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TRIANGULAR FIBROCARTILAGE COMPLEX (TFCC) INJURY

Introduction

The triangular fibrocartilage complex (TFCC), which spans the space between the distal ulna and ulnar carpus, consists of a relatively avascular cartilaginous articular disc (TFC) merged with highly vascularized, ligamentous structures of somewhat variable form. The TFCC transmits 20% of the forearm’s axial load, is the major stabilizer of the distal radioulnar joint (DRUJ), and a stabilizer of the ulnar carpus;1 thus, injuries to the TFCC can have diverse effects on wrist function.

Pathophysiology

  • The TFCC can be injured by a rotational force on the extended, deviated wrist or from a fall on an outstretch hand (FOOSH). Such acute injuries can cause tears and/or avulsions in both the cartilaginous and ligamentous structures. Overuse injuries and degenerative changes can result in related pathologies (see table below).

Related Anatomy

  • TFCC
    • TFC
    • Radioulnar ligaments (dorsal and palmar)
    • Ulnolunate ligament
    • Ulnotriquetral ligament
  • Ulna
  • Radius
  • Lunate
  • Triquetrum
  • Lunotriquetral ligament

Incidence and Related Conditions

  • Ulnar-sided wrist pain is common but has many possible causes. Palmer, whose classification of TFCC lesions is shown in the table below,1 reported that traumatic injuries were less common than overuse/degenerative injuries.
  • Of the traumatic injuries, Palmer class 1A is reported to be the most common.2

Class 1: Traumatic

 

Class 2: Degenerative
(eg, ulnocarpal abutment)

1ACentral perforation 2ATFCC wear
1BUlnar avulsion w/wo distal ulnar fracture 2BTFCC wear + Lunate and/or ulnar chondromalacia
1CVolar tear of ulnar extrinsic ligaments 2CTFCC perforation + Lunate and/or ulnar chondromalacia
1DRadial avulsion w/wo sigmoid notch fracture 2DTFCC perforation + Lunate and/or ulnar chondromalacia
+ LT ligament perforation
   2ETFCC wear + Lunate and/or ulnar chondromalacia
+ LT ligament perforation + Ulnocarpal arthritis

LT, lunotriquetral; TFCC, triangular fibrocartilage complex; w/wo, with/without.

Differential Diagnosis

  • Ulnocarpal abutment
  • DRUJ injury
  • Ulnar-sided fracture (ulnar styloid, carpal, base of fifth metacarpal)
  • Lunotriquetral ligament tear
  • Excessive ulnar styloid length with abutment against the triquetrum
  • Essex-Lopresti injury - complex simultaneous injury of the TFCC, DRUJ, interosseous membrane (IOM) and/or radial head.8
ICD-10 Codes

  • TRIANGULAR FIBROCARTILAGE COMPLEX (TFCC) INJURY

    Diagnostic Guide Name

    TRIANGULAR FIBROCARTILAGE COMPLEX (TFCC) INJURY

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    TRIANGULAR FIBROCARTILAGE COMPLEX (TFCC) INJURY S63.592_S63.591_ 

    Instructions (ICD 10 CM 2020, U.S. Version)

    THE APPROPRIATE SEVENTH CHARACTER IS TO BE ADDED TO EACH CODE FROM CATEGORY S63
    A - Initial Encounter
    D - Subsequent Routine Healing
    S - Sequela

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Basic Science Photos and Related Diagrams
TFCC Anatomy
Basic Science Pics
  • The RC joint has been open in this specimen . Note the ulnar styloid, TFCC and the lunate facet of the radius. 1. ulnar styloid insertion of the TFCC; 2. Palmar (volar or anterior) radioulnar ligament; 3. TFC articular central disc (fibrocartilage).
    The RC joint has been open in this specimen . Note the ulnar styloid, TFCC and the lunate facet of the radius. 1. ulnar styloid insertion of the TFCC; 2. Palmar (volar or anterior) radioulnar ligament; 3. TFC articular central disc (fibrocartilage).
Pathoanatomy Photos and Related Diagrams
TFCC and DRUJ Anatomy
  • T - Triquetrum; L - Lunate; R - Radius; U - Ulnar head; 1- TFC articular disc; 2- Dorsal radioulnar ligament; 3- Deep radioulnar (foveal or ligament subcruentum) insertion; 4- Ulnar styloid TFCC insertion; 5- Ulnar collateral ligament (floor of the ECU tendon sheath; 6- Ulnotriquetral and ulnolunate ligaments; 7- Palmar (volar or anterior) radioulnar ligament; 8- Lunotriquetral ligament.
    T - Triquetrum; L - Lunate; R - Radius; U - Ulnar head; 1- TFC articular disc; 2- Dorsal radioulnar ligament; 3- Deep radioulnar (foveal or ligament subcruentum) insertion; 4- Ulnar styloid TFCC insertion; 5- Ulnar collateral ligament (floor of the ECU tendon sheath; 6- Ulnotriquetral and ulnolunate ligaments; 7- Palmar (volar or anterior) radioulnar ligament; 8- Lunotriquetral ligament.
Symptoms
Ulnar-sided wrist pain
Clicking in ulnar wrist with forearm rotation
History of recent or past wrist injury
Typical History

