct...

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An anatomic study of the ligamentous structure of the triangular fibrocartilage complex

Cited by 125 publications

References 10 publications

Open Repair of the Triangular Fibrocartilage Complex from Palmar Aspect

Open Repair of the Triangular Fibrocartilage Complex from Palmar Aspect

Functional anatomy of the distal radioulnar joint in health and disease

Distal Radioulnar Joint Arthroscopy and the Volar Ulnar Portal

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