TFCC INJURIES - TRIANGULAR FIBROCARTILAGE COMPLEX
Ulnar-Sided Wrist Pain | Palmer Classification | DRUJ Stability | Arthroscopic Management
PALMER CLASSIFICATION
Critical Must-Knows
- TFCC components: TFC disc, dorsal/palmar radioulnar ligaments, meniscus homologue, ECU subsheath, ulnocarpal ligaments
- Blood supply: Peripheral 15-20% vascular (can heal), central 80% avascular (debride only)
- Foveal sign: Tenderness in soft spot distal to ulnar styloid - most sensitive clinical test
- DRUJ stability: Test in neutral, pronation, supination; compare to contralateral side
- Palmer 1B = KEY: Ulnar-sided tears repair well and are essential for DRUJ stability
Examiner's Pearls
- "Central tears (1A) = debridement only - no blood supply means no healing potential
- "Peripheral tears (1B) = repair essential - good vascularity and critical for DRUJ stability
- "Positive ulnar variance (over 2mm) = consider ulnar shortening osteotomy with TFCC procedure
- "MR arthrography is gold standard imaging - contrast leak indicates full-thickness tear
Clinical Imaging
Imaging Gallery
Critical TFCC Injury Exam Points
Blood Supply
Peripheral 15-20% = vascular (can repair). Central 80% = avascular (debride only). This dictates treatment - central tears cannot heal.
Palmer Classification
Type 1 = Traumatic (1A central, 1B ulnar, 1C distal, 1D radial). Type 2 = Degenerative (2A-E progressively severe with arthritis).
Foveal Sign
Tenderness in soft spot distal to ulnar styloid between FCU and ECU. Most sensitive clinical test for TFCC injury. Compare to other side.
Ulnar Variance
Positive UV (over 2mm) = ulnar impaction syndrome. May need ulnar shortening osteotomy in addition to TFCC debridement/repair.
Quick Decision Guide - TFCC Tear Treatment
| Palmer Type | Location | Blood Supply | Treatment |
|---|---|---|---|
| Type 1A | Central perforation | Avascular | Arthroscopic debridement |
| Type 1B | Ulnar avulsion | Vascular | Arthroscopic/open repair |
| Type 1C | Distal (ulnocarpal ligaments) | Variable | Reconstruct if unstable |
| Type 1D | Radial avulsion | Vascular | Repair if DRUJ unstable |
| Type 2A-E | Degenerative wear | N/A | Debridement +/- ulnar shortening |
Memory Aids
TED HUMSTFCC Components
Memory Hook:'TED HUMS at the ulnar wrist' - imagine Ted humming while examining the ulnar side — Exam Tip: The articular disc is central and avascular; the peripheral structures (ligaments, ECU sheath) are vascular and repairable
ABCD - from center outPalmer Traumatic Classification
Memory Hook:'A is in the middle (Articular), B is at the Base (ulnar), C is Carpal, D is by the radius (Distal radius)' — Exam Tip: Type 1B tears involve the foveal attachment - these MUST be repaired to restore DRUJ stability
PSU (Press Soft Ulnar)Foveal Sign Technique
Memory Hook:'Press the Soft spot by the Ulna' - the most reliable clinical sign for TFCC pathology — Exam Tip: The foveal sign has 95% sensitivity for TFCC tears - always examine both sides
FPPDClinical Tests for TFCC Pathology
Memory Hook:FPPD - Four key tests to diagnose TFCC tears and assess DRUJ stability!
Overview
Definition and Function
The TFCC is a complex of structures that serves three critical functions:
- Stabilization of the distal radioulnar joint (DRUJ)
- Load transmission from carpus to ulna (20% of axial load)
- Smooth articulation for ulnocarpal joint motion
Epidemiology
- Most common cause of ulnar-sided wrist pain
- Often associated with distal radius fractures (30-50%)
- Degenerative changes increase with age (50% of people over 60 have degeneration)
- Higher incidence in athletes with repetitive wrist loading
- Peak traumatic injury: 20-40 years (active adults)
Clinical Significance
- TFCC tears can cause persistent ulnar wrist pain and disability
- DRUJ instability can result from peripheral tears
- Missed diagnosis is common - "wrist sprain" is often TFCC injury
- Treatment depends on tear location and DRUJ stability
- Understanding anatomy is key to management
Anatomy
TFCC Components
1. Triangular Fibrocartilage Disc (Articular Disc):
- Horizontal disc between ulnar head and carpus
- Central portion is avascular (watershed area)
- Attached radially to sigmoid notch of radius
- Attached ulnarly to ulnar styloid base and fovea
2. Dorsal and Palmar Radioulnar Ligaments:
