Triangular Fibrocartilage Complex (TFCC) – Anatomy, Imaging, and Classifications with Special Focus on the CUP Classification

Abstract

Background

The TFCC consists of several components whose functional significance has been recognized in detail in recent years. Existing classifications are partly incomplete. In addition, the TFCC requires specific and dedicated imaging techniques.

Method

This review describes the anatomy and pathoanatomy of the TFCC. The different types of TFCC lesions on MRI as well as MR and CT arthrography are explained and compared with the current literature. In addition, the novel CUP classification is presented and illustrated with image examples.

Results and Conclusion

Anatomically and functionally, the articular disc and radioulnar ligaments with their ulnar insertions and the inhomogeneously structured TFCC periphery must be differentiated. For accurate imaging, thin slices with high in-plane resolution and techniques to optimize contrast are required. Plain MRI is exclusively dependent on T2 contrast, while gadolinium-enhanced MRI offers the additional benefit of focal contrast enhancement, e.g., of fibrovascular repair tissue at the lesion site. However, the reference standard continues to be MR and CT arthrography, which should be used for focused indications. The CUP classification, which allows a comprehensive description and categorization of TFCC lesions, is presented and illustrated.

Key Points

• Anatomically, the TFCC consists of the central ulnocarpal disc, the dorsal and palmar radioulnar ligaments, and the ulnocarpal joint capsule including intracapsular ligaments and the meniscus homologue.

• The most important restraining structure of the TFCC is the lamina fovealis, which stabilizes the DRUJ. This structure constitutes the proximal (deep) continuation of the radioulnar ligaments at the ulnar insertion.

• Imaging of the TFCC requires high spatial and contrast resolution due to its minute structures. MR and CT arthrography are the reference standard in imaging.

• The CUP classification clearly describes all structures of the TFCC with the categorization of individual or combined lesion patterns.

Citation Format

• Schmitt R, Kunz AS, Reidler P et al. Triangular Fibrocartilage Complex (TFCC) – Anatomy, Imaging, and Classifications with Special Focus on the CUP Classification. Fortschr Röntgenstr 2024; DOI 10.1055/a-2411-8444

Zusammenfassung

Hintergrund

Der TFCC besteht aus komplexen Einzelstrukturen, deren funktionelle Bedeutungen erst in den letzten Jahren im Detail erkannt wurden. Bestehende Klassifikationen sind zum Teil unvollständig. Zudem stellt der TFCC besondere Anforderungen an die Bildgebung.

Methode

In der Übersichtsarbeit werden die Anatomie und Pathoanatomie des TFCC beschrieben. Die verschiedenen Läsionsarten des TFCC werden in der MRT sowie der MR- und CT-Arthrografie erläutert und mit der aktuellen Literatur abgeglichen. Zudem wird die neuartige CUP-Klassifikation an Bildbeispielen vorgestellt.

Ergebnisse und Schlussfolgerung

Anatomisch und funktionell müssen am TFCC der Discus ulnocarpalis, die Ligg. radioulnaria mit ihren ulnaren Insertionen sowie die inhomogen aufgebaute Peripherie unterschieden werden. Zur sicheren Darstellung sind in der Bildgebung dünne Schichten mit hoher In-plane-Auflösung und Maßnahmen zur Kontrastoptimierung u.a. zur Differenzierung von Narbengewebe vonnöten. Dabei ist die native MRT ausschließlich vom T2-Kontrast abhängig, während die gadoliniumverstärkte MRT den Zusatznutzen einer fokalen Kontrastanreicherung am Läsionsort bietet. Referenzstandard sind jedoch weiterhin die MR- und CT-Arthrografie, die bei fokussierter Indikation angewendet werden sollten. Vorgestellt und illustriert wird die CUP-Klassifikation, die eine umfassende Beschreibung und Kategorisierung von TFCC-Läsionen ermöglicht.

Kernaussagen

• Anatomisch besteht der TFCC aus dem zentralen Discus ulnocarpalis, den dorsal und palmar umschließenden Ligg. radioulnaria und der ulnokarpalen Gelenkkapsel mit intrakapsulären Ligamenten und dem Meniscus homologue.

• Wichtigste Haltestruktur des TFCC ist die Lamina fovealis, die das DRUG stabilisiert. Sie ist die proximale (tiefe) Fortsetzung der Ligg. radioulnaria an deren ulnarer Insertion.

• Die Bildgebung erfordert am TFCC wegen dessen geringer Größe eine hohe Orts- und Kontrastauflösung. Die MR- und CT-Arthrografie sind der Referenzstandard in der Bildgebung.