A 31 y.o. right handed male mechanic was drilling a hole in a steel chassis when the drill bit suddenly jammed in the hole.  The drill kept twisting the mechanic's right hand, wrist and forearm violently for several seconds before he could let go of the drill.  The patient had immediate pain in his right wrist and could not grip.  His co-worker took him to a nearby walk-in clinic.  His initial examination showed marked ulnar wrist tenderness at the TFCC, swelling, decreased range of motion and poor grip.  Routine X-rays were negative.  A diagnosis of wrist sprain was made and a wrist splint applied.  The patient was referred to a hand surgeon who saw the patient two days later.  The surgeon's exam showed a tender ECU and TFCC.  Forearm rotation and ulnar deviation of the wrist caused severe tenderness.  The piano key sign was positive and the DRUJ very unstable compared to the opposite side.  The MRI was consistent with a Palmer Class 1 B tear.  Because this was an acute injury in a young patient with associated DRUJ instability, surgical treatment was recommended.  The wrist arthroscope confirmed an acute TFCC tear at the foveal insertion with a positive trampoline sign.  Some frayed edges of the TFCC were debrided arthroscopically.  Next a mini-open TFCC repair was done with a bone anchor in the fovea.  After a period of immobilization and rehabilitation the patient was doing very well and returned to work.

