Lesión del complejo fibrocartilaginoso triangular de la muñeca

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview¶

• Acute TFCC injuries require differentiation between those causing distal radioulnar joint instability and those that do not [1].
• Management of acute TFCC injuries ranges from nonsurgical immobilization to arthroscopic or open surgical repair depending on the specific injury pattern and stability [1].
• Arthroscopic-assisted repair techniques provide detailed visualization and facilitate the repair of TFCC injuries and associated pathologies with minimally invasive techniques [6].
• The diagnosis, classification, and treatment options for TFCC injuries include open and arthroscopic techniques [3].
• Surgical treatment of TFCC tears and concomitant pathology in the pediatric and adolescent population results in decreased pain, improved motion and stability, and excellent functional outcomes in the majority of patients [4].
• About 40% of patients sustaining a TFCC tear without distal radioulnar joint instability still had pain and disability at 1 year [5].
• Arthroscopic treatment of TFCC lesions leads to satisfactory functional outcomes [7].
• TFCC repair varies substantially from surgeon-to-surgeon, suggesting repairs are discretionary and preference sensitive [10].
• TFCC repair achieves good clinical outcomes with low complication rates [14].
• There was no statistical difference in clinical outcomes after open versus arthroscopic TFCC repair [17].
• There is a current lack of high-quality evidence required to draw firm conclusions on the merits of arthroscopic versus open repair of 1B TFCC tears [28].
• In high-demand athletes, arthroscopic repair of TFCC tears is becoming the treatment of choice to obtain optimum physiologic strength, complete range of motion, stability, and the shortest possible postoperative period [41].

Anatomy & Pathophysiology¶

Anatomical Structures¶

• The triangular fibrocartilage complex (TFCC) consists of the triangular (articular) disc, lunotriquetral interosseus ligament, ulnocapitate ligament, ulnotriquetral ligament, volar distal radiolunar ligament, dorsal distal radioulnar ligament, ulnolunate ligament, and short radiolunate ligament [11].
• The TFCC is a group of interrelated anatomic structures that are integral to the stability of the distal radioulnar joint (DRUJ) [33].
• The TFCC acts as the primary stabilizer of the distal radioulnar joint during forearm rotation [40].
• The TFCC provides a smooth articular surface and partially absorbs axial load from the radiocarpal joint [40].
• The ulnar attachment of the TFCC is a three-dimensional complex consisting of proximal radioulnar ligaments, a distal hammock structure (centrally located fibrocartilage disk, meniscus homologue, and ulnocarpal ligaments), and a functional ulnar collateral ligament (UCL) [30].
• The functional ulnar collateral ligament (UCL) consists of the extensor carpi ulnaris (ECU) tendon subsheath and the thickened ulnar capsule [30].
• The distal hammock structure and the UCL are considered the distal component of the TFCC, while the radioulnar ligament represents the proximal component [30].
• The dorsal and volar radioulnar ligaments span from the dorsal and volar corners of the distal radius to a broad area of the fovea at the base of the ulnar styloid [30].
• A more superficial component of the radioulnar ligaments runs obliquely and distally to the ulnar styloid [30].
• The deep foveal components of the radioulnar ligaments are considered the true stabilizers of the DRUJ [30].
• Frank DRUJ instability can occur when the proximal foveal component is injured, even if the distal component remains intact [30].
• The ulnar styloid provides attachments for portions of the ulnocarpal ligaments, the ECU tendon sheath, and superficial limbs of the radioulnar ligaments [39].
• The deep limbs of the radioulnar ligaments insert into the fovea of the ulnar head [39].
• The tip of the ulnar styloid is devoid of soft tissue attachments [39].
• The outer 10% to 40% of the articular disk is well perfused and suggests a healing potential for injured areas upon repair [30].
• The central area of the TFCC is devoid of vascularity and unable to heal [11].
• The peripheral rim of the TFCC is well vascularized, akin to the meniscus within the knee [11].

Classification¶

• Palmer classification categorizes TFCC tears into traumatic (Class 1) or degenerative (Class 2) based on mechanism [11].
• Class 1A injuries are characterized by central perforation or tear of the TFCC [11].
• Class 1B injuries are characterized by ulnar avulsion with or without ulnar styloid fracture [11].
• Class 1C injuries are characterized by distal avulsion involving the origins of the ulnolunate and ulnotriquetral ligaments [11].
• Class 1D injuries are characterized by radial avulsion involving the dorsal and/or volar radioulnar ligaments [11].
• Class 2A degenerative tears are characterized by TFCC wear or thinning [11].
• Class 2B degenerative tears are characterized by TFCC wear plus lunate and/or ulnar chondromalacia [11].
• Class 2C degenerative tears are characterized by TFCC perforation plus lunate and/or ulnar chondromalacia [11].
• Class 2D degenerative tears are characterized by TFCC perforation, lunate and/or ulnar chondromalacia, and lunotriquetral ligament disruption [11].
• Class 2E degenerative tears are characterized by TFCC perforation, lunate and/or ulnar chondromalacia, lunotriquetral ligament disruption, and ulnocarpal and DRUJ arthritis [11].
• Estrella and Ho described a dorsal type of TFCC tear located at the junction of the dorsal radioulnar ligament and the joint capsule just radial to the ECU tendon subsheath [30].