• Die CUP-Klassifikation erlaubt die übersichtliche Darstellung aller Strukturen des TFCC mit Benennung einzelner oder kombinierter Schädigungsmuster.

Keywords

triangular fibrocartilage complex (TFCC) - articular disc - foveal lamina - styloid lamina - methods & techniques - MR-imaging - arthrography

Schlüsselwörter

ulnokarpaler Komplex (TFCC) - Discus ulnocarpalis - Lamina fovealis - Lamina styloidalis - Methoden & Technik - MRT - Arthrografie

Publikationsverlauf

Eingereicht: 30. Juni 2024

Angenommen nach Revision: 02. September 2024

Artikel online veröffentlicht:
01. Oktober 2024

• References

• 1 Cerezal L, del Pinal F, Abascal F. MR imaging findings in ulnar-sided wrist impaction syndromes. Magn Reson Imaging Clin N Am 2004; 12: 281-299
• 2 Vezeridis PS, Yoshioka H, Han R. et al. Ulnar-sided wrist pain. Part I: anatomy and physical examination. Skeletal Radiol 2010; 39: 733-745
• 3 Nakamura T, Takayama S, Horiuchi Y. et al. Origins and insertions of the triangular fibrocartilage complex: A histological study. J Hand Surg Br 2001; 26: 446-454
• 4 Yoshioka H, Burns JE. Magnetic Resonance Imaging of Triangular Fibrocartilage. J Magn Reason Imag 2012; 35: 764-778
• 5 Haugstvedt JR, Langer MF, Berger RA. Distal radioulnar joint: functional anatomy, including pathomechanics. J Hand Surg Eur 2017; 42: 338-345
• 6 Atzei A, Luchetti R. Foveal TFCC tear classification and treatment. Hand Clin 2011; 27: 263-272
• 7 Palmer AK. Triangular fibrocartilage complex lesions: a classification. J Hand Surg Am 1989; 14: 594-606
• 8 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 2020; 49: 1567-1579
• 9 Herzberg G, Burnier M, Ly L. et al. A New Arthroscopic Classification of Triangular Fibrocartilage Complex Disorders. J Wrist Surg 2024; 13: 2-8
• 10 Schmitt R, Grunz JP, Langer M. Triangular fibrocartilage complex injuries – limitations of the current classification systems and the proposed new ‘CUP’ classification. J Hand Surg Eur 2023; 48: 60-66
• 11 Palmer AK, Werner FW. The triangular fibrocartilage complex of the wrist – anatomy and function. J Hand Surg Am 1981; 6: 153-162
• 12 Ehman EC, Hayes ML, Berger RA. et al. Subluxation of the Distal Radioulnar Joint as a Predictor of Foveal Triangular Fibrocartilage Complex Tears. J Hand Surg Am 2011; 36: 1780-1784
• 13 Park JH, Ahn KS, Chang A. et al. Changes in the morphology of the triangular fibrocartilage complex (TFCC) on magnetic resonance arthrography related to disruption of ulnar foveal attachment. Skeletal Radiol 2020; 49: 249-256
• 14 Yoshioka H, Carrino JA, Lang P. et al. Study of Ulnar Variance with High-Resolution MRI: Correlation with Triangular Fibrocartilage Complex and Cartilage of Ulnar Side of Wrist. J Magn Res Imag 2007; 26: 714-719
• 15 Bednar MS, Arnoczky SP, Weiland AJ. The microvasculature of the triangulare fibrocartilage complex: its clinical significance. J Hand Surg Am 1991; 16: 1101-1105
• 16 Hagert E, Hagert CG. Understanding stability of the distal radioulnar joint through an understanding of its anatomy. Hand Clin 2010; 26: 459-466
• 17 Nakamura T, Yabe Y, Horiuchi Y. Functional anatomy of the triangular fibrocartilage complex. J Hand Surg Br 1996; 21: 581-586
• 18 Ng AWH, Griffith JF, Fung CSY. et al. MR imaging of the traumatic triangular fibrocartilaginous complex tear. Quant Imaging Med Surg 2017; 7: 443-460
• 19 Kauer JM. The articular disc of the hand. Acta Anat (Basel) 1975; 93: 590-605
• 20 Burns JE, Tanaka T, Ueno T. et al. Pitfalls that may mimic injuries of the triangular fibrocartilage and proximal intrinsic wrist ligaments at MR imaging. RadioGraphics 2011; 31: 63-78
• 21 Totterman SM, Miller RJ. Triangular fibrocartilage complex: normal appearance on coronal three-dimensional gradient-recalled-echo MR images. Radiology 1995; 195: 521-527
• 22 Buck FM, Gheno R, Nico MAC. et al. Ulnomeniscal homologue of the wrist: correlation of anatomic and MR imaging findings. Radiology 2009; 253: 771-779
