Triangular Fibro-Cartilage Complex (TFFC) Injuries
Triangular fibro-cartilage complex (TFCC) is a complicated anatomical structure located inside the wrist joint. It is made up of cartilage and several ligaments. It allows gliding action inside the joint and is one of the most important wrist stabilizers.
Mild injuries of the triangular fibro-cartilage complex are often referred to as a wrist sprain. More extensive tears acquired through injury or degeneration can however, cause more than just sprain symptoms, and lead to frustrating hand disability.
The wrist consists of 8 small bones and many small joint surfaces between them. It is probably the most complex of all the joints in the body. Intricate anatomical arrangement allows fascinating joint biomechanics and provides great hand mobility, an asset fully appreciated only when injury or disease unfavorably affect our dexterity.
The triangular fibro-cartilage complex (TFCC) is a large cartilage-ligament formation suspended between the ends of two forearm bones (radius and ulna) almost as a hammock (Picture 1). As such it is prone to tears and disruptions, but as it is a soft structure it does not show on the X-rays.
There are two basic grades of triangular fibro-cartilage complex injuries:
Class 1 is for traumatic injuries
Class 2 is for degenerative (chronic) conditions
Traumatic injury is the most common mechanism of TFCC injury. Tearing or rupture occurs when there is enough force transmitted through the joint that overcomes the tensile strength of this structure. A fall onto an outstretched hand and loading whilst hand rotates (high-demand athletes such as tennis players or gymnasts) most commonly leads to TFCC injuries.
Triangular fibro-cartilage complex (TFCC) tears can also occur gradually, over the time, via degenerative changes i.e. repetitive movements which transmit high load and/or griping forces across the structure. Degenerative changes in the TFCC structure also increase in frequency and severity as we get older. Thinning soft tissue structures can result in a TFCC tearing with minor force or minimal trauma.
There may be some anatomical risk factors too. Studies show that patients with a torn triangular fibro-cartilage complex often have a greater forward curve in the ulnar bone or ulna is slightly longer than the radius, condition known as “positive ulna variance”. Causes for above anatomical variations remain unclear.
Symptoms and Diagnosis
Wrist pain along the ulnar (little finger) side is the main symptom. Some patients report diffuse pain i.e. throughout the entire wrist area. The pain is made worse by any activity or position that requires forearm rotation and movement in the ulnar direction. This includes simple activities like turning a doorknob or key in the door, or lifting a heavy objects with one hand. Other symptoms include weakness on hand rotation, swelling; clicking, or bone crackling known as crepitus. Many patients report a feeling of instability – like the wrist is going ‘to give’ especially under the load. You may feel as if something is catching inside the joint.
The grading of TFCC tears is usually based on severity of ligament disruption i.e. minimal, partial or complete.
Clinically, there is usually tenderness along the ulnar (little finger) side of the wrist. Pain is elicited under specific joint maneuvering and in most situations, specialist is able to differentiate it from other wrist pathologies whit similar clinical presentation. If a fracture at the distal end of the ulna bone (at the wrist) is present along with soft tissue instability, then forearm rotation may be limited. The direction of limitation (palm up or palm down) depends on which direction the ulna dislocates.
X-rays may show disruption of the triangular fibro-cartilage complex only when there is an associated bone fracture. Ligamentous instability without bone fracture appears normal on standard X-rays. This is why TFCC injuries are often diagnosed late. More specific imaging is required in order to detect its abnormalities. X-rays with a dye injected is called a wrist arthrography. It is positive for a TFCC tear if the dye leaks into any of the joints.
Acute injuries can be painfully swollen preventing proper examination. In such cases, more advanced imaging such as MRI (with or without a contrast dye) can be used to detect ligamentous or other soft tissue damage. When MRI is done with a dye injected into the area, the test is called MRI arthrogram. If the dye moves from one joint compartment to another, a tear of the soft tissues is suspected. However, studies have shown that almost half the patients with a true triangular fibro-cartilage complex tear have normal arthrograms. Wrist arthroscopy is really the best way to accurately assess the severity of damage. At the same time, the surgeon looks for other associated injuries of ligaments and/or cartilage. The surgeon performs the test by inserting a long thin needle into the joint. A tiny TV camera on the end of the instrument allows the surgeon to look directly at the ligaments. Using a probe, the surgeon tests the integrity of the soft tissues. A special trampoline test can be done to see if the fibrocartilage disk is okay. One advantage of an arthroscopic exam is that treatment can be done at the same time.
I base my opinion on patient’s best treatment option taking into account the following facts: 1) your perception of disability 2) objective clinical signs 3) exact anatomical damage and 4) rehabilitation needs against individual circumstances. No two patients are the same and this is why consultation is crucial.
If the tear is small and limited and wrist still stable, then conservative (non operative) care is advised. You may be given a temporary splint to wear for 4-6 weeks. The splint will immobilize (hold still) your wrist and allow scar tissue to heal the tear. Anti-inflammatory drugs and physical therapy may be prescribed. You may benefit from one or two steroid injections spaced apart by several weeks.
