Palmer previously proposed a classification system of triangular fibrocartilage complex (TFCC) injuries that proved to be useful in directing clinical management. However, dorsal peripheral tears (variants of class 1C) were not described and have rarely been reported in the literature since. We herewith present a rare case of bucket-handle tear of the TFCC. To our knowledge, this is the first case demonstrating partial separation of both the palmar and dorsal distal radioulnar ligaments (DRULs) from the articular disc. The particular wrist magnetic resonance (MR) arthrographic findings of this unusual complex peripheral TFCC tear (a variant of both class 1B and 1C) were nicely appreciated upon sagittal reformatted image

Becce, Fabio

Bollmann, Christof

Kamel, Ehab

Sturzenegger, Michael

Theumann, Nicolas

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CASE REPORTBucket-handle tear of the triangular fibrocartilage complex:case report of a complex peripheral injury with separationof the distal radioulnar ligaments from the articular discNicolas Theumann & Ehab M. Kamel &Christof Bollmann & Michael Sturzenegger & Fabio BecceReceived: 26 December 2010 /Revised: 22 August 2011 /Accepted: 24 August 2011 /Published online: 16 September 2011# ISS 2011Abstract Palmer previously proposed a classificationsystem of triangular fibrocartilage complex (TFCC) injuriesthat proved to be useful in directing clinical management.However, dorsal peripheral tears (variants of class 1C) werenot described and have rarely been reported in the literaturesince. We herewith present a rare case of bucket-handle tearof the TFCC. To our knowledge, this is the first casedemonstrating partial separation of both the palmar anddorsal distal radioulnar ligaments (DRULs) from thearticular disc. The particular wrist magnetic resonance(MR) arthrographic findings of this unusual complexperipheral TFCC tear (a variant of both class 1B and 1C)were nicely appreciated upon sagittal reformatted images.IntroductionPalmer previously proposed a classification system oftriangular fibrocartilage complex (TFCC) injuries that hasbeen widely applied by radiologists and hand surgeons, andwhich proved to be useful in directing clinical management[1–3]. This classification differentiates traumatic (class 1)from degenerative (class 2) injuries. Traumatic lesions arefurther categorized as central (class 1A) or peripheral(classes 1B–1D). Distal tears (class 1C) imply injury tothe palmar ulnocarpal (ulnolunate and/or ulnotriquetral)ligaments. However, dorsal peripheral tears, with orwithout ulnocarpal ligaments injury, were not describedin Palmer classification system and have rarely beenreported in the literature since [4–6]. Those kind ofperipheral tears are important to recognize, as they maylead to distal radioulnar joint (DRUJ) and/or wristinstability [7, 8]. Furthermore, those injuries portend goodhealing after open or arthroscopic surgical repair [4, 9].We herewith present a rare case of bucket-handle tear ofthe TFCC. To our knowledge, this is the first casedemonstrating partial separation of both the palmar anddorsal distal radioulnar ligaments (DRULs) from thearticular disc. The particular wrist magnetic resonance(MR) arthrographic findings of this unusual complexperipheral TFCC tear (a variant of both class 1B and 1C)were nicely appreciated upon sagittal reformatted images.Case reportA 44-year-old manual worker visited our hospital with acuteonset of ulnar-sided wrist pain after twisting his right wrist. Hispast medical history was unremarkable. On physical examina-tion, he presented diffuse tenderness with pain on deeppalpation at the ulnar aspect of the wrist. Posteroanterior andlateral wrist radiographs (not shown) demonstrated no fracture.The ulnar variance was negative and Gilula’s