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Schmitt R, Kunz AS, Reidler P, Huflage H, Hesse N. Triangular Fibrocartilage Complex (TFCC) - Anatomy, Imaging, and Classifications with Special Focus on the CUP Classification. ROFO-FORTSCHR RONTG 2024. [PMID: 39353587 DOI: 10.1055/a-2411-8444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2024]
Abstract
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.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.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. · 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.. · 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.
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Affiliation(s)
- Rainer Schmitt
- Department of Radiology, University Hospital Wurzburg, Würzburg, Germany
- Department of Radiology, University Hospital, LMU Munich, München, Germany
| | | | - Paul Reidler
- Department of Radiology, University Hospital, LMU Munich, München, Germany
| | - Henner Huflage
- Department of Radiology, University Hospital Wurzburg, Würzburg, Germany
| | - Nina Hesse
- Department of Radiology, University Hospital, LMU Munich, München, Germany
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Herzberg G, Burnier M, Ly L, Nakamura T, Piñal FD, Atzei A. A New Arthroscopic Classification of Triangular Fibrocartilage Complex Disorders. J Wrist Surg 2024; 13:2-8. [PMID: 38264139 PMCID: PMC10803146 DOI: 10.1055/s-0043-1769908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 05/09/2023] [Indexed: 01/25/2024]
Abstract
Introduction The use of wrist arthroscopy has become a prerequisite for diagnosis and treatment of triangular fibrocartilage complex (TFCC) disorders. Since Palmer's landmark paper, many new arthroscopic descriptions of TFCC tears have been published but there is no currently available updated comprehensive arthroscopic classification of TFCC lesions. Purpose We recently described the arthroscopic anatomy of the TFCC as viewed from a 3-4 portal. Our purpose was to propose a new TFCC disorders classification based on this new arthroscopic TFCC description. Methods We included all currently described TFCC disorders to the best of our knowledge into our arthroscopic, functional, and vascular anatomical concept. We also included patient's specific ulnar variance and distal radial ulnar joint coronal inclination as baseline treatment-oriented parameters. The fresh or chronic, reparable or nonreparable nature of some types of TFCC tears were considered as separate parameters. Results The proposed classification includes disc "D" (degenerative or traumatic), reins "R" (traumatic), and wall "W" (traumatic) lesions. Combined lesions of those three parts of the TFCC may be easily identified. This new classification should facilitate future analysis of isolated or combined TFCC disorders whether they are degenerative and/or traumatic. Discussion The authors present a new three-dimensional-three-part arthroscopic updated description of TFCC disorders with relevance to etiology and treatment principles.
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Affiliation(s)
- Guillaume Herzberg
- I-Trues Surgery Unit, Orthopedic Department, Clinique Parc Lyon, Lyon, France, Clinique Val Ouest, Lyon Ecully, France
| | - Marion Burnier
- I-Trues Surgery Unit, Department of Orthopedic, Institut Main Membre Supérieur, Villeurbanne, France
| | | | | | | | - Andrea Atzei
- Chirurgia Della Mano, Polso e Gomito, Microchirurgia Ricostruttiva MediLAB Sottoportico Teatro Dofin, Treviso, Italy
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Cerezal L, Del Piñal F, Atzei A, Schmitt R, Becce F, Klich M, Bień M, de Jonge MC, Teh J, Boutin RD, Toms AP, Omoumi P, Fritz J, Bazzocchi A, Shahabpour M, Zanetti M, Llopis E, Blum A, Lalam RK, Reto S, Afonso PD, Mascarenhas VV, Cotten A, Drapé JL, Bierry G, Pracoń G, Dalili D, Mespreuve M, Garcia-Elias M, Bain GI, Mathoulin CL, Van Overstraeten L, Szabo RM, Camus EJ, Luchetti R, Chojnowski AJ, Gruenert JG, Czarnecki P, Corella F, Nagy L, Yamamoto M, Golubev IO, van Schoonhoven J, Goehtz F, Sudoł-Szopińska I, Dietrich TJ. Interdisciplinary consensus statements on imaging of DRUJ instability and TFCC injuries. Eur Radiol 2023; 33:6322-6338. [PMID: 37191922 DOI: 10.1007/s00330-023-09698-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 03/09/2023] [Accepted: 04/05/2023] [Indexed: 05/17/2023]
Abstract
OBJECTIVES The purpose of this agreement was to establish evidence-based consensus statements on imaging of distal radioulnar joint (DRUJ) instability and triangular fibrocartilage complex (TFCC) injuries by an expert group using the Delphi technique. METHODS Nineteen hand surgeons developed a preliminary list of questions on DRUJ instability and TFCC injuries. Radiologists created statements based on the literature and the authors' clinical experience. Questions and statements were revised during three iterative Delphi rounds. Delphi panelists consisted of twenty-seven musculoskeletal radiologists. The panelists scored their degree of agreement to each statement on an 11-item numeric scale. Scores of "0," "5," and "10" reflected complete disagreement, indeterminate agreement, and complete agreement, respectively. Group consensus was defined as a score of "8" or higher for 80% or more of the panelists. RESULTS Three of fourteen statements achieved group consensus in the first Delphi round and ten statements achieved group consensus in the second Delphi round. The third and final Delphi round was limited to the one question that did not achieve group consensus in the previous rounds. CONCLUSIONS Delphi-based agreements suggest that CT with static axial slices in neutral rotation, pronation, and supination is the most useful and accurate imaging technique for the work-up of DRUJ instability. MRI is the most valuable technique in the diagnosis of TFCC lesions. The main indication for MR arthrography and CT arthrography are Palmer 1B foveal lesions of the TFCC. CLINICAL RELEVANCE STATEMENT MRI is the method of choice for assessing TFCC lesions, with higher accuracy for central than peripheral abnormalities. The main indication for MR arthrography is the evaluation of TFCC foveal insertion lesions and peripheral non-Palmer injuries. KEY POINTS • Conventional radiography should be the initial imaging technique in the assessment of DRUJ instability. CT with static axial slices in neutral rotation, pronation, and supination is the most accurate method for evaluating DRUJ instability. • MRI is the most useful technique in diagnosing soft-tissue injuries causing DRUJ instability, especially TFCC lesions. • The main indications for MR arthrography and CT arthrography are foveal lesions of the TFCC.