Pathophysiology & Mechanisms¶

• Injuries to the TFCC typically occur with extension and pronation of the axially loaded wrist [30].
• The most common mechanism of TFCC injury is a fall on an outstretched hand [30].
• Traumatic radial-sided tears of the TFCC typically occur during acute rotational injuries of the forearm, most frequently during combined axial load with a distraction injury to the ulnar border [73].
• Repetitive forceful movement of the wrist from supination to pronation can cause overload stress affecting components of the TFCC [33].
• Degenerative TFCC tears occur as a result of chronic excessive loading through the ulnocarpal joint along with natural tissue degeneration associated with age [73].
• Cadaveric examinations observed TFCC perforations and chondromalacia of the ulnar head, lunate, and triquetrum in 30% to 70% of specimens [73].
• A fracture through the base of the ulnar styloid that disrupts both deep and superficial limbs of the TFCC is more predictive of DRUJ instability than fractures through the shaft or tip [39].
• Most ulnar styloid fractures do not cause DRUJ instability, partly due to the dual ulnar attachments of the TFCC [39].
• Complete avulsion of the radioulnar ligaments and gross instability can occur without an ulnar styloid fracture [39].
• A small fleck of bone avulsed from the fovea indicates disruption of the deep limbs of the radioulnar ligaments [39].
• Class 1D injuries are frequently associated with distal radius fractures and often respond to reduction of the radius [11].
• Class 1A tears are relatively common and may cause pain and mechanical symptoms such as clicking, but do not cause DRUJ instability [29].
• Class 1B injuries involve partial or complete avulsion of the TFCC from its ulnar attachments, with or without an ulnar styloid fracture [39].
• Class 1C tears involve the distal attachment of the articular disk to the lunate, triquetrum, and lunotriquetral ligaments [37].
• Complete tears of the ulnocarpal ligaments can result in ulnar carpal instability and/or volar translocation of the ulnar carpus in relation to the radius [37].
• Deep TFCC fiber tears may contribute to decreased wrist rotational positioning sense and have biomechanical importance in DRUJ stability [31].
• The TFCC is subjected to considerable axial loading and shear stresses and is frequently injured [30].

Classification¶

Palmer Classification System¶

• The Palmer classification categorizes TFCC disorders into two basic categories: traumatic (Class 1) and degenerative (Class 2) [11, 12].
• Class 1 traumatic lesions are subdivided into four types based on the specific location of the tear within the TFCC [11, 12].
• Class 2 degenerative tears are associated with ulnocarpal impaction syndrome [11, 12].
• The class and location of the tear have important implications for treatment [11, 12].

Class 1 (Traumatic) Subtypes¶

• Class 1A injuries are characterized by central perforation or tear [11, 12].
• Type 1-B injuries are defined as peripheral tears located at the ulnar end of the TFCC [56].

Class 2 (Degenerative) Subtypes¶

• Class 2A is characterized by TFCC wear or thinning [11, 12].
• Class 2B is characterized by TFCC wear plus lunate and/or ulnar chondromalacia [11, 12].
• Class 2C is characterized by TFCC perforation plus lunate and/or ulnar chondromalacia [11, 12].
• Class 2D is characterized by TFCC perforation, lunate and/or ulnar chondromalacia, and lunotriquetral ligament disruption [11, 12].
• Class 2E is characterized by TFCC perforation, lunate and/or ulnar chondromalacia, lunotriquetral ligament disruption, and ulnocarpal and DRUJ arthritis [11, 12].

Atzei-EWAS Treatment-Oriented Classification¶

• The Atzei-EWAS classification subdivides type 1-B TFCC tears into five classes based on treatment orientation [56, 66].
• Class 1 in the Atzei-EWAS system is defined as a reparable distal tear [56, 66].
• Class 2 in the Atzei-EWAS system is defined as a reparable complete tear [56, 66].
• Class 3 in the Atzei-EWAS system is defined as a reparable proximal tear [56, 66].
• Class 4 in the Atzei-EWAS system is defined as a non-repairable tear [56, 66].
• Class 5 in the Atzei-EWAS system is defined as tears associated with DRUJ arthritis [56, 66].
• The Atzei-EWAS classification allows differentiation between distal and proximal lesions involving the foveal insertions of the TFCC [66].
• The Atzei-EWAS classification allows differentiation between reparable and irreparable lesions [66].
• The European Wrist Arthroscopy Society (EWAS) endorsed the Atzei-EWAS classification [66].

Diagnostic and Imaging Considerations¶

• Arthroscopy is the gold standard for detection of TFCC tears [11, 12].
• The diagnostic accuracy of MRI remains lower compared to wrist arthroscopy for detailed classifications such as Atzei's classification of pc-TFCC tears [24].
• Diagnostic accuracy for TFCC injuries was highest for central TFCC injuries [27].
• Classification of central triangular fibrocartilage complex lesions as traumatic or degenerative depends on the information provided upon viewing the lesion at arthroscopy [18].
• The Melone classification system does not predict the presence of TFCC lesions [51].
• Frykman Type VI and VIII fractures show a significantly higher incidence of TFCC tears [51].
• The presence of an ulnar styloid fracture associated with a distal radius fracture predicted the presence of traumatic triangular fibrocartilage complex injury and TFCC 1B injury [15].
• 1B TFCC injury is the most common type in patients with distal radius fractures and concomitant TFCC injury [8].

