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Corresponding author: Neal C. Chen, MD, Department of Orthopedic Surgery, Harvard Medical School, Department of Hand Surgery, Massachusetts General Hospital, Yawkey Center, Suite 2100, 55 Fruit St., Boston, MA 02114.
To determine the prevalence of triangular fibrocartilage complex (TFCC) signal changes in patients undergoing magnetic resonance imaging (MRI) of the wrist and its relationship to a clinical suspicion of TFCC pathology. The secondary purpose was to study factors that are associated with TFCC signal changes.
Methods
In this retrospective study, we looked for any TFCC signal changes in the reports of MRI findings performed during a 3-year period in 1,134 patients. Demographic characteristics, the categorized indications for MRI, and symptoms at the time of the MRI were also retrieved from the medical records. Patients were divided into 6 groups, based on age, to calculate the proportions of TFCC signal changes in the entire cohort and as an incidental finding among patients without a clinical suspicion of TFCC pathology within each age group.
Results
A total of 321 patients (28%) had incidental TFCC signal changes. The prevalence among 18- to 30 year-olds was 19%, and increased to 64% in patients older than 70 years. Multivariable logistic regression analysis demonstrated that an increase in age is significantly associated with having TFCC signal changes on MRI in patients who have a low clinical suspicion of TFCC pathology. The rate of incidental TFCC signal changes steadily increases with age.
Conclusions
The TFCC signal abnormalities on MRI are more common with increasing age in patients with low clinical suspicion of TFCC pathology. At age 70, more than half of all patients will have TFCC signal changes, and more than 90% are present in patients with a low clinical suspicion of TFCC pathology.
Triangular fibrocartilage complex (TFCC) signal changes are frequently found on magnetic resonance imaging (MRI) studies of the wrist. However, several studies have found that TFCC abnormalities are common in both symptomatic and asymptomatic patients and appear to have a higher prevalence with increasing age.
This changing prevalence confounds the interpretation of TFCC signal abnormalities on MRI, particularly for older patients. If the prevalence increases with age, then TFCC signal changes may occur with normal aging or may persist long after symptoms have resolved. Therefore, there is a potential risk of inappropriately attributing wrist pain to TFCC pathology, based on MRI findings alone.
Current literature on the prevalence of TFCC abnormalities has several limitations: (1) variation in the modality used to identify the changes, including arthroscopy,
Overall, there is a limited understanding of incidental TFCC signal changes on MRI and the association of these changes with age.
The goal of this study was to determine the prevalence of TFCC signal changes in patients undergoing MRI of the wrist relative to a clinical suspicion of TFCC pathology. Our null hypothesis was that the prevalence of TFCC signal changes does not increase with age. Our secondary goal was to study factors that are associated with TFCC signal changes among patients relative to a clinical suspicion of TFCC pathology. We aimed to do this by performing a retrospective study of patients of different ages, rather than inference from cadaver studies. In addition, we particularly focused on the clinical suspicion of TFCC pathology and the corresponding findings on MRI because that is most applicable to clinical scenarios. Overall, we aimed to establish a more accurate determination of the a priori probability of TFCC abnormalities at different ages, which could inform clinical decision making.
Material and Methods
Study design, setting, and patient selection
This retrospective study was reviewed by our institutional review board, and a waiver of informed consent was granted. Using an institutional database, we obtained reports of all MRIs of the wrist performed at 5 different academic centers during the 3-year period of January 1, 2013, to December 31, 2015. A sample wrist MRI protocol at 1 of the institutions was axial T2 fat-saturated, axial proton-density, coronal T1, coronal T2 fat-saturated, sagittal proton-density fat-saturated, and coronal gradient sequences, using either a 1.5- or 3-T magnet with a dedicated wrist coil. For patients who had multiple wrist MRI reports, we limited our study to the first report on record. When the first MRI was aborted for technical reasons, the second report was used. This resulted in a sample of 1,134 patients.