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Affiliation(s)
- Luis Cerezal
- Radiology Department, Diagnóstico Médico Cantabria (DMC), Castilla 6-Bajo, 39002, Santander, Spain.
| | - Francisco Del Piñal
- Instituto de Cirugía Plástica Y de La Mano, Serrano 58 1B, 28001, Madrid, Spain
| | - Andrea Atzei
- Pro-Mano, Treviso, Italy
- Ospedale Koelliker, Corso G. Ferraris 247, 10134, Torino, Italy
| | - Rainer Schmitt
- Department of Radiology, University Hospital LMU Munich, Ziemssenstraße 5, 80336, München, Germany
- Department of Radiology, University Hospital Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany
| | - Fabio Becce
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital, Lausanne, Switzerland
- University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Maciej Klich
- Department of Traumatology and Orthopaedics, Postgraduate Medical Center, A. Gruca Teaching Hospital, Otwock, Poland
| | - Maciej Bień
- Gamma Medical Center, Broniewskiego 3, 01-785, Warsaw, Poland
| | - Milko C de Jonge
- Department of Radiology, St. Antonius Hospital Utrecht, Utrecht, The Netherlands
| | - James Teh
- Department of Radiology, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Robert Downey Boutin
- Department of Radiology, Stanford University School of Medicine, 300 Pasteur Drive, MC-5105, Stanford, CA, 94305, USA
| | - Andoni Paul Toms
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ, UK
| | - Patrick Omoumi
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Jan Fritz
- Department of Radiology, New York University Grossman School of Medicine, NYU Langone Health, 660 First Avenue, New York, NY, 10016, USA
| | - Alberto Bazzocchi
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via G. C. Pupilli 1, 40136, Bologna, Italy
| | - Maryam Shahabpour
- Department of Radiology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Marco Zanetti
- Kantonsspital Baden, Im Ergel 1, CH-5404, Baden, Switzerland
| | - Eva Llopis
- Hospital de La Ribera. IMSKE. Valencia, Paseo Ciudadela 13, 46003, Valencia, Spain
| | - Alain Blum
- Guilloz Imaging Department, Central Hospital, University Hospital Center of Nancy, UDL, 29 Avenue du Maréchal de Lattre de Tassigny, 54035, Nancy, France
| | - Radhesh Krishna Lalam
- Department of Radiology, Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, UK
| | - Sutter Reto
- Balgrist University Hospital, University of Zurich, Forchstrasse 340, CH-8008 Radiology, Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Pestalozzistrasse 3, 8091, Zurich, Switzerland
| | - P Diana Afonso
- Imaging Center, Radiology Department, Musculoskeletal Imaging Unit, Hospital da Luz, Grupo Luz Saúde, Av. Lusiada 100, 1500-650, Lisbon, Portugal
- Hospital Particular da Madeira, HPA, Madeira, Portugal
| | - Vasco V Mascarenhas
- Imaging Center, Radiology Department, Musculoskeletal Imaging Unit, Hospital da Luz, Grupo Luz Saúde, Av. Lusiada 100, 1500-650, Lisbon, Portugal
- AIRC, Advanced Imaging Research Consortium, Lisbon, Portugal
| | - Anne Cotten
- Musculoskeletal Radiology Department, Lille University Hospital Center, 59037, Lille, France
- Lille University School of Medicine, Lille, France
| | - Jean-Luc Drapé
- Service de Radiologie B, AP-HP Centre, Groupe Hospitalier Cochin, Université de Paris, 75014, Paris, France
| | - Guillaume Bierry
- MSK Imaging, University Hospital, 1 Avenue Molière, 67098, Strasbourg Cedex, France
| | - Grzegorz Pracoń
- Gamma Medical Center, Broniewskiego 3, 01-785, Warsaw, Poland
| | - Danoob Dalili
- Academic Surgical Unit, South West London Elective Orthopaedic Centre (SWLEOC), Dorking Road, Epsom, KT18 7EG, London, UK
| | - Marc Mespreuve
- Department of Medical Imaging, University Hospital Ghent, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Marc Garcia-Elias