Clinical Presentation¶

Symptoms and Physical Findings¶

• A TFCC injury should be suspected when an athlete presents with vague ulnar-sided wrist pain or tenderness, possibly associated with an audible or palpable click on forearm rotation [52].
• Careful history and physical examination are required to determine whether a TFCC tear is symptomatic [13].
• It is important to quantify the severity of symptoms related to TFCC pathology to determine whether surgical treatment is necessary [13].
• Clinical correlation with provocative signs on ulnar wrist is part of the preoperative evaluation for TFCC pathology [16].
• About 40% of patients sustaining a TFCC tear without distal radioulnar joint (DRUJ) instability still had pain and disability at 1 year [5].
• Deep TFCC fiber tear may contribute to decreased wrist rotational positioning sense [31].
• Deep TFCC fiber tear may have biomechanical importance in distal radioulnar joint stability [31].

Mechanisms and Associations¶

• Traumatic injuries of the TFCC may occur from fall or hyper-rotational injuries to the forearm [33].
• Repetitive forceful movement of the athlete’s wrist from supination to pronation can cause overload stress affecting components of the TFCC [33].
• Type 1B TFCC injury is most common in patients with distal radius fractures and concomitant TFCC injury [8].
• A higher frequency of accompanying extensor carpi ulnaris (ECU) tendon and/or DRUJ disorders was found in patients with chronic TFCC tears compared to a control group [38].

Diagnostic Imaging and Assessment¶

• There is a high rate of abnormal TFCC identified on MRI in patients without corresponding ulnar-sided wrist symptoms [22].
• MR arthrography is a more sensitive and specific method for the diagnosis of TFCC tears compared to conventional wrist MRI [36].
• In detailed classification of TFCC injuries, such as pc-TFCC tears classified by Atzei's classification, the diagnostic accuracy of MRI remains lower compared to wrist arthroscopy [24].
• Diagnostic accuracy was highest for central TFCC injuries [27].
• Load-bearing radioulnar (RaUl) measurement is a simple method to diagnose an unstable distal radioulnar joint in patients with TFCC injury [62].
• MRI of the wrist is used to check for edema of the lunate in cases of ulnar positive variance or suspected impaction [16].
• Checking ulnar variance is part of the preoperative evaluation for TFCC pathology [16].

Investigations¶

Clinical Examination¶

• The arthroscopic trampoline test assesses TFCC resiliency by balloting the central portion with a small probe [11].
• The arthroscopic hook test demonstrates peripheral detachment of the TFCC [11].
• The arthroscopic suction test can show laxity of the TFCC when peripherally scarred in or foveal detachment when the DRUJ is clinically unstable [11].
• A positive ulnar fovea sign is 90% sensitive and 88% specific in detecting a split tear of the ulnotriquetral ligament [42].
• Clinical correlation with provocative signs on the ulnar wrist is part of the preoperative evaluation for TFCC debridement [16].
• Checking ulnar variance is part of the preoperative evaluation for TFCC debridement [16].
• Radiographs are used to check ulnar variance and forearm alignment in the preoperative evaluation for TFCC reconstruction with tendon graft [25].
• X-ray of the wrist is used to rule out ulnar styloid fracture in the preoperative evaluation for Class 1B TFCC repair [42].

Imaging¶

• MRI is controversial for TFCC diagnosis, but newer innovations suggest value in detection and localization of TFCC pathology [11].
• The sensitivity, specificity, and accuracy of 3.0T wrist MRI for the TFCC are consistently higher compared with those of 1.5T wrist MRI [67].
• The presence of an abnormal TFCC on MRI may be of questionable clinical meaning because there is a high incidence of TFCC abnormalities in asymptomatic subjects, particularly those over the age of 50 [74].
• Ulnar-sided contrast leakage is more common in patients with peripheral TFCC injuries, making distinction between an atypical configuration of the prestyloid recess and actual leakage important in CT arthrography [72].
• MRI of the wrist is used to check for edema of the lunate in cases of ulnar positive variance or suspected impaction during preoperative evaluation [16].
• Diagnostic arthroscopy or high-resolution MRI is used to evaluate the potential for TFCC repair in the preoperative evaluation for reconstruction [25].
• A postoperative MRI helps to analyze the integrity of TFCC postrepair and adds to understanding of its natural course of healing [70].

Classification¶

• The Palmer classification categorizes TFCC injuries as traumatic (class 1) or degenerative (class 2) [11].
• Subtypes of TFCC injuries are based on the specific location within the TFCC [11].
• Class and location of the tear have important implications for treatment [11].
• Class 1A TFCC injuries are characterized by central perforation or tear [11].
• Class 1B TFCC injuries are characterized by ulnar avulsion with or without ulnar styloid fracture [11].
• Class 1C TFCC injuries are characterized by distal avulsion involving the origins of the ulnolunate and ulnotriquetral ligaments [11].
• Class 1D TFCC injuries are characterized by radial avulsion involving the dorsal and/or volar radioulnar ligaments [11].
• Class 2A degenerative TFCC tears are characterized by TFCC wear or thinning [11].
• Class 2B degenerative TFCC tears are characterized by Class 2A changes plus lunate and/or ulnar chondromalacia [11].
• Class 2C degenerative TFCC tears are characterized by TFCC perforation plus lunate and/or ulnar chondromalacia [11].
• Class 2D degenerative TFCC tears are characterized by Class 2C changes plus lunotriquetral ligament disruption [11].
• Class 2E degenerative TFCC tears are characterized by Class 2D changes plus ulnocarpal and distal radioulnar joint arthritis [11].
• Class 1B TFCC injury is the most common type in patients with distal radius fractures and concomitant TFCC injury [8].

