Skip to main content
SpringerLink
Log in

Traumatic injury of the triangular fibrocartilage complex (TFCC)—a refinement to the Palmer classification by using high-resolution 3-T MRI

  • Scientific Article
  • Published:
Skeletal Radiology Aims and scope Submit manuscript

Abstract

Objective

The aim of this study was to investigate the MR features of the traumatic injury of the triangular fibrocartilage complex (TFCC) by using high-resolution 3-T magnetic resonance imaging (MRI) and to refine the Palmer classification system.

Materials and methods

From November 2015 to May 2019, sixty-seven patients met the including and excluding criteria and were enrolled into this retrospective study. All subjects had high-resolution 3-T MRI scan of the wrist and eleven had indirect MR arthrography of the wrist. All the MRI were read by two experienced musculoskeletal radiologists. Diagnostic sensitivity, specificity, and accuracy of MRI were calculated by using the arthroscopy and surgery as the standard of reference. A P value less than 0.05 was considered statistically significant. The interobserver agreement was assessed by kappa analysis.

Results

There were 49 cases of TFCC injuries proven by the arthroscopy or surgery. The TFCC injuries in the other 18 patients were proved by the combination of clinical follow-up examination and follow-up MRI. Among the arthroscopy- or surgery-confirmed cases, there were 32 patients with original Palmer injuries (IA = 10, IB = 19, ID = 3), 5 with capsular detachment, 4 with bucket-handle tear of the TFCC that have rarely been reported, and 8 with complex injuries that involved the listed classifications above. The sensitivities and specificities of MRI for diagnosing IA, IB, ID, complex injuries, and bucket-handle tear were 67–100% and 90–100%, and overall good to perfect interobserver agreements (kappa, 0.64–1.00). The diagnostic performance for the capsular detachment was lower (kappa, 0.38).

Conclusion

With high-resolution 3-T MRI, more detailed injury patterns were found including capsular injuries, the horizontal tear of the articular disk, and the bucket-handle tear. It is necessary to refine the classic Palmer classification of TFCC injuries.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Fig. 10
Fig. 11
Fig. 12
Fig. 13

Similar content being viewed by others

References

  1. Nakamura T, Yabe Y, Horiuchi Y. Functional anatomy of the triangular fibrocartilage complex. J Hand Surg (Br). 1996;21(5):581–6.

    Article  CAS  Google Scholar 

  2. Nakamura T, Yabe Y. Histological anatomy of the triangular fibrocartilage complex of the human wrist. J Ann Anat. 2000;182(6):567–72. https://doi.org/10.1016/S0940-9602(00)80106-5.

    Article  CAS  Google Scholar 

  3. Cerezal L, de Dios B-MJ, Canga A, et al. MR and CT arthrography of the wrist. Semin Musculoskelet Radiol. 2012;16(1):27–41. https://doi.org/10.1055/s-0032-1304299.

    Article  PubMed  Google Scholar 

  4. Cerezal L, Abascal F, García-Valtuille R, Del Piñal F. Wrist MR arthrography: how, why, when. Radiol Clin North Am. 2005;43(4):709–31. https://doi.org/10.1016/j.rcl.2005.02.004.

  5. Ahn AK, Chang D, Plate AM. Triangular fibrocartilage complex tears: a review. Bull NYU Hosp Jt Dis. 2006;64(3–4):114–8.

    PubMed  Google Scholar 

  6. Palmer AK, Werner FW. The triangular firocartilage complex of the wrist-anatomy and function. J Hand Surg [Am]. 1981;6(2):153–62.

    Article  CAS  Google Scholar 

  7. Linscheid RL. Biomechanics of the distal radioulnar joint. Clin Orthop Relat Res. 1992;275:46–55.

    Google Scholar 

  8. Moser T, Dosch JC, Moussaoui A, Dietemann JL. Wrist ligament tears: evaluation of MRI and combined MDCT and MR arthrography. AJR Am J Roentgenol. 2007;188(5):1278–86. https://doi.org/10.2214/AJR.06.0288.

    Article  PubMed  Google Scholar 

  9. 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. Skelet Radiol. 2013;42(9):1277–85. https://doi.org/10.1007/s00256-013-1666-8.

    Article  CAS  Google Scholar 

  10. Zhan H, Zhang H, Bai R, et al. High-resolution 3-T MRI of the triangular fibrocartilage complex in the wrist: injury pattern and MR features. Skelet Radiol. 2017;46(12):1695–706. https://doi.org/10.1007/s00256-017-2739-x.

