What is the best treatment for Triangular Fibrocartilage Complex (TFCC) avulsion?

Treatment of TFCC Avulsion

For TFCC avulsion injuries, surgical repair is the definitive treatment when conservative management fails, with arthroscopic foveal repair using suture anchors providing the best outcomes for restoring distal radioulnar joint (DRUJ) stability and eliminating pain.

Initial Conservative Management

• Attempt conservative treatment first for acute TFCC avulsions, including immobilization and activity modification 1
• If symptoms persist beyond 6-8 weeks of conservative care, proceed to surgical intervention as operative treatment has superior prognosis for pain relief 1
• Common pitfall: Prolonged conservative management beyond 3 months in symptomatic patients delays definitive treatment and may worsen outcomes 1

Surgical Indications

Proceed to surgery when:

• Persistent ulnar-sided wrist pain despite 6-8 weeks of conservative treatment 1
• Positive fovea sign on examination (pain with direct palpation between ulnar styloid and flexor carpi ulnaris tendon) 2
• DRUJ instability confirmed on clinical examination 3, 4
• MRI or arthroscopic confirmation of foveal avulsion (Palmer 1B classification) 4

Surgical Technique Selection

Arthroscopic foveal repair with suture anchor is the preferred surgical approach for the following reasons 3:

• Primary technique: All-inside arthroscopic repair using suture anchor placed through distal DRUJ arthroscopy directly into the fovea 3
• This approach restores anatomic TFCC attachment to the foveal insertion site, which is critical for DRUJ stability 3, 4
• Arthroscopic technique allows concurrent treatment of associated injuries (radial-sided tears, cartilage lesions) identified during diagnostic arthroscopy 5, 6

Alternative surgical options based on injury pattern:

• Open foveal repair may be considered when dorsal styloid insertion is also disrupted (more common with forced rotation injuries) 2
• Arthroscopic debridement alone is insufficient for foveal avulsions with DRUJ instability 1
• Ulnar shortening osteotomy may be added in patients with positive ulnar variance (>2mm), though foveal repair alone can succeed even with positive variance 4

Injury Mechanism Considerations

Forced wrist extension injuries (most common mechanism) 2:

• Typically present with positive fovea sign
• Usually preserve dorsal styloid insertion of radioulnar ligament
• Isolated foveal repair is generally sufficient

Forced forearm rotation injuries 2:

• More frequently involve disruption of dorsal styloid insertion
• May require repair of both foveal and styloid attachments
• Consider open approach if extensive dorsal ligament disruption identified

Post-Operative Protocol

Immobilization phase 3:

• Immobilize forearm rotation for 4 weeks post-operatively in neutral rotation
• Wrist may be immobilized in neutral position
• Critical: Adequate immobilization prevents repair failure

Rehabilitation timeline 3:

• Begin gentle active wrist motion at 4 weeks
• Progress to strengthening at 8-12 weeks
• Allow return to heavy tasks and sports at 3 months minimum
• Radiographic follow-up at 3 weeks and at immobilization cessation to confirm healing 5

Expected Outcomes

Success rates with arthroscopic foveal repair 3:

• DRUJ instability resolves in 92% of patients (44/48)
• 83.3% achieve excellent or good Mayo Wrist Scores
• 85.5% return to previous work and sport activities
• Significant improvements in grip strength, pain, and functional scores at mean 33-month follow-up

Outcomes remain favorable even in chronic cases (>3 months) with positive ulnar variance 4:

• Mean Mayo wrist score improved from 64 to 84 points post-operatively
• DRUJ instability eliminated in all cases
• Dorsal subluxation improved significantly

Complications to Monitor

Dorsal sensory branch of ulnar nerve (DSBUN) neuroapraxia 3:

• Occurs in approximately 10% of cases (5/48 patients)
• Full spontaneous recovery expected
• Related to portal placement and surgical dissection

Immobilization-related complications 5:

• Occur in 14.7% but are generally minor (skin irritation, muscle atrophy)
• Far less significant than risks of inadequate treatment

Critical Pitfalls to Avoid

• Do not rely on conservative management indefinitely - if symptoms persist beyond 6-8 weeks, surgical intervention provides superior outcomes 1
• Do not perform simple arthroscopic debridement for foveal avulsions - this fails to address DRUJ instability and leads to poor results 1, 3
• Do not remove immobilization prematurely - maintain forearm rotation immobilization for full 4 weeks to allow healing 3
• Do not miss associated injuries - arthroscopic evaluation allows identification and treatment of concurrent ligament injuries that may be missed on standard imaging 5, 6