The triangular fibrocartilage complex (TFCC) is the primary stabilizer of the ulnar aspect of the wrist. It is composed of the triangular fibrocartilage and the ulnocarpal ligaments. The TFCC functions both as a ligament and a load bearing spacer. The peripheral portion of the complex consists of ligaments originating from the sigmoid notch of the radius and inserting into the ulna. These provide stabilization for the radioulnar joint. They are vascular and have the capability to heal if surgically repaired. The central portion is composed of fibrocartilage and functions to transmit compressive loads from the carpus to the ulnar head. This area of the complex is avascular and not capable of healing if injured.
Treatment of TFCC pathology is dictated largely by which function of the complex has been affected. TFCC injuries can be classified as either traumatic or degenerative. Traumatic injures are often referred to as Type I injuries whereas degenerative injuries are often referred to as Type 2. Degenerative injuries are commonly the result of repetitive compressive forces on the central portion due to forceful use of the hand. Over time, this causes progressive destruction of the central (avascular) portion of the cartilage as well as degenerative changes on either side. Degenerative injuries generally follow a sequence of TFCC thinning with progression to chondromalacia (cartilage wear) of the adjacent ulna and lunate followed by TFCC perforation with chondromalacia of the ulna and lunate. Next, a lunotriquetral (LT) tear may occur and finally perforation of the TFCC w/ arthritis of the ulna and lunate along with a LT ligament tear. Injuries involving a rotational torque of the distal radioulnar joint (DRUJ), such as a fall on an outstretched hand is usually the cause of traumatic TFCC injuries.
Treatment of TFCC pathology is frequently dictated by pain reported by the patient. The pain is based on the ulnar side of the wrist and generally increases with activities requiring forceful grip with wrist flexion and ulnar deviation. Individuals often report pain with activities such as pouring, shaking hands or cutting food. Frequently the pain is caused by instability in the ulnocarpal or radiocarpal wrist joints (usually due to trauma) or from the LT joint (degenerative injuries) or from progressive degenerative changes between the ulna and lunate. Traumatic injuries are treated by arthroscopic debridement (central tears), ligamentous repair or immobilization.
Many patients with distal radius fractures report pain on the ulnar side of the wrist where it was not fractured. This is often due to an avulsion of the TFCC off of the sigmoid notch of the ulna sustained during the initial injury. These are treated with immobilization as the primary focus of treatment is the distal radius fracture. Degenerative injuries are generally not treated until there is bone involvement of the joint surfaces at the DRUJ. These injuries as well as central tears are treated with debridement. More advanced tears involving the LT ligament will present with increased pain and may require LT fusion or ulnar shortening in addition to debridement. Non operative management of all TFCC injuries strives to rest the DRUJ, the ECU and the TFCC. This is achieved through the use of a long arm cast or splint to limit or stop forearm rotation and weight bearing. Activity modification and gradual return to activities of daily living (ADL’s) usually under a therapist’s supervision are encouraged.
If you are experiencing pain on the ulnar side of your wrist with your daily activities, your physician can perform provocative testing in the office and may order imaging studies to determine if you have a tear and the appropriate treatment.