A 52 year old male carpenter was referred for chronic wrist pain lasting for 6 months. There was no history of recent or remote trauma and his past medical history was unremarkable with no reports of previous surgery, arthritides, medications or familiar musculoskeletal disorders.
Physical examination revealed that during ulnar deviation of the wrist joint combined with axial loading led to reproduction of the pain combined with tenderness just distal to the ulnar styloid process. This manoeuvre (provocative test) was consistent with a triangular fibrocartilage ligament complex (TFCC) tear. The patient was put on analgesic and anti-inflammatory medication and was scheduled for an MRI examination.
During the MRI examination the patient underwent an episode of claustrophobia and panic and thus the MRI scan was not completed allowing us only to evaluate the first series of sequences (Fig 1a-d). STIR weighted images were indicative of a tear of TFCC at the ulnar side (type 1B in Palmer Classification) and so as an alternative method of diagnosis we decided to perform a CT arthrographic evaluation of the wrist joint.
In our institution we prefer the single-compartment radiocarpal injection technique. Approximately 4 mL of a mixture of iodinated contrast material and 1 mL lidocaine 1% was injected into the patient’s wrist under fluoroscopic guidance. When performing CT arthrography, we use a 16x0.75 mm collimation. This allows us to create 1.25-mm sections, which we reconstruct at 1-mm intervals for high-quality 2D reformatted images in all planes. 3 mm sections can also be created for review on film upon request.
Post intraarticular injection images (Fig 2a-d) in our case showed a perforation of the radial attachment of the TFCC classified as type 1D in Palmer Classification which was surgically confirmed.
The TFCC consists of the articular disk (the triangular fibrocartilage or proper TFC), the dorsal and palmar radioulnar ligaments, the meniscal homologue, the strong sheath of the extensor carpi ulnaris tendon, the ulnar collateral ligament, and the two ulnocarpal ligaments (the ulnolunate and ulnotriquetral ligaments). The TFC acts as a cushion between the distal ulna and the proximal carpal row and has gained close attention in musculoskeletal literature because traumatic and degenerative lesions of the TFC are well accepted causes of chronic wrist pain.
The location and configuration of the tear play an important role in management decisions. The Palmer classification system is commonly used and is based on the aetiology (traumatic versus degenerative), the location, and extent of the tear. Palmer divided tears into two different categories: traumatic (class I) and degenerative (class II). Further subdivisions of the traumatic lesions are: 1.) class 1A when the tear was located 2-3 mm medial to the radial attachment of the TFC; 2.) class 1B as avulsion from its insertion into the distal ulna; 3.) class 1C as avulsion of the TFC from its distal attachment to the lunate or triquetrum; and 4.) class 1D as avulsion of the TFC from its attachment at the radius.
However central communicating TFC lesions are also found in contralateral asymptomatic wrists and thus set in question the Palmer’s theory of traumatic causes. These communicating tears are only visible when contrast material is injected into the distal radio-ulnar joint. Furthermore the ulnar-sided peripheral TFC tears have a more consistent correlation with pain than central or radial TFC tears.
While central or radial-sided tears are being established with great accuracy (up to 99% accuracy), poor accuracy has been reported for peripheral ulnar attachment tears. Both conventional arthrography and MR imaging may miss TFC tears. The best accuracy for imaging TFCC tears is achieved with MR or CT arthrography.
TFCC tear type 1D
Based on the provided CT and MRI (possibly including MR or CT arthrography) images, the main findings are as follows:
Taking into account the patient’s age (52 years old), occupation (manual woodworking with high frequency of hand usage), and a chronic wrist pain history (6 months) without a clear history of trauma, the following diagnoses are considered:
Considering the patient’s age, occupational characteristics, 6-month symptom duration without apparent traumatic event, and radiological findings showing ulnar-sided TFCC tear changes, the most likely final diagnosis is:
If differentiation remains unclear, further clinical physical examinations (e.g., ulnar fovea sign, TFCC compression test) and comparison imaging of the contralateral asymptomatic wrist are recommended. When necessary, arthroscopic evaluation can provide more direct diagnostic evidence.
Important Note: During rehabilitation exercises, avoid overexertion and prematurely loading the wrist. If you experience severe pain, instability, or swelling, stop immediately and seek medical consultation.
Disclaimer: This report is based solely on the provided medical images and clinical information and cannot replace an in-person consultation or professional medical opinion. If you have any doubts or if symptoms worsen, please consult a specialist or seek medical attention promptly.
TFCC tear type 1D