- Hand and Upper Extremity Surgery, Creu Blanca, Pº Reina Elisenda 57, 08022, Barcelona, Spain
| | - Gregory Ian Bain
- Department of Orthopaedic Surgery, Flinders Medical Centre and Flinders University, Adelaide, South, Australia
| | | | - Luc Van Overstraeten
- Hand and Foot Surgery Unit (HFSU) SPRL, Rue Pierre Caille 9, 7500, Tournai, Belgium
- Department of Orthopaedics and Traumatology, Erasme University Hospital, Route de Lennik 808, Brussels, Belgium
| | - Robert M Szabo
- Department of Orthopaedic Surgery, Health System, University of California Davis, 4800 Y Street, Sacramento, CA, 95817, USA
| | - Emmanuel J Camus
- IMPPACT Hand Surgery Unit, Clinique de Lille Sud, 94 Bis Rue Gustave Delory, Lesquin, France
- Laboratoire d'anatomie Fonctionnelle, ULB, Bruxelles, Belgium
| | | | - Adrian Julian Chojnowski
- Orthopaedics and Trauma Department, Hand and Upper Limb Surgery, Norfolk and Norwich University NHS Trust Hospital, Colney Lane, Norwich, NR4 7UY, UK
| | - Joerg G Gruenert
- Department of Hand and Plastic Surgery Berit Klinik, Klosterstrasse 19, 9403, Goldach, Switzerland
| | - Piotr Czarnecki
- Traumatology, Orthopaedics and Hand Surgery, Poznan University of Medical Sciences, Ul. 28 Czerwca 1956R. Nr 135/147, 61-545, Poznań, Poland
| | - Fernando Corella
- Orthopedic and Trauma Department. Hospital, Universitario Infanta Leonor, C/ Gran Vía del Este N° 80, 28031, Madrid, Spain
- Hand Surgery Unit. Hospital Universitario Quirónsalud Madrid, Madrid, Spain
- Surgery Department, School of Medicine, Universidad Complutense, Madrid, Spain
| | - Ladislav Nagy
- Division for Hand Surgery and Surgery of Peripheral Nerves, Balgrist University Hospital, University of Zurich, Forchstrasse 340, Zurich, Switzerland
| | - Michiro Yamamoto
- Department of Hand Surgery, Nagoya University, 65 Tsurumai-Cho, Showa-Ku, Nagoya, Japan
| | - Igor O Golubev
- Hand and Microsurgery Division, Priorov Central Institute of Traumatology and Orthopedy, Moscow, Russia
| | - Jörg van Schoonhoven
- Clinic for Hand Surgery, Rhön Medical Center, Campus Bad Neustadt, Von Guttenberg-Straße 11, 97616, Bad Neustadt/Saale, Germany
| | - Florian Goehtz
- Clinic for Hand Surgery, Rhön Medical Center, Campus Bad Neustadt, Von Guttenberg-Straße 11, 97616, Bad Neustadt/Saale, Germany
| | - Iwona Sudoł-Szopińska
- Department of Radiology, National Institute of Geriatrics, Rheumatology and Rehabilitation, Spartańska 1, 02-637, Warsaw, Poland
| | - Tobias Johannes Dietrich
- Faculty of Medicine, University of Zurich, Pestalozzistrasse 3, 8091, Zurich, Switzerland
- Division of Radiology and Nuclear Medicine, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland
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Flores DV, Umpire DF, Rakhra KS, Jibri Z, Belmar GAS. Distal Radioulnar Joint: Normal Anatomy, Imaging of Common Disorders, and Injury Classification. Radiographics 2023; 43:e220109. [DOI: 10.1148/rg.220109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Dyan V. Flores
- From the Department of Medical Imaging, Ottawa Hospital, 501 Smyth Rd, Ottawa, ON, Canada K1H 8L6 (D.V.F., K.S.R., Z.J.); Department of Radiology, Clínica Internacional, Lima, Peru (D.F.U.); and Department of Radiology, Clínica Alemana de Santiago, Vitacura, Chile (G.A.S.B.)
| | - Darwin Fernández Umpire
- From the Department of Medical Imaging, Ottawa Hospital, 501 Smyth Rd, Ottawa, ON, Canada K1H 8L6 (D.V.F., K.S.R., Z.J.); Department of Radiology, Clínica Internacional, Lima, Peru (D.F.U.); and Department of Radiology, Clínica Alemana de Santiago, Vitacura, Chile (G.A.S.B.)
| | - Kawan S. Rakhra
- From the Department of Medical Imaging, Ottawa Hospital, 501 Smyth Rd, Ottawa, ON, Canada K1H 8L6 (D.V.F., K.S.R., Z.J.); Department of Radiology, Clínica Internacional, Lima, Peru (D.F.U.); and Department of Radiology, Clínica Alemana de Santiago, Vitacura, Chile (G.A.S.B.)