• 23 von Borstel D, Wang M, Small K. et al. High-Resolution 3T MR Imaging of the Triangular Fibrocartilage Complex. Magn Reson Med Sci 2017; 16: 3-15
• 24 Moritomo H. Anatomy and clinical relevance of the ulnocarpal ligament. J Wrist Surg 2013; 2: 186-189
• 25 Cerezal L, del Pinal F, Atzei A. et al. Interdisciplinary consensus statements on imaging of DRUJ instability and TFCC injuries. Eur Radiol 2023; 33: 6322-6338
• 26 Zhan H, Zhang H, Zhang H. et al. High-resolution 3-T MRI of the triangular fibrocartilage complex in the wrist: injury pattern and MR features. Skeletal Radiol 2017; 46: 1695-1706
• 27 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. Skeletal Radiol 2013; 42: 1277-1285
• 28 Rehnitz C, Klaan B, von Stillfried F. et al. Comparison of Modern 3D and 2D MR Imaging Sequences of the Wrist at 3 Tesla. Fortschr Röntgenstr 2016; 188: 753-762
• 29 Bittersohl B, Huang T, Schneider E. et al. High-resolution MRI of the triangular fibrocartilage complex (TFCC) at 3T: comparison of surface coil and volume coil. J Magn Reson Imaging 2007; 26: 701-707
• 30 Zhao X, Yu A, Zhao H. et al. Diagnostic value of MRI in traumatic triangular fibrocartilage complex injuries: a retrospective study. BMC Musculoskelet Disord 2024; 25: 63
• 31 Luetkens KS, Laas S, Hassler S. et al. Contrast-enhanced MRI of the wrist: Intravenous application of gadolinium increases diagnostic accuracy for ulnar-sided injuries of the TFCC. Eur J Radiol 2021; 143: 109901
• 32 Rüegger C, Schmid MR, Pfirrmann CWA. et al. Peripheral Tear of the Triangular Fibrocartilage: Depiction with MR Arthrography of the Distal Radioulnar Joint. AJR Am J Roentgenol 2007; 188: 187-192
• 33 Smith TO, Drew B, Toms AP. et al. Diagnostic accuracy of magnetic resonance imaging and magnetic resonance arthrography for triangular fibrocartilaginous complex injury: a systematic review and meta-analysis. J Bone Joint Surg Am 2012; 94: 824-832
• 34 Lee YH, Choi YR, Kim S. et al. Intrinsic ligament and triangular fibrocartilage complex (TFCC) tears of the wrist: comparison of isovolumetric 3D-THRIVE sequence MR arthrography and conventional MR image at 3 T. Magn Reson Imaging 2013; 31: 221-226
• 35 Petsatodis E, Pilavaki M, Kalogera A. et al. Comparison between conventional MRI and MR arthrography in the diagnosis of triangular fibrocartilage tears and correlation with arthroscopic findings. Injury 2019; 50: 1464-1469
• 36 Huflage H, Luetkens KS, Kunz AS. et al. Improved diagnostic accuracy for ulnar-sided TFCC lesions with radial reformation of 3D sequences in wrist MR arthrography. Eur Radiol 2021; 31: 9399-9407
• 37 Moser T, Dosch JC, Moussaoui A. et al. Wrist Ligament Tears: Evaluation of MRI and Combined MDCT and MR Arthrography. AJR Am J Roentgenol 2007; 188: 1278-1286
• 38 Cerezal L, de Dios Berna-Mestre J, Canga A. et al. MR and CT arthrography of the wrist. Semin Musculoskelet Radiol 2012; 16: 27-41
• 39 Moritomo H, Arimitsu S, Kubo N. et al. Computed Tomography Arthrography Using a Radial Plane View for the Detection of Triangular Fibrocartilage Complex Foveal Tears. J Hand Surg Am 2015; 40: 245-251
• 40 Grunz JP, Gietzen CH, Luetkens K. et al. The importance of radial multiplanar reconstructions for assessment of triangular fibrocartilage complex injury in CT arthrography of the wrist. BMC Musculoskelet Disord 2020; 21: 286
• 41 Löw S, Erne H, Pillukat T. et al. Diagnosing central lesions of the triangular fibrocartilage as traumatic or degenerative: a review of clinical accuracy. J Hand Surg Eur 2017; 42: 357-362
• 42 Mikic ZD. Age related changes in the triangular fibrocartilage of the wrist. J Anat 1978; 126: 367-384
• 43 Metz VM, Schratter M, Dock WI. et al. Age-associated changes of the triangular fibrocartilage of the wrist: Evaluation of the diagnostic performance of MR imaging. Radiology 1992; 184: 217-222