arcs were notdisrupted. A diagnosis of moderate (grade 2) wrist sprain wasEhab M. Kamel and Fabio Becce contributed equally to this work.N. Theumann : E. M. Kamel : F. Becce (*)Department of Diagnostic and Interventional Radiology,Centre Hospitalier Universitaire Vaudois, University of Lausanne,Rue du Bugnon 46,1011 Lausanne, Switzerlande-mail: fabio.becce@chuv.chC. BollmannDepartment of Plastic and Hand Surgery,Clinique Longeraie and Centre Hospitalier Universitaire Vaudois,1003 Lausanne, SwitzerlandM. SturzeneggerDivision of Plastic and Hand Surgery,Clinique Longeraie and Centre Médical de Vidy,1007 Lausanne, SwitzerlandSkeletal Radiol (2011) 40:1617–1621DOI 10.1007/s00256-011-1269-1made and the patient treated with non-steroidal anti-inflammatory drugs and splint immobilization during 4 weeks.Three months later, the patient could not return to workand was dismissed. A standard wrist MR imaging (notshown) was performed in another institution on a 1.5-T unitand interpreted as normal.Six months later, he still suffered from ulnar-sided wristpain and reduced grip strength in activities of daily living.The ulnar fovea sign was positive and pain could bereproduced by the ulnocarpal stress test (both are sensitivescreening tests for an intra-articular disorder [10, 11]). Thepiano-key test (a provocative maneuver assessing DRUJstability [10, 11]) was also positive. Accordingly, a three-compartment MR arthrography of the wrist was performed.Arthrography was carried out under fluoroscopic guidance,with a dorsal approach. First, the midcarpal joint waspunctured at the triquetrohamate space and a few millilitersof a mixture of 9 ml of iodinated contrast material(Accupaque 300, GE Healthcare), 0.05 ml of gadotericacid (Dotarem, Guerbet), 1 ml of lidocaine hydrochloride(Rapidocain 1%, Sintetica) and one drop of epinephrinehydrochloride (Adrenalin, Sintetica) were injected. As aFig. 1 a–d Left to right: sequential (palmar to dorsal) coronal T1-weighted (repetition time/echo time, 11.2 ms/3.5 ms) customvolumetric interpolated breathhold examination (VIBE) MR arthro-graphic images of the right wrist display partial separation of thepalmar (black arrowhead) and dorsal (white arrowhead) distalradioulnar ligaments (DRULs) from the articular disc (arrow). Thedorsal ulnotriquetral ligament (d) and the distal lamina of triangularfibrocartilage complex (TFCC) attachment on the ulnar styloid process(s) are torn. On the contrary, the articular disc, the palmarulnotriquetral ligament (p) and the proximal lamina of TFCCattachment on the ulnar fovea (f) are preserved. This complexperipheral lesion represents a bucket-handle tear of the TFCC, withthe distal lamina of the TFCC and the DRULs partially subluxateddistal to the articular disc. The custom VIBE MR sequence wasacquired in free breathing keeping the same contrast features but afterremoving all interpolations in slice and phase direction. T=triquetrum,U=ulna, *=extensor carpi ulnaris (ECU) tendon. e Illustrativediagram depicting the aforementioned lesion of the triangularfibrocartilage complex (TFCC): 1, palmar and dorsal distal radioulnarligaments (DRULs); 2, articular disc; 3, insertion of TFCC proximallamina on the ulnar fovea; 4, insertion of TFCC distal lamina on theulnar styloid process; 5, dorsal ulnotriquetral ligament; 6, palmarulnotriquetral ligament; 7, meniscus homologue; 8, extensor carpiulnaris (ECU) tendon1618 Skeletal Radiol (2011) 40:1617–1621communication with the radiocarpal joint was notedthrough a central tear of the lunotriquetral ligament,approximately 6 ml of the mixture was injected in orderto fully distend the midcarpal and radiocarpal joints. Nocommunication with the DRUJ was observed, even afteractive wrist movements with spot filming. Consequently,the DRUJ was punctured at the radial aspect