Radial-sided avulsions of the TFCC (Palmer 1d) remain a challenging pathology to treat. No current procedures have addressed these injuries successfully and reproducibly. Ten preserved dissected cadaveric forearm specimens with intact TFCC and without ulnar positive variance underwent biomechanical testing. Specimens were tested intact, then with Palmer 1d TFCC lesion and finally post-reconstruction. Measurement of total displacement with a −20N to 20N load was performed. The results indicate that our novel anatomic intra-articular reconstruction of unstable radial-sided TFCC avulsions was successful in restoring baseline stability to the DRUJ without interfering with pronation or supination. Radial-sided avulsions of the TFCC (Palmer 1d) remain a challenging pathology to treat. No current procedures have addressed these injuries successfully and reproducibly. We tested a novel intra-articular reconstruction to address unstable radial-sided TFCC avulsions. Ten preserved dissected cadaveric forearm specimens with intact TFCC and without ulnar positive variance underwent biomechanical testing using an MTS machine. Measurement of total displacement with a −20N to 20N load was performed. Specimens were tested intact, then with Palmer 1d TFCC lesion and finally post-reconstruction. All tests were performed at neutral, maximal pronation and maximal supination. Mean total displacements of the specimens at neutral rotation were: 4.122mm ± 0.363 for the intact specimens compared to 11.839mm ± 0.782 after creation of the tear (p< 0.000002) and 3.883mm ± 0.655 for the reconstructed specimens (p=0.77). In maximal pronation mean total displacements were: 2.378mm ± 0.250 intact vs. 4.922 ± 0.657 torn (p< 0.0007) and 2.124mm ± 0.339 post-reconstruction (p=0.61). In maximal supination mean total displacements were: 1.438mm ± 0.222 intact vs. 5.704mm ± 1.258 torn (p< 0.006) and 1.004mm ± 0.091 post-reconstruction (p=0.07). All specimens obtained the same maximal pronation and supination pre and post-reconstruction. Restoration of stability and joint function have never been achieved with previous reconstruction attempts of radial-sided TFCC avulsions. Current procedures are unable to restore DRUJ stability without a significant sacrifice of motion. Our anatomic intra-articular reconstruction of unstable radial-sided TFCC avulsions succeeded in restoring baseline stability to the DRUJ without interfering with pronation/supination

INTRODUCTION. The TFCC injuries are usually diagnosed by a coronal MRI. We have described the Float image for the diagnosis of peripheral injuries of the TFCC. In a sagital image parallel to the ulnar diaphysis and placed lateral to the ulnar fovea, we can observe the radiocubital dorsal and volar ligaments of the TFCC. A distance of more than 4mm between the dorsal edge of the meniscus and the joint capsule suggests the presence of TFCC peripheral rupture. METHOD. 51 pacients were selected from all the patients who underwent wrist arthroscopy between 2006–2009. Inclusion criteria: MRI at our hospital, arthroscopy at our hospital, no presence of radial fracture. We assessed the correlation between the presence of the Float image and a TFCC injury confirmed by arthroscopy. RESULTS. The Float image for the diagnosis of peripheral TFCC injuries has a sensibility of 0.929 [0.774 to 0.98] and a specificity of 0,857 [0.654 to 0.95]. PPV: 0.897 [0.736 to 0.964] and NPV: 0.9 [0.699 to 0.972]. CONCLUSIONS. The Float MRI is a high sensibility and specificity method for the diagnosis of peripheral TFCC. The coronal MRI is useful for diagnosing central ruptures but has less sensibility for the peripheral injuries