• 44 Pfirrmann CW, Theumann NH, Chung CB. et al. What happens to the triangular fibrocartilage complex during pronation and supination of the forearm? Analysis of its morphology and diagnostic assessment with MR arthrography. Skeletal Radiol 2001; 30: 677-685
• 45 Nakamura T. Radial side tear of the triangular fibrocartilage complex. In: del Piñal F, Mathoulin C, Luchetti R. Arthroscopic management of distal radius fractures. Springer, Heidelberg: 2010: 89-98
• 46 Theumann N, Kamel EM, Bollmann C. et al. 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. Skeletal Radiol 2011; 40: 1617-1621
• 47 Jose J, Arizpe A, Barrera CM. et al. MRI findings in bucket-handle tears of the triangular fibrocartilage complex. Skeletal Radiol 2018; 47: 419-424
• 48 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 2017; 42: 405-414
• 49 Hur Y, Ahn JM, Kim HJ. et al. Peripheral tear of the triangular fibrocartilage complex: diagnostic accuracy of magnetic resonance imaging and diagnostic performance of the primary and secondary signs. Skeletal Radiol 2024; 53: 1153-1163
• 50 Nakamura T, Sato K, Okazaki M. et al. Repair of foveal detachment of the triangular fibrocartilage complex: open and arthroscopic transosseous techniques. Hand Clin 2011; 27: 281-290
• 51 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: 131-138
• 52 Ryoo HJ, Kim YB, Kwak D. et al. Ulnar positive variance associated with TFCC foveal tear. Skeletal Radiology 2023; 52: 1485-1491
• 53 Daunt N, Couzens GB, Cutbush K. et al. Accuracy of magnetic resonance imaging of the wrist for clinically important lesions of the major interosseous ligaments and triangular fibrocartilage complex; correlation with radiocarpal arthroscopy. Skeletal Radiol 2021; 50: 1605-1616
• 54 Slutsky DJ. Clinical applications of volar portals in wrist arthroscopy. Tech Hand Up Extrem Surg 2004; 8: 229-238
• 55 Protopsaltis TS, Ruch DS. Triangular fibrocartilage complex tears associated with symptomatic ulnar styloid nonunions. J Hand Surg Am 2010; 35: 1251-1255
• 56 Tomori Y, Nanno M, Takai S. The Presence and the Location of an ulnar styloid fracture associated with distal radius fracture predict the presence of triangular fibrocartilage complex 1B injury. Arthroscopy 2020; 36: 2674-2680
• 57 Santo S, Omokawa S, Iida A. et al. Magnetic resonance imaging analysis of the extensor carpi ulnaris tendon and distal radioulnar joint in triangular fibrocartilage complex tears. J Orthop Sci 2018; 23: 953-958
• 58 Nevalainen MT, Zoga AC, Rivlin M. et al. Extensor carpi ulnaris tendon pathology and ulnar styloid bone marrow edema as diagnostic markers of peripheral triangular f ibrocartilage complex tears on wrist MRI: a case–control study. Eur Radiol 2023; 33: 3172-3177
• 59 Nishikawa S, Toh S, Miura H. et al. The carpal detachment injury of the triangular fibrocartilage complex. J Hand Surg Br 2002; 27: 86-89
• 60 Watson HK, Weinzweig J. Triquetral impingement ligament tear (tilt). J Hand Surg Br 1999; 24: 321-324
• 61 Gietzen CH, Kunz AS, Luetkens KS. et al. Evaluation of prestyloid recess morphology and ulnar-sided contrast leakage in CT arthrography of the wrist. BMC Musculoskeletal Disorders 2022; 23: 284
• 62 Estrella EP, Hung LK, Ho PC. et al. Arthroscopic repair of triangular fibrocartilage complex tears. Arthroscopy 2007; 23: 729-737
• 63 Tay SC, Berger RA, Parker WL. Longitudinal Split Tears of the Ulnotriquetral Ligament. Hand Clin 2010; 26: 495-501
• 64 Ringler MD, Howe BM, Amrami KK. et al. Utility of Magnetic Resonance Imaging for Detection of Longitudinal Split Tear of the Ulnotriquetral Ligament. J Hand Surg Am 2013; 38: 1723-1727
• 65 Abe Y, Moriya A, Tominaga Y. et al. Dorsal Tear of Triangular Fibrocartilage Complex: Clinical Features and Treatment. J Wrist Surg 2016; 5: 42-46
• 66 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 2007; 32: 705-708