Treatment¶

Non-Operative Management¶

• Acute TFCC injuries are initially managed with immobilization and NSAIDs [11].
• All Class 1 (acute traumatic) TFCC injuries are initially managed with immobilization and NSAIDs [12].
• Conservative management for acute traumatic TFCC tears includes rest, immobilization, antiinflammatory medications, and occasionally corticosteroid injection [29].
• TFCC injuries are managed initially using nonsurgical measures, including immobilization of the wrist and forearm, activity modification, and analgesics, for the first 2 or 3 months [30].
• Initial treatment for Class 1B injuries involves protective above-elbow immobilization for 4 to 6 weeks toward the forearm in neutral rotation [39].
• Nonoperative management of traumatic TFCC injuries with above-elbow immobilization is a viable treatment method, particularly in patients without DRUJ subluxation [69].
• Nonsurgical treatment is moderately successful for treating patients with TFCC tears without DRUJ instability [32].
• Approximately 40% of patients sustaining a TFCC tear without DRUJ instability still had pain and disability at 1 year [5].
• 46% of patients with avulsion of the TFCC from the fovea were pain-free after conservative treatment [30].
• Patients with ulnar-positive wrists may be less likely to respond to conservative management for Class 1A tears [29].

Indications for Surgery¶

• Surgical treatment is indicated for Class 1 TFCC injuries upon failure of nonoperative treatment [11].
• Indications for surgical intervention include specific ulnar-sided wrist pain not relieved by conservative management for 3 months, especially in the presence of symptomatic instability of the DRUJ [30].
• Surgery is indicated for Class 1B injuries with persistent symptoms or evidence of DRUJ instability [39].
• Arthroscopic TFCC debridement is indicated for acute traumatic Palmar type 1A TFCC tears that fail to respond to conservative treatment with splint and medication for more than 3 months [16].
• Arthroscopic TFCC debridement is indicated for degenerative central tears of the TFCC with ulnar neutral or negative variance that fail to respond to conservative treatment for more than 3 months [16].
• TFCC reconstruction with tendon graft is indicated for symptomatic DRUJ instability after neglected chronic TFCC injury, massive nonrepairable tear, or failed previous surgical repair [25].
• TFCC reconstruction with tendon graft is indicated for irreparable TFCC injuries with symptomatic DRUJ instability, neglected chronic injuries, or after suboptimal healing following nonoperative or surgical repair [26].
• Skeletal malalignment that may be responsible for DRUJ instability should be addressed concomitantly with TFCC reconstruction [26].
• Osteoarthritis of the DRUJ and axial instability of the forearm due to interosseous membrane injury are contraindications to TFCC reconstruction [26].

Operative Techniques: Debridement¶

• Class 1A (central) TFCC tears are treated with débridement if persistently symptomatic because this area of the TFCC is devoid of vascularity and unable to heal [11].
• A 2-mm peripheral rim should be maintained during debridement of Class 1A tears [11].
• The peripheral 2 to 3 mm of the TFCC must be preserved during debridement to protect the radioulnar ligaments [16].
• The peripheral 1 to 2 mm of the articular disc must be preserved during debridement to avoid injury to the radioulnar ligaments [29].
• Arthroscopic debridement alone appears to be an effective and safe initial treatment for patients with traumatic central TFCC tears [45].
• Resection of unstable flaps is sufficient during TFCC debridement when the remaining margins are smooth and stable [16].
• A thorough synovectomy of the ulnocarpal joint and DRUJ is essential for early pain control during TFCC debridement [16].
• Excessive use of RF energy during TFCC debridement can lead to thermal chondral damage [16].
• Overaggressive debridement can cause DRUJ instability [16].
• Failure to diagnose ulnar impaction syndrome may lead to continued pain following TFCC debridement [16].

Operative Techniques: Repair¶

• Class 1B (peripheral) TFCC tears are amenable to arthroscopic or open repair because the rim is well vascularized [11].
• Concurrent fractures of the ulnar styloid with persistent instability in Class 1B injuries are either excised or fixed [11].
• Class 1C (distal avulsion) TFCC tears are amenable to arthroscopic or open repair [11].
• Class 1D (radial avulsion) TFCC tears are frequently associated with distal radius fractures and often respond to reduction of the radius [11].
• Repair of a traumatic TFCC tear within 3 months of injury allows a patient to regain 80% of wrist ROM and grip strength [11].
• Current evidence demonstrates that TFCC repair achieves good clinical outcomes, with low complication rates [14].
• Arthroscopy is effective in obtaining both correct diagnosis and treatment of peripheral TFCC tear [21].
• Coexisting type 2 TFCC tears significantly increased the risk of index surgery failure in patients undergoing arthroscopic repair of peripheral ulnar-side TFCC tears [19].
• The combined HS and suture repair effectively restores stability to both the DRUJ and UCJ in patients with TFCC-related ulnocarpal instability, considerably reducing pain and preserving range of motion [64].
• Pediatric patients commonly have Palmer 1B (ulnar peripheral) tears, which are amenable to repair rather than solely débridement due to improved vascularity at the periphery [68].