The recognition of the role of TFCC as a major distal radioulnar joint stabilizer and a buffer to compressive forces indicates the importance of preserving as much of this structure as possible. We developed arthroscopic technique for repair of Palmer I B tears of TFCC using a hypodermic needle which obviates the need of any additional skin incision. With wrist under traction important landmarks like radial styloid process, ulnar styloid process, Lister's tubercle and extensor tendons are marked using skin marker. For placement of the arthroscope, 3–4 portal is used and for instruments 6 R and 6 U portals are used. An outside-in technique is used. A 19 G needle is inserted upward from 5mm proximal to the level of the 6 R portal through skin, subcutaneous tissue, capsular tissue and then through the 2mm inner side of detached area of TFCC, while stabilizing it with probe. A 2–0 polydioxanone-PDS suture is passed through needle and caught by grasper placed in the 6 R portal. Now needle is withdrawn and then suture is retrieved out of the joint through the 6 R portal. The procedure is repeated for required number of sutures for dorsal part of peripheral tear. Thus we have stitches with one limb exiting the joint through portal and the other limb entering the joint percutaneously. A small mosquito forceps is passed through the 6 R portal undermining subcutaneous area and these percutaneously passing limbs of sutures are withdrawn through the portal. Now we have sutures entering and exiting through the 6 R portal. Similar procedure is done for ulnar part of peripheral tear through the 6 U portal. Knots are tied and slid beneath the subcutaneous tissue. It offers advantages of a lower risk of neurovascular damage, reduced postoperative pain, faster rehabilitation and better cosmesis

Aims. Studies on long-term patient-reported outcomes after open surgery for triangular fibrocartilage complex (TFCC) are scarce. Surgeons and patients would benefit from self-reported outcome data on pain, function, complications, and satisfaction after this surgery to enhance shared decision-making. The aim of this study is to determine the long-term outcome of adults who had open surgery for the TFCC. Methods. A prospective cohort study that included patients with open surgery for the TFCC between December 2011 and September 2015. In September 2020, we sent these patients an additional follow-up questionnaire, including the Patient-Rated Wrist Evaluation (PRWE), to score satisfaction, complications, pain, and function. Results. A total of 113 patients were included in the analysis. At ≥ 60 months after an open TFCC reinsertion, we found a mean PRWE total score of 19 (SD 21), a mean PRWE pain score of 11 (SD 11), and a PRWE function score of 9 (SD 10). The percentage of patients obtaining minimum clinically important difference rose from 77% at 12 months to 83% at more than 60 months (p < 0.001). Patients reported fewer complications than surgeons, and overall complication rate was low. Conclusion. Outcomes of patient-reported pain, function scores, and satisfaction are improved five years after open surgery for the TFCC. Cite this article: Bone Jt Open 2021;2(11):981–987

Injury to the triangular fibrocartilage complex (TFCC) may result in ulnar wrist pain with or without instability. One component of the TFCC, the radioulnar ligaments, serve as the primary soft-tissue stabilizer of the distal radioulnar joint (DRUJ). Tears or avulsions of its proximal, foveal attachment are thought to be associated with instability of the DRUJ, most noticed during loaded pronosupination. In the absence of detectable instability, injury of the foveal insertion of the radioulnar ligaments may be overlooked. While advanced imaging techniques such as MRI and radiocarpal arthroscopy are well-suited for diagnosing central and distal TFCC tears, partial and complete foveal tears without instability may be missed without a high degree of suspicion. While technically challenging, DRUJ arthroscopy provides the most accurate method of detecting foveal abnormalities. In this annotation the spectrum of foveal injuries is discussed and a modified classification scheme is proposed. Cite this article: Bone Joint J 2023;105-B(1):5–10

Aims. Patients with a triangular fibrocartilage complex (TFCC) injury report ulnar-sided wrist pain and impaired function. The surgical procedure of TFCC reinsertion aims to improve function in patients with this injury in whom conservative treatment has failed. The purpose of this study was to investigate the outcomes of open TFCC reinsertion. Methods. The study involved 274 patients who underwent open repair of the TFCC between December 2013 and December 2018. The patients completed the Patient-Rated Wrist Evaluation (PRWE) questionnaire, and scored pain and function using a visual analogue scale (VAS). Range of motion (ROM) was assessed by experienced hand therapists. Results. Clinically significant improvements were reported in pain, function, and grip strength in 220 patients (80%) three and 12 months postoperatively. Conclusion. These data will help surgeons to make decisions about the outcomes of open repair of the TFCC and to counsel patients appropriately. Level of evidence: III. Cite this article: Bone Joint J 2021;103-B(4):711–717