Outcome measures and explanatory variables
The primary outcome variable was the finding of a signal change in the TFCC on MRI. We first used a text-search to identify all patients whose radiology reports mentioned signal changes in the TFCC, including common misspellings and synonyms (eg, hyperintense, fluid, tear, rupture, degeneration, thickening) followed by a manual review of all MRI reports to confirm the accuracy of the search and to prevent incorrect inclusion of patients whose TFCC was reported as negative for changes (eg, reporting “no abnormal signal in the TFCC”). We chose to pool all signal changes regardless of severity because MRIs were examined by a number of different radiologists of differing levels of expertise and previous research has demonstrated that accuracy rates for detection of TFCC lesion varies substantially.
Next, we manually reviewed MRI requisition information and clinical notes prior to the MRI for each patient. Patients were categorized as having a “clinical suspicion for TFCC pathology” when the medical records specifically noted ulnar-sided wrist pain or a specific diagnosis of TFCC pathology. All other patients were classified as “low clinical suspicion of TFCC pathology.” Our main explanatory variable of interest was age. Sex, race, and clinical indication for the MRI were also included, in order to account for their potential to confound the association with age. All patients with “low clinical suspicion for TFCC pathology” were categorized by the primary diagnosis reported in the clinical notes and requisition information.
Statistical analyses
Categorical variables are presented as frequencies and percentages and continuous variables as mean with the SD. Patients were divided into 6 groups based on age: (1) 18 to 30 years (mean, 24 years; SD, 3.8 years), (2) 31 to 40 years (mean, 35 years; SD, 2.9 years), (3) 41 to 50 years (mean, 46 years; SD, 2.8 years), (4) 51 to 60 years (mean, 55 years; SD, 2.8 years), (5) 61 to 70 years (mean, 65 years; SD, 3.0 years), (6) 71+ years (mean, 77 years; SD, 5.6 years). We calculated the proportion of TFCC signal changes both overall and among only patients with low clinical suspicion of TFCC pathology, within each age group. A locally weighted scatterplot smoothing (LOWESS) graph was used to depict the gradual changes of incidental and overall TFCC signal changes as it varies with age.
Multivariable logistic regression analysis was performed to assess the independent associations of age, sex, race, and clinical indication for the MRI with level of clinical suspicion and overall TFCC signal changes.
Demographics, symptoms, associated conditions
Our sample consisted of 1,134 patients who had an MRI including the wrist. Forty-four percent (497 patients) were men. The mean age for men was 43 years (SD, 16 years) and the mean age for women was 46 years (SD, 16 years). Overall, the mean age for patients was 44 years (SD, 16 years). The majority of patients were Caucasian (75%; Table 1). Nearly all patients who underwent an MRI had wrist or hand pain as a symptom (96%; Appendix A; available on the Journal’s Web site at www.jhandsurg.org).
showed that we needed at least 59 patients in the highest age group (> 70 years) to detect a difference in proportions with a delta of 0.22 between the lowest (18–30 years) and highest (> 70 years) age group (previous reported prevalence, 27% and 49%, respectively
) with a 2-tailed alpha of 0.05 with 80% statistical power using the Fisher exact test. Three full years of MRI reports provided us with 1,134 patients and large enough age groups.
Results
Of the 1,134 patients who underwent a wrist MRI, 321 (28%) had TFCC signal changes in the setting of low clinical suspicion of TFCC pathology. In this group, the prevalence of signal changes among 18- to 30-year-olds was 19% and increased to 64% in patients older than 70 years (Table 2 and Fig. 1). Sixty percent (165 of 273) of patients with suspicion of TFCC pathology had signal changes on MRI, compared with 37% (321 of 861) of patients with low suspicion (P < .05 by Fisher exact test). The prevalence of signal changes among patients with low clinical suspicion of TFCC pathology increased from 24% in 18- to 30-year-olds to 70% in those older than 70 years (Table 2 and Fig. 2).
Table 2Prevalence of TFCC Signal Changes in 1,134 Patients Who Underwent MRI of the Wrist
Multivariable logistic regression analysis demonstrated that an increase in age is significantly associated with an increased prevalence of TFCC signal changes among patients with a low clinical suspicion of TFCC pathology (odds ratio [OR], 1.034 per year increase in age; 95% confidence interval [95% CI], 1.024–1.044; standard error [SE], 0.005; P < .05; Table 3). The LOWESS curve further confirmed that the rate of TFCC signal changes steadily with increasing with age in this group. In contrast, the LOWESS curve showed that the prevalence of TFCC signal changes initially increases among patients with a clinical suspicion of TFCC pathology, but declines at age 40 (Fig. 3). The regression analysis also showed an association of TFCC signal changes in patients with general hand/wrist pain (OR, 2.1; 95% CI, 1.2 – 3.7; SE, 0.60; P < .05) and suspected other ligament/tendon/muscle pathology (OR, 1.8; 95% CI, 1.2–2.7; SE, 0.39; P < .05) as the indication for the wrist MRI (Table 3).