Operative Techniques: Reconstruction and Salvage¶

• TFCC reconstruction with tendon graft aims to restore normal DRUJ kinematics by using a single tendon graft with uniform tension passed through the edges of the sigmoid notch and through the ulna at the foveal insertion site [26].
• The radial tunnel for TFCC reconstruction should be kept under 2.5 mm to reduce the risk of fracture and promote ingrowth [25].
• The ulnar tunnel for TFCC reconstruction should be kept under 3.5 mm to reduce the risk of fracture and promote ingrowth [25].
• The radial tunnel for TFCC reconstruction should be kept 5 mm away from the lunate sigmoid fossae to avoid fracture [25].
• Fracture of the sigmoid notch or lunate facet is a pitfall if the radial tunnel is too close to the joint line during TFCC reconstruction [25].
• Fracture of the ulnar styloid is a pitfall if the ulnar tunnel is too wide or too distal during TFCC reconstruction [25].
• Nonly placement of the ulnar tunnel leads to loss of rotation motion during TFCC reconstruction [25].
• A narrow ulnar tunnel may cause binding of the tendon graft and failure of tensioning during TFCC reconstruction [25].
• Postoperative care for TFCC reconstruction involves a reverse sugar tong cast with forearm in neutral rotation, changing to a splint after 3 weeks, allowing full active forearm rotation after 6 weeks, and passive motion after 8 weeks [25].
• Hemiresection or interposition arthroplasty maintains the ulnar insertion of the TFCC and prevents radioulnar impingement by soft tissue interposition [11].
• The Sauvé-Kapandji procedure involves DRUJ arthrodesis with creation of a proximal pseudarthrosis at the ulnar neck [11].
• Ulnar head or total joint implant arthroplasty maintains the relationship between the radius and the ulna [11].
• Results of ulnar head or total joint implant arthroplasty show good pain relief at the risk of ulnar head instability, aseptic loosening, and no appreciable change in pronosupination compared to preoperative values [11].
• One-bone forearm fusion represents the ultimate salvage operation for persistent pain or complications by fusing the proximal ulna to the distal radius shaft [11].

Complications¶

• Coexisting type 2 TFCC tears significantly increased the risk of index surgery failure in patients undergoing arthroscopic repair of peripheral ulnar-sided TFCC tears [19].
• Patients with chronic TFCC tears have a higher frequency of accompanying extensor carpi ulnaris tendon and/or distal radioulnar joint disorders compared to a control group [38].

Recovery¶

• In the first year after open TFCC reinsertion, 91% of the patients returned to work, including 50% within 12 weeks [76].
• Disability outcomes were worse in patients with distal radial fracture where TFCC was injured [71, 75].