- Primary DRUJ stabilizers
- Dorsal RUL taut in pronation
- Palmar RUL taut in supination
- Deep fibers attach to fovea (critical for stability)
- Superficial fibers attach to ulnar styloid
3. Ulnocarpal Ligaments:
- Ulnolunate ligament
- Ulnotriquetral ligament
- Stabilize ulnar carpus to TFCC
- Form floor of ECU tunnel
4. Meniscus Homologue:
- Fibrous tissue connecting disc to triquetrum
- Contains ulnotriquetral ligament
- Variable morphology
5. ECU Subsheath:
- Binds ECU tendon to ulnar head
- Prevents subluxation in supination
- Attached to TFCC periphery
Blood Supply
Vascular Zones:
- Peripheral 15-20%: Good blood supply from ulnar artery branches
- Central 80-85%: Avascular (watershed area)
Clinical Relevance:
- Peripheral tears (Type 1B, 1C, 1D) can heal with repair
- Central tears (Type 1A) cannot heal - debridement indicated
- Blood supply determines treatment strategy
Ulnar Variance
Definition: Relative length of ulna compared to radius at the wrist
Measurement:
- PA radiograph in neutral forearm rotation
- Compare ulnar head to lunate fossa of radius
- Positive: Ulna longer than radius
- Negative: Ulna shorter than radius
- Neutral: Equal length
Clinical Significance:
- Positive ulnar variance increases TFCC load
- Each 1mm positive variance increases ulnar load by 10%
- Positive variance associated with:
- Degenerative TFCC tears
- Ulnocarpal impaction syndrome
- Kienbock's disease (negative variance)
Classification
Palmer Classification
Type 1: Traumatic Tears
Location: Central perforation of articular disc
Blood Supply: Avascular zone
Mechanism: Traumatic disruption of central disc (FOOSH, rotational injury)
Clinical Features:
- Ulnar wrist pain with gripping
- May have clicking
- DRUJ stable (peripheral structures intact)
Treatment: Arthroscopic debridement
- Remove unstable tissue
- Preserve peripheral 2mm
- Cannot heal due to lack of blood supply
Outcomes: 70-90% good results with debridement.
[End of section]
Type 2: Degenerative (Ulnocarpal Impaction)
Type 2A: TFCC wear (central thinning)
- No perforation yet
- Early degenerative changes
Type 2B: 2A + lunate/ulnar chondromalacia
- Cartilage damage developing
- No full-thickness perforation
Mechanism: Positive ulnar variance causing chronic impaction
Treatment:
- Address ulnar variance (shortening osteotomy)
- Debride if symptomatic
- May respond to conservative treatment initially
[End of section]
Atzei Classification (More Recent)
Based on DRUJ stability and foveal attachment:
| Class | Foveal Attachment | DRUJ Stability | Treatment |
|---|---|---|---|
| 1 | Intact | Stable | Debridement +/- repair |
| 2 | Proximal disruption | Unstable | Foveal repair |
| 3 | Complete distal detachment | Unstable | Reconstruction |
| 4 | Pan-TFCC injury | Grossly unstable | Reconstruction/fusion |
Clinical Utility:
- Addresses limitation of Palmer (doesn't address stability)
- Guides surgical approach based on stability
- Emphasizes importance of foveal attachment
Clinical Assessment
History
Typical Presentation:
- Ulnar-sided wrist pain (activity-related)
- May follow specific injury (FOOSH, rotation)
- Weakness with gripping and rotation
- Clicking or clunking with forearm rotation
- Pain worse with ulnar deviation
Key Questions:
- Mechanism of injury (fall, rotation, gradual onset)
- Timing and duration of symptoms
- Occupation and hand dominance
- Activities that provoke pain (gripping, rotation)
- Previous wrist injuries or treatment
Physical Examination
Inspection:
- Swelling over ulnar wrist (less common)
- Compare to contralateral wrist
Palpation:
Foveal Sign (Key Test):
- Examiner's finger in soft spot between:
- FCU tendon (volar)
- Ulnar styloid (dorsal)
- Press deeply toward fovea
- Positive: Pain reproduction
- Sensitivity: 95%
Other Palpation Sites:
- Ulnar styloid
- Lunotriquetral joint
- ECU tendon
- Pisotriquetral joint
Special Tests
DRUJ Stability Testing:
- Compare to contralateral side
- Test in neutral, pronation, and supination
- Stabilize radius, translate ulna dorsally and palmarly
- Increased laxity or painful endpoint = positive
DRUJ Compression Test:
- Squeeze radius and ulna together at DRUJ
- Rotate forearm with compression
- Positive: Pain or crepitus
Ulnar Fovea Sign:
- As described above
- Most specific test for TFCC tears
