TFCC Injection

Other Names

Anatomy of the TFCC

Axial diagram of the triangular fibrocartilage complex depicting normal anatomy.

• TFCC Injection
• Triangular Fibrocartilage Complex (TFCC) Injection

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Background

Key Points

• This page refers to injections of the TFCC (triangular fibrocartilage complex)
• Use high frequency, linear transducer
• Needle: 24-27 gauge, 1.0 to 1.5 inch needle

Anatomy of the Triangular Fibrocartilage Complex

• Triangular Fibrocartilage Complex (TFCC) formed by:
  • Triangular Fibrocartilage Disc (TFC)
  • Radioulnar Ligaments (RULs)
  • Ulnocarpal Ligaments (UCLs)
• Allows for:
  • Load transmission and shock absorption across the ulnocarpal joint
  • Forearm rotation with strong, flexible connection between distal radius and ulna
  • Supports the ulnar portion of the carpus

Palpation vs Ultrasound Guidance

• We recommend ultrasound guidance
• Nam et al compared palpation- vs ultrasound-guided techniques and showed that ultrasound guidance improved accuracy

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Indications

• TFCC Injury

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Contraindications

• Absolute
  • Anaphylaxis to injectates
  • Overlying cellulitis, skin lesion or systemic infection
• Relative
  • Can be treated with less invasive means
  • Hyperglycemia or poorly controlled diabetes
  • Lack of symptom improvement with previous injection

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(A/B): Long axis, out of plane approach. (C/D): Short axis, In plane approach. (E/F): Short axis, in plane approach.

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Video demonstration of long axis, out of plane approach

Demonstration of the palpation guided approach

Procedure

Equipment

• Sterile including chloraprep, chlorhexadine, iodine
• Ultrasound with sterile probe cover
• Gloves
• Needle: typically 25 gauge, 0.5-1 inch
• Syringe: 1-3 mL
• Gauze
• Ethyl Chloride
• Bandage
• Injectate
  • Local anesthetic
  • Corticosteroid

Ultrasound Findings

• Needs to be updated

Technique: Long Axis, Out of Plane

• Patient Position
  • Wrist is placed on pillow
  • Forearm is pronated, radially deviated
• Transducer position
  • Parallel to ECU tendon between the ulnar styloid process, triquetrum
• Needle Approach/ Orientation
  • Out of plane
  • Ulnar to radial
• Target
  • TFCC
• Pearls and Pitfalls
  • Advance toward the radial aspect, deep to ECU tendon until needle tip reaches target

Technique: Short Axis, In Plane

• Patient Position
  • Wrist is placed on pillow
  • Forearm is pronated, radially deviated
• Transducer position
  • Over the dorsal wrist in a horizontal plane
• Needle Approach/ Orientation
  • In plane
  • Ulnar to radial
• Target
  • TFCC
• Pearls and Pitfalls
  • Advance radially deep to ECU

Technique: Palpation Guided

• Patient Position
  • Wrist is placed on pillow
  • Forearm is pronated, radially deviated
• Anatomy
  • Identify the tip of the ulnar styloid and triquetrum
  • Target is space between the two bones
• Procedure
  • Advance needle into the ulnar-triquetrum space just distal to the ulnar styloid
  • You may need to redirect proximal/distal slightly to advance needle
  • Injectate should flow smoothly, if not, try redirecting needle slightly

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Aftercare

• No significant restrictions
• Can augment with ice, NSAIDS
• Consider Cock Up Wrist Splint for 24-48 hours following injection

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Complications

• Skin: Subcutaneous fat atrophy, skin atrophy, skin depigmentation
• Painful local reaction
• Infection
• Hyperglycemia
• Tendon, nerve or blood vessel injury

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See Also

• Procedures Main
• Ultrasound Main
• Wrist Pain Main

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