Key Evidence¶

• [L5] Acute TFCC injuries require differentiation between those causing distal radioulnar joint instability and those that do not, with management ranging from nonsurgical immobilization to arthroscopic or open surgical repair depending on the specific injury pattern and stability. [1] (10.5435/00124635-200806000-00004)
• [L5] The article reviews diagnosis, classification, and treatment options including open and arthroscopic techniques for TFCC injuries. [3] (10.1016/j.hcl.2010.07.003)
• [L4] Surgical treatment of TFCC tears and concomitant pathology in the pediatric and adolescent population results in decreased pain, improved motion and stability, and excellent functional outcomes in the majority of patients. [4] (10.1016/j.jhsa.2019.06.019)
• [L4] About 40% of patients sustaining TFCC tear without DRUJ instability still had pain and disability at 1 year. [5] (10.1016/j.jhsa.2018.06.064)
• [L5] Arthroscopic-assisted repair techniques have revolutionized surgical management, providing detailed visualization and facilitating the repair of TFCC injuries and associated pathologies with minimally invasive techniques. [6] (10.1016/j.jhsg.2024.03.011)
• [L4] Arthroscopic treatment of TFCC lesions leads to satisfactory functional outcomes. [7] (10.1055/s-0039-3400454)
• [L3] 1B TFCC injury is most common in patients with DRF and concomitant TFCC injury. [8] (10.1186/s13018-023-04438-5)
• [L4] TFCC repair varies substantially from surgeon-to-surgeon, suggesting repairs are discretionary and preference sensitive. [10] (10.1055/s-0038-1625953)
• [L4] Careful history and physical examination are required to determine whether a TFCC tear is symptomatic, and it is important to quantify the severity of symptoms related to TFCC pathology to determine whether surgical treatment is necessary. [13] (10.5435/jaaos-d-20-00998)
• [L4] Current evidence demonstrates that TFCC repair achieves good clinical outcomes, with low complication rates. [14] (10.1055/s-0040-1718913)
• [L4] The presence of ulnar styloid fracture associated with distal radius fracture predicted the presence of frequently occurring traumatic triangular fibrocartilage complex injury and TFCC 1B injury. [15] (10.1016/j.arthro.2020.05.025)
• [L3] There was no statistical difference in clinical outcomes after open versus arthroscopic TFCC repair. [17] (10.1016/j.jhsa.2008.01.020)
• [L2] Classification of central triangular fibrocartilage complex lesions as traumatic or degenerative depends on the information provided upon viewing the lesion at arthroscopy. [18] (10.1177/1753193416684658)
• [L4] However, coexisting type 2 TFCC tears significantly increased the risk of index surgery failure in these patients. [19] (10.1016/j.arthro.2020.05.012)
• [L4] Arthroscopy is effective in obtaining both correct diagnosis and treatment of peripheral TFCC tear. [21] (10.2174/1874325001711010525)
• [L4] There is a high rate of abnormal TFCC identified on MRI in patients without corresponding ulnar-sided wrist symptoms. [22] (10.1177/15589447241277846)
• [L4] In more detailed classification of TFCC injuries, such as pc-TFCC tears classified by Atzei's classification, the diagnostic accuracy of MRI remains lower compared to wrist arthroscopy. [24] (10.1186/s12891-023-07140-z)
• [L1] Diagnostic accuracy was highest for central TFCC injuries. [27] (10.1055/s-0038-1629911)
• [L4] This SR demonstrates a current lack of high-quality evidence required to draw firm conclusions on the merits of arthroscopic versus open repair of 1B TFCC tears. [28] (10.1177/1558944718815244)
• [L3] Deep TFCC fiber tear may contribute to decreased wrist rotational positioning sense and may have biomechanical importance in distal radioulnar joint stability. [31] (10.1016/j.jhsa.2018.01.022)
• [L3] Nonsurgical treatment is moderately successful for treating patients with TFCC tears without DRUJ instability. [32] (10.1097/corr.0000000000000533)
• [L5] [33] (10.1016/j.csm.2019.12.008)
• [L3] MR arthrography is more sensitive and specific method in terms of the diagnosis of TFCC tears compared to conventional wrist MRI. [36] (10.1016/j.injury.2019.07.032)
• [L3] We found a higher frequency of accompanying ECU tendon and/or DRUJ disorders in patients with chronic TFCC tears as compared to the control group. [38] (10.1016/j.jhsa.2016.07.040)
• [Paper] [40] (10.1055/s-0040-1713580)
• [L4] In high-demand athletes, arthroscopic repair of TFCC tears is becoming the treatment of choice to obtain optimum physiologic strength, complete range of motion, stability, and the shortest possible postoperative period. [41] (10.1016/j.hcl.2009.05.011)
• [L3] Arthroscopic debridement alone appears to be an effective and safe initial treatment for patients with traumatic central TFCC tears. [45] (10.1302/0301-620x.106b4.bjj-2023-0642.r3)
• [L3] The Melone classification system does not predict the presence of TFCC lesions, while Frykman Type VI and VIII fractures show a significantly higher incidence of TFCC tears. [51] (10.1177/1753193408090106)
• [L5] [52] (10.1016/j.hcl.2012.05.014)
• [L5] [56] (10.1177/1753193409100120)
• [L2] Load-bearing RaUl measurement is a simple method to diagnose an unstable distal radioulnar joint in patients with TFCC injury. [62] (10.1016/j.jhsa.2022.01.008)
• [L4] The combined HS and suture repair effectively restores stability to both the DRUJ and UCJ in patients with TFCC-related ulnocarpal instability, considerably reducing pain and preserving range of motion. [64] (10.1016/j.jhsg.2025.100806)
• [L4] [66] (10.1055/s-0035-1544226)
• [L3] The sensitivity, specificity, and accuracy of 3.0T wrist MRI for the TFCC is consistently higher compared with those of 1.5T wrist MRI, suggesting improved capability for detection of TFCC injuries. [67] (10.1016/j.jhsa.2008.02.028)
• [L5] [68] (10.5435/jaaos-d-21-01029)
• [L3] Nonoperative management of traumatic TFCC injuries with above-elbow immobilization is a viable treatment method, particularly in patients without DRUJ subluxation. [69] (10.1302/0301-620x.103b8.bjj-2020-2310.r2)
• [L5] A postoperative MRI as a noninvasive tool helps to analyze the integrity of TFCC postrepair and adds to our understanding on the natural course of its healing. [70] (10.1016/j.eats.2025.103568)
• [L2] Disability outcomes were worse in patients with distal radial fracture where TFCC was injured. [71] (10.1016/j.jht.2017.09.002)
• [L4] Since ulnar-sided contrast leakage is more common in patients with peripheral TFCC injuries, distinction between an atypical configuration of the prestyloid recess and actual leakage is important in CT arthrography of the wrist. [72] (10.1186/s12891-022-05241-9)
• [L4] [73] (10.1177/15589447221084125)
• [L3] The presence of an abnormal TFCC on MRI may be of questionable clinical meaning, because there is a high incidence of TFCC abnormalities in asymptomatic subjects, particularly those over the age of 50. [74] (10.1016/j.jhsa.2011.10.006)
• [L2] Disability outcomes were worse in patients with distal radius fracture where TFCC was injured. [75] (10.1016/j.jht.2017.09.012)
• [L3] In the first year after open TFCC reinsertion, 91% of the patients returned to work, including 50% within 12 weeks. [76] (10.1016/j.hansur.2021.03.012)

References¶

[1] Management of Acute Triangular Fibrocartilage Complex Injury of the Wrist. Journal of the American Academy of Orthopaedic Surgeons. 2008. DOI: 10.5435/00124635-200806000-00004

[3] Arthroscopic and Open Repair of the TFCC. Hand Clinics. 2010. DOI: 10.1016/j.hcl.2010.07.003