Press Test:
- Patient pushes up from seated position using ulnar border of hands
- Positive: Ulnar wrist pain
Supination Lift Test:
- Lift underside of heavy table with palms facing up
- Positive: Ulnar wrist pain
ECU Synergy Test:
- Resisted wrist extension with ulnar deviation
- Tests ECU subsheath integrity
Investigations
Plain Radiographs
Standard Views:
- PA in neutral rotation (for ulnar variance)
- Lateral
- Oblique
Key Findings:
- Ulnar variance measurement
- DRUJ widening or subluxation
- Ulnar styloid fractures (associated with TFCC avulsion)
- Degenerative changes at DRUJ or ulnocarpal joint
- Ulnar impaction changes on lunate/triquetrum
PA Grip View:
- PA with fist clenched
- Increases ulnar variance (forearm pronates slightly)
- May unmask dynamic positive variance
MRI
Technique:
- 1.5T or 3T magnet
- Dedicated wrist coil
- Coronal sequences most useful
Findings:
- Central perforation: High signal through disc on T2
- Peripheral tear: Fluid at ulnar or radial attachment
- Associated pathology: LT tears, ECU tendinopathy
Limitations:
- Sensitivity 70-90% for tears
- Less reliable for partial tears
- Cannot assess DRUJ stability dynamically
MR Arthrography:
- Intra-articular contrast improves sensitivity to 90-95%
- Gold standard non-invasive test
- Shows contrast leaking through tears
CT
Indications:
- DRUJ subluxation assessment
- Associated fractures
- Planning for ulnar shortening osteotomy
Bilateral CT:
- Compare DRUJ alignment bilaterally
- Useful for instability assessment
Arthroscopy (Gold Standard)
Advantages:
- Direct visualization
- Can palpate tears with probe
- Assess DRUJ stability from inside
- Therapeutic at same sitting
Portals:
- 3-4 portal: Main viewing portal
- 4-5 portal: Instrumentation
- 6R portal: Ulnar visualization
- DRUJ portal: Direct DRUJ assessment
Trampoline Test:
- Probe central TFCC
- Normal: Firm, springy resistance
- Abnormal: Soft, boggy, or probe passes through
Hook Test:
- Hook peripheral TFCC with probe
- Test for detachment from fovea/radius
- Assesses integrity of deep RUL fibers
Management
Non-Operative Treatment
Indications:
- Acute injuries without instability
- Low-demand patients
- Significant medical comorbidities
Protocol:
- Splinting (Muenster or long arm) for 4-6 weeks
- Activity modification
- NSAIDs
- Corticosteroid injection (diagnostic and therapeutic)
- Hand therapy
Expected Outcomes:
- 50% success for stable injuries
- Central tears may remain symptomatic despite splinting
- Instability rarely resolves with conservative treatment
Management Algorithm
Assessment: DRUJ stability testing normal, no increased laxity
Central Tear (Type 1A):
- Arthroscopic debridement
- Remove unstable tissue only
- Preserve peripheral 2mm
Peripheral Tear (Type 1B/D):
- Consider repair if good tissue quality
- Debridement may be sufficient if small
- Monitor for development of instability
Non-surgical option: Trial of conservative treatment (4-6 weeks immobilization) before surgery
[End of section]
Arthroscopic Debridement (Type 1A)
Indications:
- Central TFCC tears (avascular zone)
- DRUJ stable
- No peripheral involvement
Technique:
- Establish portals (3-4 viewing, 4-5 working, 6R)
- Assess tear extent with probe
- Debride unstable tissue with shaver
- Preserve peripheral 2mm (stabilizing structures)
- Smooth edges with radiofrequency
Postoperative:
- Soft dressing, immediate ROM
- Strengthening at 4 weeks
- Full activity 6-8 weeks
Outcomes:
- 70-90% good/excellent results
- Best for small central tears
- Large tears may destabilize DRUJ
Peripheral TFCC Repair (Type 1B/D)
Indications:
- Ulnar avulsion (1B)
- Radial avulsion (1D) with instability
- Intact foveal attachment
Techniques:
Outside-In Repair:
- Small incision over ulnar wrist
- Pass suture through TFCC arthroscopically
- Retrieve suture percutaneously
- Tie over capsule/bone
All-Inside Repair:
- Use suture anchor system
- Anchor placed in ulnar fovea
- Sutures passed through TFCC
- Tied arthroscopically
Open Repair:
- Dorsal approach between 5th/6th compartments
- Capsulotomy to expose TFCC
- Repair with suture anchors or transosseous sutures
- Address associated pathology
Postoperative:
- Long arm cast/splint 4-6 weeks (neutral rotation)
- Then removable splint for 2-4 more weeks
