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(Radiology. 2000;216:840-845.)
© RSNA, 2000

Musculoskeletal Imaging

Characteristics of Triangular Fibrocartilage Defects in Symptomatic and Contralateral Asymptomatic Wrists1

Marco Zanetti, MD, M. David Linkous, MD, Louis A. Gilula, MD and Juerg Hodler, MD

1 From the Department of Radiology, Orthopedic University Hospital Balgrist, University of Zurich, Forchstrasse 340, CH-8008 Zurich, Switzerland (M.Z., J.H.); the Department of Radiology, Caritas Medical Center, Louisville, Ky (M.D.L.); and the Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (L.A.G.). Received June 22, 1999; revision requested August 10; final revision received November 19; accepted November 24. Address correspondence to M.Z. (e-mail: mzanetti@balgrist.unizh.ch).


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
PURPOSE: To characterize triangular fibrocartilage (TFC) defects in symptomatic and contralateral asymptomatic wrists.

MATERIALS AND METHODS: Communicating and noncommunicating defects of the TFC were depicted on bilateral wrist arthrograms in 56 patients with unilateral wrist pain and without associated lesions of the scapholunate or lunotriquetral ligaments. The exact location of each TFC lesion was noted.

RESULTS: Communicating defects were noted in 36 (64%) of 56 symptomatic and in 26 (46%) of 56 asymptomatic wrists. Twenty-five (69%) of 36 communicating defects were bilateral. Except for one defect in each group of symptomatic and asymptomatic wrists, all communicating defects were noted radially. Noncommunicating defects were noted in 28 (50%) of 56 symptomatic wrists and in 15 (27%) of 56 asymptomatic wrists. Eleven (39%) of 28 noncommunicating defects were bilateral. On the symptomatic side, 28 of 36 noncommunicating defects (including eight multiple defects) were located proximally at the ulnar side. On the asymptomatic side, 11 of 17 noncommunicating defects (including two multiple defects) were at or near the ulna.

CONCLUSION: Noncommunicating TFC defects, which typically are located on the proximal side of the TFC near its ulnar attachment, have a more reliable association with symptomatic wrists than do communicating defects. Radial-sided communicating defects described in the literature (Palmer type 1A and 1D) as posttraumatic commonly are seen bilaterally and in asymptomatic wrists.

Index terms: Wrist, abnormalities, 434.483 • Wrist, arthrography, 434.122 • Wrist, injuries, 434.483


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
The diagnosis of ulnar-sided pain challenges radiologists and hand surgeons. Triangular fibrocartilage (TFC) lesions have been recognized as a cause of ulnar wrist pain (1). Although magnetic resonance (MR) imaging has shown promise in recent investigations (2–4), the reliability of MR imaging for depicting triangular fibrocartilage lesions has been questioned by other researchers (5–7). Wrist arthrography has been reported to be more accurate for depicting TFC lesions (5,6).

Despite controversy surrounding the use of MR imaging versus that of wrist arthrography, both modalities depict a large number of abnormalities in patients with asymptomatic wrists, which decreases the clinical importance of such findings in patients with symptomatic wrists (8–10). During wrist arthrography, communicating defects of the TFC on the asymptomatic contralateral side have been recorded in more than 80% of patients (8,11). Moreover, no positive association between the sites and/or the side of the symptoms and the sites of communications could be demonstrated in a previous study (12). In a classification scheme of TFC lesions by Palmer (1), certain radial defects are stated to be uncommon and to represent traumatic lesions. Yet, anecdotally, we had noted that such defects near the radial attachment of the TFC to the radius are the most common sites of communicating defects and commonly are present contralaterally in asymptomatic wrists. On the proximal surface of the TFC, we have observed partial avulsions of the ulnar attachment of the TFC (a noncommunicating defect) in many symptomatic cases. The purpose of our retrospective study was to characterize TFC defects in symptomatic and in contralateral asymptomatic wrists. This was done to evaluate the importance of these noncommunicating defects and of the communicating defects of the TFC at various sites.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
The data sheets of 407 consecutive patients who underwent bilateral wrist arthrography at the Mallinckrodt Institute of Radiology in St Louis, Mo, between January 1995 and November 1998 were reviewed. Included in this retrospective study were patients with isolated TFC lesions and with unilateral wrist pain. Patients with communicating scapholunate or lunotriquetral ligament defects were excluded. Those patients who had an alternative explanation of wrist pain, such as unhealed fractures of the carpal bones or arthritis, also were excluded. By using these criteria, 56 patients (34 female patients, 22 male patients; mean age, 32 years; age range, 16–52 years) were included in the study. Forty-one of 56 patients had trauma-related pain. Two had acute trauma, with symptoms that lasted less than 4 weeks; 18 had subacute trauma, with symptoms that lasted 4–36 weeks; and 21 had remote trauma, with symptoms that lasted longer than 36 weeks.