[4] Early Results of Surgical Treatment of Triangular Fibrocartilage Complex Tears in Children and Adolescents. The Journal of Hand Surgery. 2020. DOI: 10.1016/j.jhsa.2019.06.019

[5] The Natural Course of Triangular Fibrocartilage Complex Tear without Distal Radioulnar Joint Instability. The Journal of Hand Surgery. 2018. DOI: 10.1016/j.jhsa.2018.06.064

[6] Arthroscopic-Assisted Repair of the Triangular Fibrocartilage Complex. Journal of Hand Surgery Global Online. 2024. DOI: 10.1016/j.jhsg.2024.03.011

[7] Patient-Reported Outcomes following Arthroscopic Triangular Fibrocartilage Complex Repair. Journal of Wrist Surgery. 2019. DOI: 10.1055/s-0039-3400454

[8] Association between imaging parameter changes and triangular fibrocartilage complex injury after distal radius fractures. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-04438-5

[10] Variation in Repair of the Triangular Fibrocartilage Complex. Journal of Wrist Surgery. 2018. DOI: 10.1055/s-0038-1625953

[11] Miller S Review Of Orthopaedics. DISTAL RADIOULNAR JOINT, TRIANGULAR FIBROCARTILAGE COMPLEX, AND WRIST ARTHROSCOPY > 2. TFCC tears.

[12] Miller S Review Of Orthopaedics. SECTION 16 PATELLAR TRACKING IN TOTAL KNEE ARTHROPLASTY > DISTAL RADIOULNAR JOINT, TRIANGULAR FIBROCARTILAGE COMPLEX, AND WRIST ARTHROSCOPY > 2. TFCC tears.

[13] Open and Arthroscopic Triangular Fibrocartilage Complex (TFCC) Repair. Journal of the American Academy of Orthopaedic Surgeons. 2021. DOI: 10.5435/jaaos-d-20-00998

[14] Surgical Repair of Triangular Fibrocartilage Complex Tears: A Systematic Review. Journal of Wrist Surgery. 2020. DOI: 10.1055/s-0040-1718913

[15] The Presence and the Location of an Ulnar Styloid Fracture Associated With Distal Radius Fracture Predict the Presence of Triangular Fibrocartilage Complex 1B Injury. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2020. DOI: 10.1016/j.arthro.2020.05.025

[16] Green S Operative Hand Surgery. AUTHOR'S PREFERRED METHOD OF TREATMENT: ARTHROSCOPIC PARTIAL WRIST FUSION > Arthroscopic TFCC Debridement.

[17] Clinical Comparison of Arthroscopic Versus Open Repair of Triangular Fibrocartilage Complex Tears. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2008.01.020

[18] Diagnosing central lesions of the triangular fibrocartilage as traumatic or degenerative: a review of clinical accuracy. Journal of Hand Surgery (European Volume). 2017. DOI: 10.1177/1753193416684658

[19] What Is the Effect of the Ulnar‐Plus Variance on the Outcomes of Arthroscopic Repair of the Peripheral Ulnar‐Side Triangular Fibrocartilage Complex Tear?. Arthroscopy. 2020. DOI: 10.1016/j.arthro.2020.05.012

[21] Results of Arthroscopic Repair of Peripheral Triangular Fibrocartilage Complex Tear With Exploration of Dorsal Sensory Branch of Ulnar Nerve. The Open Orthopaedics Journal. 2017. DOI: 10.2174/1874325001711010525

[22] Incidental Triangular Fibrocartilage Complex Changes on Wrist MRI. HAND. 2024. DOI: 10.1177/15589447241277846

[24] Diagnostic value of MRI in traumatic triangular fibrocartilage complex injuries: a retrospective study. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-023-07140-z

[25] Green S Operative Hand Surgery. AUTHOR'S PREFERRED METHOD OF TREATMENT: ARTHROSCOPIC PARTIAL WRIST FUSION > Arthroscopic TFCC Reconstruction With Tendon Graft.

[26] Green S Operative Hand Surgery. AUTHOR'S PREFERRED METHOD OF TREATMENT: ARTHROSCOPIC PARTIAL WRIST FUSION > TFCC Reconstruction with Tendon Graft.

[27] TFCC Injuries: Meta-Analysis and Comparison of Diagnostic Imaging Modalities. Journal of Wrist Surgery. 2018. DOI: 10.1055/s-0038-1629911

[28] Open Versus Arthroscopic Repair of 1B Ulnar-Sided Triangular Fibrocartilage Complex Tears: A Systematic Review. HAND. 2019. DOI: 10.1177/1558944718815244

[29] Green S Operative Hand Surgery. Chronic Perilunate Instability (SL Plus LT Instability) > Palmer’s Classification of TFCC Lesions > Class 1A Tear.

[30] Green S Operative Hand Surgery. AUTHOR'S PREFERRED METHOD OF TREATMENT: ARTHROSCOPIC PARTIAL WRIST FUSION > TFCC Repair > Classification, Functional Anatomy, Clinical Features, and Indication for Repair.

