TFCC (Triangular Fibrocartilage Complex) Tears

By admin On Nov 5, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Stephen Paul

Holly McNulty

Anna Waterbrook

Basics

3–9% of all athletic injuries involve the wrist and hand (1).
TFCC tears are part of the spectrum of ulnar-sided pain, often with clicking, and they can be disabling to the athlete.
The TFCC acts as a primary stabilizer to the distal radioulnar joint (DRUJ) and a cushion to the ulnar-sided carpal bones, transmitting up to 18% of the load on the wrist (2).
TFCC tears are either traumatic or degenerative.
Traumatic tears may be acute or acute on chronic, repetitive events.
Tears are either from acute collision (axial load with rotation, hyperpronation-supination, or traction) or repetitive injury (chronic loading of ulnar wrist).

Description

The TFCC has 5 major components as described by Palmer (2):
- TFC proper, the articular disc distal to the ulna
- Meniscus homologue (ulnocarpal meniscus)
- Radioulnar ligaments (dorsal and volar)
- Sheath of the extensor carpi ulnaris
- Ulnar collateral ligament
Fibers of the TFCC originate on the distal radius, inserting on the distal ulna, base of the ulnar stylus, and extending to lunate, triquetrum, and base of the 5th metacarpal
The periphery of the TFCC is vascular, and the central aspect is avascular.

Epidemiology

No studies have addressed the epidemiology of TFCC tears.
Degenerative tears often are seen in an older, general population.
Traumatic tears are seen frequently in the athletic population.

Risk Factors

Type of sport can lead to tears from collision, falling on outstretched hand, and hyperrotation or traction.
Racquet sports (tennis, racquetball), pole vault, gymnastics, golf, weight training (bench press), hockey (collision and hyperrotation with a slapshot), and water skiing (traction)
Positive ulnar variance is associated with TFCC tears.
Distal radius fractures and fractures of the base of the ulnar stylus are associated with TFCC tears.

Etiology

The thickness of the TFCC is inversely related to the ulnar variance (the more ulnar plus, the thinner the TFCC).
In neutral mechanics, with axial load on, the load on the forearm is 82% at the distal radius and 18% at the TFCC; with removal of the TFCC, the radius takes 95% of the load (3).
Palmer classified TFCC tears in to 2 types: traumatic and degenerative (2):
- Traumatic:
  - 1A: Central perforation
  - 1B: Ulnar avulsion ± distal ulnar fracture
  - 1C: Avulsion from lunate or triquetrum
  - 1D: Avulsion from sigmoid notch of radius
- Degenerative:
  - 2A: TFCC wear
  - 2B: TFCC wear + lunate and/or ulnar chondromalacia
  - 2C: TFCC perforation + lunate and/or ulnar chondromalacia
  - 2D: TFCC perforation + lunate and/or ulnar chondromalacia + ligament tear
  - 2E: TFCC perforation + lunate and/or ulnar chondromalacia + ligament tear + ulnocarpal arthritis
Several mechanisms have been described to cause TFCC tears.
Axial loading the ulnar side of the wrist with a rotational force (often a fall on an outstretched hand)
Hyperrotation with hyperpronation or hypersupination
Traction to the ulnar side of the wrist
Chronic repetitive loading the ulnar carpus

Commonly Associated Conditions

Positive ulnar variance (repetitive loading of ulnar carpus)
Distal radius fractures
Fracture/nonunion of base of the ulnar stylus: Base of stylus fractures tear the TFCC.
Instability (subluxation or dislocation) of the DRUJ, midcarpus, or triquetrum-lunate
Ulnar impaction syndrome (abutment syndrome, impingement syndrome) with positive ulnar variance and risk factors (sport, repetitive trauma): There is central tear to TFCC, and chondromalacia develops in the lunate, triquetrum, and ulnar head.

Diagnosis

History

In athletes, there is a history of:
- Acute trauma such as a fall on an outstretched hand, especially with ulnar load or ulnar deviation
- Traction or hyperrotation
- Previous Colles fracture
- Previous dislocated/subluxed DRUJ
- “Insignificant” wrist injury
Overuse and repetitive trauma to the ulnar side of the wrist as seen in club and racquet sports
Patients often report ulnar-sided pain ± clicking.
Weak hand grip
Subjective sense of wrist instability
Pain with pronation, supination, or extension with axial load

Physical Exam

Point tenderness at the recess of the TFCC [area between the dorsal aspect and distal ulnar styloid and between the pisiform and the extensor carpi ulnaris (ECU) and flexor carpi ulnaris (FCU)]: Described as fovea sign
TFCC impaction/load/compression test: Axially load the wrist and ulnar deviate; reproduces pain ± click
May have pain/weakness with isometric resisted wrist flexion (patient tries to lift table in supination); this is seen with dorsal-sided peripheral tears.
Pain/weakness pushing out of a chair (wrist extension with axial load)
Tests to rule out associated instability:
- Distal ulnar movement in anteroposterior (AP) plane with fixed distal radius
- AP translation of triquetrum to fixed lunate
- AP translation of triquetrum to fixed hamate
- Ulnar compression test: Squeeze ulnar head against sigmoid notch of distal radius.
Diagnostic test: Injection with lidocaine: ECU, FCU, TFCC space, DRUJ, midcarpus, or lunotriquetrum; may help to differentiate pain

Diagnostic Tests & Interpretation

Imaging

Radiographs: Posteroanterior (PA) neutral zero rotation and lateral to rule out associated fractures and determine ulnar variance (preoperative assessment of ulnar variance may be augmented with PA pronation with hand-grip views)
The standard is arthroscopy, which is still diagnostic and therapeutic (can successfully diagnose peripheral tears with trampoline sign: Lack of spring to TFCC with probe).
MR arthrogram and high-resolution dedicated MRI are improving in accuracy to diagnose TFCC tears.
Peripheral lesions are difficult to diagnose with imaging.