Examination Technique
Wrist arthrography (Angioskop D33; Siemens Medical Systems, Iselin, NJ) was performed by using a standardized protocol. This protocol consisted of a three-compartment assessment of the symptomatic wrist and of tailored arthrography of the contralateral asymptomatic wrist, which also was assessed. The three compartments were injected with contrast material (43% iothalamate meglumine [Conray-43; Mallinckrodt Medical, St Louis, Mo]) in the following sequence: the midcarpal joint, the distal radioulnar joint (DRUJ), and the radiocarpal joint. Contralateral arthrography consisted of DRUJ and radiocarpal joint injection. The same compartment in the asymptomatic wrist was injected when abnormalities in one compartment in the symptomatic wrist were identified. The midcarpal compartment was not injected in the subgroup with isolated TFC defects, as the midcarpal injection on the symptomatic side was normal. It was typical that if a communicating defect of the TFC was identified in the symptomatic wrist, the DRUJ was injected first in the asymptomatic wrist. If no communicating defect was shown, then the radiocarpal joint also was injected to evaluate for a one-way TFC defect. The detailed technique has been described previously (13). Special attention was paid to profiling the inner surface of the base of the ulnar styloid process (the fovea) and the ulnocarpal space (Fig 1), with cranial-caudal and radial-ulnar tilting of the image intensifier to optimally evaluate the TFC and its peripheral attachment sites.



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  		Figure 1. Posteroanterior arthrogram of the normal DRUJ. The DRUJ is distended fully. The margins along the TFC are smooth (white arrows). The fovea (arrowheads) at the base of the ulnar styloid process is profiled. Contrast material radial to the needle is extravasation (black arrow) from the needle track or the DRUJ, and that proximal and ulnar to the black arrow is extravasation from the proximal portion of the DRUJ (a common site for extravasation with full distention of the DRUJ).

 
Image Analysis
All wrist arthrograms were evaluated separately by two musculoskeletal radiologists (L.A.G. and M.Z.) without knowledge of the presence or absence of symptoms in each case. The presence or absence of communicating and noncommunicating TFC defects was recorded, along with the precise location of each defect. The location (Fig 2) was categorized as 1 if it was at the cartilage attachment to the radius; 2, pararadial (2–3 mm from the radius); 3, at the mid portion; 4, paraulnar (2–3 mm from the ulnar insertion point of the TFC); or 5, at the ulnar insertion point. A communicating defect was defined as a defect in the TFC through which contrast material passed between the radiocarpal compartment and the DRUJ compartment (Fig 3). A noncommunicating defect was defined as localized contrast material leakage without communication to the adjacent compartment (Figs 4–6). A consensus readout was performed; its results were used as definite results.



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  		Figure 2. Drawing of a coronal wrist arthrogram demonstrates locations 1-5.

 


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  		Figure 3. Posteroanterior arthrogram shows a communicating defect of the TFC 2 mm ulnar to its radial insertion (location 2) in an asymptomatic wrist. There is a slitlike contrast material communication (arrow) between the DRUJ and the radiocarpal joint that corresponds to Palmer classification 1A.

 


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  		Figure 4. Posteroanterior arthrogram shows a noncommunicating defect at the mid portion of the TFC (location 3) (small arrow). After full distention of the DRUJ, an additional transverse slitlike noncommunicating defect (large arrow) is visible.

 


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  		Figure 5. Posteroanterior arthrogram shows a noncommunicating paraulnar defect (location 4). Localized contrast material leakage (arrow) is demonstrated 2-3 mm from the ulnar insertion point. The fovea at the base of the ulnar styloid process is not profiled in this view, which prevents the evaluation of location 5 on this spot arthrogram. Extravasation out of the proximal DRUJ capsule is from full distention of this joint.

 


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  		Figure 6. Posteroanterior arthrogram shows a noncommunicating defect at the ulnar insertion (location 5) (arrow). The fovea (arrowheads) at the base of the ulnar styloid process is profiled clearly, which allows the detection of noncommunicating defects in this location.

