Peripheral Lesions of the Triangular Fibrocartilage Complex

Abstract

The recently introduced CUP classification of the triangular fibrocartilage complex divides the lesions into central (C), ulnar (U), and peripheral (P). The periphery of the triangular fibrocartilage complex consists of the meniscus homologue, the ulnocarpal joint capsule including the extensor carpi ulnaris tendon sheath, and the ulnotriquetral and ulnolunate ligaments. Peripheral triangular fibrocartilage complex lesions can occur in isolation or in combination with injuries of the ulnar insertions and/or the articular disk. Most commonly the meniscus homologue and dorsal capsule are affected. Magnetic resonance imaging and computed tomography/magnetic arthrography are used to assess peripheral lesions. The arthroscopic assessment of peripheral triangular fibrocartilage complex lesions is limited. To date, data on the clinical relevance of the radiologic reporting of peripheral lesions are lacking. This pictorial review illustrates typical peripheral lesions of the triangular fibrocartilage complex according to the CUP classification.

Keywords

triangular fibrocartilage complex - peripheral lesions - meniscus homologue - radioulnar ligaments - ulnocarpal ligaments

Publication History

Article published online:
03 December 2025

• References

• 1 Estrella EP, Hung LK, Ho PC, Tse WL. Arthroscopic repair of triangular fibrocartilage complex tears. Arthroscopy 2007; 23 (07) 729-737 , 737.e1
• 2 Atzei A, Luchetti R. Foveal TFCC tear classification and treatment. Hand Clin 2011; 27 (03) 263-272
• 3 Palmer AK. Triangular fibrocartilage complex lesions: a classification. J Hand Surg Am 1989; 14 (04) 594-606
• 4 Zhan H, Zhang H, Bai R. et al. High-resolution 3-T MRI of the triangular fibrocartilage complex in the wrist: injury pattern and MR features. Skeletal Radiol 2017; 46 (12) 1695-1706
• 5 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 (01) 60-66
• 6 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 2025; 197 (07) 759-769
• 7 Buck FM, Gheno R, Nico MA, Haghighi P, Trudell DJ, Resnick D. Ulnomeniscal homologue of the wrist: correlation of anatomic and MR imaging findings. Radiology 2009; 253 (03) 771-779
• 8 Moritomo H. Anatomy and clinical relevance of the ulnocarpal ligament. J Wrist Surg 2013; 2 (02) 186-189
• 9 von Borstel D, Wang M, Small K, Nozaki T, Yoshioka H. High-resolution 3T MR imaging of the triangular fibrocartilage complex. Magn Reson Med Sci 2017; 16 (01) 3-15
• 10 Nakamura T, Takayama S, Horiuchi Y, Yabe Y. Origins and insertions of the triangular fibrocartilage complex: a histological study. J Hand Surg [Br] 2001; 26 (05) 446-454
• 11 Cerezal L, Del Piñal F, Atzei A. et al. Interdisciplinary consensus statements on imaging of DRUJ instability and TFCC injuries. Eur Radiol 2023; 33 (09) 6322-6338
• 12 Yoshioka H, Burns JE. Magnetic resonance imaging of triangular fibrocartilage. J Magn Reson Imaging 2012; 35 (04) 764-778
• 13 Ng AWH, Griffith JF, Fung CSY. et al. MR imaging of the traumatic triangular fibrocartilaginous complex tear. Quant Imaging Med Surg 2017; 7 (04) 443-460
• 14 Lee RK, Ng AW, Tong CS. et al. Intrinsic ligament and triangular fibrocartilage complex tears of the wrist: comparison of MDCT arthrography, conventional 3-T MRI, and MR arthrography. Skeletal Radiol 2013; 42 (09) 1277-1285
• 15 Rehnitz C, Klaan B, von Stillfried F. et al. Comparison of modern 3D and 2D MR imaging sequences of the wrist at 3 Tesla. Rofo 2016; 188 (08) 753-762
• 16 Zhao X, Yu A, Zhao H, Qiu Y. Diagnostic value of MRI in traumatic triangular fibrocartilage complex injuries: a retrospective study. BMC Musculoskelet Disord 2024; 25 (01) 63
• 17 Luetkens KS, Laas SF, Haßler S. et al. Contrast-enhanced MRI of the wrist: Intravenous application of gadolinium improves diagnosis in ulnar-sided injuries of the TFCC. Eur J Radiol 2021; 143: 109901
• 18 Bednar MS, Arnoczky SP, Weiland AJ. The microvasculature of the triangular fibrocartilage complex: its clinical significance. J Hand Surg Am 1991; 16 (06) 1101-1105