If the wrist is unstable but patient does not want surgery, then the cast should be applied over the wrist and forearm. It may be possible to use a splint for six weeks (instead of casting) and start physical therapy.
Surgical treatment is based on the specific injury pattern. Complete ligament rupture usually results in instability which may be best addressed by early surgery. Injuries associated with bone fracture also often require surgery.
The outside perimeter of the triangular fibro-cartilage complex has a good blood supply and this is why surgical repairs in this zone usually heal well. The torn structures can be reattached with sutures. This can be achieved either arthroscopically (key hole surgery) or by open surgical technique. When tears occur in the central area, surgical repairs are not possible as torn edges sprung apart. The blood supply to this area is poor so healing potential is also low. Arthroscopic debridement (smoothing) of the center of the ligament is therefore, usually the best surgical option. Arthroscopic debridement works well for simple tears. Much of the damaged tissue can be removed while still keeping a stable wrist joint.
There are complex tears that require open repair. Open repair means that TFCC is approached from outside, (not inside like via arthroscopy) via incision through the skin and surrounding soft tissues (Picture 3 – scar at 3 weeks). This gives the surgeon a better view and better access to the area allowing not only a repair of torn TFCC, but tightening of neighboring ligaments and/or joint capsule if needed.
Chronic, degenerative TFCC problems may require a different surgical approach. Debridement might not be as successful with this group as it is with acute TFCC injuries. Sometimes it is necessary to shorten the ulna bone at the wrist to obtain adequate pain relief.
Many patients with mild triangular fibro-cartilage complex injury are able to return to work and/or return to sports at a pre-injury level. Pain-free movement and full strength are possible.
Residual laxity may remain after non-operative treatment of a TFCC injury. If conservative care is unsuccessful, persistent joint laxity and instability can lead to degeneration of the joint cartilage. Too much force or compression on either side of the joint can lead to pain and altered movement patterns. Surgery may be needed to restore normal wrist movement.
Your wrist will be immobilized in a bulky dressing or cast, which is rather restricting, and prevent rotation of the hand in particular. Motion exercises are usually started 5-7 days after the operation. Pain relief, improved motion, and increased function are the main goals of surgery for most patients. The surgeon is also interested in restoring wrist stability and the load bearing function of the wrist. Many patients report being pain free.
Few days after surgery, the cast applied at the time of surgery is replaced by custom made (light weight) splint (Picture 4). It is usually secured by Velcro straps and is easy to put on and remove at home. Immobilisation of the wrist is required for 6-8 weeks, but wrist movements are advised from 10-14 days and are usually supervised by the physiotherapist. After 6 weeks a cumbersome splint involving the elbow is exchanged for much shorter and simpler cast which supports operated side of the joint (Picture 5) allowing mobe mobility for the fingers. Finger movements are encouraged straight after surgery.
The goal of physiotherapy is to restore full motion, strength, and function. The rehab program will be geared towards your needs at home, work, and play. Many patients are able to return to work with no restrictions. A small number may require some work restrictions or changes in work tasks.
Complications are rare, but as with any surgical procedure, there are general and procedure specific risks which patients should be aware of:
- Skin/wound infection
- Hypertrophic (lumpy and itchy) scarring
- Painful scars
- Reflex Sympathetic Dystrophy – RSD (bad reaction to surgery with painful and stiff hands – this can occur with any hand surgery from a minor procedure to a complex reconstruction)
TFCC surgery specific complications:
- Tendon injury
- Nerve injury (with numbness at the back of the wrist)
- Joint infection
- Failure of stabilisation
- Persistent wrist weakness
- Joint stiffness and reduced range of motion
- Repeated or additional surgery
Things to look out for
- Disproportionate swelling and pain in your hand
- Signs of infection in vicinity of the operated area i.e. hand/wrist are very hot, prominent redness, pain, swelling, puss collection
- Grazing of the skin (and possibly fluid leaking/oozing from the wounds)
- Increased temperature in the area
- Strange smells coming from the wounds.
If you notice any of above symptoms in the first few days, feel free to contact the team on numbers below.
If you have any concerns following your surgery please contact:
|Hospital stay||Day care|
|Anaesthetic||General or Regional (the whole arm is numbed)|
|Surgery time||60-90 minutes|
|Wound healing||2 weeks|
|Ligament healing||8 weeks|
|Hand therapy||6-12 weeks|
|Shower / Bath||from week 2|
|Time off work||1-2 weeks for office based work | 6-8 weeks for manual work|
|Sports and exercise||from week 8|
|Driving||from week 3 (automatic car week 1) | please check details with your insurance company|
|Full recovery||8-12 weeks|
Picture 1: Wrist anatomy. R = radius; U= ulna; TFCC (tri-angular fibrocartilage complex)
Picture 2: The commonest site of TFCC tear
Picture 3: Scar at two weeks following open repair of the TFCC
Picture 4: Splint during the first 4-6 weeks (both wrist and elbow immobilised)
Picture 5: Splint after 6 weeks (wrist immobilised only)