 
In addition, the presence or absence of a volar ulnar recess was evaluated by one author (L.A.G.) with extensive experience in studying this area. The volar ulnar recess was analyzed on the lateral and oblique views with shallow supination of the forearm. The degree of obliquity on the shallow-supinated oblique views varied slightly for profiling of the volar ulnar recess. These recesses were categorized as 1, small and smoothly delineated and definitely normal (Fig 7); 2, slightly larger and irregular and probably normal; 3, moderately large and irregular, with uncertain clinical importance; 4, moderately large, with slight contrast material leakage, and probably abnormal (Fig 8); or 5, large, with definite contrast material leakage, and definitely abnormal.



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  		Figure 7. Shallow-supinated oblique arthrogram shows a normal DRUJ with a small, smoothly delineated volar recess (arrow).

 


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  		Figure 8. Shallow-supinated oblique arthrogram shows a moderately large volar ulnar recess with slight contrast material leakage (type 4) (arrow).

 
The McNemar test was performed to determine if the imaging findings in the symptomatic and contralateral asymptomatic wrists differed significantly (14). A P value of less than .05 was considered to indicate a significant difference. STATMATE software (GraphPad Software, San Diego, Calif) was used to perform the McNemar test. {kappa} statistics were used to calculate interobserver agreement (15). JMP software (SAS Institute, Cary, NC) was used for this purpose.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Communicating defects were noted in 36 (64%) of 56 symptomatic wrists and in 26 (46%) of 56 asymptomatic wrists (P = .006) (Table). Twenty-five (69%) of 36 communicating defects were bilateral. Twenty of these 25 bilateral communicating defects had identical locations in the symptomatic and in the asymptomatic wrists. Except for one defect (Fig 9) in each group, all communicating defects were noted radially in locations 1 and 2. Noncommunicating defects were present in 28 (50%) of 56 symptomatic wrists and in 15 (27%) of 56 asymptomatic wrists (P = .011). Eleven (39%) of 28 noncommunicating defects were bilateral. Eight of these 11 bilateral noncommunicating defects were at the same location in symptomatic and asymptomatic wrists. The total number of noncommunicating defects (36 on the symptomatic side and 17 on the asymptomatic side) was higher than the number of wrists with a noncommunicating defect (28 symptomatic wrists and 15 asymptomatic wrists) because of multiple lesions at various locations.


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  		Characteristics and Locations of TFC Lesions in Symptomatic and Contralateral Asymptomatic Wrists (n = 56)
 


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  		Figure 9. Posteroanterior arthrogram shows a communicating defect of the TFC at the ulnar attachment (location 5). Slitlike contrast medium leakage (thick arrow) into the TFC is demonstrated. Contrast medium injected into the DRUJ reaches the radiocarpal joint (thin arrows) and passes through the pisotriquetral joint.

 
Twenty-eight of 36 noncommunicating defects on the symptomatic side were located proximally at the ulnar side in locations 4 and 5. On the asymptomatic side, 11 of 17 noncommunicating defects were located ulnarly. The most significant difference among all subtypes of defects between symptomatic and asymptomatic wrists was in noncommunicating defects at location 4 (22 symptomatic, eight asymptomatic; P = .003). Multiple noncommunicating defects at various locations (Fig 10) were present in five symptomatic and in two asymptomatic wrists. The simultaneous presence of a communicating defect and a noncommunicating defect was found in 10 symptomatic and in two asymptomatic wrists. All noncommunicating defects were on the proximal side of the TFC. They were visible only after injection into the DRUJ (Fig 11). Minimal radial contour irregularities on the distal side of the TFC at location 1 or 2 occasionally were identified but were considered to represent a normal variation on the basis of the experience of Hardy et al (16).



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  		Figure 10. Posteroanterior arthrogram shows multiple noncommunicating defects at locations 2, 3, 4, and 5 (arrows).

 


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  		Figure 11a. Noncommunicating defects are visible only at DRUJ arthrography. (a) Posteroanterior arthrogram of DRUJ injection in the symptomatic wrist demonstrates a large noncommunicating defect (arrow). (b) Posteroanterior arthrogram obtained after radiocarpal contrast material injection in the same wrist as in a shows no abnormality within the TFC.

 


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  		Figure 11b. Noncommunicating defects are visible only at DRUJ arthrography. (a) Posteroanterior arthrogram of DRUJ injection in the symptomatic wrist demonstrates a large noncommunicating defect (arrow). (b) Posteroanterior arthrogram obtained after radiocarpal contrast material injection in the same wrist as in a shows no abnormality within the TFC.

