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The Classic - Review of Palmer and Werner (1981) on the triangular

fibrocartilage complex of the wrist anatomy and function

Article in Journal of ISAKOS Joint Disorders & Orthopaedic Sports Medicine · August 2017
DOI: 10.1136/jisakos-2017-000135

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 The Classic

The Classic: Review of Palmer and Werner (1981)

on the triangular fibrocartilage complex of the wrist
anatomy and function
Teun Teunis,1 David Ring2
1
Department of Plastic, Abstract usually asymptomatic. They referenced the study by
Reconstructive and Hand This classic discusses the original publication by Palmer Mikic2 on age-related changes of the TFCC, who
Surgery, University Medical
Center Utrecht, Utrecht, The and Werner (1981) on the anatomy and function of a found no perforation before the age of 30 and a
Netherlands set of soft tissue stabilising the distal radioulnar joint. linear progression in prevalence with increasing age
2
Department of Surgery and They labelled this confluent structure the triangular thereafter. But they do not comment on the age of
Perioperative Care, Dell Medical fibrocartilage complex (TFCC) of the wrist, and concluded their own cadavers.
School, Austin, Texas, USA A follow-up study by Palmer 8 years later cited
that abnormalities were typically degenerative and
usually asymptomatic. Eight years later Dr Palmer experience with 75 patients treated surgically
Correspondence to
Professor David Ring, published a follow-up taking a different perspective. to classify TFCC abnormalities and came to very
Department of Surgery and In this article he differentiated between traumatic different conclusions. It presented a classification
Perioperative Care, Dell Medical and degenerative TFCC lesions and outlined surgical differentiating between traumatic and degenerative
School-University of Texas at treatment for each type. The debate about the diagnosis, TFCC lesions and outlined surgical treatment for
Austin, Austin, Texas TX 78712, each type.
interpretation and treatment of TFCC abnormalities today
USA; ​david.​ring@​austin.​utexas.​
edu is captured by the contrast between both articles. Given that the TFCC is now universally discussed,
imaged and treated, the original 1981 article intro-
Received 22 May 2017 ducing this concept is considered a ‘landmark’. But
Revised 6 August 2017 the realm of debate on the diagnosis, interpretation
Accepted 13 August 2017 Introduction
and treatment of TFCC pathology is captured in the
In 1981 Palmer and Werner described the anatomy
contrast between this 1981 article and the subse-
and function of a set of soft tissue structures stabi-
quent 1989 article that introduced the concepts of
lising the distal radioulnar joint (DRUJ), which
trauma and operative treatment. There is substan-
they labelled the triangular fibrocartilage complex
tial surgeon-to-surgeon variation in the diagnosis
(TFCC) (figure 1).1 In addition to the primary
and management of TFCC pathology that may be
DRUJ stabilisers—the dorsal and volar distal radi-
elucidated by a review of the historical context.
oulnar ligaments—and the intervening fibrocar-
tilage disc, they included the ulnar collateral liga-
ment (a capsular thickening between the distal ulna Anatomy and function
and the triquetrum) and the extensor carpi ulnaris The ligaments between the distal radius and the
tendon sheath. They also included a fibrous thick- ulna, the dorsal and volar radioulnar ligaments, are
ening arising from the ulnar collateral ligament key stabilisers of the joint (table 1, figure 2). The
and the extensor carpi ulnaris tendon sheath that origin of these ligaments from the ulnar styloid is
extends into the joint between the ulnar styloid, broad and extends from the fovea towards the tip of
articular disc and the triquetrum. They somewhat the ulnar styloid. There is often a high fluid signal
confusingly labelled this the ‘meniscus homologue’. on MRI adjacent to the ulna between the deep and
Their rationale for considering these structures as superficial layers that is felt to reflect an area of
part of a single complex is that they are confluent high vascularity and should not be mistaken for an
and difficult to separate. But it is not entirely clear abnormality.3 This area is sometimes referred to as
that each of these structures contributes to DRUJ the ligament subcruentum.3 4 Studies show that on
stability. pronation and supination, the radioulnar ligaments
Palmer and Werner found that more than 50% of tighten,5 although in which direction tightening
cadavers had a perforation in the fibrocartilage disc. occurs is an area of debate. One study found the
They emphasised that these perforations were typi- volar radioulnar ligament to be taught in pronation
cally degenerative and that changes in the disc were and the dorsal ligament in supination.6 Another