[31] The Effect of Triangular Fibrocartilage Complex Tear on Wrist Proprioception. The Journal of Hand Surgery. 2018. DOI: 10.1016/j.jhsa.2018.01.022

[32] What is the Natural History of the Triangular Fibrocartilage Complex Tear Without Distal Radioulnar Joint Instability?. Clinical Orthopaedics & Related Research. 2018. DOI: 10.1097/corr.0000000000000533

[33] Ulnar-Sided Wrist Pain in the Athlete. Clinics in Sports Medicine. 2020. DOI: 10.1016/j.csm.2019.12.008

[36] Comparison between conventional MRI and MR arthrography in the diagnosis of triangular fibrocartilage tears and correlation with arthroscopic findings. Injury. 2019. DOI: 10.1016/j.injury.2019.07.032

[37] Green S Operative Hand Surgery. AUTHOR'S PREFERRED METHOD OF TREATMENT: ARTHROSCOPIC PARTIAL WRIST FUSION > Arthroscopic-Assisted Suture Anchor Technique (Atzei) > Arthroscopic Repair of Class IC TFCC Tears.

[38] The Factors Correlated with the Extensor Carpi Ulnaris Tendon and Distal Radioulnar Joint Disorder in Patients with Chronic Triangular Fibrocartilage Tears. The Journal of Hand Surgery. 2016. DOI: 10.1016/j.jhsa.2016.07.040

[39] Green S Operative Hand Surgery. Chronic Perilunate Instability (SL Plus LT Instability) > Palmer’s Classification of TFCC Lesions > Class 1B Tear.

[40] A Systematic Review and Analysis of Palmer Type I Triangular Fibrocartilage Complex Injuries: Outcomes of Treatment. Journal of Hand and Microsurgery. 2020. DOI: 10.1055/s-0040-1713580

[41] Repair of Arthroscopic Triangular Fibrocartilage Complex Tears in Athletes. Hand Clinics. 2009. DOI: 10.1016/j.hcl.2009.05.011

[42] Green S Operative Hand Surgery. AUTHOR'S PREFERRED METHOD OF TREATMENT: ARTHROSCOPIC PARTIAL WRIST FUSION > Arthroscopic Repair of Class 1B TFCC Tears.

[45] Prognostic factors for clinical outcomes after arthroscopic treatment of traumatic central tears of the triangular fibrocartilage complex. The Bone & Joint Journal. 2024. DOI: 10.1302/0301-620x.106b4.bjj-2023-0642.r3

[51] The Value of Plain X-Rays in Predicting TFCC Injury after Distal Radial Fractures. Journal of Hand Surgery (European Volume). 2008. DOI: 10.1177/1753193408090106

[52] Triangular Fibrocartilage Complex Injuries in the Elite Athlete. Hand Clinics. 2012. DOI: 10.1016/j.hcl.2012.05.014

[56] New trends in arthroscopic management of type 1-B TFCC injuries with DRUJ instability. Journal of Hand Surgery (European Volume). 2009. DOI: 10.1177/1753193409100120

[62] Load-Bearing Radioulnar Distances to Evaluate an Unstable Distal Radioulnar Joint in Patients With Triangular Fibrocartilage Complex Tears. The Journal of Hand Surgery. 2022. DOI: 10.1016/j.jhsa.2022.01.008

[64] Extensor Retinaculum Capsulorrhaphy and Suture Repair for Ulnocarpal and Distal Radioulnar Joint Instability: One-Year Results. Journal of Hand Surgery Global Online. 2025. DOI: 10.1016/j.jhsg.2025.100806

[66] Arthroscopic Foveal Repair of the Triangular Fibrocartilage Complex. Journal of Wrist Surgery. 2015. DOI: 10.1055/s-0035-1544226

[67] Diagnostic Comparison of 1.5 Tesla and 3.0 Tesla Preoperative MRI of the Wrist in Patients With Ulnar-Sided Wrist Pain. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2008.02.028

[68] Pediatric Ulnar-sided Wrist Pain: A Review of the Current Literature. Journal of the American Academy of Orthopaedic Surgeons. 2022. DOI: 10.5435/jaaos-d-21-01029

[69] Predictors for poor outcome for conservatively treated traumatic triangular fibrocartilage complex tears. The Bone & Joint Journal. 2021. DOI: 10.1302/0301-620x.103b8.bjj-2020-2310.r2

[70] Bucket‐Handle Tear of the Triangular Fibrocartilage Complex: Surgical Technique With Clinical and Radiologic Outcome. Arthroscopy Techniques. 2025. DOI: 10.1016/j.eats.2025.103568

[71] Outcomes of surgically treated distal radial fractures with associated triangular fibrocartilage complex injury. Journal of Hand Therapy. 2019. DOI: 10.1016/j.jht.2017.09.002

[72] Evaluation of prestyloid recess morphology and ulnar-sided contrast leakage in CT arthrography of the wrist. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05241-9

[73] Radial Sided Triangular Fibrocartilage Complex Tears: A Comprehensive Review. HAND. 2022. DOI: 10.1177/15589447221084125

[74] Prevalence of Triangular Fibrocartilage Complex Abnormalities on MRI Scans of Asymptomatic Wrists. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2011.10.006

[75] Outcomes of surgically treated distal radius fractures associated with triangular fibrocartilage complex injury. Journal of Hand Therapy. 2020. DOI: 10.1016/j.jht.2017.09.012

[76] Factors associated with return to work after open reinsertion of the triangular fibrocartilage. Hand Surgery and Rehabilitation. 2021. DOI: 10.1016/j.hansur.2021.03.012