 
Interobserver agreement for the presence or absence of communicating defects was almost perfect ({kappa} = 0.96); it was substantial ({kappa} = 0.69) for the presence or absence of noncommunicating defects (15).

A volar ulnar recess was found in 36 symptomatic wrists (19 of type 1, five of type 2, four of type 3, six of type 4, and two of type 5) and in 31 asymptomatic wrists (17 of type 1, six of type 2, six of type 3, two of type 4, and zero of type 5). The presence or absence of a volar ulnar recess was not significant (P = .26).


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
Noncommunicating TFC defects, to our knowledge, have never been evaluated systematically. Our results indicate that noncommunicating TFC defects are worthwhile to record specifically because they were associated more reliably with symptomatic wrists than were communicating TFC defects. We have found these noncommunicating defects most commonly on the ulnar side. The systematic description of noncommunicating TFC defects also may improve the sensitivity of wrist arthrography overall, which is relatively poor for ulnarly located lesions. In a series of 23 arthroscopically proved TFC lesions, Trumble and colleagues (7) reported that only the avulsion on the radial side had positive arthrographic findings. Of the 11 patients with negative arthrographic findings, 10 had ulnar-sided noncommunicating defects in the capsular attachments. This experience parallels that of investigators in other studies (17,18), in which positive arthrographic findings tended to be an avulsion of the TFC from the radius, whereas the ulnar detachment seldom demonstrated positive arthrographic findings.

The treatment of noncommunicating defects may be the same as for communicating defects. Ulnar-sided noncommunicating defects represent lesions on which surgery may be performed commonly but which were not diagnosed previously; this is because many radiologists would not have diagnosed them as long as the only criterion for such lesions was the communication of contrast material between compartments. These lesions also may not be seen without a separate injection into the DRUJ in wrists with no communicating defects of the TFC when radiocarpal injection is performed. Ulnar-sided noncommunicating defects may represent avulsion of the ulnar attachment of the TFC, which, when symptomatic, can be reattached surgically.

In this study, we found noncommunicating defects only at the proximal side of the TFC. However, anecdotally, one of the authors has seen a few cases of noncommunicating defects that involved the distal surface of the TFC (Gilula LA, unpublished data, 1999). The noncommunicating defects of the proximal surface were located most commonly near the ulnar attachment. The location of these noncommunicating defects possibly is explained by the histologic findings in this region. Benjamin and colleagues (19) described the ulnar part of the TFC as split into two laminae. Strands of collagen from the more proximally located laminae arch through a region of vascular connective tissue toward the styloid process and toward the head of the ulna. The more distal laminae extend beyond the ulna and blend with the dense fibrous connective tissue of the prominent sheath of the extensor carpi ulnaris tendon (19). This dense distally located fibrous connective tissue seems less likely to undergo degeneration than the proximal-sided cartilage of the TFC and the proximally located laminae (20). The predominance of the degeneration of the proximal side of the TFC also has been explained by more intensive biomechanical forces in this region (20). We hypothesize that, as long as the dense distally located laminae are intact, a noncommunicating defect appears more likely to occur than a communicating defect.

The detection of noncommunicating defects at wrist arthrography is not hard, but attention must be paid to details. A tailored examination technique is required. It is important to profile the fovea at the base of the ulnar styloid process and the ulnocarpal space, with cranial-caudal and radial-ulnar tilting of the image intensifier to optimally evaluate the TFC and its peripheral attachment sites. If an angled beam is not available, the wrist can be positioned to profile these two portions of the ulna by flexing or extending while rotating the wrist radially or ulnarly during fluoroscopy.

It is the authors’ opinion that the lack of description of ulnar-sided lesions in the literature may be because the fovea of the ulnar styloid process may not be profiled routinely to show the ulnar attachment of the TFC. When noncommunicating defects are described, additional attention should be paid to not confuse these defects with volar ulnar recesses. The volar ulnar recess is demonstrated optimally on a lateral or shallow-supinated oblique view; however, on the anteroposterior view, this recess may resemble a noncommunicating defect. Because wrist arthrography has been performed at the Mallinckrodt Institute of Radiology for many years in more than 2,000 patients, the volar ulnar recess has been commented on with various degrees of emphasis. Reviewing some of these arthrograms retrospectively provided us with a chance to study these findings again. Such review also seemed important because anecdotal comments from wrist surgeons imply that radiologists routinely miss peripheral separations or tears of the TFC or of the TFC complex area. In the present study, small, regular recesses (types 1 and 2) were found commonly in both symptomatic and asymptomatic wrists. Larger and irregular recesses (types 4 and 5) were found more commonly in symptomatic wrists (eight in symptomatic and two in asymptomatic wrists); however, a definite assessment was difficult because of the small numbers. It is possible that a volar ulnar recess with contrast material leakage (types 4 and 5) could have significance in a larger study group. Larger, irregular recesses or the ready departure of contrast material from this area potentially represents these peripheral separations, which we radiologists are said to miss. Although we do not have proof of disease in this area, we hope that knowledge of the material we present will open a door in the search for important disease conditions with arthrography and also with MR imaging.