Summary of the classic

In 1981 Palmer and Werner described the anatomy and function of a confluent soft tissue structure that they
labelled the triangular fibrocartilage complex. They included the dorsal and volar distal radioulnar ligaments,
articular disc, ulnar collateral ligament, extensor carpi ulnaris tendon sheath and a fibrous thickening arising
To cite: Teunis T, Ring D. from the ulnar collateral ligament and the extensor carpi ulnaris tendon sheath, somewhat confusingly
JISAKOS Published Online labelled the ‘meniscus homologue’. It is not entirely clear that each of these structures contributes to distal
First: [please include Day
Month Year]. doi:10.1136/
radioulnar joint stability. They found that more than 50% of cadavers had a perforation in the articular disc
jisakos-2017-000135 and emphasised that these perforations were typically degenerative and probably asymptomatic.

Teunis T, Ring D. JISAKOS 2017;0:1–5. doi:10.1136/jisakos-2017-000135. Copyright © 2017 ISAKOS 1

 The Classic

Figure 1 AD, fibrocartilage disc (articular disc); MH,

meniscus homologue; RUL, volar/dorsal distal radioulnar ligament; UCL,
ulnar collateral ligament.1

study found the exact opposite.7 A potential explanation is that

the superficial and deep layers tighten in different directions. In
pronation the dorsal superficial and volar deep fibres tighten and
in supination the other way around,8 although this is difficult
to confirm. One might argue that these details are of uncertain
relevance.
Between the dorsal and volar distal radioulnar ligaments,
there is an articular disc of fibrocartilage. In general anatomy
an articular disc separates synovial cavities in a joint, whereas a
meniscus partly divides a joint cavity. Because there is no artic-
ulation between the ulna and the carpus, the articular disc is
more similar to the meniscus in the knee (and may be a vestige Figure 2 1, Volar ulnocarpal ligaments; 2, meniscus homologue;
from evolutionary precursors where the ulna did articulate with 3, fibrocartilage disc; 4, dorsal distal radioulnar ligament; 5, extensor carpi
the carpus). The naming of the nearby extension from the ulnar ulnaris sheath; 6, distal oblique band of the interosseous ligament.5
collateral ligament into the joint as a ‘meniscus homologue’ by
Palmer and Werner is confusing, because the articular disc itself
is somewhat similar to a meniscus. Since this meniscus homo- fibres integrate with the fibres from the dorsal radioulnar
logue had no clear function and is not a clear source of symp- ligament9; therefore it was included in the TFCC descrip-
toms, it may not benefit from a specific name. It seems prefer- tion. Histologically the radioulnar and ulnolunate ligaments
able to simply describe it rather than naming it. consist of dense collagen fibres, while the extensor carpi
Palmer and Werner felt that it was useful to group other ulnaris sheath and articular disc consist of looser connective
structures with the ligaments and fibrocartilage because they tissue, suggesting that the radioulnar and ulnolunate liga-
are confluent and cannot be separately dissected. This gives the ments are the more important stabilisers.10
sense that all of these named areas are structurally important, Fibres running from the ulnar aspect of the ulnar styloid to
which is probably not the case. the triquetrum, hamate and base of the fifth metacarpal were
The extensor carpi ulnaris sheath inserts on the triquetrum named the ulnar collateral ligament. This refers to their posi-
and originates from the dorsal and ulnar aspect of the tion on the ulnar side of the wrist joint, similar to collateral
ulnar styloid. At its origin the extensor carpi ulnaris sheath ligaments on the lateral side of the knee and elbow.