- ROM begins at 6 weeks
- Strengthening at 10-12 weeks
Foveal Repair
Indications:
- Foveal detachment (Atzei Class 2)
- DRUJ instability
Technique:
- Open approach preferred for foveal attachment
- Decorticate fovea
- Place suture anchor in fovea
- Repair deep RUL fibers
- May require additional TFCC repair
Postoperative:
- Long arm cast 6 weeks in neutral rotation
- Protected ROM 6-10 weeks
- Full activity 4-6 months
TFCC Reconstruction
Indications:
- Irreparable TFCC (chronic, attenuated)
- Failed previous repair
- Persistent DRUJ instability
Techniques:
- Adams-Berger reconstruction (palmaris longus or FCU strip)
- Anatomic reconstruction targeting foveal attachment
- Consider DRUJ stabilization procedures
Addressing Ulnar Variance
Ulnar Shortening Osteotomy:
Indications:
- Positive ulnar variance (greater than 2mm)
- Degenerative TFCC tears (Type 2)
- Ulnocarpal impaction syndrome
Technique:
- Ulnar shaft approach
- Oblique or transverse osteotomy
- Remove 2-4mm bone
- Fix with compression plate
Postoperative:
- Splint until union (8-12 weeks)
- High union rate (greater than 95%)
Wafer Procedure:
- Arthroscopic resection of 2-4mm distal ulna
- Alternative to shortening osteotomy
- Less morbid but less predictable
Surgical Technique
Arthroscopic Setup
Patient Position:
- Supine or lateral decubitus
- Arm table or traction tower
- 10-15 lbs traction
Portals:
- 3-4 portal: Primary viewing (between EPL and EDC)
- 4-5 portal: Instrumentation (between EDC and EDM)
- 6R portal: Ulnar viewing (radial to ECU)
- DRUJ portal: Direct DRUJ access
Systematic Examination:
- Assess articular disc (trampoline test)
- Probe peripheral attachments (hook test)
- Examine ulnocarpal ligaments
- Assess DRUJ from radiocarpal space
- Enter DRUJ directly if needed
Repair Techniques
Indications:
- Peripheral TFCC tears (Type 1B/D)
- Good tissue quality
- Adequate working space
Equipment:
- Suture anchors (1.3-2.0mm)
- Suture passer device
- Arthroscopic knot pusher
Surgical Steps:
- Identify peripheral tear extent through 3-4 portal
- Debride tear edges lightly with shaver
- Insert suture anchor into ulnar styloid/fovea via 6U portal
- Pass suture limbs through TFCC using suture passer
- Retrieve sutures through 6R portal
- Tie sutures arthroscopically using knot pusher
- Confirm repair integrity with probe (hook test)
Tips:
- Maintain capsular integrity for anchor security
- Pre-loaded anchors simplify technique
- Use probe to ensure adequate tissue capture
- Multiple sutures (2-3) improve strength
Advantages:
- All arthroscopic (minimal invasiveness)
- Good visualization
- Precise placement
Disadvantages:
- Technical difficulty
- Learning curve
- Limited to certain tear patterns
[End of section]
Complications
Complications of TFCC Tears
If Untreated:
- Chronic ulnar wrist pain
- DRUJ instability and arthritis
- Ulnocarpal impaction syndrome progression
- Functional disability
Surgical Complications
General:
- Infection (1-2%)
- Stiffness
- CRPS
- Nerve injury (dorsal sensory branch ulnar nerve)
Debridement Specific:
- Inadequate debridement (residual symptoms)
- Excessive debridement (DRUJ instability)
Repair Specific:
- Failure of repair (10-20%)
- Anchor/suture problems
- Stiffness from prolonged immobilization
Ulnar Shortening:
- Nonunion (rare with plate fixation)
- Hardware prominence
- Over/under-correction
Prognostic Factors
Better Outcomes:
- Acute injury (less than 6 months)
- Isolated TFCC tear
- Stable DRUJ
- Neutral ulnar variance
Worse Outcomes:
- Chronic injury
- Associated DRUJ instability
- Positive ulnar variance (unaddressed)
- Workers' compensation claims
- Associated arthritis
Postoperative Care
Debridement Protocol (Type 1A, Type 2 with stable DRUJ)
Immediate Postoperative (0-2 weeks):
- Soft dressing or removable splint
- Immediate gentle ROM exercises
- Elevation to reduce swelling
- Wound care
Early Recovery (2-4 weeks):
- Progress ROM exercises
- Begin light grip strengthening
- Avoid forceful pronation/supination
- Continue splint for comfort
Return to Function (4-8 weeks):
- Progressive strengthening program
- Sport-specific rehabilitation
- Full ROM expected by 6 weeks
- Return to unrestricted activity 6-8 weeks
Outcomes: Most patients achieve good pain relief with debridement alone if DRUJ remains stable.
