TFCC TEARS

Triangular Fibrocartilage Complex (TFCC) Degeneration/Tears

Description:

A TFCC injury typical presents with ulnar sided wrist pain and can result in a distal radioulnar joint (DRUJ) injury. ¹ The triangular fibrocartilage complex (TFCC) is a fibrocartilaginous structure located on the ulnar side of the wrist. It has 4 attachments to the ulnar: 2 inserting at the styloid and 2 inserting at the fovea. ¹
The TFCC is comprised of (see Figures 1 and 2): ²

• the triangular fibrocartilage
• the proximal radioulnar (PRU) ligament
• the distal radioulnar (DRU) ligament
• the meniscal homologue
• the ulnar collateral ligament (UCL)
• the sheath of the extensor carpi ulnaris (ECU) ligament

Figure 1 – Anatomy of TFCC – Dorsal View           Figure 2 – Anatomy of TFCC – Axial View

(DRUJ – Distal Radial Ulnar Joint, DL – Dorsal ligament, ECU – Extensor Carpi Ulnaris tendon, LT – Lister’s Tubercle, Lu – Lunate, LR – Lunate Recess/Articular fossa, PL – Palmar ligament Ra – Radius, Sc-scaphoid, SR – Scaphoid Recess/Articular fossa, Sy – styloid, # triangular fibrocartilage complex disc,  Tq- Triquetrum, Ul – Ulna, * – Ulnarlunate ligament,  @ – Ulnartriquetral ligament)

TFCC injuries are classified by the mechanism of injury and include: Palmer Class 1 (an acute tear) and Palmer Class 2 (chronic degenerative changes). ³

Injury Mechanism:

The TFCC is stressed during axial loading, ulnar deviation, and extremes of forearm rotation or wrist extension. ^1, 2A single traumatic event and/or a repetitive strain with the aforementioned mechanism can lead to degeneration.   This can occur with a fall on an outsretched hand, repetitive loads, such as in pushups or from riding a bike with wrist in extension.

Differential Diagnosis

Ulnocarpal impaction syndrome

Lunotriquetral ligament tears

Distal radioulnar joint (DRUJ) subluxation

Guyon’s canal/Ulnar canal syndrome

Hook of hamate fracture

ECU tenosynovitis/tendinosis

ECU subluxation/snapping tendon

Pisiform fracture/contusion

Ulnar Styloid Fracture

Exam:

Inspection: Prominent ulnar dorsal deviation may indicate a DRUJ injury. ¹

Palpation: Fovea sign: pain on palpation between the ulnar styloid, flexor carpiulnaris (FCU), volar aspect of the ulnar head, and pisiform. A positive fovea sign has a sensitivity of 95.2% and a specificity of 86.5%.10 for a TFCC injury. ⁴

Range of Motion: May be normal or limited to ulnar deviation, supination, and/or pronation.

Special Tests:

• Tests for DRUJ laxity: (i) piano key test: dorsal to volar pressure applied to the dorsal ulna 4 cm proximal to the DURJ; positive test = pain, increase ulnar mobility. ¹ (ii) manual DRUJ manipulation by grasping the DRUJ and applying a shear force, positive test = pain and increased mobility.
• Ulnocarpal stress test:⁵ axial load, ulnar deviation, and extension of the wrist.

Investigations:

XRay: DRUJ visualized with widening on the AP, and dorsal or volar displacement on the lateral.  Look for ulnar variance, a positive ulnar variance can lead to ulnar impaction syndrome and TFCC tears and degeneration.

US:  Can be used with limited effect to visualize hyperaemia, or occasionally tears.  Dependent on operator performing the scan.⁶

CT: Can help confirm DRUJ injury.

MRI plus/minus arthrography: Most accurate in diagnosing TFCC injuries.

Management:^{1, 2, 7}

Surgical management is indicated for TFCC tears with associated fractures or instability.

Class 1A tears (most common): perforation of central TFCC disc with no instability

• Conservative management including activity modification with-or-without a volar splint for support x 4 weeks
• If still symptomatic an ulnocarpal corticosteroid injection may be beneficial
• Failed conservative treatment: surgical management
  Figure 3 – Type 1A tear

Class 1B tears: traumatic avulsions of the TFCC at distal ulnar attachement or involving an ulnar styloid fracture
Figure 4 – Type 1B tear

• Surgical management

Class 1C tears: Injury to the volar ulnar (ulnar-carpal) ligaments with instability.
Figure 5 – Type 1C tear

• Surgical management

Class 1D tears: Radial-sided detachment of the TFCC (may be associated with fracture of the radial sigmoid notch).
Figure 6 – Type 1D tear

• Surgical management

Class 2 tears: Degenerative
Figure 7 – Type E/Degenerative Tear

• May start with trial of conservative management but may ultimately require surgical management.

References:

1. Sachar K. Ulnar-sided wrist pain: evaluation and treatment of triangular fibrocartilage complex tears, ulnocarpal impaction syndrome, and lunotriquetral ligament tears. Journal of Hand Surgery 2012;37:1489-500.
2. Henry MH. Management of acute triangular fibrocartilage complex injury of the wrist. Journal of the American Academy of Orthopaedic Surgeons 2008;16:320-9.
3. Palmer AK. Triangular fibrocartilage complex lesions: a classification. Journal of Hand Surgery 1989;14:594-606.
4. Tay SC, Tomita K, Berger RA. The “ulnar fovea sign” for defining ulnar wrist pain: an analysis of sensitivity and specificity. Journal of Hand Surgery 2007;32:438-44.
5. Nakamura R, Horii E, Imaeda T, Nakao E, Kato H, Watanabe K. The ulnocarpal stress test in the diagnosis of ulnar-sided wrist pain. Journal of Hand Surgery (Edinburgh, Scotland) 1997;22:719-23.
6. Watanabe A, Souza F, Vezeridis PS, Blazar P, Yoshioka H. Ulnar-sided wrist pain. II. Clinical imaging and treatment. Skeletal Radiol. 2010 Sep;39(9):837-57
7. Chidgey LK. The Distal Radioulnar Joint: Problems and Solutions. J Am Acad Orthop Surg. 1995 Mar;3(2):95-109.

Dr. David Lawrence (PR ND June 16, 2014)