Aims. The study aimed to assess the clinical outcomes of arthroscopic debridement and partial excision in patients with traumatic central tears of the triangular fibrocartilage complex (TFCC), and to identify prognostic factors associated with unfavourable clinical outcomes. Methods. A retrospective analysis was conducted on patients arthroscopically diagnosed with Palmer 1 A lesions who underwent arthroscopic debridement and partial excision from March 2009 to February 2021, with a minimum follow-up of 24 months. Patients were assessed using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, Mayo Wrist Score (MWS), and visual analogue scale (VAS) for pain. The poor outcome group was defined as patients whose preoperative and last follow-up clinical score difference was less than the minimal clinically important difference of the DASH score (10.83). Baseline characteristics, arthroscopic findings, and radiological factors (ulnar variance, MRI, or arthrography) were evaluated to predict poor clinical outcomes. Results. A total of 114 patients were enrolled in this study, with a mean follow-up period of 29.8 months (SD 14.4). The mean DASH score improved from 36.5 (SD 21.5) to 16.7 (SD 14.3), the mean MWS from 59.7 (SD 17.9) to 79.3 (SD 14.3), and the mean VAS pain score improved from 5.9 (SD 1.8) to 2.2 (SD 2.0) at the last follow-up (all p < 0.001). Among the 114 patients, 16 (14%) experienced poor clinical outcomes and ten (8.8%) required secondary ulnar shortening osteotomy. Positive ulnar variance was the only factor significantly associated with poor clinical outcomes (p < 0.001). Positive ulnar variance was present in 38 patients (33%); among them, eight patients (21%) required additional operations. Conclusion. Arthroscopic debridement alone appears to be an effective and safe initial treatment for patients with traumatic central TFCC tears. The presence of positive ulnar variance was associated with poor clinical outcomes, but close observation after arthroscopic debridement is more likely to be recommended than ulnar shortening osteotomy as a primary treatment. Cite this article: Bone Joint J 2024;106-B(4):380–386

Introduction. Prospective comparative study to evaluate the efficacy of the ultrasound diagnosis vs MRI in rupture of the Triangular fibrocartilage with arthroscopic confirmation.

Material and methods. 55 patients presenting clinical wrist pain were studied from January’2004 untill september 2006. Our patient selection was composed by 30 men and 25 women, and the age range was 17 to 70 years old. 40 were Right-handed and 15 Left-Handed. Patients presented wrist pain related to several disorders. Our protocol included Sonography with a 11–MHz linear array probe using real-time compound spatial imaging and 1T-MRI studies. Wrist arthroscopy was performed in all of them.

Results. 67 % of our patients presented Triangular fibrocartilage rupture at arthroscopy. The distribution of our patients related to the complementary tests was:

- Arthroscopy (+) 37 cases out of 50 (64%)

According to this results we can easily calculate the sensibility/specificity and PPV/PNV of both tests:

- Ultrasound Sensibility/Specificity: 58,3 %/36,8 %

Conclusions. Due to the results we obtained in our study, we can consider ultrasound as sensible and specific as MRI at diagnosis for the rupture of the Triangular fibrocartilage. In our opinion we conclude that neither MRI nor ultrasound results should be considered satisfactory for a proper diagnosis. This could be sorted out by the use of more resolutive MRI and ultrasound equipments.

