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TFCC Injury

From WikiSM

Other Names

  • Triangular Fibrocartilage Complex Injury
  • Triangular Fibrocartilage Complex Tear
  • TFCC Tear
  • Meniscus tear of the wrist

Background

History

  • Needs to be updated

Epidemiology

  • Estimated to represent between 3% and 9% of the hand-wrist injuries in athletes[1]
  • Prevalence increases with age

Introduction

Anatomy ofe a TFCC tear
Anatomy of the TFCC[2]
Axial diagram of the triangular fibrocartilage complex depicting normal anatomy. [3]

General

  • Most common cause of wrist ulnar sided wrist pain
  • Injuries to the TFCC can occur from either trauma or degeneration
  • Diagnosis is based on history, physical examination and appropriate imaging
  • Management is controversial and depends on acuity, type, severity of symptoms, and individual patient factors

Anatomy

Mechanism of Injury

  • Different combinations of axial-loading, rotation and radial or ulnar deviations have been reported
  • Direct trauma on the ulnar side of the wrist is a rare but existing occurrence
  • Mechanical stress of the distal radioulnar joint is thought to contribute
  • Sports involving axial-load and mechanical stress on the wrist
    • Particularly if the axial-load is associated with rotations and radial/ulnar deviations
    • Examples: tennis, padel, golf, ping-pong, baseball, javelin, etc.

Etiology: Traumatic

  • Most common injury pattern is falling on a pronated, outstretched hand[5]
  • Typically a load compressed on the TFCC while wrist is in ulnar deviation
    • Examples include swinging a racket or bat

Etiology: Degenerative

  • Repetitive pronation-supination as the axis of twisting passes through the articular disc[6]
  • Repetitive axial loading on the ulnar aspect of the wrist
  • Associated with ulnar variance, ulnocarpal impaction

Associated Conditions

  • Ulnar Variance
  • Chondromalacia of the ulna, lunate, triquetrum cartilage
  • DRUJ Instability

Risk Factors

Intrinsic

  • Ulnar variance
  • Ulnocarpal impaction
  • Forced ulnar deviation

Extrinsic

  • Common sports
    • Tennis
    • Padel
    • Table Tennis
    • Golf
    • Baseball
  • Uncommon sports
    • Volleyball
    • Basketball
    • Water board sports
    • Gymnastics

Differential Diagnosis

Differential Diagnosis Ulnar Sided Wrist

Differential Diagnosis Wrist Pain

Clinical Features

Clinical demonstration of the TFCC Stress test or Compression test[7]

History

  • Wrist pain on ulnar side
  • Worse with activities such as turning keys, opening doors painful
  • Athletes report pain during forearm rotation, axial loading of wrist
  • Patients may report dorsal radioulnar wrist instability
  • Decreased handgrip strength

Physical Exam: Physical Exam Wrist

  • Swelling may or may not be present
  • Often tender at the ulnocarpal space
  • Painful, limited forearm supination and pronation
  • Tenderness mainly found at the level of the fovea
  • Painful resistance of pronation and supination
  • Joint sagging can be seen during rotation or load-bearing activities
  • Audible and palpable “click” from the ulnar side of the wrist during forearm rotations
  • Need to exclude muscle/ tendon related etiology (i.e. FCU, ECU, etc)

