TFCC (Triangular Fibrocartilage Complex) Tears

Ovid: 5-Minute Sports Medicine Consult, The

TFCC (Triangular Fibrocartilage Complex) Tears
Stephen Paul
Holly McNulty
Anna Waterbrook
  • 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).
  • 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.
  • 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.
  • 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.
  • 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
  • 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.


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
Ongoing Care
Follow-Up Recommendations
After initial injury, follow-up should be at 2–3 wks to gauge response to immobilization.
  • 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.
842.09 Other wrist sprain

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