• 19 Rüegger C, Schmid MR, Pfirrmann CW, Nagy L, Gilula LA, Zanetti M. Peripheral tear of the triangular fibrocartilage: depiction with MR arthrography of the distal radioulnar joint. AJR Am J Roentgenol 2007; 188 (01) 187-192
• 20 Smith TO, Drew B, Toms AP, Jerosch-Herold C, Chojnowski AJ. Diagnostic accuracy of magnetic resonance imaging and magnetic resonance arthrography for triangular fibrocartilaginous complex injury: a systematic review and meta-analysis. J Bone Joint Surg Am 2012; 94 (09) 824-832
• 21 Lee YH, Choi YR, Kim S, Song HT, Suh JS. Intrinsic ligament and triangular fibrocartilage complex (TFCC) tears of the wrist: comparison of isovolumetric 3D-THRIVE sequence MR arthrography and conventional MR image at 3 T. Magn Reson Imaging 2013; 31 (02) 221-226
• 22 Petsatodis E, Pilavaki M, Kalogera A, Drevelegas A, Agathangelidis F, Ditsios K. Comparison between conventional MRI and MR arthrography in the diagnosis of triangular fibrocartilage tears and correlation with arthroscopic findings. Injury 2019; 50 (08) 1464-1469
• 23 Moser T, Dosch JC, Moussaoui A, Dietemann JL. Wrist ligament tears: evaluation of MRI and combined MDCT and MR arthrography. AJR Am J Roentgenol 2007; 188 (05) 1278-1286
• 24 Cerezal L, de Dios Berná-Mestre J, Canga A. et al. MR and CT arthrography of the wrist. Semin Musculoskelet Radiol 2012; 16 (01) 27-41
• 25 Pfirrmann CW, Theumann NH, Chung CB, Botte MJ, Trudell DJ, Resnick D. What happens to the triangular fibrocartilage complex during pronation and supination of the forearm? Analysis of its morphology and diagnostic assessment with MR arthrography. Skeletal Radiol 2001; 30 (12) 677-685
• 26 Grunz JP, Gietzen CH, Luetkens K. et al. The importance of radial multiplanar reconstructions for assessment of triangular fibrocartilage complex injury in CT arthrography of the wrist. BMC Musculoskelet Disord 2020; 21 (01) 286
• 27 Moritomo H, Arimitsu S, Kubo N, Masatomi T, Yukioka M. Computed tomography arthrography using a radial plane view for the detection of triangular fibrocartilage complex foveal tears. J Hand Surg Am 2015; 40 (02) 245-251
• 28 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 (10) 1567-1579
• 29 Löw S, Erne H, Pillukat T, Mühldorfer-Fodor M, Unglaub F, Spies CK. Diagnosing central lesions of the triangular fibrocartilage as traumatic or degenerative: a review of clinical accuracy. J Hand Surg Eur Vol 2017; 42 (04) 357-362
• 30 Santo S, Omokawa S, Iida A, Shimizu T, Hasegawa H, Tanaka Y. Magnetic resonance imaging analysis of the extensor carpi ulnaris tendon and distal radioulnar joint in triangular fibrocartilage complex tears. J Orthop Sci 2018; 23 (06) 953-958
• 31 Nevalainen MT, Zoga AC, Rivlin M, Morrison WB, Roedl JB. Extensor carpi ulnaris tendon pathology and ulnar styloid bone marrow edema as diagnostic markers of peripheral triangular fibrocartilage complex tears on wrist MRI: a case-control study. Eur Radiol 2023; 33 (05) 3172-3177
• 32 Nishikawa S, Toh S, Miura H, Arai K. The carpal detachment injury of the triangular fibrocartilage complex. J Hand Surg [Br] 2002; 27 (01) 86-89
• 33 Watson HK, Weinzweig J. Triquetral impingement ligament tear (TILT). J Hand Surg [Br] 1999; 24 (03) 321-324
• 34 Tay SC, Berger RA, Parker WL. Longitudinal split tears of the ulnotriquetral ligament. Hand Clin 2010; 26 (04) 495-501
• 35 Ringler MD, Howe BM, Amrami KK, Hagen CE, Berger RA. Utility of magnetic resonance imaging for detection of longitudinal split tear of the ulnotriquetral ligament. J Hand Surg Am 2013; 38 (09) 1723-1727
• 36 Abe Y, Moriya A, Tominaga Y, Yoshida K. Dorsal tear of triangular fibrocartilage complex: clinical features and treatment. J Wrist Surg 2016; 5 (01) 42-46
• 37 Morisawa Y, Nakamura T, Tazaki K. Dorsoradial avulsion of the triangular fibrocartilage complex with an avulsion fracture of the sigmoid notch of the radius. J Hand Surg Eur Vol 2007; 32 (06) 705-708