Table 3Multivariable Logistic Regression Analysis of Factors Associated With TFCC Signal Changes in Patients Undergoing MRI of the Wrist Relative to Clinical Suspicion of TFCC Pathology (n = 861)
Among all patients, regardless of clinical suspicion, 43% (486 of 1134) had TFCC signal changes. The prevalence ranged from 31% in 18- to 30-year-olds to 69% in patients older than 70 (Table 2 and Fig. 1). Multivariable logistic regression analysis demonstrated a significant association between age and the prevalence of TFCC signal changes (OR, 1.028 per year increase in age; 95% CI, 1.020–1.037; SE, 0.004; P < .05). The LOWESS curve showed an increasing prevalence in overall TFCC signal changes as well. The regression analysis also showed a decreased prevalence in overall TFCC signal changes for all MRI indications, with the exception of general hand/wrist pain. There was no variation by sex. Patients whose race was categorized as “Other” were less likely to have TFCC signal changes, but no difference was found between White, African American, Hispanic, and Asian patients (Table 4).
Table 4Multivariable Logistic Regression Analysis of Factors Associated With TFCC Signal Changes (n = 1,134)
Variable
OR
Lower (95% CI)
Upper (95% CI)
SE
P Value
Age
1.028
1.020
1,037
0.004
< .001
Male
1.1
0.89
1.5
0.15
.31
Race (reference: Caucasian)
African American
1.2
0.72
2.0
0.31
.49
Hispanic
1.4
0.75
2.5
0.41
.31
Asian
0.95
0.49
1.9
0.32
.88
Other
0.62
0.40
0.95
0.14
.029
Indication (reference: Clinical suspicion for TFCC pathology)
The TFCC abnormalities have been found to be common in both symptomatic and asymptomatic individuals, and prior studies suggest that these abnormalities increase with age.
In a large series of MRIs, we found that TFCC signal abnormalities appear to be more common with increasing age in patients with a low clinical suspicion of TFCC pathology. At age 70, more than half of all patients had TFCC signal changes, and more than 90% were observed in patients with a low clinical suspicion of TFCC pathology. We found that the prevalence of TFCC signal changes in patients with a clinical suspicion of TFCC pathology increases up to about 40 years of age and then begins to decrease at higher decades.
This study has several limitations. First, the presence of TFCC signal changes was based on radiology reports of MRIs including the wrist. We did not independently review the images, but relied on the interpretations of radiologists at the included institutions, which may vary from other institutions. There is also a potential for variation between MRI scanners, imaging techniques, and radiologist experience, for which we could not account. In addition, it is possible that radiologists may have underreported TFCC abnormalities in cases in which it was not relevant to the indication for imaging. However, MRI reports are generally structured to include all anatomical regions, which would mitigate this limitation.
Second, there was variation in the terms used by radiologists to describe TFCC abnormalities (eg, tear, partial tear, degeneration). In this study, we chose to categorize all abnormalities as TFCC signal changes. We did not account for differences in the type or severity of the abnormality. Therefore, our data do not give insight as to whether there is a difference in the characteristics or severity of signal changes between groups.
Third, all the included patients underwent MRI because of a clinical suspicion of underlying hand or wrist pathology, as opposed to asymptomatic volunteers. Therefore, patients with low clinical suspicion of TFCC pathology are not fully representative of the general asymptomatic population.