Positive Tests, Exams or Signs
Work-up Options
Images (X-Ray, MRI, etc.)
Imaging for TFCC Injuries
  • Contrast has been injected into the RC joint. The absence of contrast in the DRUJ suggests the TFCC is intact. The classic wrist arthrogram has been replaced by MRI and MRI arthrogram imaging.
    Contrast has been injected into the RC joint. The absence of contrast in the DRUJ suggests the TFCC is intact. The classic wrist arthrogram has been replaced by MRI and MRI arthrogram imaging.
Treatment Options
Treatment Goals
  • Eliminate pain associated with torn TFCC and DRUJ instabilty
  • Maintain the instability and function of the TFCC, DRUJ and RC joint
  • Maintain range of motion and strength of the hand and wrist
Conservative
  • TFCC injuries frequently respond to conservative treatment, including rest and job restriction, splinting, anti-inflammatory drugs.1,2
  • Acute injuries , especially in younger patients, may require a long arm cast which controls forearm rotation for 4- 6 weeks.
  • Many authorities recommend conservative management for 3 - 4 months unless there is associated DRUJ instability in which case earlier surgical treatment is indicated.
  • Healing of ulnar styloid avulsions fractures, ligamentous injuries and/or TFCC tears may be facilitated by proper positioning splints or immobilization.1
Operative
  • Acute avulsions and ligamentous TFCC tears may be repaired surgically, either open or arthroscopically especially in younger patients.3
  • Central articular disc (TFC) tears cannot be repaired (owing to its avascularity) and should be treated by limited arthroscopic debridement while preserving load-carrying function as much as possible.
  • If TFCC debridement is ineffective, or possibly as a primary procedure in cases with a significant positive ulnar variance , some form of ulnar shortening may be indicated (eg, ulnocarpal abutment), including:6,7
    • Ulnar shortening osteotomy
    • Wafer resection of the distal ulna
    • Distal metaphyseal ulnar shortening osteotomy
Treatment Photos and Diagrams
Open Surgical Repair of TFCC
  • 3cm incision (dashed blue line) for exposing the DRUJ and TFCC.
    3cm incision (dashed blue line) for exposing the DRUJ and TFCC.
  • Extensor retinaculum incisions for exposing the DRUJ. Extensor tendons labeled.
    Extensor retinaculum incisions for exposing the DRUJ. Extensor tendons labeled.
  • DRUJ and TFCC Exposure: 1. retinacular flap; 2 EDM tendon; 3. ECU tendon and intact edge of its sub-sheath and retinaculum; 4. DRUJ dorsal capsule.
    DRUJ and TFCC Exposure: 1. retinacular flap; 2 EDM tendon; 3. ECU tendon and intact edge of its sub-sheath and retinaculum; 4. DRUJ dorsal capsule.
  • Capsular incisions for opening the RC joint (1) jus distal to the TFCC and (2) for opening the DRUJ and exposing the ulnar head just proximal to the TFCC. Note tendon and bone labels.
    Capsular incisions for opening the RC joint (1) jus distal to the TFCC and (2) for opening the DRUJ and exposing the ulnar head just proximal to the TFCC. Note tendon and bone labels.
  • A transverse incision has been made in the DRUJ capsule. The arrow is pointing to the proximal dorsal part of the TFCC. The needle is in the fovea. The "S' is over the ulnar styloid.
    A transverse incision has been made in the DRUJ capsule. The arrow is pointing to the proximal dorsal part of the TFCC. The needle is in the fovea. The "S' is over the ulnar styloid.
  • A second transverse incision at the distal edge of the TFCC (arrow) has opened the RC joint. A suture anchor is being place in the ulnar head at the fovea. The anchor sutures have been passed through the volar and dorsal edges of the peripheral TFCC. Tying these suture ends together will reattach the TFCC to the fovea.
    A second transverse incision at the distal edge of the TFCC (arrow) has opened the RC joint. A suture anchor is being place in the ulnar head at the fovea. The anchor sutures have been passed through the volar and dorsal edges of the peripheral TFCC. Tying these suture ends together will reattach the TFCC to the fovea.
  • Closure of the capsular incisions in the DRUJ and RC joints.
    Closure of the capsular incisions in the DRUJ and RC joints.
  • The transverse incisions in the DRUJ and RC joint capsules have been repair to the dorsal edge of the TFCC. The retinacular flap (arrow) is used to reconstruct the ECU sheath. This reconstructed sheath is now being sutured to the intact proximal retinaculum.
    The transverse incisions in the DRUJ and RC joint capsules have been repair to the dorsal edge of the TFCC. The retinacular flap (arrow) is used to reconstruct the ECU sheath. This reconstructed sheath is now being sutured to the intact proximal retinaculum.
  • Closure of the extensor retinaculum and ECU sheath reconstruction.
    Closure of the extensor retinaculum and ECU sheath reconstruction.
  • Closed 3cm incision. The 3-4 portal incision (arrow) used for the wrist arthroscopy done before the TFCC repair will also be sutured.
    Closed 3cm incision. The 3-4 portal incision (arrow) used for the wrist arthroscopy done before the TFCC repair will also be sutured.
Wrist Arthroscopy for Diagnosis and Treatment of TFCC Injuries
  • Arthroscopic image of the shaver deriding the central stable tear of the TFCC
    Arthroscopic image of the shaver deriding the central stable tear of the TFCC
CPT Codes for Treatment Options

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Common Procedure Name
Open TFCC repair
CPT Description
Arthrotomy, distal radioulnar joint including repair of triangular cartilage, complex
CPT Code Number
25107
Common Procedure Name
Diagnostic arthroscopy with debridement
CPT Description
Arthroscopy, wrist w/excision fibrocartilage &/or debridement
CPT Code Number
29846
CPT Code References

The American Medical Association (AMA) and Hand Surgery Resource, LLC have entered into a royalty free agreement which allows Hand Surgery Resource to provide our users with 75 commonly used hand surgery related CPT Codes for educational promises. For procedures associated with this Diagnostic Guide the CPT Codes are provided above. Reference materials for these codes is provided below. If the CPT Codes for the for the procedures associated with this Diagnostic Guide are not listed, then Hand Surgery Resource recommends using the references below to identify the proper CPT Codes.

