What is the recommended treatment for a Triangular Fibrocartilage Complex (TFCC) foveal avulsion in the left wrist that occurred 3 months ago?

Treatment of TFCC Foveal Avulsion at 3 Months Post-Injury

Arthroscopic foveal repair with suture anchor is the recommended treatment for a 3-month-old TFCC foveal avulsion, as this timeframe still allows for successful surgical repair with restoration of DRUJ stability and functional outcomes. 1

Surgical Approach

Arthroscopic foveal repair using a suture anchor is the preferred technique because it restores the anatomic TFCC attachment to the foveal insertion site, which is critical for distal radioulnar joint (DRUJ) stability. 1 This approach also allows concurrent treatment of associated injuries that may be present. 1

Technical Considerations:

• DRUJ arthroscopy is performed to débride the TFCC and prepare the foveal area, with the suture anchor inserted via the distal foveal portal under arthroscopic guidance to repair the TFCC onto the fovea. 2
• Sutures are tied on the radiocarpal surface of the TFCC to secure the repair. 2
• Arthroscopic evaluation identifies concurrent ligament injuries that may be missed on standard imaging, ensuring comprehensive treatment. 1

Alternative Approach for Chronic Cases:

• Open volar surgical approach with suture anchor repair is an effective alternative, particularly for chronic foveal tears with DRUJ instability, combined with temporary DRUJ pinning for 8 weeks. 3
• This approach has demonstrated reliable outcomes even in delayed presentations (average 8.4 months from injury), with all patients achieving stable DRUJ and significant pain reduction. 3

Post-Operative Protocol

Immobilization is critical to prevent repair failure:

• Forearm rotation is immobilized for 4 weeks post-operatively in neutral rotation, with the wrist also immobilized in neutral position. 1
• Radiographic follow-up at 3 weeks and at immobilization cessation confirms healing. 1

Rehabilitation timeline follows a structured progression:

• Gentle active wrist motion begins at 4 weeks post-operatively. 1
• Strengthening exercises progress at 8-12 weeks. 1
• Return to heavy tasks and sports is permitted at 3 months minimum. 1

Expected Outcomes

Clinical results demonstrate significant improvement:

• DRUJ instability resolves in approximately 92% of patients (44 of 48 in one series). 2
• Pain improves significantly, with mean pain scores dropping from 6.8 preoperatively to 0.70 postoperatively in chronic cases. 3
• Excellent and good functional outcomes occur in 83.3% of patients based on Modified Mayo Wrist Score. 2
• 85.5% of patients resume previous work and sport activities. 2
• Grip strength, range of motion, and functional scores all improve significantly following repair. 2, 4

Complications and Pitfalls

Common complications are generally minor:

• Dorsal sensory branch of ulnar nerve (DSBUN) neuroapraxia occurs in approximately 10% of cases, with full spontaneous recovery expected, related to portal placement and surgical dissection. 1, 2
• Immobilization-related complications (skin irritation, muscle atrophy) occur in 14.7% of cases but are less significant than risks of inadequate treatment. 1
• No significant rates of recurrent DRUJ instability or need for revision surgery are reported when proper technique and immobilization protocols are followed. 3

Critical Decision Points

The 3-month timeframe is still within the window for successful repair:

• Chronic cases up to 23 months post-injury have been successfully treated with open repair techniques, demonstrating that delayed presentation does not preclude good outcomes. 3
• Positive ulnar variance does not contraindicate repair, as arthroscopic-assisted reconstruction can reduce DRUJ instability and pain even in chronic cases with positive ulnar variance. 4
• The mechanism of injury affects anatomic disruption patterns: forced wrist extension commonly leaves the dorsal styloid insertion intact, while forced forearm rotation more frequently disrupts the dorsal styloid insertion. 5