The triangular fibrocartilage complex (TFCC) is a cartilage structure located on the small finger side of the wrist. An injury or tear to the TFCC can cause chronic wrist pain.

The Anatomy

On the little finger (ulnar) side of the wrist joint, there is a small triangular shaped piece of cartilage called the triangular fibrocartilage complex, or TFCC. The TFCC performs several important functions:

  • It acts as a shock absorber on the ulnar side of the wrist.
  • It helps to spread out pressure more evenly on that side of the joint. 
  • It helps to hold the radius and ulnar together, stabilizing the distal radial ulnar joint (the joint where the radius and ulna rotate around each other to allow your hands to rotate). 

A volar radial ulnar ligament and dorsal radial ulnar ligament are also incorporated in both sides of the TFCC, and help hold the two bones together. An ulnar collateral ligament that holds the ulnar side of the wrist together attaches to the TFCC. Finally, a sheath that holds one of the wrist extensor tendons (ECU) attaches to the TFCC. 

Because of its many functions, the TFCC is small but important.

The Injury

The TFCC may be damaged by both injury and attrition.

By repetitive wrist motion and forearm rotation, the central portion of the TFCC may become thinned or degenerate. Some research papers estimate that 50% of people over the age of 50 have some degeneration of the central portion of the TFCC. 

A TFCC tear may also be produced by a fall or sudden twist (pronation or supination) of the wrist. During this incident, they may notice a sudden pop at the time of injury. 

The Symptoms

Symptoms of a torn TFCC are primarily pain/swelling on the ulnar side of the wrist. There may also be pain with ulnar deviation of the wrist (i.e. moving the wrist towards the little finger). Additionally, there may be pain and popping or clicking with extremes of pronation or supination of the wrist and forearm.

The Diagnosis

Evaluation of a TFCC injury includes a careful physical examination to look for swelling and tenderness. There are multiple anatomical structures that can cause ulnar sided wrist pain, so it is our job to determine the exact cause of your symptoms. 

In cases of TFCC tearing:

  • There should be tenderness directly over the TFCC. 
  • Extremes of pronation and supination may cause discomfort or clicking. 
  • Moving or balloting the distal radius and ulna back and forth may produce discomfort. 
  • X-rays may be taken to evaluate a possible ulnar fracture that sometimes accompanies a TFCC tear.
  • Usually an MRI – with or without the introduction of dye into the joint(arthrogram) – is the gold standard for evaluating a possible TFCC tear. 
  • Note that some small partial tears can still not be visualized by the MRI and may only be detected by arthroscopy, or looking in the joint with a small scope.

The Treatment

Treatment of acute or recent TFCC tears associated with a nondisplaced styloid fracture of the ulna may be treated conservatively with a long-arm splint or cast for 6 weeks. Good results may be achieved if the ulnar styloid fracture heals with the attached TFCC. 

Most TFCC injuries do not involve a fracture and are strictly soft tissue. However, cases that do not respond to conservative care are usually addressed by arthroscopic debridement surgery

  • In this surgery, two small incisions – or portals – are made at the wrist. One portal is used to introduce a small scope in order to visualize or see the joint. The other portal is used to introduce a small shaver or other tools. 
  • Most TFCC tears are in the central portion of the structure or wrist, and it will not heal due to very poor blood supply of the cartilage. Because of this, our approach is to simply trim back to a stable rim using the shaver. 
  • Occasionally, the TFCC tear will occur out on the periphery where blood supply is better. These tears may be addressed either through the arthroscope or through a small incision. 

Surgery is usually performed on an outpatient basis with general anesthesia or an axillary block, numbing the arm. After debridement or trimming of the TFCC, a simple dressing is applied and gentle active motions are permitted. A long-arm splint or cast is also applied post-op, since the repair must be protected for 6 weeks. 

Risks with these procedures include anesthesia-related risks, wound healing problems or infection, and continued irritation or arthritis of the wrist.

In some cases of TFCC injury, the ulna may be longer than average. This can impact or rub against the ulnar side of the wrist joint, causing more aggravation of the TFCC tear. This is called ulnar impaction syndrome. If the above treatment does not help in these cases, the ulna may need to be shortened by either arthroscopic or open methods.