| | - Zaid Jibri
- From the Department of Medical Imaging, Ottawa Hospital, 501 Smyth Rd, Ottawa, ON, Canada K1H 8L6 (D.V.F., K.S.R., Z.J.); Department of Radiology, Clínica Internacional, Lima, Peru (D.F.U.); and Department of Radiology, Clínica Alemana de Santiago, Vitacura, Chile (G.A.S.B.)
| | - Gonzalo A. Serrano Belmar
- From the Department of Medical Imaging, Ottawa Hospital, 501 Smyth Rd, Ottawa, ON, Canada K1H 8L6 (D.V.F., K.S.R., Z.J.); Department of Radiology, Clínica Internacional, Lima, Peru (D.F.U.); and Department of Radiology, Clínica Alemana de Santiago, Vitacura, Chile (G.A.S.B.)
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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 Vol 2023; 48:60-66. [PMID: 36113053 DOI: 10.1177/17531934221121931] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Rainer Schmitt
- Department of Radiology, University Hospital, LMU Munich, Muenchen, Germany.,Department of Radiology, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Jan-Peter Grunz
- Department of Radiology, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Martin Langer
- Department of Hand Surgery, University Hospital Muenster, Muenster, Germany
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van der Post A, Jens S, Daams JG, Obdeijn MC, Maas M, Oostra RJ. The Triangular Fibrocartilage Complex In The Human Wrist: A Scoping Review Towards Uniform And Clinically Relevant Terminology. Clin Anat 2022; 35:626-648. [PMID: 35396731 PMCID: PMC9322592 DOI: 10.1002/ca.23880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 04/06/2022] [Accepted: 04/06/2022] [Indexed: 11/20/2022]
Abstract
The aim of this scoping review was to assess the composition, terminology, and anatomy of the triangular fibrocartilage complex (TFCC) of the wrist and propose unambiguous terminology regarding the individual components. The review was conducted according to the methodological framework by Arksey and O'Malley (International Journal of Social Research Methodology, 2005, 8, 19–32). Electronic databases were searched from inception until September 1, 2021 for original anatomical studies, using MeSH terms and keywords on terminology and anatomy of TFCC components. Studies using gross dissections or macro‐ or microscopic histology were included. Animal studies, fetal studies and studies with unknown disease status, were excluded. A total of 24 studies were included. The articular disc, the radioulnar ligaments, the meniscus homologue and the extensor carpi ulnaris tendon (sub)sheath were unanimously classified as TFCC components. One study did not include the ulnolunate and ulnotriquetral ligaments and only one study did include the ligamentum subcruentum. The largest disagreement existed regarding the inclusion of the ulnar collateral ligament. Terminological ambiguity was seen in “triangular fibrocartilage,” “triangular ligament,” “igamentum subcruentum,” and the “proximal and distal lamina.” Anatomical ambiguity existed especially regarding the radioulnar ligaments, the ulnar attachments of the TFCC and the ulnar collateral ligament. Definitions of the individual TFCC components are redundant, ambiguous, and ill‐defined and therefore subject to different interpretations. In order to preclude confusion, consensus regarding terminology is recommended. We proposed a concise definition of the healthy TFCC that can be used as a starting point for future studies and current clinical practice.
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Affiliation(s)
- A van der Post
- Amsterdam UMC, University of Amsterdam, Department of Radiology and Nuclear Medicine, Amsterdam Movement Sciences, Meibergdreef 9, Amsterdam, Netherlands.,Academic Center for Evidence-based Sports medicine (ACES), Amsterdam, Netherlands.,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), International Olympic Committee (IOC) Research Center AMC/VUmc, Amsterdam, Netherlands
| | - S Jens
- Rijnstate Arnhem, Department of Radiology and Nuclear Medicine, Arnhem, Netherlands
| | - J G Daams
- Amsterdam UMC, University of Amsterdam, Medical Library, Meibergdreef 9, Amsterdam, Netherlands
| | - M C Obdeijn
- Academic Center for Evidence-based Sports medicine (ACES), Amsterdam, Netherlands.,Amsterdam UMC, University of Amsterdam, Department of Plastic, Reconstructive and Hand Surgery, Meibergdreef 9, Amsterdam, Netherlands
| | - M Maas
- Amsterdam UMC, University of Amsterdam, Department of Radiology and Nuclear Medicine, Amsterdam Movement Sciences, Meibergdreef 9, Amsterdam, Netherlands.,Academic Center for Evidence-based Sports medicine (ACES), Amsterdam, Netherlands.,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), International Olympic Committee (IOC) Research Center AMC/VUmc, Amsterdam, Netherlands
| | - R J Oostra
- Amsterdam UMC, University of Amsterdam, Department of Medical Biology, Section Clinical Anatomy and Embryology, Meibergdreef 9, Amsterdam, Netherlands
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Abstract
Carpal stability depends on the integrity of both intra-articular and intracapsular carpal ligaments. In this review, the role of the radial-sided and ulnar-sided extrinsic and intrinsic ligaments is described, as well as their advanced imaging using magnetic resonance arthrography (MRA) and contrast-enhanced magnetic resonance imaging (MRI) with three-dimensional (3D) scapholunate complex sequences and thin slices. In the last decade, the new concept of a so-called "scapholunate complex" has emerged among hand surgeons, just as the triangular ligament became known as the triangular fibrocartilage complex (TFCC).The scapholunate ligament complex comprises the intrinsic scapholunate (SL), the extrinsic palmar radiocarpal: radioscaphocapitate (RSC), long radiolunate (LRL), short radiolunate (SRL) ligaments, the extrinsic dorsal radiocarpal (DRC) ligament, the dorsal intercarpal (DIC) ligament, as well as the dorsal capsular scapholunate septum (DCSS), a more recently described anatomical structure, and the intrinsic palmar midcarpal scaphotrapeziotrapezoid (STT) ligament complex. The scapholunate (SL) ligament complex is one of the most involved in wrist injuries. Its stability depends on primary (SL ligament) and secondary (RSC, DRC, DIC, STT ligaments) stabilizers.The gold standard for carpal ligament assessment is still diagnostic arthroscopy for many hand surgeons. To avoid surgery as a diagnostic procedure, advanced MRI is needed to detect associated lesions (sprains, midsubstance tears, avulsions and chronic fibrous infiltrations) of the extrinsic, midcarpal and intrinsic wrist ligaments, which are demonstrated in this article using 3D and two-dimensional sequences with thin slices (0.4 and 2 mm thick, respectively).