Peripheral Repair Protocol (Type 1B/D)
Immobilization Phase (0-6 weeks):
- Long arm cast or splint in neutral rotation
- Elbow at 90 degrees
- Forearm neutral (prevents stress on repair)
- NO ROM during this phase - healing critical
Protected Motion Phase (6-10 weeks):
- Transition to removable wrist splint
- Begin gentle wrist ROM (flexion/extension first)
- Begin gentle forearm rotation (pain-limited)
- Continue splint between exercises and at night
- Hand therapy essential
Strengthening Phase (10-16 weeks):
- Progressive strengthening exercises
- Functional activity training
- Sport-specific rehabilitation begins
- Discontinue splint when comfortable
Return to Activity (4-6 months):
- Full unrestricted activity at 4-6 months
- Contact sports delayed until 6 months
- Heavy manual labor delayed until 6 months
Critical Points:
- Early motion risks repair failure
- DRUJ stability must be protected during healing
- Compliance with immobilization is key to success
Foveal Repair Protocol (More Restrictive)
Immobilization Phase (0-6 weeks):
- Long arm cast mandatory
- Neutral rotation strictly maintained
- NO ROM whatsoever
- Protect deep RU ligament healing
Protected Motion Phase (6-12 weeks):
- Transition to removable long arm splint
- Very gentle ROM under therapist supervision
- Limit rotation until 10 weeks
- Night splinting continues
Strengthening Phase (12-20 weeks):
- Progressive strengthening
- Functional activities
- Continue protecting DRUJ stability
Return to Activity (6-9 months):
- Delayed return due to critical nature of repair
- Full activity 6-9 months
- Heavy labor/contact sports 9+ months
Ulnar Shortening Osteotomy Protocol
Immobilization Phase (0-8 weeks):
- Splint or cast until radiographic union
- Check X-rays at 2, 4, 6, 8 weeks
- NO weight bearing through wrist
- Union typically 8-12 weeks
After Union Confirmed:
- Begin ROM and strengthening
- Progress based on bone healing
- Hardware removal if prominent (after 1 year)
Return to Activity:
- Light activity 3 months
- Full unrestricted activity 4-6 months
Complications to Monitor
All Procedures:
- Infection (rare - under 2%)
- Stiffness (more common with prolonged immobilization)
- CRPS (rare but serious)
- Nerve injury (dorsal sensory branch ulnar nerve)
Repair-Specific:
- Failure of repair (10-20% risk)
- Suture pullout
- Development of DRUJ instability
Ulnar Shortening:
- Nonunion (very rare with plate fixation)
- Hardware prominence requiring removal
- Over or under-correction of variance
Follow-Up Schedule
Standard Protocol:
- 2 weeks: Wound check, adjust therapy
- 6 weeks: Remove/transition immobilization, X-ray if osteotomy
- 12 weeks: Assess progress, advance strengthening
- 6 months: Final assessment, return to activity clearance
Outcomes/Prognosis
Overall Success Rates by Treatment Type
Arthroscopic Debridement (Type 1A):
- Success rate: 70-90% good to excellent results
- Pain relief achieved in most patients
- Best results with small central perforations
- Large tears may lead to DRUJ instability
Peripheral TFCC Repair (Type 1B/D):
- Success rate: 80-90% at 2-5 year follow-up
- Arthroscopic repair comparable to open repair
- DRUJ stability restored in most cases
- Failure rate: 10-20% (may require revision)
Foveal Repair:
- Success rate: 75-85% for DRUJ stability restoration
- More unpredictable than standard peripheral repair
- Chronic injuries have lower success
- May require secondary reconstruction if failed
TFCC Reconstruction:
- Reserved for salvage situations
- Success rate: 60-75% (variable outcomes)
- Best for chronic instability after failed repair
- Functional improvement but rarely normal
Ulnar Shortening Osteotomy:
- Success rate: 80-90% for degenerative TFCC tears with positive UV
- Union rate: greater than 95% with plate fixation
- Combined with debridement better than debridement alone
- Most predictable treatment for ulnocarpal impaction
Outcomes by Palmer Classification
Type 1A (Central):
- Good outcomes with debridement if tear is small
- 70-80% satisfaction at 2 years
- Risk of progression if DRUJ becomes unstable
- May require conversion to repair if unstable
Type 1B (Ulnar):
- Excellent outcomes with repair (80-90% success)
- Critical to restore DRUJ stability
- Better outcomes if repaired within 6 months
- Chronic tears have lower success rates
Type 1C (Distal):
- Variable outcomes depending on associated injuries
- Good if ulnocarpal stability restored
- LT tears complicate prognosis
Type 1D (Radial):
- Good outcomes if repaired when indicated
- Less common, limited outcome data
- Usually good with appropriate treatment
Traumatic tears have excellent outcomes when treated appropriately.