Table 1 Anatomy of TFCC

Anatomical structure Course Function
Original article of Palmer and Werner
Volar distal radioulnar ligament Volar and dorsal sigmoid notch to ulnar styloid fovea and tip Primary stabiliser distal radioulnar joint
Dorsal distal radioulnar ligament
Fibrocartilage disc Between volar and dorsal radioulnar ligaments
Ulnar collateral ligament Capsular thickening between the distal ulna and the triquetrum Do not seem to contribute to DRUJ stability
Extensor carpi ulnaris sheath Capsular thickening below the extensor carpi ulnaris tendon
Meniscus homologue Fibrous thickening from the ulnar collateral ligament and the Confusing name given that the articular disc seems more
extensor carpi ulnaris tendon sheath extending into the joint like a meniscus; no clear function or source of symptoms;
between the ulnar styloid, articular disc and triquetrum preferable to simply describe it rather than naming it
Additional structures
Volar ulnocarpal ligaments Ulnocapitate, ulnolunate and ulnotriquetral ligaments Do not seem to contribute to DRUJ stability
Distal oblique band of the interosseous From distal ulna to dorsal inferior rim of the sigmoid notch Not initially considered as part of the ‘TFCC’; possibly
ligament involved in DRUJ stability
DRUJ, distal radioulnar joint; TFCC, triangular fibrocartilage complex.

2 Teunis T, Ring D. JISAKOS 2017;0:1–5. doi:10.1136/jisakos-2017-000135

 The Classic
Sometimes the volar ulnocarpal ligaments (ulnocapitate, ulno- of lesion, suggesting this was based more on experience than
lunate and ulnotriquetral ligaments) are also included in the analysis.12
definition of the TFCC,3 4 because they originate at the fovea DRUJ, distal radioulnar joint; TFCC, triangular fibrocartilage
and base of the ulnar styloid and are confluent with the volar complex.
radioulnar ligament.9 Palmer and Werner did not include these It is not clear how traumatic (class 1) and degenerative (class
ligaments in their original description. 2) lesions are distinguished. To our knowledge the reliability and
It is worth considering the principles by which we group accuracy of the classification are untested. Most surgery on the
structures. In our opinion, grouping based on confluence is TFCC occurs months after a perceived injury. Many of those
confusing. It seems better to group structures based on function. events may have represented initiation of symptoms rather than
The ulnocarpal ligaments, the ulnar collateral ligament and the traumatic lesions to the stabilisers of the DRUJ. Several months
ECU tendon sheath do not seem to contribute to radioulnar joint after an acute injury, the physical findings would not easily be
stability. Grouping these structures together as the TFCC may distinguished from a degenerative condition.
have introduced unnecessary confusion.
It is suggested that a distal oblique band of the interosseous
Traumatic lesions
ligament contributes to DRUJ stability. This band originates from
Traumatic (type 1) lesions were separated into A (tear or slit in
the distal ulna running distally to insert on the dorsal inferior
the articular disc, running from volar to palmer, 2–3 mm from
rim of the sigmoid notch under the pronator quadratus. Based
the radial attachment), B (detachment of the origin from the
on one study, it is estimated to be present in 40% of forearms
distal ulna or an ulnar styloid base fracture), C (avulsion of the
(12 out of 30 specimens). Some fibres of this ligament extending
ulnocarpal ligament attachments to the lunate or triquetrum,
along the volar and dorsal ridge of the sigmoid notch confluent
with potential carpal instability) and D (complete detachment
with the radioulnar ligaments.11 It may be more consistent to
of the TFCC from the radius). It is worth rethinking injuries in
include this distal band, when considering the TFCC than the
this area.
ECU tendon sheath and ulnocarpal and ulnar collateral liga-
Type 1A: Our ability to reliably and accurately distinguish a
ments.
traumatic slit in the articular disc from normal variations and
degeneration and the optimal treatment strategy remain uncer-
TFCC abnormalities tain. Given the prevalence of articular disc variations and degen-
Palmer and Werner found that perforation of the articular disc erations in particular, it is probably best to consider disc issues
was present in 81% (13 of 16) of the specimens with ulna plus collectively and separate them from DRUJ ligament pathology.
alignment, 50% (3 out of 6) with ulna neutral and 17% (2 out of Type 1C: Carpal instability has—to our knowledge—never
12) that were ulna-negative. This indicates that ulnolunate abut- been clearly associated with ulnocarpal ligament pathology. In
ment is associated with degeneration of the central portion of the any case that would be distinct from the primary concern of
articular disc. This implies that the articular disc acts as a cushion DRUJ instability.
between the lunate/triquetrum and the distal ulna. More than So in our opinion, types 1A and 1C (ie, including disc and
50% (18 of 34) of cadavers had a perforation in the fibrocarti- ulnocarpal ligament trauma along with DRUJ trauma) are
lage disc. Based on a study by Mikic, who found no perforation distracting, confusing and unhelpful.
before the age of 30 and a linear progression thereafter,2 Palmer Type 1 B and D: In trauma, the key issue is disruption of the
and Werner concluded that perforations were typically degen- structures that stabilise the DRUJ: the volar and dorsal radi-
erative and that changes in the disc were usually asymptomatic. oulnar ligaments, and perhaps the distal oblique band of the
They do not comment on the age of their own cadavers. interosseous ligament. Injuries to the radioulnar ligaments are
In the second article on the TFCC by Dr Palmer, he described extremely common in association with fractures of the distal
a classification for TFCC abnormalities based on 10 years of radius. This typically occurs via avulsion of the ligament origin
experience with 75 patients treated surgically (table 2). The from the distal ulna or a fracture of the base of the ulnar styloid
article does not mention the numbers of patients with each class (type 1B). It is not clear how often the failure occurs via avulsion