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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. [PMID: 33474588 DOI: 10.1007/s00256-020-03701-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To demonstrate the utility of MRI in separating clinically relevant from minor or incidental lesions of the triangular fibrocartilage complex and the major interosseous ligaments in the wrist. MATERIALS AND METHODS In this retrospective study, we identified 89 patients and correlated MRI finding with subsequent arthroscopy. Triangular fibrocartilage complex abnormalities have been subdivided into disc lesions-central and radial-or ulnar-sided tears according to MRI appearances and surgical findings as the clinical and surgical approach is very different. Interosseous ligament tears were subdivided into partial or complete, highlighting the principle of recognising surgically relevant lesions. RESULTS For simple central to radial tears and perforations of the triangular fibrocartilage complex, MRI was 98.3% accurate. MRI identified all peripheral triangular fibrocartilage complex tears seen at arthroscopy; however, the specificity of 66.7% may reflect partly the use of arthroscopy limited to the radiocarpal joint. MRI proved 95.4% accurate for surgically relevant scapholunate interosseous ligament tears and was highly accurate at separating limited from complete lunotriquetral interosseous ligament tears showing 100% accuracy for complete tears. CONCLUSIONS The study shows excellent correlation between MRI and arthroscopic findings that determine surgical relevance with a very high sensitivity for triangular fibrocartilage complex lesions and accurate separation of minor versus surgically relevant ligamentous tears.
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[The ulnocarpal complex : New clinical and radiological considerations]. Radiologe 2021; 61:343-350. [PMID: 33620507 DOI: 10.1007/s00117-021-00824-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2021] [Indexed: 12/28/2022]
Abstract
CLINICAL ISSUE The triangular fibrocartilage complex (TFCC) is an anatomically complex structure with high demands on spatial and contrast resolution in imaging. RADIOLOGICAL METHODS The central, predominantly avascular articular disc can be distinguished from the ligamentous, vascularized periphery. Imaging methods include magnetic resonance imaging (MRI, preferably contrast-enhanced) as well as MR and computed tomography (CT) arthrography. DIAGNOSTIC INNOVATIONS While high-resolution MRI represents the standard diagnostic tool for the TFCC in general, arthrographic imaging is particularly useful for assessment of the foveal (proximal) lamina of the TFCC. In radiological reporting, the convergence of the TFCC periphery towards the ulnar styloid process and the ulnar fovea must be considered. ACHIEVEMENTS The Palmer classification is suitable for evaluating lesions of the articular disc, whereas the Atzei classification is superior for lesions of the ulnar TFCC insertions. PRACTICAL RECOMMENDATION Use of a high-resolution examination technique and anatomy-based image interpretation are important for reliable MRI of the TFCC.