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Diagnostic Procedures/Surgery

Diagnostic injection with lidocaine in to ECU, FCU, TFCC space, DRUJ, midcarpus, or lunotriquetrum may help to differentiate pain.

Differential Diagnosis

Tendinopathy (ECU, FCU)
DRUJ instability (dislocation, subluxation) and arthritis
Carpal instability (lunotriquetral, midcarpal)
Fracture (distal radius, ulnar styloid nonunion, triquetrum, hamate, pisiform)
Ulnar carpal impingement (ulnar abutment syndrome)
Kienböck disease

Treatment

Initial treatment for traumatic and symptomatic degenerative tears for up to 8–12 wks (4):
- Immobilization in slight flexion and ulnar deviation in a short-arm cast for 4–6 wks, followed by removable wrist splints and physical therapy
- Initial treatment with long-arm casting for 4–6 wks for traumatic tears and 3–4 wks of short-arm casting for degenerative tears recommended by some
McAdams (5)[C] and Rettig (1)[C] recommend more aggressive approach for high-level athletes:
- A trial of immobilization of the wrist for 2–3 wks if distal DRUJ is stable
- Arthroscopic surgery if that fails or there is any associated instability
Care to not load the ulnar wrist or load in pronosupination is important.
Peripheral lesions often will heal owing to the improved vascularity.
Injections with corticosteroids are often tried, but there is no evidence for efficacy to support this approach.

Medication

Trial of NSAIDs for pain

Additional Treatment

Referral

For competitive athletes, a more aggressive approach has been recommended (1,5)[C].
If any instability to the DRUJ or lunotriquetrum is noted, refer for arthroscopy (1,5)[C].
If the wrist is stable and not responding to initial immobilization, refer for arthroscopy (1,5)[C].

Surgery/Other Procedures

For traumatic type 1A lesions, arthroscopic débridement/repair is recommended (5)[C].
For traumatic type 1B–D peripheral ulnar and radius lesions, arthroscopic repair is recommended (5)[C].
For degenerative type 2 lesions, ulnar variance is assessed as well as midcarpal stability and wear.
- If ulnar variance is 3 mm or less, wafer procedure is recommended (5)[C].
- If ulnar variance is >3 mm, wafer + ulnar shortening is recommended (1,5,6,7)[C].
- Wafer procedure is arthroscopic decompression of the ulnocarpal joint with débridement of the TFCC.

Ongoing Care

Follow-Up Recommendations

After initial injury, follow-up should be at 2–3 wks to gauge response to immobilization.

Prognosis

Return to play:
- McAdams (5) recommends a conservative approach postoperatively to avoid ulnar synovitis: 6 wks of immobilization in a short-arm or Muenster cast followed by 6 wks of progressive range of motion and strength, with full return to sport at 3 mos postoperatively.
- Rettig (1) recommends return to restricted sport (golf and tennis) 4–6 wks after débridement of central TFCC tear (1A) and 3–4 mos after repair.
Prognosis:
- McAdams (5) reported excellent results for return to play with improvement in pain relief after arthroscopic surgery in 14 of 16 high-level athletes.
- The 2 who did not return to play at 3 mos had DRUJ instability and ulnar-carpal abutment; both returned to play after an additional period postoperatively.

Complications

Previously undiagnosed carpal or DRUJ instability or ulnar-carpal abutment syndrome

References

1. Rettig AC. Athletic injuries of the wrist and hand: part II: overuse injuries of the wrist and traumatic injuries to the hand. Am J Sports Med. 2004;32:262–273.

2. Palmer AK. Triangular fibrocartilage complex lesions: a classification. J Hand Surg [Am]. 1989;14:594–606.

3. Palmer AK, Werner FW. Biomechanics of the distal radioulnar joint. Clin Orthop Relat Res. 1984;26–35.

4. emedicine: Verheyden JR, Palmer AK: Triangular fibrocartilage complex injuries, emedicine > orthopedic surgery > hand & upper extremity, updated June 23, 2009.

5. McAdams TR, Swan J, Yao J. Arthroscopic treatment of triangular fibrocartilage wrist injuries in the athlete. Am J Sports Med. 2008.

6. Steinberg B. Acute wrist injuries in the athlete. Orthop Clin North Am. 2002;33:535–545, vi.

7. Ahn AK, Chang D, Plate AM. Triangular fibrocartilage complex tears—a review. Bull Hosp Jt Dis. 2006;64:114–118.

8. Coggins CA. Imaging of ulnar-sided wrist pain. Clin Sports Med. 2006;25:505–526, vii.

Additional Reading

eMedicine Specialties > Orthopedic Surgery > Hand & Upper Extremity > Ulnar-Sided Wrist Pain Author: David M Lichtman, MD, Chair, Department of Orthopedic Surgery, John Peter Smith Hospital; Clinical Professor, Department of Orthopedic Surgery, University of Texas Southwestern Medical Center; Professor, Department of Surgery, Uniformed Services University of the Health Sciences; Professor and Chair, Department of Orthopedic Surgery, University of North Texas Health Science Center. Coauthor(s): Atul Joshi, MD, MCh, FRCS, Consulting Staff, Department of Orthopedics, Covenant Medical Center. Contributor Information and Disclosures Updated: July 9, 2009 (⁸).

Palmer AK, Werner FW. The triangular fibrocartilage complex of the wrist–anatomy and function. J Hand Surg [Am]. 1981;6:153–162.

Codes

ICD9

842.09 Other wrist sprain