Triangular Fibrocartilage Complex (TFCC) Injuries

The triangular fibrocartilage complex (TFCC) is a stabilizing and load-bearing structure in the wrist, located between the ulna, lunate, and triquetrum. Injuries to the TFCC are a common cause of ulnar-sided wrist pain and may be either acute or degenerative. This condition often occurs during forceful ulnar deviation or in cases of positive ulnar variance — when the ulna is longer than the radius¹–³.

Clinically Relevant Anatomy

The TFCC consists of several structures that together provide stability to the ulnar side of the wrist and the distal radioulnar joint (DRUJ):

• Triangular fibrocartilage disc (central, avascular portion)

• Ulnocarpal ligaments (ulnolunate and ulnotriquetral)

• Dorsal and volar radioulnar ligaments

• Meniscal homolog (meniscus-like structure)

• Subsheathe of the extensor carpi ulnaris (ECU) tendon

The TFCC attaches to the medial edge of the radius and the ulnar styloid process. The volar portion stabilizes against dorsal displacement of the ulna and tightens in pronation, while the dorsal portion resists volar displacement and tightens in supination⁴ ⁵.

TFCC injuries most commonly occur due to loading in ulnar deviation, particularly in the presence of positive ulnar variance. This can be congenital or secondary to radial shortening (e.g., post-fracture). Sports involving repetitive wrist compression or rotation, such as baseball, tennis, and gymnastics, increase the risk of injury² ⁷.

• Positive ulnar variance increases stress on the TFCC, especially in pronation

• Acute injury may occur due to twisting or direct trauma to the wrist

• ECU tendon changes may lead to secondary strain on the TFCC²

Clinical Presentation

Patients with TFCC injuries typically report:

• Ulnar-sided wrist pain aggravated by activity

• Clicking, instability, or weakened grip strength

• Point tenderness between the pisiform and ulnar head

• Pain during loading, lifting, or rotation

Acute injuries are common in baseball players after an incorrect swing or falls on an extended wrist. Chronic overuse injuries are frequently seen in gymnasts, tennis players, and manual workers.

Diagnostic Evaluation

Physical Examination

Palpation is best performed in pronation, between the flexor carpi ulnaris, ulnar styloid, and pisiform. Relevant clinical tests include:

• TFCC compression test: ulnar deviation in neutral forearm → pain

• TFCC stress test: compression of ulna in ulnar deviation → pain

• Press test: patient lifts from a chair with extended wrist → pain

• Supination test: patient grips under a table → dorsal impingement pain

• Piano key sign: ulnar prominence at rest → DRUJ instability

• Grind test: rotation with compression → pain in degenerative TFCC injury²

Imaging

• X-ray: may show ulnar styloid avulsion, radial fracture, volar angulation of lunate/triquetrum, or ulnar variance

• Triple-contrast arthrography: limited specificity, can detect tears

• MRI: high sensitivity and specificity for TFCC injuries; useful in degenerative or unclear cases

• Arthroscopy: considered the gold standard for definitive diagnosis

Outcome Measures

• DASH / QuickDASH

• Modified Mayo Wrist Score

• ADL function scales

  
  

Treatment

Conservative Management

For stable injuries without distal radioulnar joint (DRUJ) instability:

• Rest and avoidance of provocative activities (grip, rotation, ulnar deviation)

• Immobilization with a splint (3–6 weeks)

• NSAIDs and, if needed, corticosteroid injections

• Referral to a hand therapist for follow-up and rehabilitation¹⁰

If symptoms do not improve within 6 months, surgical intervention should be considered.

Surgical Management

Surgery is indicated in cases of:

• Persistent symptoms despite conservative management

• DRUJ instability

• Palmer class 1 injury (traumatic tears)

Common surgical procedures include:

• Arthroscopic debridement – induces bleeding to stimulate healing; suitable for central tears

• TFCC repair – performed in peripheral or ligamentous tears

• Ulnar shortening / wafer procedure – used in positive ulnar variance

• Open surgery – for complex or degenerative injuries

Postoperative Rehabilitation

Type 1 injuries (traumatic):

• Immobilization for 1 week → then initiate ROM exercises

• Light athletic activity allowed after 3 weeks

• Full return to sports (e.g., tennis, golf) after 4–6 weeks¹⁴

• In more severe cases: Muenster cast for 4 weeks → followed by removable splint (4–8 weeks)

Example of a rehabilitation protocol:

Timeline	Goals	Interventions
0–2 weeks	Protect joint, reduce pain & swelling	Sugar-tong or long-arm splint, elevation, ice, finger & shoulder mobility
2–6 weeks	Increase ROM, scar management	Removable splint, gentle elbow/wrist motion, avoid loading
6–8 weeks	Improve strength & mobility	Isometric strengthening, full AROM, cross-friction massage
8–12 weeks	Active training	Eccentric grip exercises, coordination drills, isometric grip in neutral
3 months +	Return to sport/work	Graded pain-free training, proprioception, balance, stability

Manual Therapy and Mobilization

• Radiocarpal traction: for pain in flexion

• Volar glide: to improve extension

• Radial/ulnar glide: for deviation mobility

• Soft tissue therapy: scar mobilization and prevention of ECU tendinopathy

General Exercises

• Wrist rotations

• Pronation and supination training

• Radial and ulnar deviation

• Stretching and mobility in flexion/extension

Strength Training

• Flexion and extension with dumbbells or resistance bands

• Pronation and supination against resistance

• Eccentric grip training

• Isometric strengthening in neutral position

Special focus:

• Unilateral isometric exercises – shown to have bilateral effects by enhancing neuromuscular control

• Pronator quadratus activation in supination – improves DRUJ stability pre- and postoperatively²⁹

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Differential Diagnoses

• Hypothenar hammer syndrome: vascular disorder, confirmed with angiography

• Ulnar carpal impingement: often occurs after surgical ulnar shortening

• Tendon irritation: pain worsens with muscle activation

• DRUJ osteoarthritis or cartilage lesion: detected radiologically

• Ulnar styloid impingement: TFCC remains intact but pain occurs upon contact

Conclusion

TFCC injuries are a frequent cause of ulnar-sided wrist pain, especially in athletes and manual workers. Accurate diagnosis and early conservative management provide the best prognosis. If symptoms persist, surgical treatment should be considered, followed by structured rehabilitation. Multidisciplinary collaboration between physicians, physiotherapists, and hand therapists is crucial for optimal follow-up and restoration of wrist function².

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