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van der Post AS, Jens S, Smithuis FF, Obdeijn MC, Oostra RJ, Maas M. The triangular fibrocartilage complex on high-resolution 3 T MRI in healthy adolescents: the thin line between asymptomatic findings and pathology. Skeletal Radiol 2021; 50:2195-2204. [PMID: 33864484 PMCID: PMC8449761 DOI: 10.1007/s00256-021-03779-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 03/31/2021] [Accepted: 03/31/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The objective of the study is to provide a reference for morphology, homogeneity, and signal intensity of triangular fibrocartilage complex (TFCC) and TFCC-related MRI features in adolescents. MATERIALS AND METHODS Prospectively collected data on asymptomatic participants aged 12-18 years, between June 2015 and November 2017, were retrospectively analyzed. A radiograph was performed in all participants to determine skeletal age and ulnar variance. A 3-T MRI followed to assess TFCC components and TFCC-related features. A standardized scoring form, based on MRI definitions used in literature on adults, was used for individual assessment of all participants by four observers. Results per item were expressed as frequencies (percentages) of observations by all observers for all participants combined (n = 92). Inter-observer agreement was determined by the unweighted Fleiss' kappa with 95% confidence intervals (95% CI). RESULTS The cohort consisted of 23 asymptomatic adolescents (12 girls and 11 boys). Median age was 13.5 years (range 12.0-17.0). Median ulnar variance was -0.7 mm (range - 2.7-1.4). Median triangular fibrocartilage (TFC) thickness was 1.4 mm (range 0.1-2.9). Diffuse increased TFC signal intensity not reaching the articular surface was observed in 30 (33%) observations and a vertical linear increased signal intensity with TFC discontinuation in 19 (20%) observations. Discontinuation between the volar radioulnar ligament and the TFC in the sagittal plane was seen in 23 (25%) observations. The extensor carpi ulnaris was completely dislocated in 10 (11%) observations, more frequent in supinated wrists (p = 0.031). Inter-observer agreement ranged from poor to fair for scoring items on the individual TFCC components. CONCLUSION MRI findings, whether normal variation or asymptomatic abnormality, can be observed in TFCC and TFCC-related features of asymptomatic adolescents. The rather low inter-observer agreement underscores the challenges in interpreting these small structures on MRI. This should be taken into consideration when interpreting clinical MRIs and deciding upon arthroscopy.
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Affiliation(s)
- Anne-Sophie van der Post
- grid.7177.60000000084992262Department of Radiology and Nuclear Medicine, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands ,grid.491090.5Academic Center for Evidence-based Sports medicine (ACES), Amsterdam, The Netherlands ,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), International Olympic Committee (IOC) Research Center AMC/VUmc, Amsterdam, The Netherlands
| | - Sjoerd Jens
- grid.415930.aDepartment of Radiology and Nuclear Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Frank F. Smithuis
- grid.7177.60000000084992262Department of Radiology and Nuclear Medicine, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Miryam C. Obdeijn
- grid.491090.5Academic Center for Evidence-based Sports medicine (ACES), Amsterdam, The Netherlands ,grid.7177.60000000084992262Department of Plastic, Reconstructive and Hand Surgery, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Roelof-Jan Oostra
- grid.7177.60000000084992262Department of Medical Biology, Section Clinical Anatomy and Embryology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Mario Maas
- grid.7177.60000000084992262Department of Radiology and Nuclear Medicine, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands ,grid.491090.5Academic Center for Evidence-based Sports medicine (ACES), Amsterdam, The Netherlands ,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), International Olympic Committee (IOC) Research Center AMC/VUmc, Amsterdam, The Netherlands
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Banjar M, Nor FEM, Singh P, Horiuchi S, Quek ST, Yoshioka H. Comparison of visibility of ulnar sided triangular fibrocartilage complex (TFCC) ligaments between isotropic three-dimensional and two-dimensional high-resolution FSE MR images. Eur J Radiol 2020; 134:109418. [PMID: 33302025 DOI: 10.1016/j.ejrad.2020.109418] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 10/29/2020] [Accepted: 11/15/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Assessment of the ulnar attachment of the triangular fibrocartilage complex (TFCC) in a neutral forearm position remains challenging. Our study aims to evaluate the visibility of ulnar sided TFCC on 3 T MRI and compare isotropic 3D FSE sequences utilizing multiplanar reformation (MPR) with standard high-resolution 2D FSE sequences. METHODS Ninety-nine MRI wrist studies in patients with wrist pain were retrospectively analyzed. Patients were scanned with a neutral forearm position and reviewed with isotropic 3D coronal FSE proton density-weighted images (PDWI) and 2D coronal FSE PDWI. MPR was used for 3D assessment. Visibility of the dorsal radioulnar ligament (DRUL), triangular ligament (TL), and volar radioulnar ligament (VRUL) was assessed by three raters utilizing a five-point grading scale. Grades were compared between 2D and 3D sequences. Intrarater and interrater reliability for the delineation of anatomic structures was measured by Spearman's rank correlation coefficient, Cohen's kappa, and percentage of exact agreement/agreement within a range of ±1 score point. RESULTS Visibility grades in 3D were statistically significantly higher than those in 2D in all ligaments by all raters (p < 0.01). In Spearman's rank correlation coefficient and Cohen's kappa analysis, interrater correlations and agreements are variable but tended to be higher on 3D than on 2D. Both 2D and 3D sequences showed high intrarater exact agreement in all ligaments (80-91 % on 2D and 88-95 % on 3D). All exact interrater agreements on 3D were acceptable for TL (83-93 %) and acceptable to close to acceptable for VRUL (72-96 %). CONCLUSION The utilization of isotopic 3D imaging combined with MPR function significantly improves visibility of ulnar attachment of the TFCC.