The triangular fibrocartilage complex (TFCC) is a known stabiliser of the distal radioulnar joint (DRUJ). An injury to these structures can result in significant disability including pain, weakness and joint stiffness. The contribution each of its components makes to the stability of the TFCC is not well understood. This study was undertaken to investigate the role of the individual ligaments of the TFCC and their contribution to joint stability. The study was undertaken in two parts. 30 cadaveric forearms were studied in each group. The ligaments of the TFCC were progressively sectioned and the resulting effect on the stability of the DRUJ was measured. A custom jig was created to apply a 20N force through the distal radius, with the ulna fixed. Experiment one measured the effect on DRUJ translation after TFCC sectioning. Experiment two added the measurement of rotational instability. Part one of the study showed that complete sectioning of the TFCC caused a mean increase in translation of 6.09(±3) mm. Sectioning the palmar radioulnar ligament of the TFCC caused the most translation. Part two demonstrated a change in rotation with a mean of 18 (± 6) degrees following sectioning of the TFCC. There was a progressive increase in rotational instability until the palmar radioulnar ligament was also sectioned. Linear translation consistently increased after sectioning all of the TFCC ligaments, confirming its importance for DRUJ stability. Sectioning of the palmar radioulnar ligament most commonly caused the greatest degree of translation. This suggests injury to this ligament would more likely result in a greater degree of translational instability. The increase in rotation also suggests that this type of instability would be symptomatic in a TFCC injury

Aims. The aim of this study was to analyze the association between the shape of the distal radius sigmoid notch and triangular fibrocartilage complex (TFCC) foveal tear. Methods. Between 2013 and 2018, patients were retrospectively recruited in two different groups. The patient group comprised individuals who underwent arthroscopic transosseous TFCC foveal repair for foveal tear of the wrist. The control group comprised individuals presenting with various diseases around wrist not affecting the TFCC. The study recruited 176 patients (58 patients, 118 controls). The sigmoid notch shape was classified into four types (flat-face, C-, S-, and ski-slope types) and three radiological parameters related to the sigmoid notch (namely, the radius curvature, depth, and version angle) were measured. The association of radiological parameters and sigmoid notch types with the TFCC foveal tear was investigated in univariate and multivariate analyses. Receiver operating characteristic curves were used to estimate a cut-off for any statistically significant variables. Results. Univariate analysis showed that the flat-face type was more prevalent in the patients than in the control group (43% vs 21%; p = 0.002), while the C-type was lower in the patients than in the control group (3% vs 17%; p = 0.011). The depth and version angle of sigmoid notch showed a negative association with the TFCC foveal tear in the multivariate analysis (depth: odds ratio (OR) 0.380; p = 0.037; version angle: OR 0.896; p = 0.033). Estimated cut-off values were 1.34 mm for the depth (area under the curve (AUC) = 0.725) and 10.45° for the version angle (AUC = 0.726). Conclusion. The proportion of flat-face sigmoid notch type was greater in the patient group than in the control group. The depth and version angle of sigmoid notch were negatively associated with TFCC foveal injury. Cite this article: Bone Joint J 2020;102-B(6):749–754

Abstract. Background. We know that tears of the Triangular fibrocartilage complex (TFCC) can cause DRUJ instability and ulnar sided wrist pain. This study shows the clinical result of patients who had arthroscopic transosseous repair of the TFCC tear with DRUJ instability. Arthroscopic repair of TFCC tear is a promising, minimally invasive surgical technique especially in patients with DRUJ instability. Materials and methods. Fifteen patients who underwent TFCC one tunnel repair form 2018–2021 were reviewed retrospectively in hospital. The proximal component of TFCC was repaired through arthroscopic one- tunnel transosseous suture technique. VAS score for pain, wrist range of motion, grip strength and post operative complications were evaluated and each patient was rated according to the DASH score. Results. The patients had a TFCC tear confirmed on MRI and was confirmed on arthroscopy by doing a hook test. The patients were followed up for 6 months. Twelve patients had normal stability of DRUJ and three patients showed mild laxity compared with the contralateral side. The mean VAS score reduced from 4.7 to 0.8 (P=0.001) and grip strength increased significantly. The quick DASH score (P=0.001)also showed significant functional improvement. No surgical related complications occurred. Conclusions. Arthroscopic one tunnel transosseous TFCC foveal repair can be an excellent and safe method for repair of TFCC tear with DRUJ instability. Its a good treatment option in terms of reliable pain relief, functional improvement and reestablishment of DRUJ stability

