TFCC Injury

Patients describe ulnar-sided wrist pain aggravated by forearm rotation, gripping, and ulnar deviation. Mechanical clicking or catching with rotation suggests an unstable peripheral tear. Loss of grip strength is common. A clear traumatic onset (FOOSH, racquet impact, fall) points to Palmer 1 injury; insidious onset with positive ulnar variance points to Palmer 2 degeneration.

Examination:

• •Tenderness in the "ulnar fovea" (the soft spot between the ulnar styloid, FCU, and pisiform). The fovea sign is sensitive for TFCC injury
• •Pain on ulnar deviation and axial compression (the press test): patient pushes up from a chair using the ulnar wrist, reproducing pain
• •TFCC compression test: passive ulnar deviation with axial load, with or without forearm rotation; positive when pain is reproduced over the ulnocarpal joint
• •DRUJ ballottement (piano-key): dorsal-volar translation of the distal ulna assesses DRUJ stability; compare with the contralateral side
• •Document active range, grip strength, and any clicking or catching during pronation-supination under load

Differentiate from ECU tendinopathy or subsheath instability (tender ECU tendon, ECU snapping with supination-ulnar deviation), lunotriquetral ligament injury (positive ballottement of LT joint), pisotriquetral arthritis (pisiform tenderness), and ulnar styloid fracture.

Plain radiographs (PA, lateral, dedicated grip view) are first-line. Assess for fracture, DRUJ congruity, ulnar styloid avulsion (associated with peripheral 1B tear), and ulnar variance. A neutral PA grip view loads the wrist and accentuates dynamic positive ulnar variance.

MRI is the imaging investigation of choice for the TFCC itself: it identifies central perforations, peripheral avulsions, and associated lunate or ulnar head changes. A 3-T magnet with dedicated wrist coil and contrast (MR arthrography) improves sensitivity for small peripheral tears. Wrist MR arthrography is the local gold standard where surgery is contemplated.

CT is useful for assessing fracture displacement, DRUJ subluxation under stress, and bony ulnar impaction changes.

Diagnostic wrist arthroscopy remains the reference standard - it visualises and treats peripheral tears in the same setting. Reserved for cases where imaging is equivocal but symptoms and instability persist after a conservative trial. Routine bloods are not indicated.

Management depends on Palmer class, DRUJ stability, and patient demand (BSSH and BSSH-affiliated UK guidance).

Acute traumatic stable tears (Palmer 1A, 1D, isolated 1B without instability):

• •Short period of immobilisation: above-elbow Munster cast or removable splint for 4-6 weeks to control pronation-supination
• •Simple analgesia; topical or oral NSAIDs
• •Activity modification - avoid loaded pronation-supination, racquet sport, weighted gripping

Acute traumatic unstable tears (Palmer 1B with foveal detachment, DRUJ instability):

• •Refer urgently to hand surgery for arthroscopic or open repair
• •Acute repair has better outcomes than chronic repair; do not delay

Degenerative tears (Palmer 2):

• •First-line is conservative: splinting, activity modification, simple analgesia
• •Intra-articular corticosteroid injection (ulnocarpal joint, ultrasound-guided) for persistent symptoms
• •Failed conservative care: arthroscopic debridement (small central tears), wafer procedure or ulnar shortening osteotomy (where ulnar impaction is the driver, especially with positive ulnar variance over 2 mm)

Chronic peripheral tears in failed conservative care: arthroscopic or open repair if DRUJ stability is achievable; ulnar-shortening osteotomy if positive ulnar variance is contributing.

Referral pathway: refer for hand surgery opinion in DRUJ instability, suspected peripheral 1B tear, mechanical clicking with locking, failed conservative trial of 8-12 weeks, or radiographic ulnar impaction with persistent symptoms.

Conservative pathway: gentle range-of-motion exercises within pain limits once acute pain settles, progressing to grip and rotational strengthening at 4-6 weeks. Hand therapy referral is appropriate for splinting fit and graded loading.

Post-arthroscopic debridement: short period of splinting (1-2 weeks), then progressive ROM and strengthening over 4-6 weeks. Return to sport at 6-12 weeks depending on demand.

Post-TFCC repair (peripheral 1B):

• •Weeks 0-6: above-elbow Munster cast or splint, pronation-supination blocked. Hand and finger ROM encouraged
• •Weeks 6-12: progressive forearm rotation, wrist ROM, gentle grip strengthening
• •Weeks 12-16: resistance training and sport-specific loading
• •Return to contact sport and heavy load: 4-6 months

Post-ulnar-shortening osteotomy: hardware-dependent immobilisation 4-6 weeks, then progressive rotation and grip strengthening. Bony union confirmed before unrestricted load (typically 12 weeks).

Persistent symptoms beyond 3-6 months should prompt review for occult instability, missed associated injury (lunotriquetral ligament tear, ECU subsheath rupture), or progression to ulnocarpal arthritis.

• •Palmer classification (1989) - Definitive UK and international framework: Class 1 traumatic with subtypes A-D; Class 2 degenerative with stages 2A-2E reflecting ulnar impaction progression.
• •BSSH TFCC Patient Information - UK hand-surgery framework: arthroscopic assessment remains the reference standard for peripheral 1B tears with DRUJ instability.
• •Atzei classification (2008) - Sub-classifies peripheral 1B foveal tears into repairable, partially repairable, and irreparable categories, guiding choice of repair vs reconstruction.
• •Adams et al. (1991, 2002) - Foundational anatomical and biomechanical studies establishing the radioulnar ligaments as the primary DRUJ stabilisers and the disc as the load-transmitter; underpins surgical-repair targets.
• •Tomaino & Weiser (2005) - Ulnar-shortening osteotomy outperforms arthroscopic debridement alone in ulnar impaction with positive ulnar variance over 2 mm; supports variance-targeted UK practice.

• •Palmer 1 (traumatic) vs Palmer 2 (degenerative) is the foundational classification. Class 1B is the unstable peripheral avulsion with foveal detachment - the only subtype that mandates urgent surgical opinion.
• •Fovea sign (tenderness in the soft spot between ulnar styloid, FCU, and pisiform) is sensitive for TFCC injury. DRUJ ballottement (piano-key sign) checks stability.
• •MRI is the imaging investigation of choice; MR arthrography improves sensitivity for small peripheral tears. PA grip view is essential to demonstrate dynamic positive ulnar variance.
• •Positive ulnar variance over 2 mm with degenerative tearing points toward ulnar-shortening osteotomy rather than debridement alone. Variance is dynamic; grip view is the discriminator.
• •The classic mechanism for a traumatic TFCC tear is fall on outstretched extended pronated wrist (FOOSH) with axial load; for degenerative, repetitive loaded pronation-supination (racquet sports, gymnastics) is the giveaway.
• •ECU tendinopathy and subsheath instability are the major ulnar-sided differentials. ECU snapping with active supination-ulnar deviation distinguishes ECU subsheath rupture from a TFCC tear.