Updated: 5/3/2022

TFCC Injury

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  • 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
Flashcards (1)
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Questions (7)

(SBQ17SE.8) A 34-year-old right-hand-dominant squash player falls onto an outstretched hand during a qualifying match. Since this fateful match, he has had ulnar-sided wrist pain, decreased range of motion, and periodic clicking in his wrist. The physical exam finding in Figure A is noted, in which you are able to manipulate and easily translate the ulna against the radius. This finding is not present on his contralateral wrist. The deep portion of the injured ligamentous structure inserts on what anatomical landmark?

QID: 211193
FIGURES:

Ulnar styloid

23%

(432/1904)

Ulnar fovea

50%

(945/1904)

Dorsal radio-ulnar capsule

15%

(293/1904)

Dorsal oblique band of the interosseous membrane

11%

(201/1904)

Radial styloid

1%

(21/1904)

L 1 A

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(OBQ13.65) A 30-year-old male laborer sustained a right wrist injury 9 months ago. He continues to have symptoms of recurrent ulnar-sided wrist pain that impairs his ability to work. An MRI is performed and shows a triangular fibrocartilage complex (TFCC) injury. Which of the following is an indication to combine a Wafer procedure with arthroscopic TFCC debridement?

QID: 4700

Ulnar styloid fracture

2%

(135/5711)

Radial styloid fracture

0%

(24/5711)

2 mm of positive ulnar variance and ulnocarpal impingment

91%

(5196/5711)

2 mm of negative ulnar variance and radiocarpal joint arthritis

4%

(208/5711)

Scapholunate ligament injury

2%

(95/5711)

L 1 C

Select Answer to see Preferred Response

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(SBQ07SM.61) A 20-year-old park ranger trips and falls onto his right wrist with the wrist in extension and pronation. The local urgent care orders both radiographs and a CT, which you review and determine to be normal. The patient complains of ulnar-sided wrist pain. On exam, his tenderness is localized to the fovea. Ulnar deviation also causes him pain. There is no snapping sensation with wrist supination, flexion, and ulnar deviation. He otherwise has 5/5 strength to his first dorsal interosseous muscle with 4mm static two-point discrimination on the ulnar side of the 4th digit. Which of the following injuries is most likely responsible for his symptoms and exam?

QID: 1446

TFCC tear

89%

(1472/1650)

Ulnar styloid fracture

2%

(33/1650)

Hook of hamate fracture

4%

(65/1650)

Ulnar nerve injury in Guyon's canal

3%

(48/1650)

ECU subluxation

1%

(20/1650)

L 1 C

Select Answer to see Preferred Response

(SAE07SM.3) The most common mechanism of injury to the triangular fibrocartilage complex (TFCC) involves

QID: 8665

wrist extension and forearm pronation.

56%

(597/1060)

wrist extension and forearm supination.

15%

(164/1060)

wrist flexion and forearm pronation.

5%

(48/1060)

wrist flexion and forearm supination.

4%

(41/1060)

axial load in ulnar deviation.

19%

(204/1060)

L 4 E

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(SBQ07SM.3) A 19-year-old football player suffers a fall onto a pronated, extended wrist. He has pain with resisted ulnar deviation and is tender to palpation just distal to the ulnar styloid. He has no tenderness over the extensor carpi ulnaris (ECU) tendon. Current radiographs are shown in in Figures A and B and and MRI of the wrist is shown in FIgure C. Which of the following is the most likely diagnosis?

QID: 1388
FIGURES:

ECU tendon rupture

1%

(26/3452)

Triangular fibrocartilaginous complex (TFCC) tear

90%

(3112/3452)

Hook of hamate fracture

6%

(191/3452)

Scapholunate ligament injury

1%

(42/3452)

Perilunate dislocation

2%

(68/3452)

L 1 C

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(OBQ05.273) Which of the following structures is an anatomical component of the triangular fibrocartilage complex?

QID: 1159

Extensor carpi ulnaris tendon sheath

73%

(3692/5069)

Lunotriquetral interosseous ligament

8%

(418/5069)

Extensor digiti minimi tendon sheath

2%

(81/5069)

Radioscaphocapitate ligament

6%

(288/5069)

Flexor carpi ulnaris tendon sheath

11%

(557/5069)

L 1 C

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EXPERT COMMENTS (19)
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