Summary Triangular Fibrocartilage Complex (TFCC) Injuries, a common cause of ulnar-sided wrist pain, may result from trauma or due to degenerative changes. Diagnosis is made clinically with ulnar sided wrist pain that is worse with ulnar deviation and a positive "fovea" sign. An MRI can help confirm diagnosis. Treatment is generally conservative with NSAIDs and immobilization. Surgical debridement, TFCC repair or ulnar shortening procedures may be indicated depending on severity of symptoms and underlying cause. Etiology Mechanism of TFCC injury Type 1 traumatic injury mechanism most common is fall on extended wrist with forearm pronation traction injury to ulnar side of wrist traction injury to ulnar wrist Type 2 degenerative injury associated with positive ulnar variance associated with ulnocarpal impaction Anatomy TFCC made up of dorsal and volar radioulnar ligaments deep lig, known as ligamentum subcruentum, attach to the ulnar fovea superficial fibers attach to the ulnar styloid central articular disc meniscus homolog ulnar collateral ligament ECU subsheath origin of ulnolunate and ulnotriquetral ligaments Blood supply periphery is well vascularized (10-40% of the periphery) central portion is avascular Origin dorsal and volar radioulnar ligaments originate at the sigmoid notch of the radius Insertion dorsal and volar radioulnar ligaments converge at the base of the ulnar styloid deep fibers insert on to the ulnar fovea superficial fibers insert on the ulnar styloid Classification Class 1 - Traumatic TFCC Injuries 1A Central perforation or tear 1B Ulnar avulsion (without ulnar styloid fx) 1C Distal avulsion (origin of UL and UT ligaments) 1D Radial avulsion Class 2 - Degenerative TFCC Injuries 2A TFCC wear and thinning 2B 2A + Lunate and/or ulnar chondromalacia 2C 2B + TFCC perforation 2D 2C + Ligament disruption 2E 2D + Ulnocarpal and DRUJ arthritis Presentation Symptoms wrist pain turning a door key often painful Physical exam positive "fovea" sign tenderness in the soft spot between the ulnar styloid and flexor carpi ulnaris tendon, between the volar surface of the ulnar head and the pisiform 95% sensitivity and 87% specificity for foveal disruptions of TFCC or ulnotriquetral ligament injuries pain elicited with ulnar deviation (TFCC compression) or radial deviation (TFCC tension) Imaging Radiographs usually negative zero rotation PA view evaluates ulnar variance dynamic pronated PA grip view may show pathology Arthography joint injection shows extravasation MRI has largely replaced arthrography tear at ulnar part of lunate indicates ulnocarpal impaction sensitivity = 74-100% Arthroscopy most accurate method of diagnosis indicated in symptomatic patients after failing several months of splinting and activity modification Differential Ulnocarpal abutment syndrome Ulnar styloid impaction syndrome ECU tendonitis Hook of hamate fracture Ulnar tunnel syndrome Pisotriquetral arthritis Treatment Nonoperative immobilization, NSAIDS, steroid injections indications all acute Type I injuries first line of treatment for Type 2 injuries Operative arthroscopic debridement indications type 1A diagnostic gold standard arthroscopic repair indications type 1B, 1C, 1D best for ulnar and dorsal/ulnar tears generally acute, athletic injuries more amenable to repair than chronic injuries outcomes patient should expect to regain 80% of motion and grip strength when injuries are classified as acute (<3 months) ulnar diaphyseal shortening indications Type II with ulnar positive variance is > 2mm advantage of effectively tightening the ulnocarpal ligaments and is favored when LT instability is present Wafer procedure indications Type II with ulnar positive variance is < 2mm type 2A-C limited ulnar head resection indications type 2D Darrach procedure indications contraindicated due to problems with ulnar stump instability Techniques Arthroscopic debridement approach arthroscopic approach to the wrist performed through combination of 3-4 and 6R portal technique maintain 2 mm rim peripherally otherwise joint can become unstable pros & cons not effective if patient has ulnar positive variance 80% of patients obtain good relief of pain Arthroscopic repair approach arthroscopic approach to the wrist technique many techniques exist such as outside-in and inside-out generally suture based repair pros & cons only works for peripheral tears where blood supply is present patient immobilized for 6 weeks complications ECU tendonitis from suture knot dorsal sensory nerve injury Ulnar diaphyseal shortening approach dorsal approach to the forearm technique osteotomy of the diaphysis or metaphysis followed by plate fixation pros & cons can address > 2 mm ulnar variance requires immobilization and time for fracture healing can help tension the ulnocarpal ligaments complications nonunion hardware irritation necessitating removal Wafer procedure approach dorsal approach to the forearm technique ulnar cortex is not disrupted do not extend bone removal into the DRUJ pros & cons intrinsic stability of ECU, TFCC, and ulnar periosteum obviate need for plate fixation Limited ulnar head resection approach arthroscopic approach to the wrist technique removal of approximately 2-4 mm of bone under the TFCC distal ulnar burred through central TFCC defect pros & cons can be technically difficult to obtain level shortening through TFCC window only applicable when patient has < 2mm of ulnar variance Darrach procedure approach dorsal approach to the forearm technique resection of the distal 1-2cm of the distal ulna TFCC should be approximated to the wrist capsule pros & cons salvage procedure for pain relief only distal joint is unstable complications ECU tendon can sublux over remaining ulna causing pain