The purpose of this study was to evaluate treatment results following arthroscopic triangular fibrocartilage complex (TFCC) debridement for recalcitrant ulnar wrist pain. According to the treatment algorithm, 66 patients (36 men and 30 women with a mean age of 38.1 years (15 to 67)) with recalcitrant ulnar wrist pain were allocated to undergo ulnar shortening osteotomy (USO; n = 24), arthroscopic TFCC repair (n = 15), arthroscopic TFCC debridement (n = 14) or prolonged conservative treatment (n = 13). The mean follow-up was 36.0 months (15 to 54). Significant differences in Hand20 score at 18 months were evident between the USO group and TFCC debridement group (p = 0.003), and between the TFCC repair group and TFCC debridement group (p = 0.029). Within-group comparisons showed that Hand20 score at five months or later and pain score at two months or later were significantly decreased in the USO/TFCC repair groups. In contrast, scores in the TFCC debridement/conservative groups did not decrease significantly. Grip strength at 18 months was significantly improved in the USO/TFCC repair groups, but not in the TFCC debridement/conservative groups. TFCC debridement shows little benefit on the clinical course of recalcitrant ulnar wrist pain even after excluding patients with ulnocarpal abutment or TFCC detachment from the fovea from the indications for arthroscopic TFCC debridement. Cite this article: Bone Joint J 2013;95-B:1687–96

Aims. The aim of this study was to assess and compare active rotation of the forearm in normal subjects after the application of a short-arm cast (SAC) in the semisupination position and a long-arm cast (LAC) in the neutral position. A clinical study was also conducted to compare the functional outcomes of using a SAC in the semisupination position with those of using a LAC in the neutral position in patients who underwent arthroscopic triangular fibrocartilage complex (TFCC) foveal repair. Methods. A total of 40 healthy right-handed volunteers were recruited. Active pronation and supination of the forearm were measured in each subject using a goniometer. In the retrospective clinical study, 40 patients who underwent arthroscopic foveal repair were included. The wrist was immobilized postoperatively using a SAC in the semisupination position (approximately 45°) in 16 patients and a LAC in 24. Clinical outcomes were assessed using grip strength and patient-reported outcomes. The degree of disability caused by cast immobilization was also evaluated when the cast was removed. Results. Supination was significantly more restricted with LACs than with SACs in the semisupination position in male and female patients (p < 0.001 for both). However, pronation was significantly more restricted with SACs in the semisupination position than with LACs in female patients (p = 0.003) and was not significantly different in male patients (p = 0.090). In the clinical study, both groups showed improvement in all parameters with significant differences in grip strength, visual analogue scale scores for pain, modified Mayo Wrist Score, the Disability of the Arm, Shoulder, and Hand (DASH) score, and the Patient-Rated Wrist Evaluation (PRWE) score. No significant postoperative differences were noted between LACs and SACs in the semisupination position. However, the disability caused by immobilization in a cast was significantly higher in patients who had a LAC on the dominant hand (p < 0.001). Conclusion. We found that a SAC in the semisupination position is as effective as a LAC in restricting pronation of the forearm. In addition, postoperative immobilization with a SAC in the semisupination position resulted in comparable pain scores and functional outcomes to immobilization with a LAC after TFCC foveal repair, with less restriction of daily activities. Therefore, we recommend that surgeons consider using a SAC in the semisupination position for postoperative immobilization following TFCC foveal repair for dorsal instability of the distal radioulnar joint. Cite this article: Bone Joint J 2022;104-B(2):249–256

