TFCC Tear (Triangular Fibrocartilagenous Cartilage Complex)
What is a TFCC Tear?
Triangular FibroCartilage Complex (TFCC)- A short triangular shaped articular disc, plus ligament complex, on the ulnar or small finger side of the wrist. This complex connects the radius to the ulna. (See figure 1). This provides a continuous gliding surface across the entire distal face of the 2 forearm bones for flexion-extension and translational movements. The TFCC is considered the ‘wrist meniscus,’ because it functions much like the knee meniscus. When injured, it can cause ulnar wrist pain, popping and clicking.
There are different types of TFCC tears. TFCC tears may be traumatic (type 1) or degenerative (type 2). Traumatic TFCC tears usually occur from loading or twisting forces to the wrist, such as when falling onto an outstretched hand with the palm down (pronated) and the wrist extended. Degenerative TFCC tears typically result from chronic overloading of the wrist joint and may also occur in older individuals with thin disc cartilage. Occasionally there is concomitant Ulno-Carpal Impingement, where the ulna may “pinch” or abut against the lunate, this may require a surgical procedure (See Ulno-Carpal Impingement).
Figure 2 below illustrates 4 types of TFCC tears. A Degenerative Stellate Tear can be characterized by a thinning of the TFCC. A Flap tear is a portion of the TFCC that is easily turned back over on its self. Radial Tear is classified as a TFCC tear near the radial side of the forearm. Ulnar Tear is when the TFCC tears are located at the ulna side of the forearm.
SYMPTOMS: The most common sensations experienced with TFCC tear include clicking, popping, or pain on the ulnar or pinky side of the wrist. The wrist may also feel weakened. Swelling can occur on the ulnar side of the wrist and sometimes a small cyst will develop off of a chronic tear.
EXAM: A careful history and physical examination is critical to diagnosing a TFCC tear. The patient may have tenderness in response to gentle probing (palpation) of the wrist on the ulnar surfaces combined with ulnar deviation or rotating the forearm palm up or palm down can reproduce clicking, popping and pain symptoms. The position of using a hammer, turning a door knob or throwing a dart can also cause pain on the ulnar side of the wrist.
IMAGING: X-rays of the wrist are useful to rule out bone problems, such as, an ulnar styloid avulsion, fracture, distal radioulnar joint injury or lunotriquetral joint injury. X-rays can also help to identify an ulnocarpal impingement (See Ulno-Carpal Impingement). A tear in the TFCC is not apparent on an x-ray unless it is calcified abnormality; however, an x-ray is a very informative diagnostic tool for the surgeon to use.
MRI: Magnetic Resonance Imaging scan can be used as a diagnostic tool for predicting a TFCC tear, especially if combined with a dye injection of arthrogram into the wrist joint. A MRI arthrogram is a very useful tool to show the tear; however, not all TFCC tears seen on MRI arthrogram create symptoms. Therefore, it’s important that all diagnostic tools are combined with a thorough exam.
Treatment options vary with the individual’s symptoms, length of time of injury, and the severity of the injury. New or acute tears that are less than 4 weeks may be treated conservatively. Conservative management of TFCC injuries includes splinting for a period of time to reduce symptoms, avoidance of aggravating activities, and non-steroidal anti-inflammatory drugs, followed by progressive range of motion (ROM) and strengthening. However, if the patient’s symptoms are not alleviated in 4-6 weeks, surgical repair or debridement may be suggested.
Most patients with TFCC tears present to the office with subacute or chronic tears that they have had symptoms extending beyond a month or two. Conservative management tends to be ineffective for chronic and symptomatic injuries. Many of these patients may require a surgical procedure, wrist arthroscopy, to either trim out the torn fragment or repair the torn edges.
Wrist Arthroscopy, or placement of a small camera into the wrist joint is used to visually evaluate the wrist through very small incisions. Arthroscopy allows the surgeon to evaluate and treat the TFCC tears. Some patients will require an arthroscopic debridement or a trimming, much like trimming the meniscus in the knee. Some patients may require that their tear be sutured down to repair the torn edges. (See figure 3). Usually small incisions are utilized and Steri-Strips placed rather than sutures after surgery. A splint or brace is placed on the wrist for about ten days to allow swelling to go down and then a removable splint is placed for a period of time, often about a month while therapy is utilized to help progressively increase motion while allowing the trimmed TFCC to heal. Returning to work is tailored to specific work activities.
Some TFCC tears are combined with pinching of the TFCC between the ulna and the carpal bones on the small finger side of the wrist. An arthroscopic debridement of just the TFCC alone where there is ulnocarpal impingement present may not be successful and may require subsequent ulnar shortening to reduce the symptoms. Ulnar shortening is a procedure where a cut is made across the ulna and the ulna is shortened, and then fixed with a plate and screws. This surgical procedure decompresses the impingement site so that the TFCC and the ulnar bone are no longer being pinched against the carpal bones (See figure 4).
Post-op ulnar shortening requires a dorsal volar splint or brace for approximately ten days and often a cast or a removable brace is used again for another four to six weeks. It will often take approximately ten weeks for an ulnar shortening procedure to heal; in some cases it may take longer. X-rays are often taken at about the eight- to ten-week point to determine if the ulnar shortening is healed. In many cases, the plate is removed at a later date, often a year to two years later if it becomes bothersome, prominent or sensitive to the cold.
Each of these treatment options is very effective in correcting the issue presented. Our office providers will work with you to determine what is causing you problems and then make an informed decision on the best treatment option.