MR IMAGING OF TRIANGULAR FIBROUS CARTILAGE COMPLEX

DR.PREM CHAND PALADUGUAARUPADAI VEEDU MEDICAL COLLEGE & HOSPITAL

TRIANGULAR FIBROUS CARTILAGE COMPLEX (TFCC) COMPONENTS

• TRIANGULAR FIBROUS CARTILAGE / ARTICULAR DISC

• DORSAL & VOLAR RADIOULNAR LIGAMENTS

• ULNOCARPAL LIGAMENTS ( ULNOLUNATE , ULNOTRIQUETRAL )

• ULNARCOLLATERAL LIGAMENT

• TRIANGULAR LIGAMENT

• MENISCUS HOMOLOGUE

• SHEATH OF ECU TENDON

TFCC COMPONENTS

• TFC IS A BICONCAVE DISK. ITS THICKNESS IS DIRECTLY PROPORTIONAL TO DEGREE OF ULNAR VARIANCE.

• THE DORSAL AND VOLAR RADIOULNAR LIGAMENT ARE BROAD STRIATED LIGAMENT ARISING FROM THE DORSAL AND VOLAR CORTEX OF THE DISTAL RADIUS SIGMOID NOTCH RESPECTIVELY.THE RESPECTIVE LIGAMENTS BLEND WITH DORSAL AND VOLAR SURFACE OF TFC, AND ATTACHES TO ULNAR STYLOID MEDIALLY AND DISTAL RADIUS LATERALLY.

• THE EXTENSOR CARPI ULNARIS TENDON SHEATH IS NORMALLY FOUND WITHIN THE GROOVE ON THE DORSUM OF ULNA IN NEUTRAL POSITION

• ULNAR COLLATERAL LIGAMENT REPRESENTS THICKENING OF WRIST JOINT CAPSULE, AND EXTENDS FROM THE ULNAR STYLOID PROCESS PROXIMALLY TO THE TRIQUETRUM DISTALLY.

• MENISCUS HOMOLOGUE IS THICKENING OF ULNAR JOINT CAPSULE AND IS INCONSISTENTLY PRESENT. IT IS LOCATED DISTAL TO THE PRESTYLOID RECESS AND ATTACHES TO THE TRIQUETRUM.

NORMAL ANATOMY

POSITIONING

• WRIST NEUTRAL AT SIDE OR OVERHEAD WHILE PRONE; PRONE WITH AXIAL TRACTION DURING MR ARTHROGRAPHY

TECHNIQUE

• AXIAL FOV 110 mm

• CORONAL FOV 120 mm

• SAGITTAL FOV 120 mm

• NO INTERSLICE GAP

• MATRIX 448 F X 314 P

• BANDWIDTH 248 Hz PER PIXEL

STANDARD SEQUENCES

• CORONAL GRADIENT ECHO: EVALUATION OF TFCC AND ALSO INTRINSIC LIGAMENTS AND CARTILAGE

• CORONAL PD AND SAG PD : TFCC, INTRINSIC LIGAMENTS

• CORONAL IR: SENSITIVE TO MARROW EDEMA AND PATHOLOGICAL FLUID

• AXIAL PD FS : INTRINSIC WRIST LIGAMENTS, FLEXOR AND EXTENSOR TENDONS, DRUJ, MEDIAN AND ULNAR NERVES

• T1 FAT SAT MR ARTHROGRAPHY : AXIAL , SAGITTAL, CORONAL

TECHNICAL PARAMETERS

INDIRECT MR ARTHROGRAPHY

• IV INJECTED CONTRAST MATERIAL DIFFUSES INTO THE JOINT IN SUCH CONCENTRATIONS THAT AN ARTHROGRAPHIC EFFECT CAN BE OBTAINED ON T 1 wt IMAGES WITHOUT DECREASE IN SNR

• SIGNIFICANT IMPROVEMENT IN DETECTION OF SL LIGAMENT PATHOLOGY

• NO SIGNIFICANT IMPROVEMENT IN DETECTION OF CENTRAL DISC OF TFCC / LT LIGAMENT

DIRECT MR ARTHROGRAPHY

• FULLY DISTENDS JOINT CAVITY , OUTLINES TFCC, LIGAMENT DEFECTS

• DEPICT PRECISE LOCATION OF TFCC, LIGAMENTOUS DEFECT

• INJECTION - SINGLE/ TRIPLE COMPARTMENT

• INJECTION GUIDANCE - FLOUROSCOPY, USG ,CT, MRI

• MR ARTHROGRAM: 2-5 ml SOLUTION OF 0.1 ml GADOLINIUM DILUTED IN 20 ml SOLUTION COMPOSED OF 15 ml OF NORMAL SALINE AND 5 ml OF IODINATED CONTRAST( DIATRIZOATE MEGLUMINE ) 370 mg I / ml

TYPES OF MR ARTHROGRAPHY

1. RADIOCARPAL (RC)

2. DISTAL / INFERIOR RADIOULNAR (DRU

3. MID CARPAL(MC)

4. PISOTRIQUETRAL (PT)

5. 1 st CARPOMETACARPAL

6. COMMON CARPOMETACARPAL

7. INTERMETACARPAL

COMPARTMENTAL ANATOMY

CHINESE FINGER TRAPS WITH A PULLEY SYSTEM & WEIGHTS

CORONAL 3D GE MRI SHOWING NORMAL TFCC (VOLAR TO DORSAL)