Table 2 Palmer’s classification of TFCC abnormalities

Class 1: traumatic Comment
Tear or slit in the articular disc, running from volar Hard to distinguish acute from developmental or
A to palmer, 2–3 mm from the radial attachment degenerative lesions
B Detachment of the origin from the distal ulna or an ulnar Common in conjunction with distal radius fracture;
styloid base fracture generally do well without specific treatment
C Avulsion of the ulnocarpal ligament attachments to the Unclear association between ulnocarpal ligament
lunate or triquetrum, with potential carpal instability disruption and carpal instability; seems to distract from
the focus on DRUJ stability
D Complete detachment of the TFCC from the radius Unclear prevalence, setting and prognosis
Class 2: degenerative
A Wear without perforation of the articular disc Changes in the articular disc are more common with
B Wear, without perforation, with cartilage damage of the age in symptomatic and asymptomatic patients. It is
lunate or ulnar head unclear if surgery for any form of articular disc variations
outperforms regression to the mean, natural history or
C Central perforation with cartilage damage at the lunate
resilience.
and/or ulnar head
D Same as C, with lunotriquetral ligament insufficiency

Teunis T, Ring D. JISAKOS 2017;0:1–5. doi:10.1136/jisakos-2017-000135 3

 The Classic
or fracture-avulsion from the insertion onto the radius, but it obtained. Patients with symptoms thought to be related to ulno-
seems very uncommon (type 1D). Most of these lesions are not carpal impaction can be offered surgery to shorten the ulna, but
repaired and there are few or no long-term consequences, at continuing with and adapting to their original anatomy is also
least in the setting of distal radius volar plate fixation.13 14 an appealing option given the potential downsides of surgery.20
The DRUJ can be a little lax after a displaced fracture of the The rationale for including the lunotriquetral ligament in
distal radius, but dislocation with forearm rotation is uncommon type 2D abnormalities was articulated as follows: ‘we postulate
and seems related more to alignment of the radius than insuffi- that chronic loading of the ulnar aspect of the lunate leads to
ciency of the radioulnar ligaments. An osteotomy of the distal degenerative laxity and eventual attenuation of the interosseous
radius to improve volar translation and volar angulation usually portion of the lunotriquetral ligament’. To our knowledge this
resolves the tendency to dislocate. In other words, acute injuries theory is untested. It seems confusing and unhelpful to combine
of the DRUJ ligaments heal. Isolated DRUJ dislocations are too considerations of instability (radioulnar ligament insufficiency),
rare to study well, but reduction and immobilisation in a stable articular disc pathology and intercarpal relationships.
position seem to restore stability and function, supporting the
concept that acute DRUJ ligament injuries heal.
The study of DRUJ instability after fracture of the distal radius Rethinking the ‘TFCC’
is hampered by the lack of a clear definition of instability and In our opinion, there is no clear advantage to including ulno-
no objective way to quantify the instability. Instability can be carpal structures in a complex with stabilisers of the distal radi-
confused with symptoms more accurately classified as discom- oulnar joint. Grouping structures based on anatomical conflu-
fort, or as instability based on a subjective assessment of ‘laxity’ ence may have created more confusion than is helpful. We
without objective dislocation or subluxation. The definition and prefer to avoid labelling pain or anatomical variations as ‘TFCC