of the ulnarhead and about 2 ml of the mixture were injected. MRimaging was then performed on a 3-T unit (Trio, Siemens,Erlangen, Germany) with a dedicated wrist coil (Alpha IIITx/Rx Quadrature, Siemens). Upon coronal isotropichigh-resolution (section thickness 0.4 mm) T1-weighted(repetition time/echo time, 11.2 ms/3.5 ms) customvolumetric interpolated breathhold examination (VIBE)(acquired in free breathing without changing contrastfeatures but after removing all interpolations in slice andphase direction) MR arthrographic images (Fig. 1a–d), acomplex peripheral TFCC tear was noted. Indeed, thedorsal ulnotriquetral ligament and the distal lamina ofTFCC attachment on the ulnar styloid process were torn(Figs. 1c–d and 2a–c). Moreover, the palmar and dorsalDRULs were partially separated from the articular discand subluxated distal to it (Figs. 1b–d and 2c–d).Interestingly, no communication between the radiocarpaljoint and the DRUJ could be noted at the time ofarthrography, as the articular disc and the proximal laminaof TFCC attachment on the ulnar fovea were preserved(Fig. 1a–d). Besides, the extensor carpi ulnaris (ECU)tendon and its tendon sheath were both intact. Upon asagittal reformatted (section thickness 0.4 mm) T1-weightedVIBE MR arthrographic view at the level of the TFCC(Fig. 2c), this complex peripheral TFCC tear mimicked theappearance of a pair of sunglasses.The bucket-handle tear of the TFCC was subsequentlyconfirmed at arthroscopy of the radiocarpal jointthrough the 3–4 portal (Fig. 3). The articular disc wasintact and no communication was seen between theradiocarpal joint and the DRUJ (Fig. 3a). A complexperipheral tear partially separated the DRULs from thearticular disc (Fig. 3b). However, the palmar and dorsalulnocarpal ligaments could not be assessed at arthros-copy. This tear was then repaired using a mini-opensuture anchor technique, with reinsertion of the distallamina of the TFCC on the ulnar styloid process.Unfortunately, no clinical improvement was observedin the few days following surgery. The patient was thenlost to follow-up at 1 month when he left the countryfor personal reasons.Fig. 2 a–d Left to right: sequential (radial to ulnar) sagittalreformatted T1-weighted (repetition time/echo time, 11.2 ms/3.5 ms)custom volumetric interpolated breathhold examination (VIBE) MRarthrographic images of the right wrist show partial separation of thepalmar (black arrowhead) and dorsal (white arrowhead) distalradioulnar ligaments (DRULs) from the articular disc (arrow). Thedorsal ulnotriquetral ligament (d) is torn, but the palmar ulnotriquetralligament (p) is intact. This bucket-handle tear of the triangularfibrocartilage complex (TFCC) mimics the appearance of a pair ofsunglasses (c), with the dorsal DRUL partially floating within theintra-articular contrast material, between the preserved articular discand the triquetrum (T). The custom VIBE MR sequence was acquiredin free breathing keeping the same contrast features but after removingall interpolations in slice and phase direction. U=ulna, *=extensorcarpi ulnaris (ECU) tendonFig. 3 Arthroscopic images of the radiocarpal joint. Distal is to theleft and dorsal is to the top of the pictures. The arthroscope is inserteddorsally through the 3–4 portal, while the instruments are passedbetween the extensor tendons using the 6R portal. a The articular disc(*) is intact and no communication between the radiocarpal joint anddistal radioulnar joint (DRUJ) is seen. b The hook probe is passedthrough the complex peripheral tear that partially separates the distalradioulnar ligaments (DRULs) from the articular disc (*). †=prestyloid recessSkeletal Radiol (2011) 40:1617–1621 1619DiscussionUlnar-sided wrist pain is a diagnostic challenge for bothhand surgeons and radiologists due to the small