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Affiliation(s)
- Mai Banjar
- Department of Diagnostic Imaging, National University Hospital, Singapore; Medical Imaging Department, King Abdullah Medical Complex Jeddah, Saudi Arabia.
| | | | - Pavel Singh
- Department of Diagnostic Imaging, National University Hospital, Singapore
| | - Saya Horiuchi
- Department of Radiology, St Luke's International Hospital, Tokyo, Japan
| | - Swee Tian Quek
- Department of Diagnostic Imaging, National University Hospital, Singapore
| | - Hiroshi Yoshioka
- Department of Radiological Sciences, University of California, Irvine, CA, USA
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Zhan H, Bai R, Qian Z, Yang Y, Zhang H, Yin Y. 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. [PMID: 32372253 DOI: 10.1007/s00256-020-03438-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 03/30/2020] [Accepted: 03/31/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The aim of this study was to investigate the MR features of the traumatic injury of the triangular fibrocartilage complex (TFCC) by using high-resolution 3-T magnetic resonance imaging (MRI) and to refine the Palmer classification system. MATERIALS AND METHODS From November 2015 to May 2019, sixty-seven patients met the including and excluding criteria and were enrolled into this retrospective study. All subjects had high-resolution 3-T MRI scan of the wrist and eleven had indirect MR arthrography of the wrist. All the MRI were read by two experienced musculoskeletal radiologists. Diagnostic sensitivity, specificity, and accuracy of MRI were calculated by using the arthroscopy and surgery as the standard of reference. A P value less than 0.05 was considered statistically significant. The interobserver agreement was assessed by kappa analysis. RESULTS There were 49 cases of TFCC injuries proven by the arthroscopy or surgery. The TFCC injuries in the other 18 patients were proved by the combination of clinical follow-up examination and follow-up MRI. Among the arthroscopy- or surgery-confirmed cases, there were 32 patients with original Palmer injuries (IA = 10, IB = 19, ID = 3), 5 with capsular detachment, 4 with bucket-handle tear of the TFCC that have rarely been reported, and 8 with complex injuries that involved the listed classifications above. The sensitivities and specificities of MRI for diagnosing IA, IB, ID, complex injuries, and bucket-handle tear were 67-100% and 90-100%, and overall good to perfect interobserver agreements (kappa, 0.64-1.00). The diagnostic performance for the capsular detachment was lower (kappa, 0.38). CONCLUSION With high-resolution 3-T MRI, more detailed injury patterns were found including capsular injuries, the horizontal tear of the articular disk, and the bucket-handle tear. It is necessary to refine the classic Palmer classification of TFCC injuries.
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Affiliation(s)
- Huili Zhan
- Department of Radiology, Beijing Jishuitan Hospital, Peking University Fourth School of Clinical Medicine, No. 31, Xinjiekou East St, Xicheng District, Beijing, 100035, China
| | - Rongjie Bai
- Department of Radiology, Beijing Jishuitan Hospital, Peking University Fourth School of Clinical Medicine, No. 31, Xinjiekou East St, Xicheng District, Beijing, 100035, China.
| | - Zhanhua Qian
- Department of Radiology, Beijing Jishuitan Hospital, Peking University Fourth School of Clinical Medicine, No. 31, Xinjiekou East St, Xicheng District, Beijing, 100035, China
| | - Yong Yang
- Department of Hand Surgery, Beijing Jishuitan Hospital, No. 31, Xinjiekou East St, Xicheng District, Beijing, 100035, China
| | - Heng Zhang
- Department of Radiology, Beijing Jishuitan Hospital, Peking University Fourth School of Clinical Medicine, No. 31, Xinjiekou East St, Xicheng District, Beijing, 100035, China
| | - Yuming Yin
- Radiology Associates, LLP, 1814 South Alameda Street, Corpus Christi, TX, 78404, USA
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Park JH, Ahn KS, Chang A, Kwon YW, Choi IC, Park JW. 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. [PMID: 31321453 DOI: 10.1007/s00256-019-03278-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 06/24/2019] [Accepted: 07/04/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To assess whether a proximal ligamentous component (PLC) of the triangular fibrocartilage complex (TFCC) with a distally prolapsing morphology is associated with the presence of a TFCC foveal tear on arthroscopy. METHODS One-hundred thirty-two patients (134 wrists) who underwent MR arthrography and subsequent wrist arthroscopy between September 2014 and March 2018 were retrospectively evaluated. The degree of distal PLC prolapse was measured on coronal MR arthrography using the height-to-length ratio (HLR). Subjects' demographics, ulnar variance, presence of a degenerative TFCC tear, and ulnar styloid nonunion were assessed. The association between specific variables and the presence of a foveal tear was investigated. RESULTS A TFCC foveal tear was identified in a total of 101 of 134 wrists examined by arthroscopy. Univariable analysis showed that the HLR of the PLC was significantly greater in the foveal tear group compared with the intact fovea group (44.6 vs. 38.9%, respectively, p < 0.001). Multivariable analysis showed that HLR was positively associated with a foveal tear (odds ratio [OR], 1.211; p < 0.001). The estimated cut-off value of the HLR was 41% (area under the curve [AUC] 0.77). CONCLUSIONS PLCs with a distal prolapse pattern and large HLR are associated with TFCC foveal tears. The HLR of the PLC measured on coronal MR images can therefore be used as an additional predictor of tears of the foveal attachment of the TFCC.