Functional Outcomes
Pain Relief:
- 75-85% achieve significant pain reduction
- Complete pain elimination uncommon (50-60%)
- Activity-related pain may persist
- Better with peripheral repair than debridement
Grip Strength:
- Recovery to 80-90% of contralateral side
- May take 6-12 months for full recovery
- Repair protocols achieve better strength than debridement
- Chronic injuries recover less strength
Range of Motion:
- Most patients regain full ROM
- Pronation/supination may be slightly limited (5-10 degrees)
- Stiffness more common with prolonged immobilization
- ROM exercises essential in rehabilitation
Return to Work:
- Office work: 4-8 weeks
- Light manual labor: 3-4 months
- Heavy manual labor: 6-9 months
- Overhead athletes: 4-6 months (debridement), 6-9 months (repair)
Return to Sport:
- Non-contact: 3-4 months (debridement), 4-6 months (repair)
- Contact sports: 6 months minimum after repair
- Overhead sports (tennis, golf): 4-6 months
- Gymnastics/high-impact: 6-9 months
Factors Affecting Outcomes
Patient Factors:
- Age: Younger patients (under 40) have better outcomes
- Chronicity: Acute injuries (under 6 months) do better
- Occupation: Manual laborers have worse outcomes
- Litigation/compensation: Associated with worse outcomes
- Compliance: Critical for success of repair protocols
Injury Factors:
- Tear type: Peripheral repairs do better than central debridement
- DRUJ stability: Stable DRUJ has better prognosis
- Ulnar variance: Addressing positive UV improves outcomes dramatically
- Associated injuries: LT tears, arthritis worsen prognosis
Surgical Factors:
- Timing: Early surgery (within 6 months) better for repairs
- Technique: Arthroscopic vs open - similar outcomes if done well
- Foveal restoration: Critical for DRUJ stability
- Addressing UV: Essential for degenerative tears
Revision Surgery
Indications for Revision:
- Persistent pain after debridement (consider repair if unstable)
- Failed repair with continued instability
- Under-corrected ulnar variance
- New/progressive tears
Revision Outcomes:
- Generally worse than primary surgery (60-70% success)
- Tissue quality often poor in revisions
- May require reconstruction rather than repair
- Consider salvage procedures if multiple failures
Long-Term Prognosis
5-10 Year Outcomes:
- Maintained improvement in 70-80% of patients
- Some deterioration over time (especially degenerative)
- DRUJ arthritis may develop (10-15% at 10 years)
- Repeat procedures needed in 10-15%
Risk of DRUJ Arthritis:
- Higher with untreated instability
- Lower if DRUJ stability restored
- Positive UV increases arthritis risk
- May eventually require salvage procedures
Evidence Base
Palmer Classification
- Established classification system distinguishing traumatic (Type 1) from degenerative (Type 2) TFCC tears with treatment implications
Arthroscopic TFCC Repair Outcomes
- Arthroscopic TFCC repair achieved 81% good/excellent results at mean 2.4 years. Better outcomes with foveal reattachment technique.
Foveal Sign Diagnostic Accuracy
- Foveal sign had 95% sensitivity and 87% specificity for ulnar-sided TFCC tears when compared to arthroscopy
Ulnar Shortening for TFCC Tears
- Ulnar shortening osteotomy combined with TFCC debridement achieved 85% good/excellent results for degenerative TFCC tears with positive ulnar variance
MR Arthrography vs Arthroscopy
- MR arthrography had 91% sensitivity and 98% specificity for TFCC tears compared to arthroscopy gold standard
Viva Scenarios
Exam Viva Scenarios
Practice these scenarios to excel in your viva examination
Acute TFCC Tear with DRUJ Instability
"A 35-year-old tennis player sustains a fall on his dominant hand. He has ulnar wrist pain, positive foveal sign, and the DRUJ is unstable compared to the opposite side. X-rays show neutral ulnar variance and no fractures. MR arthrography confirms a peripheral TFCC tear."
Assessment: This is an acute peripheral TFCC tear (likely Palmer Type 1B - ulnar avulsion) with DRUJ instability. The positive foveal sign localizes the pathology to the ulnar attachment, and instability indicates deep radioulnar ligament involvement.
Key point: This is NOT a central tear - peripheral tears have blood supply and must be repaired (not debrided) to restore DRUJ stability.
Management: I would recommend surgical repair given the DRUJ instability. Options include: (1) Arthroscopic repair using suture anchor technique - my preference for most peripheral tears, (2) Open repair if complex tear or foveal avulsion requiring bone anchor placement.
Surgical approach: Arthroscopic setup with 3-4, 4-5, 6R portals. Assess tear extent with probe and hook test. Place suture anchor into ulnar styloid/fovea. Pass sutures through TFCC using suture passer. Tie arthroscopically.
Postoperative: Long arm cast in neutral rotation for 4-6 weeks, then protected ROM. Strengthening begins at 10-12 weeks. Return to tennis at 4-6 months.
Central TFCC Tear
"A 45-year-old secretary presents with 8-month history of ulnar wrist pain after lifting a heavy box. Examination shows positive foveal sign but DRUJ is stable. MRI shows central TFCC perforation. Ulnar variance is neutral."
Assessment: This is a central TFCC tear (Palmer Type 1A). The central portion of the TFCC is avascular (the central 80% has no blood supply), so these tears cannot heal and repair is not indicated.
Conservative trial: Given the chronic nature, I would offer a course of conservative treatment: activity modification, splinting, NSAIDs, possibly corticosteroid injection. If symptoms persist after 3 months of conservative treatment, surgical debridement is indicated.
Surgical management: Arthroscopic debridement. Key technique points: (1) Debride only unstable tissue, (2) Preserve peripheral 2mm (contains the RU ligaments), (3) Smooth edges with radiofrequency device. The goal is to remove mechanical catching while preserving DRUJ stability.
Why no repair: No blood supply means no healing potential. Sutures would not integrate and would just create a foreign body response.
If positive ulnar variance: Would add ulnar shortening osteotomy to address the underlying cause of impaction and degeneration.