The clinical diagnosis of distal radioulnar joint (DRUJ) instability remains challenging. The current diagnostic gold standard is a dynamic computerized topography (CT) scan. This investigation compares the affected and normal wrists in multiple static positions of forearm rotation.. However, its accuracy has been questioned, as the wrist is unloaded and not placed under stress. This may fail to capture DRUJ instability that does not result in static malalignment between the ulnar head and sigmoid notch. The purpose of this biomechanical study was to evaluate the effectiveness of both dynamic and stress CT scans in detecting DRUJ instability. A customized DRUJ arthrometer was designed that allows for both static positioning, as well as dorsal and volar loading at the DRUJ in various degrees of forearm rotation. Ten fresh frozen cadavers were prepared and mounted in the apparatus. CT scans were performed both in the unloaded condition (dynamic CT) and with each arm subjected to a standardized 50N volar and dorsal force (stress CT) in neutral and maximum pronation/ supination. The TFCC (triangular fibrocartilage complex)was then sectioned peripherally to simulate DRUJ instability and the methodology was repeated. CT scans were then evaluated for displacement using the radioulnar ratio method. When calculating the radioulnar ratio for intact wrists using the dynamic CT technique, values were 0.50, 0.64, 0.34 for neutral, pronation and supination, respectively. When the TFCC was sectioned and protocol repeated, the values for the simulated unstable wrist for dynamic CT were 0.54, 0.62, 0.34 for neutral, pronation and supination, respectively. There was no statistically significant difference between the intact and sectioned states for any position of forearm rotation using dynamic CT. Usingstress CT, mean radioulnar ratios for the intact specimens were calculated to be 0.44, 0.36 and 0.31 for neutral, pronation and supination, respectively. After sectioning the TFCC, the radioulnar ratios increased to 0.61, 0.39 and 0.46 for neutral, pronation and supination. There was a statistically significant difference between intact and simulated-unstable wrists in supination (p = 0.002) and in neutral (p=0.003). The radioulnar ratio values used to measure DRUJ translation for dynamic CT scans were unable to detect a statistically significant difference between stable and simulated unstable wrists. This was true for all positions of forearm rotation. However, when a standard load was placed across the DRUJ, statically significant changes in the radioulnar ratio were seen in neutral and supination between stable and simulated unstable wrists. This discrepancy challenges the current gold standard of dynamic CT in its ability to accurately diagnosis DRUJ instability. It also introduces stress CT as a possible solution for diagnosing DRUJ instability from peripheral TFCC lesions

Aims. The primary aim of this study was to assess if traumatic triangular fibrocartilage complex (TFCC) tears can be treated successfully with immobilization alone. Our secondary aims were to identify clinical factors that may predict a poor prognosis. Methods. This was a retrospective analysis of 89 wrists in 88 patients between January 2015 and January 2019. All patients were managed conservatively initially with either a short-arm or above-elbow custom-moulded thermoplastic splint for six weeks. Outcome measures recorded included a visual analogue scale for pain, Patient-Rated Wrist Evaluation, Disabilities of the Arm, Shoulder and Hand score, and the modified Mayo Wrist Score (MMWS). Patients were considered to have had a poor outcome if their final MMWS was less than 80 points, or if they required eventual surgical intervention. Univariate and logistic regression analyses were used to identify independent predictors for a poor outcome. Results. In total, 76% of wrists (42/55) treated with an above-elbow splint had a good outcome, compared to only 29% (10/34) with a short-arm splint (p < 0.001). The presence of a complete foveal TFCC tear (p = 0.009) and a dorsally subluxated distal radioulnar joint (DRUJ) (p = 0.032) were significantly associated with a poor outcome on univariate analysis. Sex, age, energy of injury, hand dominance, manual occupation, ulnar variance, and a delay in initial treatment demonstrated no significant association. Multiple logistic regression revealed that short-arm immobilization (p < 0.001) and DRUJ subluxation (p = 0.020) were significant independent predictive factors of an eventual poor outcome. Conclusion. Nonoperative management of traumatic TFCC injuries with above-elbow immobilization is a viable treatment method, particularly in patients without DRUJ subluxation. Early surgery should be considered for patients with dorsal ulnar subluxation treated with short-arm splints to prevent prolonged morbidity. Cite this article: Bone Joint J 2021;103-B(8):1386–1391