Special Tests

Evaluation

TFCC tear annotated with findings[8]
Triangular fibrocartilage complex (TFCC) tears. a, b Fluoroscopic (a) and coronal MR arthrogram (b) images in a 13-year-old girl demonstrate a lunotriquetral ligament tear and Palmer type 1A (solid arrowhead) and 1B (notched arrowhead) TFCC tears. Note in the fluoroscopic image from the arthrogram injection, a 25-gauge butterfly needle was inserted at the mid-carpal row and contrast medium is seen extending from this single injection point through the midcarpal row to the distal radioulnar joint (DRUJ) and radio-carpal joint, confirmed on MRI to result from tears of the lunotriquetral ligament (LTL) and the TFCC. The TFCC tear proved to be complex at surgery — involving both the radioulnar ligaments, and the mid-aspect of the articular disc portion of the TFCC. c Coronal MRI arthrogram image in a 16-year-old female softball pitcher with 2 years of wrist pain, worse with pitching, reveals a Palmer class 1B tear involving the ulnar styloid attachment of the TFCC (arrowhead). d, e Fluoroscopic (d) and coronal MR arthrogram (e) images in a 14-year-old boy demonstrate a Palmer type 1D TFCC tear. The single compartment arthrogram image (d) with needle placement in the radiocarpal joint demonstrates abnormal extension of contrast medium from this compartment to the DRUJ. Subsequent MRI (e) demonstrates a corresponding tear at the radial attachment of the TFCC complex (arrowhead)[9]

Radiographs

CT

  • Rarely indicated
  • Useful if intra-articular fractures of the wrist are also present

MRI

  • Typically with arthrogram[10]
  • Up to 100% sensitive
    • Sensitivity/ specificity vary depending on the resolution of the MRI machine
  • Potential findings
    • Articular disc lesions
    • Adjacent bony edema
    • Adjacent ligament tears

Ultrasound

  • Needs to be updated

Arthroscopy

  • Gold standard for diagnosis, most accurate
  • Allows for direct visualization of anatomy

Classification

Class 1: Traumatic TFCC Injuries

  • 1A: Central perforation or tear [11]
  • 1B: Ulnar avulsion (w/o ulnar styloid fx)
  • 1C: Distal avulsion (origin of UL and UT ligaments)
  • 1D: Radial avulsion

Class 2: Degenerative TFCC Injuries

  • 2A: TFCC wear and thinning
  • 2B: Lunate and/or ulnar chondromalacia + 2A
  • 2C: TFCC perforation + 2B
  • 2D: Ligament disruption + 2C
  • 2E: Ulnocarpal and DRUJ arthritis + 2D

Management

Cock Up Wrist Splint

After identification and refreshing edges of triangular fibrocartilage complex (TFCC) tear, needle with suture loop is inserted proximal to 6R portal to pass across the tear under visualization through 3-4 portal.[12]

Athlete Considerations

  • Clinician needs to consider
    • Level of pain and movement limitations
    • Type of lesion
    • Severity of the injury
    • Level of competition
    • Timing of the injury in relation to the stage of the agonistic season, sport, and position

Nonoperative

Operative

  • Indications
    • DRUJ Instability
  • Arthroscopy
    • Diagnostic gold standard
    • Debridement: 1A
    • Repair: 1B, 1C, 1D

Rehab and Return to Play

Rehabilitation

  • Post operative rehab (central lesions)
    • Splint for 1 to 2 weeks
    • Can then begin passive and active range of motion
    • Sport specific movements around week 3
  • Post operative rehab (peripheral lesions)
    • Require immobilization for 2 to 6 weeks
    • 6 to 8 weeks of active passive ROM, strengthening exercises
    • Return to sport specific activity at 3 to 3 months

Return to Play/Work

  • Driven by degree of pain
  • In surgical cases, at discretion of surgeon
  • Depends on degree of axial force, radioulnar deviation, rotation of wrist
    • Golf can often return in 4 to 6 weeks
    • Tennis, padel may take 6-8 weeks
    • Boxing, gymnastics may take 8 to 12 weeks
  • Return to sports can be aided by
    • Taping, splinting, padded casts to reduce stress
    • Not all sports allow use of these aids

Prognosis and Complications

Prognosis

  • General
    • Prognosis depends on the type of tear and associated injuries
    • Above elbow immobilization is associated with better outcomes than short arm splinting
  • TFCC tear without DRUJ instability
    • Nonsurgical management lieads to complete recovery in 30% of patients at 6 months, 50% of patients at 1 year[13]
    • A substantial number of patients have persistent symptoms
  • Conservative treatment
    • Sander et al compared conservative versus arthroscopic management and found similar outcomes regardless of lesion type[14]
  • Surgical treatment[15][16]
    • Generally yields good pain relief, functional improvement
    • Most patients regaining grip strength and returning to work, but a minority may experience residual pain
  • Concomitant injuries
    • The presence of DRUJ subluxation or complete fovea tears predicts poorer outcome, need for surgical intervention[17]