Ulnocarpal Impaction Syndrome
"A 50-year-old manual laborer has progressive ulnar wrist pain for 2 years. X-rays show 3mm positive ulnar variance and cystic changes in the lunate. MRI shows TFCC perforation and lunate chondromalacia. What is your diagnosis and management?"
Diagnosis: Ulnocarpal impaction syndrome - Palmer Type 2C (TFCC perforation + lunate chondromalacia). This is a degenerative condition caused by positive ulnar variance creating excessive load on the ulnar carpus through the TFCC.
Key concept: Each 1mm of positive variance increases ulnar load by approximately 10%. At 3mm positive, this patient has significant overload causing progressive TFCC wear and secondary cartilage damage.
Management: Treatment must address the positive ulnar variance - TFCC debridement alone will not solve the underlying mechanical problem. My recommendation is ulnar shortening osteotomy combined with arthroscopic TFCC debridement.
Technique: I would shorten 3-4mm to achieve neutral to slightly negative variance. Oblique osteotomy with compression plating gives reliable union. Combined with arthroscopic debridement of unstable TFCC tissue and assessment of lunate cartilage.
Alternative - Wafer procedure: Arthroscopic resection of distal 2-4mm of ulnar dome. Less invasive but less predictable correction. Best for minimal positive variance.
If LT tear: This would be Palmer Type 2D. LT repair or debridement would be added to the ulnar shortening. May need to address LT instability if significant.
MCQ Practice Points
TFCC Blood Supply
Q: Why can't you repair a central TFCC tear (Palmer 1A)? A: Central 80% is avascular - No blood supply means no healing potential. Only debridement is appropriate for central tears.
Palmer 1B Importance
Q: Which TFCC tear type must always be repaired and why? A: Palmer 1B (ulnar avulsion) - The peripheral zone is vascular AND the deep radioulnar ligaments attach here, making repair essential for DRUJ stability.
Foveal Sign
Q: What is the most sensitive clinical test for TFCC tears? A: Foveal sign (95% sensitivity) - Press the soft spot between FCU and ulnar styloid distal to ulnar head. Compare to contralateral side.
Ulnar Variance Effect
Q: How does positive ulnar variance affect TFCC load? A: Each 1mm positive variance increases ulnar load by 10% - Positive UV greater than 2mm requires ulnar shortening osteotomy for degenerative tears.
DRUJ Stability Test
Q: How do you test DRUJ stability? A: Test in neutral, pronation, and supination - Compare to contralateral side. Translate ulna dorsally and palmarly. Increased laxity or pain = positive.
High-Yield MCQ Facts
Anatomy and Physiology:
- TFCC transmits 20% of axial load from carpus to ulna (radius takes 80%)
- Central 80% is avascular (peripheral 15-20% vascular from ulnar artery)
- Deep radioulnar ligaments attach to fovea - primary DRUJ stabilizers
- Superficial fibers attach to ulnar styloid (less important for stability)
- Dorsal RUL taut in pronation, palmar RUL taut in supination
Palmer Classification (Most Tested):
- Type 1A = Central perforation (traumatic, avascular, debride only)
- Type 1B = Ulnar avulsion (traumatic, vascular, MUST repair for DRUJ stability)
- Type 1C = Distal avulsion of ulnocarpal ligaments
- Type 1D = Radial avulsion from sigmoid notch
- Type 2 = Degenerative (progressive stages A through E with arthritis)
Clinical Examination:
- Foveal sign = 95% sensitivity (most reliable clinical test)
- Located in soft spot between FCU and ulnar styloid
- DRUJ stability tested in neutral, pronation, supination (compare to opposite)
- Press test = push up from chair with palms down
- Supination lift test = lift heavy table with supinated forearms
Imaging:
- PA radiograph in neutral rotation for ulnar variance measurement
- Each 1mm positive variance increases ulnar load by 10%
- MR arthrography = gold standard (91% sensitivity, 98% specificity)
- Arthroscopy = true gold standard (diagnostic and therapeutic)
- Grip view PA may unmask dynamic positive variance
Treatment Principles:
- Central tears (1A) = debride (avascular, cannot heal)
- Peripheral tears (1B) = repair essential (vascular, restores DRUJ stability)
- Preserve peripheral 2mm during debridement (contains RU ligaments)
- Positive UV (greater than 2mm) requires ulnar shortening for degenerative tears
- Immobilization after repair = 6 weeks minimum in neutral rotation
Ulnar Variance Pearls:
- Positive UV associated with degenerative TFCC tears (Type 2)
- Negative UV associated with Kienbock disease (lunate AVN)
- Ulnar shortening removes 2-4mm to achieve neutral/slight negative
- Shortening addresses mechanical cause of impaction
- Debridement alone for Type 2 tears has high failure without addressing UV
Outcomes:
- Debridement (Type 1A) = 70-90% success for small tears
- Peripheral repair (Type 1B) = 80-90% success
- Ulnar shortening + debridement = 85-90% success for Type 2C
- Acute injuries (under 6 months) have better outcomes than chronic
- Failure rate of repair = 10-20% (may need revision)
Common MCQ Stems and Answers
Scenario: Ulnar wrist pain after fall, positive foveal sign, DRUJ unstable. MRI shows peripheral TFCC tear.