Noncommunicating defects should also be looked for at MR imaging. This may be difficult because high signal intensity has been recorded at the ulnar attachment of normal TFCs (9,21). The use of MR arthrography may improve the accuracy of standard MR imaging for TFC lesions (4); however, on the basis of our results, with an exclusively proximal location of noncommunicating defects, the DRUJ instead of the radiocarpal joint should be filled with contrast material.

With regard to radial-sided communicating defects, we confirm the results of previous studies (8,22) in which these defects were found commonly in the asymptomatic contralateral wrist. The clinical importance of radial-sided communicating defects remains unclear, although the surgical repair of such lesions has led to favorable results in some cases (7,18). The questionable clinical importance of communicating radial TFC defects has been emphasized by the results of a cadaveric study of the TFC in fetuses and in infants that revealed a high prevalence of congenital perforation. Of 60 cadavers, 11 had bilateral perforations and five had unilateral perforations (23).

Although we did not systematically analyze the sizes of the lesions in our study, we noted that the communicating defects were slitlike and fulfilled the criteria for traumatic lesions according to the widely accepted Palmer classification (1). Palmer stressed that traumatic lesions are slitlike and defined them as class 1 lesions. He differentiated degenerative (class 2) lesions when they were broader because of TFC wear. Moreover, he defined traumatic lesions as class 1A if there was central perforation 2–3 mm medial to the radial attachment of the TFC, as class 1B if there was avulsion from the insertion of the TFC into the distal ulna, as class 1C if there was avulsion of the TFC from its distal attachment to the lunate or triquetrum, or as class 1D if there was avulsion of the TFC from its attachment to the radius. The ulnarly located noncommunicating defects in the present study resembled class 1B lesions. The stronger correlation of noncommunicating defects with the symptomatic wrist rather than with the asymptomatic contralateral wrist in patients who predominantly have traumatized wrists (41 of 56 patients) emphasizes that these ulnar-sided noncommunicating defects truly may be trauma related. The communicating defects at locations 1 and 2 that corresponded to Palmer traumatic class 1D and 1A lesions, however, also were found commonly in the contralateral asymptomatic wrist. Although a designation as asymptomatic does not mean that the wrist never was traumatized, as most people have had minor wrist injuries at many times throughout their lives, we believe that the genesis of radial-sided TFC lesions by a substantial trauma should be questioned.

We acknowledge that, as limitations of our study, other abnormalities may have caused symptoms, although patients with communicating defects of the scapholunate and lunotriquetral ligaments and with unhealed fractures were excluded. Also, although the description of the noncommunicating TFC defects perfectly fits the previously described lesions at surgery, we have no surgical correlation for our arthrographic findings. Small radial-sided noncommunicating defects have been shown to be normal variants and to occur commonly when detailed spot radiographs are obtained specifically to look for these defects, which often are small (16). In the current study, such small defects were not prospectively searched for; therefore, the prevalence of such defects in this series may be artifactually small.

In conclusion, noncommunicating TFC defects, which typically are located at the proximal side of the TFC near its ulnar attachment, have a more reliable association with symptomatic wrists than do communicating radial defects. Separate injections of the DRUJ commonly are needed to show proximal ulnar noncommunicating defects.


   FOOTNOTES
 
Abbreviations: DRUJ = distal radioulnar joint, TFC = triangular fibrocartilage

Author contributions: Guarantor of integrity of entire study, M.Z.; study concepts, M.D.L., L.A.G.; study design, M.Z., M.D.L., L.A.G.; definition of intellectual content, L.A.G.; literature research, M.Z., M.D.L.; clinical studies, L.A.G.; data acquisition and analysis, M.Z., L.A.G.; statistical analysis, M.Z., J.H.; manuscript preparation, M.Z.; manuscript editing, J.H., L.A.G.; manuscript review, M.D.L., L.A.G.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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