andintricate anatomical structures involved. The differentialdiagnosis is wide, with tears of the TFCC representing oneof the most common causes [10, 12]. History and physicalexamination may help to differentiate tears of the articulardisc from lesions of the peripheral portion of the TFCC[10–13]. Indeed, patients with articular disc injuries willcomplain of discomfort during pro/supination of the wrist,whereas peripheral destabilizing TFCC tears will induce amore constant pain in activities of daily living and a greaterlimitation of range of motion [11, 12]. Moreover, the ulnarfovea sign was reported to be a sensitive (95.2%) andspecific (86.5%) clinical maneuver for foveal disruptions ofthe DRULs and/or ulnotriquetral ligament injuries [13].However, as other injuries may mimic TFCC tears onphysical examination, most hand surgeons rely on wristMDCT and/or MR arthrographic findings to direct clinicalmanagement [3, 7, 14].The TFCC consists of the articular disc (also known asthe triangular fibrocartilage, TFC), the palmar and dorsalDRULs, the palmar and dorsal ulnocarpal (ulnolunate andulnotriquetral) ligaments, the meniscus homologue, theulnar collateral ligament, and the sheath of the ECU tendon[10, 15]. The ulnar attachment of the TFCC is composed oftwo distinct laminae which are separated by the ligamentumsubcruentum: the proximal lamina is oriented vertically andinserts on the ulnar fovea, whereas the distal lamina runshorizontally and inserts on the ulnar styloid process [16].To our knowledge, dorsal peripheral tears of the TFCC,with or without associated ulnocarpal ligaments injury,have rarely been reported in the literature so far [4–6]. Ourcase seems to be the first to demonstrate partial separationof both palmar and dorsal DRULs from the articular disc,forming a bucket-handle tear of the TFCC (in analogywith a superior labral anteroposterior (SLAP) 3 lesion,Figs. 1b–d and 2c–d). The radiological profile of thiscomplex peripheral lesion, which could be regarded as acombination of Palmer class 1B (ulnar attachment tear ofTFCC distal lamina) and 1C (distal palmar and dorsal tearsof the DRULs), was in the form of two discs connected by afine thread and mimicked the appearance of a pair ofsunglasses upon sagittal reformatted wrist MR arthrographicimages (Fig. 2c). With the successful introduction of 3-TeslaMR imaging of the wrist, isotropic high-resolution MRimages are now obtained in clinical routine. As thesensitivity, specificity, and accuracy of 1.5-T wrist MRimaging for traumatic peripheral tears (classes 1B and 1C)were previously reported to be as low as 17, 79, and 64%,respectively [17], the analysis of high-resolution sagittalreformatted MR arthrographic images might be helpful indetecting more dorsal peripheral TFCC tears and theirassociated abnormalities, such as extrinsic carpal ligamentsinjuries. However, further studies are needed to assess theutility of those sagittal reformatted MR images.Peripheral tears of the TFCC are important to recognizefor several reasons. First, due to the rich blood supply ofthe peripheral portion of the TFCC, those tears portendgood healing after open or arthroscopic surgical repair[4, 9, 18]. Second, those injuries may be associated withDRUJ and/or wrist instability. Indeed, Munk et al.evaluated the changes in wrist stability after experimentaltraumatic TFCC lesions [8]. They concluded that wriststability was significantly related to Palmer class 1Clesions, in contrast to the other classes of traumatic TFCCinjuries which mainly affected the stability of the DRUJ.Third, due to the loss of the cushion function of the TFCCfor the ulnar carpus, peripheral tears may lead todegenerative changes in the radiocarpal joint and/or theDRUJ [10, 12].Finally, we have to acknowledge two limitations of ourcase report. First, while