objective measurement of DRUJ ‘instability’ short of frank dislo- lesions’. It seems much more useful and intuitive to distinguish
cation are unclear, unreliable and have no reference standard. (1) injury to and potential insufficiency of the volar and dorsal
The diagnosis and rate of surgery for DRUJ instability vary widely radioulnar ligaments and (2) variations of the articular disc.
from surgeon to surgeon, with some surgeons never making this Future research on injury to the radioulnar ligaments should
diagnosis and others operating on it rather frequently. determine the prevalence of injury and the diagnosis and best
Ulnar side wrist pain lasts upwards of a year after fracture of management of insufficiency. It should also include the relative
the distal radius. In our opinion, the only clear instability of the contributions to distal radioulnar joint laxity by distal radius
DRUJ is dislocation with forearm rotation. All other forms of malalignment and other soft tissue structures like the distal
laxity and pain should be considered and managed separately. oblique band of the interosseous ligament. The diagnosis of
It seems unwise to recommend intervention for ulnar side wrist instability should have a clear definition separate from discom-
symptoms of any sort within 1 year of injury. Time is both diag- fort, and we need an objective and reproducible method for
nostic and therapeutic in this setting. quantifying instability.
Future research on variations of the articular disc and ulno-
carpal impingement might address the overall incidence of
Degenerative lesions these anatomical variations in symptomatic and asymptomatic
Palmer distinguished several types of degenerative (type 2) wrists; the reliability and accuracy of attempts to distinguish
lesions: A (wear without perforation of the articular disc), B normal variations, traumatic changes and degenerative lesions of
(wear, without perforation, with cartilage damage of the lunate the articular disc; the reliability and accuracy of diagnoses that
or ulnar head), C (central perforation with cartilage damage at ascribe wrist symptoms to variations in the articular disc; and the
the lunate and/or ulnar head) and D (same as C, with lunotrique- value of operative treatments over sham operative treatments for
tral ligament insufficiency). symptoms ascribed to variations in the articular disc.
The initial article introducing the concept of the TFCC
Acknowledgements We thank Martin Langer for providing us with high-quality
concluded that a patient’s wrist pain is probably not related to
images of the TFCC he created.
articular disc perforation. Wrist pain is common, and TFCC
Contributors Both authors have contributed to the planning, conducting and
abnormalities are seen in symptomatic and asymptomatic people
reporting of this work.
and in affected and unaffected wrists in the same patient.15 16 A
Competing interests None declared.
recent systematic review found that changes in the articular disc
are more common with age and nearly universally asymptom- Provenance and peer review Commissioned; externally peer reviewed.
atic.15 Wrist pain and articular disc abnormalities are expected © International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports
to be coincident and are likely unrelated in a high percentage of Medicine (unless otherwise stated in the text of the article) 2017. All rights reserved.
No commercial use is permitted unless otherwise expressly granted.
patients. This situation makes it easy to misinterpret diagnostic
tests.
It is unclear if surgery for any form of articular disc variations References
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