    Article  Google Scholar 

  11. Oneson SR, Scales LM, Timins ME, Erickson SJ, Chamoy L. MR imaging interpretation of the Palmer classification of triangular fibrocartilage complex lesions. RadioGraphic. 1996;16(1):97–106. https://doi.org/10.1148/radiographics.16.1.97.

    Article  CAS  Google Scholar 

  12. Cody ME, Nakamura DT, Small KM, Yoshioka H. MR imaging of the triangular fibrocartilage complex. Magn Reson Imaging Clin N Am. 2015;23(3):393–403. https://doi.org/10.1016/j.mric.2015.04.001.

    Article  PubMed  Google Scholar 

  13. Skalski MR, White EA, Patel DB, Schein AJ, RiveraMelo H, Matcuk GR Jr. The traumatized TFCC: an illustrated review of the anatomy and injury patterns of the triangular fibrocartilage complex. Curr Probl Diagn Radiol. 2016;45(1):39–50. https://doi.org/10.1067/j.cpradiol.2015.05.004.

    Article  PubMed  Google Scholar 

  14. Daunt N. Magnetic resonance imaging of the wrist: anatomy and pathology of interosseous ligaments and the triangular fibrocartilage complex. Curr Probl Diagn Radiol. 2002;31(4):158–76.

    Article  Google Scholar 

  15. Morisawa Y, Nakamura T, Tazaki K. Dorsoradial avulsion of the triangular fibrocartilage complex with an avulsion fracture of the sigmoid notch of the radius. J Hand Surg Eur Vol. 2007;32(6):705–8. https://doi.org/10.1016/J.JHSE.2007.06.008.

    Article  CAS  PubMed  Google Scholar 

  16. Estrella EP, Hung LK, Ho PC, Tse WL. Arthroscopic repair of triangular fibrocartilage complex tears. J Arthrosc. 2007;23(7):729–737.e1. https://doi.org/10.1016/j.arthro.2007.01.026.

    Article  Google Scholar 

  17. Abe Y, Moriya A, Tominaga Y, Yoshida K. Dorsal tear of triangular fibrocartilage complex: clinical features and treatment. J Wrist Surg. 2016;5(1):42–6. https://doi.org/10.1055/S-0035-1570037.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Haugstvedt JR, Berger RA, Nakamura T, Neale P, Berglund L, An KN. Relative contributions of the ulnar attachments of the triangular fibrocartilage complex to the dynamic stability of the distal radioulnar joint. J Hand Surg [Am]. 2006;31(3):445–51. https://doi.org/10.1016/j.jhsa.2005.11.008.

    Article  Google Scholar 

  19. Haugstvedt JR, Soreide E. Arthroscopic management of triangular fibrocartilage complex peripheral injury. Hand Clin. 2017;33(4):607–18. https://doi.org/10.1016/j.hcl.2017.06.005.

    Article  PubMed  Google Scholar 

  20. Nakamura T, Sato K, Okazaki M, Toyama Y, Ikegami H. Repair of foveal detachment of the triangular fibrocartilage complex: open and arthroscopic transosseous techniques. Hand Clin. 2011;27(3):281–90. https://doi.org/10.1016/j.hcl.2011.05.002.

    Article  PubMed  Google Scholar 

  21. Dy CJ, Ouellette EA, Makowski ALH, Milne E, Latta LL. Peripheral triangular fibrocartilage complex tears cause ulnocarpal instability: a biomechanical pilot study. Clin Orthop Relat Res. 2012;470(10):2771–5. https://doi.org/10.1007/S11999-012-2399-z.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Petsatodis E, Pilavaki M, Kalogera A, Drevelegas A, Agathangelidis F, Ditsios K. Comparison between conventional MRI and MR arthrography in the diagnosis of triangular fibrocartilage tears and correlation with arthroscopic findings. Injury. 2019;50(8):1464–9. https://doi.org/10.1016/j.injury.2019.07.032.

    Article  PubMed  Google Scholar 

  23. Omar NN, Mahmoud MK, Saleh WR, et al. MR arthrography versus conventional MRI and diagnostic arthroscope in patients with chronic wrist pain. Eur J Radiol Open. 2019;6:265–74. https://doi.org/10.1016/j.ejro.2019.06.003.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Magee T. Comparison of 3-T MRI and arthroscopy of intrinsic wrist ligament and TFCC tears. AJR Am J Roentgenol. 2009;192(1):80–5. https://doi.org/10.2214/AJR.08.1089.