we believe that the complexity ofthis lesion would only be fully appreciated with wrist MRarthrography, we have not had the opportunity to review theinitial standard MR imaging study. Second, as the patientwas rapidly lost to follow-up after surgery, we have notbeen able to evaluate the efficacy of surgical repair of thisbucket-handle tear of the TFCC and its potential long-termcomplications.Acknowledgments The authors gratefully thank Philippe Clavel forhis computer graphics work.Funding or grant None.References1. Palmer AK. Triangular fibrocartilage complex lesions: a classifi-cation. J Hand Surg Am. 1989;14:594–606.2. Palmer AK. Triangular fibrocartilage disorders: injury patternsand treatment. Arthroscopy. 1990;6:125–32.3. Potter HG, Asnis-Ernberg L, Weiland AJ, Hotchkiss RN,Peterson MG, McCormack Jr RR. The utility of high-resolution magnetic resonance imaging in the evaluation ofthe triangular fibrocartilage complex of the wrist. J Bone JointSurg Am. 1997;79:1675–84.4. Estrella EP, Hung LK, Ho PC, Tse WL. Arthroscopic repairof triangular fibrocartilage complex tears. Arthroscopy. 2007;23:729–37.5. Machiels F, Moermans JP, Brutus JP. Arthrographic and CTarthrographic findings in dorsal peripheral detachment of thetriangular fibrocartilaginous complex. JBR-BTR. 2001;84:114–7.6. Morisawa Y, Nakamura T, Tazaki K. Dorsoradial avulsion ofthe triangular fibrocartilage complex with an avulsion fractureof the sigmoid notch of the radius. J Hand Surg Eur Vol.2007;32:705–8.1620 Skeletal Radiol (2011) 40:1617–16217. Watanabe A, Souza F, Vezeridis PS, Blazar P, Yoshioka H.Ulnar-sided wrist pain. Part II: clinical imaging and treatment.Skeletal Radiol. 2010;39:837–57.8. Munk B, Jensen SL, Olsen BS, Kroener K, Ersboell BK. Wriststability after experimental traumatic triangular fibrocartilagecomplex lesions. J Hand Surg Am. 2005;30:43–9.9. Corso SJ, Savoie FH, Geissler WB, Whipple TL, Jiminez W,Jenkins N. Arthroscopic repair of peripheral avulsions of thetriangular fibrocartilage complex of the wrist: a multicenter study.Arthroscopy. 1997;13:78–84.10. Vezeridis PS, Yoshioka H, Han R, Blazar P. Ulnar-sided wristpain. Part I: anatomy and physical examination. Skeletal Radiol.2010;39:733–45.11. Raskin KB, Beldner S. Clinical examination of the distal ulna andsurrounding structures. Hand Clin. 1998;14:177–90.12. Sachar K. Ulnar-sided wrist pain: evaluation and treatment oftriangular fibrocartilage complex tears, ulnocarpal impactionsyndrome, and lunotriquetral ligament tears. J Hand Surg Am.2008;33:1669–79.13. Tay SC, Tomita K, Berger RA. The “ulnar fovea sign” fordefining ulnar wrist pain: an analysis of sensitivity and specificity.J Hand Surg Am. 2007;32:438–44.14. Moser T, Khoury V, Harris PG, Bureau NJ, Cardinal E, Dosch JC.MDCT arthrography or MR arthrography for imaging the wristjoint? Semin Musculoskelet Radiol. 2009;13:39–54.15. Theumann NH, Pfirrmann CW, Antonio GE, Chung CB,Gilula LA, Trudell DJ, et al. Extrinsic carpal ligaments:normal MR arthrographic appearance in cadavers. Radiology.2003;226:171–9.16. Benjamin M, Evans EJ, Pemberton DJ. Histological studies onthe triangular fibrocartilage complex of the wrist. J Anat.1990;172:59–67.17. Haims AH, Schweitzer ME, Morrison WB, et al. Limitations ofMR imaging in the diagnosis of peripheral tears of the triangularfibrocartilage of the wrist. Am J Roentgenol. 2002;178:419–22.18. Thiru RG, Ferlic DC, Clayton ML, McClure DC. Arterialanatomy of the triangular fibrocartilage of the wrist and itssurgical significance. J Hand Surg Am. 1986;11:258–63.Skeletal Radiol (2011) 40:1617–1621 1621

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

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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

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