Triangular Fibrocartilage Complex Injury

Aka: Triangular Fibrocartilage Complex Injury, TFCC Injury, Ulnar Complex Injury, Triangular Fibrocartilage Tear, Wrist Injury to Triangular Fibrocartilage

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II. Physiology

  1. Triangular Fibrocartilage Complex is a pad of connective tissue overlying distal ulna
    1. Originates at ulnar aspect of the radius
    2. Two layers
      1. Deep layer inserts on ulnar fovea at base of ulnar styloid (most important for stability)
      2. Superficial layer inserts on ulnar styloid process
    3. Components
      1. TFCC Disc
      2. Radioulnar ligaments
      3. Ulnar collateral ligament
      4. Ulnocarpal ligaments
  2. TFCC Roles
    1. Anchors articular disc between ulna and proximal Carpal Bones of the wrist
    2. Cushions weight-bearing forces while grasping
    3. Helps to stabilize the distal radial-ulnar joint

III. Pathophysiology: Mechanism of injury

  1. Types
    1. Acute Traumatic Injury
      1. Follows injury with hyperpronation and an axial load (e.g. Fall on an outstretched hand)
      2. Typically affects medial insertion of TFCC at radius
    2. Chronic degenerative changes
      1. Typically affects central TFCC
    3. Inflammatory conditions
  2. Examples
    1. Injury of wrist pronation in Skiing

IV. Symptoms

  1. Ulnar dorsal Wrist Pain

V. Signs

  1. Click may be perceived on Forearm rotation
  2. Weak grip strength

VI. Signs

  1. Tenderness over Ulnar complex triangle
    1. Triangle of tissue between ulnar and radius
  2. Provocative maneuvers
    1. Provocative range of motion planes (with pain limiting range of motion)
      1. Pronation and supination (may also result in a painful click at end points)
      2. Radial and ulnar wrist deviation
    2. Shuck Test positive for instability (excessive movement) or pain at radial-ulnar joint
    3. Radial-ulnar compression by squeezing
    4. Ulnocarpal compression
      1. Maximal ulnar deviation at full pronation and full supination
      2. High sensitivity but low Specificity

VII. Imaging

  1. Wrist XRay
    1. Typically normal in TFCC ligament tear
    2. Ulnar variance may be present where ulna appears longer than radius (PA View)
  2. MRI Wrist (definitive study)
    1. Preferred with intraarticular gadolinium for contrast (MR Arthrography)

VIII. Management

  1. Conservative Therapy (injuries >2 weeks old)
    1. Hand therapy
    2. NSAIDs
    3. Relative rest
  2. Splint Immobilization for acute injuries or refractory chronic injuries
    1. Cock-up Wrist Splint for 4-6 weeks
  3. Surgical repair in refractory cases

IX. References

  1. Titchner, Morris and Davenport (2021) Crit Dec Emerg Med 35(5): 17-23
  2. Moore (1997) AAFP Sports Medicine Conference, Lecture
  3. Morgan (1997) Am Fam Physician 55(3): 857-68 [PubMed]

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