    Article  PubMed  Google Scholar 

  25. Ng AWH, Griffith JF, Fung CSY, et al. MR imaging of the traumatic triangular fibrocartilaginous complex tear. Quant Imaging Med Surg. 2017;7(4):443–60. https://doi.org/10.21037/qims.2017.07.01.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Atzei A. New trends in arthroscopic management of type 1-B TFCC injuries with DRUJ instability. J Hand Surg Eur Vol. 2009;34(5):582–91. https://doi.org/10.1177/1753193409100120.

    Article  CAS  PubMed  Google Scholar 

  27. Atzei A, Luchetti R. Foveal TFCC tear classification and treatment. Hand Clin. 2011;27(3):263–72. https://doi.org/10.1016/j.hcl.2011.05.014.

    Article  PubMed  Google Scholar 

  28. Atzei A, Luchetti R, Garagnani L. Classification of ulnar triangular fibrocartilage complex tears. A treatment algorithm for Palmer type IB tears. J Hand Surg Eur Vol. 2017;42(4):405–14. https://doi.org/10.1177/1753193416687479.

    Article  CAS  PubMed  Google Scholar 

  29. Park JH, Kim D, Park JW. Arthroscopic one-tunnel transosseous foveal repair for triangular fibrocartilage complex (TFCC) peripheral tear. Arch Orthop Trauma Surg. 2018;138(1):131–8. https://doi.org/10.1007/s00402-017-2835-3.

    Article  PubMed  Google Scholar 

  30. Park JH, Ahn KS, Chang A, Kwon YW, Choi IC, Park JW. Changes in the morphology of the triangular fibrocartilage complex (TFCC) on magnetic resonance arthrography related to disruption of ulnar foveal attachment. Skelet Radiol. 2019;49(2):249–56. https://doi.org/10.1007/s00256-019-03278-x.

    Article  Google Scholar 

  31. Theumann N, Kamel EM, Bollmann C, Sturzenegger M, Becce F. Bucket-handle tear of the triangular fibrocartilage complex: case report of a complex peripheral injury with separation of the distal radioulnar ligaments from the articular disc. Skelet Radiol. 2011;40(12):1617–21. https://doi.org/10.1007/s00256-011-1269-1.

    Article  Google Scholar 

  32. Jean J, Azael A, Barrera CM, Ezuddin NS, Chen D. MRI findings in bucket-handle tears of the triangular fibrocartilage complex. Skelet Radiol. 2018;47(3):419–24. https://doi.org/10.1007/s00256-017-2796-1.

    Article  Google Scholar 

  33. Pahwa S, Srivastava DN, Sharma R, Gamanagatti S, Kotwal PP, Sharma V. Comparison of conventional MR and MR arthrography in the evaluation wrist ligament tears: a preliminary study. Indian J Radiol Imaging. 2014;24(3):259–67. https://doi.org/10.4103/0971-3026.137038.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Thomsen NOB, Besjakov J, Björkman A. Accuracy of pre- and postcontrast, 3T indirect MR arthrography compared with wrist arthroscopy in the diagnosis of wrist ligament injuries. J Wrist Surg. 2018;7(5):382–8. https://doi.org/10.1055/s-0038-1661419.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

Download references

Funding

This study was funded by the National Natural Science Foundation of China (grant number 81771809, 81371515), the Beijing Natural Science Foundation of China (grant number 7202063, 7142075), the Capital Medical Development and Scientific Research Fund of China (grant number 2016-2-1122).

Author information

Authors and Affiliations

  1. Department of Radiology, Beijing Jishuitan Hospital, Peking University Fourth School of Clinical Medicine, No. 31, Xinjiekou East St, Xicheng District, Beijing, 100035, China

    Huili Zhan, Rongjie Bai, Zhanhua Qian & Heng Zhang

  2. Department of Hand Surgery, Beijing Jishuitan Hospital, No. 31, Xinjiekou East St, Xicheng District, Beijing, 100035, China

    Yong Yang

  3. Radiology Associates, LLP, 1814 South Alameda Street, Corpus Christi, TX, 78404, USA

    Yuming Yin

Authors
  1. Huili Zhan
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Rongjie Bai
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Zhanhua Qian
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Yong Yang
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Heng Zhang
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Yuming Yin
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Rongjie Bai.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Zhan, H., Bai, R., Qian, Z. et al. Traumatic injury of the triangular fibrocartilage complex (TFCC)—a refinement to the Palmer classification by using high-resolution 3-T MRI. Skeletal Radiol 49, 1567–1579 (2020). https://doi.org/10.1007/s00256-020-03438-4

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00256-020-03438-4

Keywords

Search

Navigation