- Answer: Palmer Type 1B requiring repair (not debridement) to restore DRUJ stability
Scenario: Central TFCC perforation, DRUJ stable, failed 3 months conservative treatment.
- Answer: Arthroscopic debridement, preserve peripheral 2mm
Scenario: 55-year-old with chronic ulnar pain, 3mm positive UV, lunate chondromalacia, TFCC perforation on MRI.
- Answer: Palmer Type 2C, requires ulnar shortening osteotomy + arthroscopic debridement
Scenario: Which structure is the primary stabilizer of the DRUJ?
- Answer: Deep fibers of dorsal and palmar radioulnar ligaments (not ECU, not superficial fibers)
Scenario: What percentage of axial load is transmitted through TFCC?
- Answer: 20% (NOT 50%, common distractor)
Scenario: Most sensitive clinical test for TFCC tear?
- Answer: Foveal sign (95% sensitivity), NOT press test or supination lift test
Scenario: Why can't you repair a Type 1A central tear?
- Answer: Avascular zone has no healing potential (sutures would not integrate)
Scenario: How long immobilization after peripheral TFCC repair?
- Answer: 6 weeks minimum in neutral rotation (NOT 2-4 weeks)
Scenario: What imaging modality has highest sensitivity for TFCC tears?
- Answer: MR arthrography (91% sensitivity) is best non-invasive; arthroscopy is true gold standard
Scenario: Patient with TFCC repair now has DRUJ instability. What structure likely failed?
- Answer: Foveal attachment of deep radioulnar ligaments
Key Differentials and Pitfalls
TFCC vs LT Ligament Tear:
- TFCC = Ulnar-sided pain, DRUJ instability, foveal sign positive
- LT tear = Midcarpal pain, lunotriquetral ballottement positive, may coexist
Type 1B vs Type 1D:
- 1B = Ulnar avulsion (most common, MUST repair)
- 1D = Radial avulsion (less common, repair only if unstable)
Positive vs Negative Ulnar Variance:
- Positive UV = TFCC degeneration, ulnocarpal impaction, Type 2 tears
- Negative UV = Kienbock disease (lunate AVN), Type 1 tears more common
Debridement vs Repair:
- Central location (1A) = Debride
- Peripheral location (1B/D) = Repair
- DRUJ unstable = Repair mandatory (even if tear is small)
Arthroscopic vs Open:
- Both have similar outcomes when done appropriately
- Open better for foveal avulsion requiring bone anchor
- Arthroscopic preferred for standard peripheral tears
Australian Context
TFCC injuries are common in Australian manual laborers and athletes, with significant implications for workers' compensation claims. Wrist arthroscopy services are widely available across metropolitan and regional centers for both diagnostic and therapeutic procedures.
Imaging access varies across Australia. Standard MRI is readily available in most centers, though MR arthrography (the gold standard for TFCC tears) is primarily limited to major tertiary centers and specialist musculoskeletal imaging practices. Public hospital waiting times can range from 4-12 weeks, while private imaging is usually available within days.
Workers' compensation claims for TFCC injuries require careful documentation of mechanism, chronicity, and pre-existing conditions. Positive ulnar variance on X-ray may indicate degenerative changes predating the claimed injury, affecting claim acceptance. Return to work timelines vary significantly - office workers may return within 4-8 weeks post-debridement, while heavy manual laborers often require 6-9 months after repair procedures.
Hand therapy is essential for optimal outcomes and is well-established across Australia. Most patients require 8-12 supervised therapy sessions post-surgery with additional home exercise programs. Occupational therapy assessment for workplace modifications is important for manual workers returning to duty after TFCC surgery.
TFCC Injuries
High-Yield Exam Summary
Anatomy & Function
- •TFCC = DRUJ stability + load transmission (20%)
- •Central 80% avascular (debride only)
- •Peripheral 15-20% vascular (can repair)
- •Deep fibers of RUL are primary stabilizers
Palmer Classification
- •1A = Central perforation → debride
- •1B = Ulnar avulsion → MUST repair (DRUJ stability)
- •1C = Distal avulsion, 1D = Radial avulsion
- •Type 2 = Degenerative (address ulnar variance)
Clinical Tests
- •Foveal sign = 95% sensitive (soft spot test)
- •DRUJ stability in neutral, pronation, supination
- •Hook test = peripheral detachment
- •Press test = pain loading extended wrist
Treatment Principles
- •Central = debride, Peripheral = repair
- •Preserve peripheral 2mm in debridement
- •Positive UV greater than 2mm → ulnar shortening
- •Immobilize repair 6 weeks in neutral rotation
Key Numbers
- •Each 1mm positive UV = 10% more ulnar load
- •80-90% success with Type 1B repair
- •6 weeks immobilization post-repair
- •20% of axial load through ulna (80% radius)