What is a TFCC tear?
The triangular fibrocartilaginous complex (TFCC) is a soft tissue structure located on the small (pinky) finger side of the wrist. It is the primary stabilizer to the wrist in pronation and supination (rotation). It also cushions and supports the small bones of the wrist, especially while the hand is gripping. An injury to the TFCC can cause chronic wrist pain, but, fortunately, successful treatment does not depend on chronicity of the injury, so patients with long-standing pain can often get better.
What are the symptoms of a TFCC tear?
TFCC tears cause pain on the “ulnar side” of the wrist, the side opposite the thumb. It sits directly on top of the ulna bone, the small bone in the forearm. The radius rotates around the ulna when you pronate (palm down) or supinate (palm up) the hand. The most common symptom of a TFCC tear is pain and weakness at end range supination, with grip, and when bearing weight on the affected arm. There also can be numbness and tingling radiating toward the small finger.
How do TFCC tears happen?
To understand a TFCC injury, you must first understand the different types of TFCC tears. The two principal types of tears are traumatic (Type I) and degenerative (Type II). A traumatic tear will often be the result of a fall on an outstretched hand, or a forced twisting injury, which can be caused by the catching of a drill, baseball, or hockey, among other things. Traumatic tears usually occur through the outside ligamentous portion of the TFCC. If you have an acute injury with significant pain, you should be seen as soon as possible because it is possible to treat this type of TFCC tear without surgery.
Degenerative or ‘wear and tear’ injuries (Type II) to the TFCC are more common. They can be associated with generalized wrist arthritis, an ulna bone that is too long, or old distal radius fractures. The cause of this type of TFCC tear is thought to be pressure from the ulna pushing up on the articular disc of the TFCC, ultimately causing injury.
How is a TFCC tear diagnosed?
A comprehensive history and physical examination of the injury are critically important for diagnosis. X-rays of both wrists are taken to check for any bony abnormalities, and MRI is also very helpful in making a diagnosis. Unfortunately, MRI is not perfect and can miss a TFCC tear, especially in those that have had the tear for a long time. However, MRI is helpful in ruling out other conditions of the wrist that can mimic a TFCC tear. Anyone undergoing wrist arthroscopy for the diagnosis of a TFCC tear should have an MRI.
How do we treat a TFCC tear?
Treatment depends on the type of tear.
- Traumatic tears:
- Acute: If a TFCC tear is suspected following an injury, an MRI is obtained to confirm the diagnosis and ensure there are no other If the injury is less than one to two weeks old, we can usually get the injury to heal without surgery. A long arm cast is used for a month to prevent rotation. A brace that limits rotation to a small arc is then used for another month. Depending on the sport and symptom level, a patient can return to activities at two to three months with the wrist taped.
- Chronic: A ‘wrist sprain’ that just hasn’t gotten better is the most common type of traumatic tear. Of course, the patient did not know they had a significant injury and may even have been to the ER and had normal x-rays. They may have worn a splint for a couple of These patients are treated with wrist arthroscopy and arthroscopic repair of the TFCC. They will also have to be prevented from rotating after surgery just like the non-operative patients. Surgical patients can’t return to sport for at least three months.
- Degenerative Tears.
- Patients with degenerative tears are treated according to other pathology that may be Most patients will have had pain for some time and will opt for surgical intervention. The difference in surgery for a degenerative tear is that the TFCC cannot be repaired. The portion that is injured in a degenerative tear is the center or avascular zone of the TFCC. This is treated much like a meniscal tear in the knee. We will use arthroscopic means to shave down the torn edges and decrease the mechanical catching that causes pain. Sometimes we can shave the tip of the ulna bone off if it is in the way. If the ulna bone is quite long, we may need to shorten the bone, although this is very rare.
Outcomes of TFCC injuries
Outcomes for nonsurgical acute casting of TFCC tears is excellent. Unfortunately, the only patients who are typically seen early enough for this type of treatment are high-level athletes. Surgical treatment for traumatic tears is generally better than degenerative tears. As in most orthopaedic injuries, younger patients do better than older patients. The good news is that it doesn’t matter how long a TFCC has been injured; surgery has been performed on patients who have had tears for more than eight years with excellent results.