Complications

See Also

Internal

External

References

  1. ↑ Rettig AC. Epidemiology of hand and wrist injuries in sports. Clin Sports Med. 1998;17:401–406.
  2. ↑ Image courtesy of https://musculoskeletalkey.com/, Triangular Fibrocartilage Complex Injuries
  3. ↑ Case courtesy of Matt Skalski, Radiopaedia.org, rID: 30416
  4. ↑ Skalski MR, White EA, Patel DB, Schein AJ, RiveraMelo H, Matcuk GR. The Traumatized TFCC: An Illustrated Review of the Anatomy and Injury Patterns of the Triangular Fibrocartilage Complex. Curr Probl Diagn Radiol. 2016 Jan-Feb;45(1):39-50.
  5. ↑ Watanabe A., Souza F., Vezeridis P.S., Blazar P., Yoshioka H. Ulnar-sided wrist pain. II. Clinical imaging and treatment. Skelet. Radiol. 2010;39:837–857. doi: 10.1007/s00256-009-0842-3
  6. ↑ Kataoka T., Moritomo H., Omokawa S., Iida A., Murase T., Sugamoto K. Ulnar variance: Its relationship to ulnar foveal morphology and forearm kinematics. J. Hand Surg. 2012;37:729–735. doi: 10.1016/j.jhsa.2012.01.033.
  7. ↑ Waterbrook, Anna, ed. Sports Medicine for the Emergency Physician. Cambridge University Press, 2016.
  8. ↑ Case courtesy of Mohamed El Deen, Radiopaedia.org, rID: 47619
  9. ↑ Maloney, Ezekiel, et al. "Anatomy and injuries of the pediatric wrist: beyond the basics." Pediatric radiology 48.6 (2018): 764-782.
  10. ↑ Pederzine, L., et al. "Evaluation of the triangular fibrocartilage complex tears by arthroscopy, arthrography, and magnetic resonance imaging." Arthroscopy: The Journal of Arthroscopic & Related Surgery 8.2 (1992): 191-197.
  11. ↑ https://www.orthobullets.com/hand/6047/tfcc-injury
  12. ↑ Mahmoud, Mostafa, et al. "Trans-6R portal repair of superficial TFCC tears; a modified arthroscopic outside-in technique." Arthroscopy Techniques 11.12 (2022): e2225-e2232.
  13. ↑ Lee, Joon Kyu, et al. "What is the natural history of the triangular fibrocartilage complex tear without distal radioulnar joint instability?." Clinical Orthopaedics and Related Research® 477.2 (2019): 442-449.
  14. ↑ Sander, Anna Lena, et al. "Outcome of conservative treatment for triangular fibrocartilage complex lesions with stable distal radioulnar joint." European Journal of Trauma and Emergency Surgery 47 (2021): 1621-1625.
  15. ↑ Cho, Jae-Yong, et al. "Prognostic factors for clinical outcomes after arthroscopic treatment of traumatic central tears of the triangular fibrocartilage complex." The Bone & Joint Journal 106.4 (2024): 380-386.
  16. ↑ Saito, Taichi, Sunitha Malay, and Kevin C. Chung. "A systematic review of outcomes after arthroscopic débridement for triangular fibrocartilage complex tear." Plastic and reconstructive surgery 140.5 (2017): 697e-708e.
  17. ↑ Xiao, Ji-Yang, et al. "Predictors for poor outcome for conservatively treated traumatic triangular fibrocartilage complex tears." The bone & joint journal 103.8 (2021): 1386-1391.
Created by:
John Kiel on 18 June 2019 23:24:00
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Last edited:
29 September 2025 16:46:48
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