RADIAL ATTACHMENT OF TFCC

ULNAR ATTACHMENT OF TFCC

MR ARTHROGRAPHY SAGITTAL SECTIONS SHOWING NORMAL TFCC

MR ARTHROGRAPHY AXIAL SECTIONS SHOWING NORMAL TFCC

TRIANGULAR LIGAMENT : STRANDS OF COLLAGEN FIBRES WITH VASCULAR CONNECTIVE TISSUE PRODUCE INCREASED SIGNAL INTENSITY WITH A STRIATED PATTERN

FOVEA & BASE OF ULNAR HEAD : PROXIMAL LAMINA CONTAINS HIGHLY VASCULAR LOOSE TYPE CONNECTIVE TISSUE WITH BUNDLES OF COLLAGEN FIBRES WHICH PRODUCES RELATIVELY HIGH SIGNAL INTENSITY

TIP OF ULNAR STYLOID PROCESS : HYALINE LIKE CARTILAGE AT TIP OF ULNAR STYLOID PROCESS HAS INTERMEDIATE SIGNAL INTENSITY ON PD & GRE IMAGES

LIGAMENTUM SUBCRUENTUM : NORMALLY SHOWS INCREASED SIGNAL INTENSITY

PITFALLS IN MRI INTERPRETATION OF TEAR

TFCC DEGENERATION : HIGH SIGNAL INTENSITY WITHIN DISC PROPER WITHOUT EXTENSION TO ARTICULAR SURFACE

PERFORATION OF TFCC DISK : LINEAR CORRELATION BETWEEN PREVALENCE OF PERFORATION TYPE TEAR OF HORIZONTAL PORTION OF TFCC AND INCREASING AGE

SIGMOID NOTCH OF RADIUS: HYALINE CARTILAGE AT THE CENTRAL PORTION OF ATTACHMENT OF TFCC TO RADIUS SHOWS INTERMEDIATE SIGNAL INTENSITY

PRESTYLOID RECESS : VARIOUS SHAPES, SACCULAR, TUBULAR, CONICAL, TONGUE SHAPED ( IN DECREASING ORDER OF INCIDENCE)

CHANGES IN TFCC SHAPE DUE TO ROTATIONAL MOTION : NO SIGNIFICANT CHANGE IF TFCC SHAPE OCCURS THAT MIMICS A TEAR

PITFALLS IN MRI INTERPRETATION OF TEAR

NORMAL VARIANTS THAT CAN SIMULATE TEAR(1-4)

DEGENERATION VS TEAR(5-6)

PRESTYLOID RECESS TYPES(7-8)

5

1 2 3 4

6 7 8

PALMER CLASSIFICATION OF

TFCC LESIONS

PALMER TYPE 1 : TRAUMA

TYPE 1 B : ULNAR AVULSIONTYPE 1 A : CENTRAL

PERFORATION

TYPE 1 D: RADIAL AVULSION

TYPE 1 C : DISTAL AVULSION

TYPE 2 B : TFCC THINNING + CHONDROMALACIA

TYPE 2 A : DEGENERATIVE THINNING OF TFCC

PALMER TYPE 2 : DEGENERATIVE

TYPE 2 C : PERFORATED TFCC+ CHONDROMALACIA

TYPE 2 D: TYPE 2 C PERFORATION +LUNATE CHONDROMALACIA +

LTL PERFORATION

TYPE 2 E : TFCC PERFORATION +CHONDROMALACIA +LTL PERFORATION +

SECONDARY ARTHRITIS

1. INSTABILITY OF DRUJ ( # RADIUS, ULNA ; TFCC DISRUPTION DUE TO TRAUMA , INFLAMMATORY DISORDERS )

2. INCONGRUITY OF DRUJ ( TRAUMATIC , INFLAMMATORY DISORDERS )

3. IMPINGEMENT OF ULNA ON CARPUS

4. ISOLATED LESIONS OF ARTICULAR DISC ( WHICH OCCUR WITHOUT INSTABILITY OF DRUJ )

NATHAN & SCHNEIDER CLASSIFICATION OF TFCC TEARS

• MR ARTHROGRAPHY MOST USEFUL IN DETECTING CLASS 1- B,C,D LESIONS

• ARTHROSCOPY BOTH DIAGNOSTIC & THERAPEUTIC ; THERAPEUTIC FOR PALMER CLASS- 1A ,1D ,2C

• A NEGATIVE MRI IS NOT AN END POINT AND NOT A CONTRAINDICATION FOR FURTHER EXPLORATION, IN PARTICULAR FOR ARTHROSCOPY

CONCLUSION

REFERENCES • 1.INTERNAL DERANGEMENT OF JOINTS;

DONALD RESNICK,HEUNG SIK KANG;

• 2.MEASUREMENTS & CLASSIFICATION IN MUSCULOSKELETAL RADIOLOGY , SIMONE WALDT, KLAUS WOERTLER

• 3.PITFALLS THAT MAY MIMIC INJURIES OF TRIANGULAR FIBROUS CARTILAGE COMPLEX AND PROXIMAL INTRINSIC WRIST LIGAMENTS AT MR IMAGING ; JOSEPH E.BURNS ET AL radiographics 2011 ; 31:63-78