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Complications
  • Chondromalacia and arthritis of the distal ulna and lunate
  • DRUJ instability
  • DRUJ arthritis
Outcomes
  • In a recent study of patients with 2C lesions, those who received debridement only had similar outcomes to those who received additional ulnar shortening (DASH scores of 18 modified Mayo wrist scores of 88 and 89, and significant pain reductions from 7.6 to 2.0 and from 7.4 to 2.5).4
  • This study also recommended +1.8mm of ulnar variance as an indication for early ulnar shortening in the case of persistent ulnar-sided wrist pain after arthroscopic debridement.
Key Educational Points
  • A recent review suggested that diagnostic scans and clinical tests are helpful for detecting TFCC damage, but arthroscopy remains the gold standard.5
  • Newer studies have shown that MRI arthrograms are approximately 80% accurate when diagnosing peripheral TFCC tears. 2
  • The peripheral components of the TFCC complex , e.g. dorsal and volar radioulnar ligaments, are relative vascular structures and therefore reparable while the central disc (TFC) is relatively avascular so debridement rather than repair is indicated. 6,7
  • After age 40 degenerative changes in the TFCC increase significantly in all individuals. 6
  • Although TFCC tears with or without an ulnar styloid fractures are commonly associated with distal radius fractures, the simultaneous repair of the TFCC injury while performing the distal radius ORIF does not appear to be clinically necessary in order to obtain an acceptable functional outcome. 6
  • Studies comparing open and closed arthroscopic TFCC repairs show similar results.7
References

Cited

  1. Palmer AK. Triangular fibrocartilage complex lesions: A classification. J Hand Surg Am 1989;14(4):594-606. PMID: 2666492
  2. Sachar K. Ulnar-sided wrist pain: Evaluation and treatment of triangular fibrocartilage complex tears, ulnocarpal impaction syndrome, and lunotriquetral ligament tears. J Hand Surg Am 2012;37(7):1489-1500. PMID: 22721461
  3. Shinohara T, Tatebe M, Okui N, et al. Arthroscopically assisted repair of triangular fibrocartilage complex foveal tears. J Hand Surg Am 2013;38(2):271-277. PMID: 23351910
  4. Moldner M, Unglaub F, Hahn P, et al. Functionality after arthroscopic debridement of central triangular fibrocartilage tears with central perforations. J Hand Surg Am 2015;40(2):252-258. PMID: 25617955
  5. Andersson JK, Andernord D, Karlsson J, Friden J. Efficacy of magnetic resonance imaging and clinical tests in diagnostics of wrist ligament injuries: A systematic review. Arthroscopy 2015;31(10):2014-20. PMID: 26095820
  6. Roenbeck K, Imbriglia JE. Peripheral triangular fibrocartilage complex tesars.  JHand Surg Am. 2011; 36A:1687-1690.
  7. Strauss NL, Goldfarb CA. Arthroscopic management of traumatic peripheral triangular fibrocartilage complex tears. J Hand Surg Am. 2011; 36(A): 136-138.
  8. Loeffler BJ, Green JB, Zelouf DS. Forearm instability. J Hand Surg Am. 2014; 39(1): 156-167.

New Articles (within the past 3 years)

  1. Moldner M, Unglaub F, Hahn P, et al. Functionality after arthroscopic debridement of central triangular fibrocartilage tears with central perforations. J Hand Surg Am 2015;40(2):252-258. PMID: 25617955
  2. Shinohara T, Tatebe M, Okui N, et al. Arthroscopically assisted repair of triangular fibrocartilage complex foveal tears. J Hand Surg Am 2013;38(2):271-277. PMID: 23351910

Reviews

  1. Andersson JK, Andernord D, Karlsson J, Friden J. Efficacy of magnetic resonance imaging and clinical tests in diagnostics of wrist ligament injuries: A systematic review. Arthroscopy 2015;31(10):2014-20. PMID: 26095820
  2. Sachar K. Ulnar-sided wrist pain: Evaluation and treatment of triangular fibrocartilage complex tears, ulnocarpal impaction syndrome, and lunotriquetral ligament tears. J Hand Surg Am 2012;37(7):1489-1500. PMID: 22721461
  3. Henry MH. Management of acute triangular fibrocartilage complex injury of the wrist.  J Am Acad Orthop Surg 2008; 16: 320-329.
  4. Kleinman WB. Stability of the distal radioulna joint: biomechanics, pathophysiology, physical diagnosis and restoration of function what we have learned in 25 years. J Hand Surg Am. 2007; 32A (70: 1086-1106.

Classics

  1. Palmer AK. Triangular fibrocartilage complex lesions: A classification. J Hand Surg Am 1989;14(4):594-606. PMID: 2666492
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