Fourth, we considered patients with a pre-MRI diagnosis of TFCC tear or ulnar-sided wrist pain as having a clinical suspicion of TFCC pathology. The MRIs were ordered by various providers including primary care physicians, internists, general orthopedic or plastic surgeons, and hand surgeons. We designated ulnar-sided wrist pain and an explicit TFCC diagnosis as “clinical suspicion for TFCC pathology.” We felt that “ulnar-sided wrist pain” is a term in hand surgery that indicates some level of suspicion of TFCC pathology, and that this term would be infrequently used in other contexts or by other non–hand surgery providers. We assumed that if a hand surgeon assigned a diagnosis of nonspecific pain, this was an indicator of an equivocal diagnosis, although we recognize that some may assign a nonspecific diagnosis of “pain” for convenience. Fifth, we did not take into account a history of ulnar-sided wrist injection, which could in theory cause signal changes in close temporal vicinity to the MRI. Finally, a number of the MRIs were performed for vague or unclear complaints of pain, which we categorized under “General hand/wrist pain.” This could potentially underestimate the number of individuals with a clinical suspicion of TFCC pathology. We tried to mitigate this problem through review of the past medical reports of all patients to look for any history of TFCC-specific symptoms, provocation testing, or diagnoses (Appendix B; available on the Journal’s Web site at www.jhandsurg.org).
Our findings are in line with results of several prior studies. Soft tissues in the wrist are thought to degenerate with increasing age.
found TFCC abnormalities on MRI in 38% (39 of 103) of asymptomatic volunteers, using similar criteria as our own to define signal changes. However, this study included only 11 patients over the age of 50 and none over the age of 70, limiting the ability to compare the relationship with age. They found that the proportion of signal changes increased from 34% in 20 to 29-year-olds to 73% in individuals older than 50. Mikic,
examined cadavers to estimate the prevalence of TFCC abnormalities, with the assumption that the cadavers were asymptomatic. All 3 studies found an increase in abnormalities with age with a prevalence of 7.6% to 25% in young populations, whereas in older populations, it was 53% to 84%. In a systematic review, which included several of the previous studies, Chan et al
found an overall prevalence of 35% (252 of 714) among asymptomatic individuals. There was a prevalence of 15% in those younger than age 30, and a prevalence of 49% in those older than age 70.
There is a wide variation in the quality and diagnostic accuracy of MRI of the wrist. The sensitivity of MRI for TFCC pathology ranges from 0.76 to 1.0 and the specificity ranges from 0.41 to 1.0.
Intrinsic ligament and triangular fibrocartilage complex tears of the wrist: comparison of MDCT arthrography, conventional 3-T MRI, and MR arthrography.
Diagnostic accuracy of magnetic resonance imaging and magnetic resonance arthrography for triangular fibrocartilaginous complex injury: a systematic review and meta-analysis.
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.
Diagnostic accuracy of magnetic resonance imaging and magnetic resonance arthrography for triangular fibrocartilaginous complex injury: a systematic review and meta-analysis.
Most of these studies use the reference standard of arthroscopy; however, detection of TFCC tears with arthroscopy is subject to surgeon experience as well.
Overall, these data give a reference for clinical decision making by characterizing the a priori probability of TFCC abnormalities relative to patient age. Even if MRI were a highly sensitive and specific advanced imaging study, the probability that a TFCC abnormality is clinically meaningful diminishes with patient age.
In conclusion, MRI for the evaluation of ulnar-sided wrist pain is most useful in younger patients in whom the prevalence of incidental TFCC signal abnormalities is low. The usefulness of MRI for nonspecific wrist pain diminishes because TFCC findings become more prevalent with age. Like all tests, MRI results should be interpreted in a clinical context, because there is an association between TFCC abnormalities and age, regardless of diagnosis. In an older person with unexplained wrist pain, obtaining an MRI is unlikely to make the diagnosis clearer.
Acknowledgments
The work was performed at the Hand and Upper Extremity Service, Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
Intrinsic ligament and triangular fibrocartilage complex tears of the wrist: comparison of MDCT arthrography, conventional 3-T MRI, and MR arthrography.
Diagnostic accuracy of magnetic resonance imaging and magnetic resonance arthrography for triangular fibrocartilaginous complex injury: a systematic review and meta-analysis.
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.
N.C.C. has received lecture fees from Depuy/Synthes; consultancy fees from Miami Device solutions; and served as the fellowship director for a program which received educational grants from OMeGA, Skeletal Dynamics, and Acumed. The rest of the authors declare that no benefits in any form have been received or will be received related directly or indirectly to the subject of this article.
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