What is the treatment for a tear of the Triangular Fibrocartilage Complex (TFCC) disc in the hand?

Treatment of TFCC Tears

For TFCC tears without distal radioulnar joint (DRUJ) instability, begin with a minimum of 6 months of conservative management including activity modification, immobilization, NSAIDs, and physical therapy; surgical intervention is reserved for persistent symptoms after failed conservative treatment or when DRUJ instability is present. 1

Initial Conservative Management (First-Line Treatment)

Non-operative treatment is moderately successful and should be attempted for at least 6 months before considering surgery. 1

• Activity modification: Complete abstinence from sporting activities, gym exercises, and yoga maneuvers that stress the wrist joint, particularly those involving forearm rotation 2
• Immobilization: Temporary splint or cast immobilization to rest the injured structures 2
• Pharmacologic management: NSAIDs for pain control and inflammation 2
• Corticosteroid injection: Can be used in conjunction with physical therapy for grossly symptomatic patients 2
• Physical therapy: Initiated after initial immobilization period 2

Expected Recovery Timeline

• 30% of patients achieve complete recovery (PRWE score ≤20) at 6 months 1
• 50% achieve complete recovery at 1 year 1
• No specific risk factors (age, gender, obesity, dominant hand, chronicity, trauma mechanism, or ulnar variance) predict treatment failure 1

Indications for Surgical Treatment

Surgery is indicated when conservative management fails to provide relief after 6 months, or when patients present initially with frank DRUJ instability or unstable/displaced fractures. 2

Surgical Options Based on Palmer Classification

The choice of operative treatment is guided by the type and extent of injury identified on arthroscopy:

Palmer Type I (Traumatic Tears)

• Palmer 1A (Central perforation): Arthroscopic debridement 3, 2
• Palmer 1B (Peripheral ulnar-sided tear with intact deep fibers): Outside-in suture repair of superficial fibers to ulnar capsule 4, 5
• Palmer 1B (Peripheral tear with disrupted deep fibers/foveal detachment): Arthroscopic foveal repair with suture anchor to restore anatomic TFCC attachment 6
• Palmer 1D (Radial-sided tear): Arthroscopic repair 5

Palmer Type II (Degenerative Tears)

• Degenerative tears with ulnar impaction: Ulnar shortening osteotomy or Wafer procedure (partial resection of ulnar head) 3, 2

Preferred Surgical Technique for Foveal Avulsions

Arthroscopic foveal repair with suture anchor is preferred as it restores anatomic TFCC attachment to the foveal insertion site, which is critical for DRUJ stability, and allows concurrent treatment of associated injuries. 6

Post-Operative Protocol

Immobilization phase:

• Immobilize forearm rotation for 4 weeks post-operatively in neutral rotation 6
• Wrist immobilized in neutral position 6

Rehabilitation timeline:

• Gentle active wrist motion begins at 4 weeks 6
• Strengthening exercises at 8-12 weeks 6
• Return to heavy tasks and sports at minimum 3 months 6

Radiographic follow-up:

• Obtain radiographs at 3 weeks post-operatively 6
• Additional imaging at immobilization cessation to confirm healing 6

Expected Surgical Outcomes

For peripheral tears with intact deep fibers treated with outside-in repair:

• VAS scores improve from 5 to 1 4
• DASH scores improve from 38 to 9 4
• No measurable loss in motion or grip strength 4
• No DRUJ instability at final follow-up 4
• Return to sport is variable: 64% of high-level athletes return, with better outcomes for racquet sports versus weight-bearing activities 4

For all TFCC surgical repairs:

• Wrist pain significantly diminished or disappeared after surgical treatment and rehabilitation 3

Complications and Pitfalls

Common complications:

• Dorsal sensory branch of ulnar nerve (DSBUN) neuroapraxia occurs in approximately 10% of cases, with full spontaneous recovery expected 6
• Immobilization-related complications (skin irritation, muscle atrophy) occur in 14.7% of cases but are generally minor 6
• Re-tear rate: approximately 3-4% requiring revision repair 4

Critical pitfall to avoid:

• Arthroscopic evaluation allows identification and treatment of concurrent ligament injuries (scapholunate, lunotriquetral) that may be missed on standard imaging; failure to address these at the time of TFCC repair leads to persistent symptoms 6

Diagnostic Imaging Considerations

When conservative treatment fails and surgery is being considered:

• MR arthrography provides better diagnostic accuracy than standard MRI for TFCC tears and associated ligament injuries 7
• 3.0T MRI without contrast has sensitivity of 63-100% and specificity of 42-100% for TFCC tears 7
• CT arthrography is superior to MRI and similar to MR arthrography for TFCC lesions 7