Summary. When a TFCC tear is diagnosed, practitioners should maintain a high level of suspicion for the presence of a concomitant SL or LT ligament tear. Introduction. Disruption of the scapholunate (SL) or lunotriquetral (LT) ligament leads to dorsal and volar intercalated segment instability, respectively, while triangular fibrocartilage complex (TFCC) tears result in distal radioulnar joint (DRUJ) instability. Viegas et al. (1993) demonstrated that 56% of grossly visualised cadaveric wrists had one or more tears of a ligament or of the TFCC. The purpose of this investigation is to quantify the incidence, distribution, and correlation of SL, LT, and TFCC tears in a large group of cadaver wrists using magnetic resonance imaging (MRI). Additionally, statistical analysis was performed to predict. Methods. Spin density weighted, fat suppressed, and STIR MRI scans of the wrist were obtained in 48 fresh frozen cadaver arms using a 3 Tesla MRI scanner. The scans were scrutinised by one of us (PC) – a board certified musculoskeletal radiologist. The dorsal, volar, and membranous portions of the SL and LT ligaments were examined sequentially for the presence of a tear. Similarly, the central disk and radioulnar attachments of the TFCC were inspected for tears. Results. A ligament or the TFCC was labeled as torn if there was a complete tear, partial tear, or perforation of one or more of its components, but not if sole degenerative changes, thinning, or fraying of the fibers was observed. Four of the 48 images could not be interpreted due to unsatisfactory scans. The most prevalent injury was a TFCC tear, which was present in 28 (64%) of the 44 wrists examined. SL ligament tears were discovered in 20 (45%) of the wrists, and LT tears were present in 14 (32%) of the wrists. Moreover, 45% of the wrists examined had a TFCC tear and either a SL or LT ligament tear. Specifically, 50% of the 28 wrists with a TFCC tear had a concomitant LT tear, and 46% had a concomitant SL tear. Discussion. SL, LT, and TFCC tears were found in a substantial portion of the wrists examined. Moreover, the majority of wrists with a TFCC tear also had a SL or LT ligament tear. Viegas et al. found that 70% of wrists with a TFCC perforation also had a LT ligament tear. In our series, 71% had a TFCC tear, and 50% of those had a concomitant LT tear

This study examined the effect of wrist fracture deformities on the work and kinematics of forearm rotation in vitro. An osteotomy was performed on eight fresh frozen upper extremities just proximal to the distal radioulnar joint and a three-degree of freedom modular implant designed to simulate distal radius fracture deformities was secured in place. This allowed for accurate adjustment of dorsal angulation, dorsal displacement, and radial shortening. The study was divided into two parts, the first phase examining the effects of distal radius deformity and the second sectioned the TFCC and repeated the testing, reviewing the effects of a progressive soft tissue injury in conjunction with distal radius deformity. The magnitude of muscle activity required to achieve the motion, namely the work of rotation, was affected by the degree of simulated malunion and whether the TFCC was intact or sectioned. Increasing dorsal angulation caused a significant reduction in forearm pronation and supination. Once the TFCC ligaments were sectioned, the range of motion was restored to the pre-injured state for both pronation and supination. Dorsal displacement decreased the forearm range of motion significant at 10mm from native (p=0.02) and 5mm (p=0.03) for intact pronation. Radial shortening of 5mm or less had no effect on forearm rotation. However, 7.5mm of radial shortening could not be achieved in any of the specimens until the TFCC was divided. Our results reveal that a significant loss of forearm rotation can be expected if a radius fracture exceeds thirty degrees dorsal angulation or 10mm of dorsal displacement. Radial shortening greater than 7.5mm could only be achieved concomitant with a TFCC rupture. This and further study in this area, should assist clinicians in developing treatment strategies for their patients with fractures and deformities of the distal radius