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Affiliation(s)
- Ji Hun Park
- Department of Orthopedic Surgery, Korea University Guro Hospital, 148 Gurodong-ro, Guro-gu, Seoul, 08308, South Korea
| | - Kyung-Sik Ahn
- Department of Radiology, Korea University Anam Hospital, 73, Inchon-ro, Sungbuk-gu, Seoul, 06334, South Korea
| | - Anseong Chang
- Department of Orthopedic Surgery, Korea University Guro Hospital, 148 Gurodong-ro, Guro-gu, Seoul, 08308, South Korea
| | - Young Woo Kwon
- Department of Orthopedic Surgery, Korea University Anam Hospital, 73, Inchon-ro, Sungbuk-gu, Seoul, 06334, South Korea
| | - In Cheul Choi
- Department of Orthopedic Surgery, Korea University Anam Hospital, 73, Inchon-ro, Sungbuk-gu, Seoul, 06334, South Korea
| | - Jong Woong Park
- Department of Orthopedic Surgery, Korea University Anam Hospital, 73, Inchon-ro, Sungbuk-gu, Seoul, 06334, South Korea.
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Ulnar Wrist Pain Revisited: Ultrasound Diagnosis and Guided Injection for Triangular Fibrocartilage Complex Injuries. J Clin Med 2019; 8:jcm8101540. [PMID: 31557886 PMCID: PMC6832410 DOI: 10.3390/jcm8101540] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 09/19/2019] [Accepted: 09/23/2019] [Indexed: 11/29/2022] Open
Abstract
The triangular fibrocartilage complex (TFCC) serves as the major stabilizer of the wrist. Its injuries can result from trauma or degeneration, both of which are strongly correlated with the loading stress on the ulnar shaft and carpal joints. The TFCC is made of the articular disc, meniscus homologue, ulnocarpal ligament, radioulnar ligament, ulnotriquetral ligament, ulnolunate ligament, and subsheath of the extensor carpi ulnaris tendon. Because of its complexity, it is challenging to confirm the exact component affected in TFCC injuries. The Palmer classification is widely used for investigation of TFCC lesions using magnetic resonance imaging. Recently, high-resolution ultrasound (US) has become more popular in diagnosing musculoskeletal disorders. However, the utility of US imaging in TFCC lesions is less common because its anatomy under US imaging is not described in the current literature. Accordingly, in this review, we aimed to propose a standard US scanning protocol for the TFCC, present relevant images for its pathologies, and illustrate appropriate US-guided injection techniques for their management.
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Lee SH, Yun SJ. Point-of-care wrist ultrasonography in trauma patients with ulnar-sided pain and instability. Am J Emerg Med 2018; 36:859-864. [PMID: 29307765 DOI: 10.1016/j.ajem.2018.01.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 01/03/2018] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE We evaluated the effectiveness of point-of-care wrist ultrasonography compared with 3T-magnetic resonance imaging (MRI) for diagnosing triangular fibrocartilage complex (TFCC) injuries in trauma patients with ulnar-sided pain and instability. Moreover, we assessed the inter-observer variability between an emergency physician and a musculoskeletal radiology fellow. MATERIAL AND METHODS A prospective cross-sectional study was conducted in an emergency department; patients with ulnar-sided sprain and instability were recruited. An emergency physician and a musculoskeletal radiology fellow independently evaluated the TFC, meniscal homologue, volar and dorsal distal radioulnar ligaments, and extensor carpi ulnaris using point-of-care ultrasonography. Findings were classified as normal, partial rupture, or complete rupture. Wrist 3T-MRI was used as the reference standard. We compared the diagnostic values for point-of-care ultrasonography obtained by both reviewers using DeLong's test. Intra-class correlation coefficients (ICCs) were calculated for agreement between each reviewer and the reference standard, and directly between the two reviewers. RESULTS Sixty-five patients were enrolled. Point-of-care wrist ultrasonography showed acceptable sensitivity (97.2-99.1%), specificity (96.8-97.3%), and accuracy (96.9-97.9%); these diagnostic performance values did not differ significantly between reviewers (p=0.58-0.98). Agreement between each reviewer and the reference standard was excellent (emergency physician, ICC=0.964; musculoskeletal radiology fellow, ICC=0.976), as was the inter-observer agreement (ICC=0.968). CONCLUSION Point-of-care wrist ultrasonography is as precise as MRI for detecting TFCC injuries, and can be used for immediate diagnosis and further preoperative imaging. Moreover, it may shorten the interval from emergency department admission to surgical intervention while reducing costs.
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Affiliation(s)
- Sun Hwa Lee
- Department of Emergency Medicine, Sanggye Paik Hospital, Inje University College of Medicine, 1342 Dongil-ro, Nowon-gu, Seoul 01757, Republic of Korea
| | - Seong Jong Yun
- Department of Radiology, Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, 892 Dongnam-ro, Gangdong-Gu, Seoul 05278, Republic of Korea.
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