TFCC Tear

Georgios Panagopoulos MD | Orthopaedic Surgeon

Η ρήξη τρίγωνου χόνδρου ή ρήξη TFCC (Triangular Fibrocartilage Complex) είναι η μερική ή πλήρης βλάβη του τριγωνικού ινοχόνδρινου συμπλέγματος του καρπού, μιας σύνθετης ανατομικής δομής στην ωλένια πλευρά του καρπού που λειτουργεί ως κύριος σταθεροποιητής της κάτω κερκιδοωλένιας άρθρωσης και ως αποσβεστήρας φορτίων μεταξύ ωλένης και καρπικών οστών, προκαλώντας πόνο, αστάθεια και λειτουργικό περιορισμό του άνω άκρου.

What Is the TFCC?

The Triangular Fibrocartilage Complex (TFCC) is a complex anatomical structure located on the ulnar side of the wrist.

It consists of:

• a fibrocartilaginous disc
• ligaments
• tendon components
• capsular structures

Its main functions are:

• stabilization of the distal radioulnar joint (DRUJ)
• load transmission between the ulna and carpal bones
• contribution to grip strength and forearm rotation

More specifically, the triangular fibrocartilage complex consists of the following delicate anatomical structures:

• fibro-cartilaginous disc
• ulno-meniscal homologue
• dorsal and volar radio-ulnar ligaments
• ulnar collateral ligament
• extensor carpi ulnaris (ECU) tendon sub-sheath

What's a TFCC tear?

A TFCC tear is a partial or complete injury to one or more components of the triangular fibrocartilage complex, leading to:

• wrist pain
• instability
• wrist weakness

It is one of the most common causes of chronic ulnar-sided wrist pain.

In general, tears are also divided into central tears & peripheral tears. The topography of the tears affects the final treatment.

How is it caused?

🔹 Traumatic tears

Typically occur after:

• a fall on an outstretched hand
• sudden twisting of the wrist
• sports injuries (tennis, golf, CrossFit)
• work-related accidents

🔹 Degenerative tears

Associated with:

• age
• repetitive wrist loading
• positive ulnar variance

The difference in length between the radius and ulna, with the ulna being more often longer (positive ulnar variance), is also considered a predisposing factor for the occurrence of triangular cartilage tears.

The study of the blood supply of the triangular cartilage has shown that only 15%-20% is well vascularized, with the remaining portion being avascular, resulting in increased difficulty in healing, especially in central tears, i.e. those that are close to the radius.

Symptoms

Symptoms may be acute or insidious and include:

• Pain on the ulnar side of the wrist
• Pain during forearm rotation (pronation–supination)
• Clicking, catching, or popping sensations
• Weak grip strength
• Worsening pain with loading or weight-bearing on the wrist

Traumatic vs Degenerative Tears

Distinguishing between these two entities is clinically crucial:

Traumatic TFCC Tear	Degenerative TFCC Tear
Younger patients	Older patients
Sudden onset	Gradual onset
Better healing potential	Often associated with arthritis

Tears of the triangular cartilage are divided into traumatic and degenerative, i.e. the result of wear and tear over time. Traumatic tears are due to direct injury to the wrist and occur mainly in young people, who usually have significant sports activity. Degenerative tears appear after the age of 40, without a clear history of injury.

Diagnosis

Clinical exam

Diagnosis begins with a medical history and physical examination to assess range of motion, stability, and the presence of tenderness in the wrist. Plain radiographs are usually not diagnostic, and MRI is required to confirm the clinical diagnosis. In questionable cases, diagnostic arthroscopy may be required.

• Localized tenderness on the ulnar side
• Positive provocative tests (e.g., ulnar fovea sign, ballotment, piano key sign)
• Assessment of DRUJ stability

The pain is typically localized over the distal end of the ulna, in the area of ​​the triangular cartilage (fovea sign). It is reproduced in extreme positions of wrist rotation. The reproduction of pain in ulnar deviation is characteristic, as is the piano key sign, where reciprocating pressure on the distal end of the ulna reproduces the symptom. Comparison with the contralateral healthy wrist is of utmost importance.

Imaging

• MRI of the wrist: primary imaging modality
• MR arthrogram: increased sensitivity in selected cases

Wrist Arthroscopy

• Considered the gold standard
• Allows simultaneous diagnosis and treatment

Treatment of TFCC Tears

Conservative treatment

Indicated in:

• stable tears
• mild to moderate symptoms
• degenerative lesions without instability

Includes:

• immobilisation
• NSAIDS
• physiotherapy
• activity modification

⚠️ Persistent symptoms require reassessment.

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Surgical treatment

Surgical treatment is considered when:

• symptoms persist despite conservative management
• distal radioulnar joint instability is present
• he patient has high functional demands

Wrist arthroscopy may entail:

• debridement
• repair
• reattachment

🔧 When Is Surgery Indicated?

Surgical treatment is considered when:

• symptoms persist despite conservative management
• distal radioulnar joint instability is present
• he patient has high functional demands
• a traumatic tear occurs in a young, active individual
• anatomical factors contribute to ongoing TFCC overload

Wrist Arthroscopy – Treatment of Choice

Wrist arthroscopy is the preferred surgical technique for most TFCC tears.

It is:

• minimally invasive
• performed through small portals
• highly accurate
• associated with faster recovery

Types of Arthroscopic TFCC Procedures

🔹 Arthroscopic Debridement

Best suited for:

• degenerative tears
• central TFCC lesions
• stable distal radioulnar joint

Goals:

• removal of damaged tissue
• pain relief
• improved wrist motion

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🔹 Arthroscopic TFCC Repair

Indicated when:

• the tear involves the peripheral vascular zone
• distal radioulnar joint instability is present
• the tear is traumatic

Advantages:

• preservation of native anatomy
• restoration of stability
• superior long-term outcomes

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🔹 TFCC Reattachment

In selected cases, the TFCC must be:

• reattached to the ulna
• stabilized using sutures or anchors

This technique aims to:

• restore distal radioulnar joint stability
• eliminate the sensation of wrist looseness

When Are Additional Procedures Required?

🦴 Ulnar Shortening Osteotomy

In patients with:

• positive ulnar variance
• degenerative TFCC tears
• chronic ulnar-sided wrist pain

arthroscopy alone may be insufficient.

Ulnar shortening osteotomy:

• unloads the TFCC
• restores wrist biomechanics
• improves long-term outcomes

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🔹 Combined Procedures

In selected patients, TFCC surgery may be combined with:

• treatment of associated ligament injuries
• management of chondral damage
• correction of wrist instability

Postoperative Rehabilitation

• Short period of immobilization (procedure-dependent)
• Gradual restoration of motion
• Return to work: 4–6 weeks
• Athletes: individualized return-to-sport protocol

Early diagnosis is very important for a great outcome.

Postoperatively, immobilization of the wrist is applied for a period of 4-6 weeks and then a rehabilitation program is followed to restore wrist movement. Return to demanding sports activities is generally allowed in 4-6 months, but is individualized on a case-by-case basis.

Factors Affecting Outcome

• Type of TFCC tear
• Timing of surgery
• Appropriate surgical technique
• Compliance with rehabilitation

Key Facts – TFCC tears

• 🖐 Common cause of ulnar-sided wrist pain
• 🧠 Frequently overlooked or misdiagnosed
• 🧲 MRI helpful but not definitive
• 🔍 Arthroscopy is the diagnostic gold standard
• 🔧 Arthroscopic treatment yields high success rates

FAQs - Frequently Asked Questions