Objective. Retrospective study to assess the outcomes of ulnar shortening for TFCC tear and distal radial malunion. Method. Retrospective note and x-ray review of all patients undergoing ulnar shortening over a ten year period along with a clinic assessment and scoring to date. The ulnar shortening was performed using the Stanley Jigs (Osteotec). A 5–6 holed DCP was used to stabilize the osteotomy site. Physiotherapy was commenced immediately following the surgery to promote prono-supination and wrist exercises. Result. 28 patients studied with one subsequent death. 13 patients with an average age of 53 years underwent ulnar shortening for distal radius malunion, whereas 15 pateints with an average age of 47 years had a primary indication of ulnar abutment with TFCC tear. Six patients underwent reoperation for non-union. 2 patients needed plate removal for prominent metalware. Patients undergoing the procedure for TFCC deficiency compared to radial malunion did worse, on functional scoring (DASH & SF36). Failure to place an interfragmentary screw was associated with a higher risk of non-union. Conclusion. Ulnar shortening is not a benign procedure, especially for the treatment of TFCC insufficiency. Interfragmentary screw placement is important in avoiding non-union

There is a difference of opinion regarding the usefulness of MR Imaging as a diagnostic tool for triangular fibrocartilage complex (TFCC) tears in the wrist. Our aim was to determine the accuracy of direct magnetic resonance arthrography (MRA) in the diagnosis of triangular fibrocartilage complex (TFCC) tears of the wrist in a district general hospital setting. In a retrospective review of 21 patients who presented with complains of wrist pain and following a clinical examination, all had direct MR arthrography of the wrist in our hospital in a 1.5Tesla scanner. All had a diagnostic arthroscopy within 2-4 months of the MR scan. All patients had chronic ulnar sided wrist pain, although only two had a definite history of trauma. The findings of each diagnostic method were compared, with arthroscopy considered the gold standard. Twenty-one patients were studied (10 male: 11 female), mean age 42 years (range 27-71) years). Seventeen TFCC tears were diagnosed on arthroscopy. For the diagnosis of TFCC tears MRA had a sensitivity, specificity and accuracy of 67%. Our results echoed the opinion of some of the previous investigators with an unacceptable sensitivity or specificity for a diagnostic tool. MR arthrography needs to be further refined as a technique before it can be considered to be accurate enough to replace wrist arthroscopy for the diagnosis of TFCC tears. Other centres have reported better accuracy, using more advanced MRI technology. Until this iswidely available at all levels of healthcare the results of MRI for the diagnosis of TFCC tears should be interpreted with caution

Introduction. We reports the accuracy of direct Magnetic Resonance Arthrography (MRA) in detecting Triangular Fibrocartilage Complex (TFCC), Scapho-Lunate Ligament (SLL) and Luno-Triquetral Ligament (LTL) tears using wrist arthroscopy as the gold standard. Methods. We reviewed the records of all patients who underwent direct wrist MRA and subsequent arthroscopy over a 4-year period between June 2007 and March 2011. Demographic details, MRA findings, arthroscopy findings and the time interval between MRA and arthroscopy were recorded. The scans were performed using a 1.5T scanner and a high resolution wrist coil. All scans were reported by a musculoskeletal radiologist. Sensitivity, specificity, positive and negative predictive values (PPV & NPV) were calculated. Results. Two hundred and thirty four (234) MRA were performed over the study period. Fifty patients (50), who subsequently underwent 51 wrist arthroscopies (one bilateral), were included. The mean age was 35 years (range 16–64 years). The average delay between MRA and arthroscopy was 4.8 months (median 4 months, range 17 days–18 months). All patients were symptomatic with wrist pain. At arthroscopy, 26 TFCC tears, 7 SLL tears and 3 LTL tears were found. For TFCC, sensitivity was 96%, specificity 88%, PPV 89% and NPV 96%. For SLL, the values were 57%, 66%, 21% and 91% respectively. For LTL, 67%, 79%, 17% and 97%, respectively. Receiver Operating Characteristic (ROC) curve analysis showed that MRA only reliably differentiates between patients with and without TFCC tears (Area Under Curve AUC = 0.92, p < 0.0001) but not SLL (AUC = 0.62, p=0.28) or LTL (AUC = 0.73, p=0.17) tears. Conclusion. MRA is a sensitive and specific imaging modality for diagnosing TFCC tears. However, the diagnostic accuracy for SLL and LTL tears was not satisfactory. Wrist arthroscopy remains the gold standard if there is a clinical suspicion of inter-carpal ligament tears