What is the treatment for a tear of the central Triangular Fibrocartilage Complex (TFCC) disc with a tear of the scapholunate ligament and rotary subluxation of the scaphoid?

Treatment of Combined Central TFCC Tear, Scapholunate Ligament Tear, and Rotary Subluxation of Scaphoid

This combined injury pattern requires surgical intervention with arthroscopic or open repair of both the scapholunate ligament and TFCC, as conservative management will not adequately address the instability and prevent progressive degenerative changes.

Initial Diagnostic Confirmation

Before proceeding to surgery, confirm the full extent of injuries with advanced imaging:

• CT arthrography is the preferred diagnostic modality, achieving nearly 100% sensitivity and specificity for both scapholunate ligament tears and TFCC lesions, with superior accuracy for detecting partial tears compared to other modalities 1
• MR arthrography serves as an alternative if CT arthrography is unavailable, with high sensitivity (63-100%) for TFCC tears and ability to identify which specific segments of the scapholunate ligament are torn—critical information for surgical planning 1, 2
• Wrist arthroscopy remains the gold standard for definitive diagnosis and allows concurrent treatment 3

Surgical Treatment Algorithm

Primary Surgical Approach: Combined Repair

The optimal treatment is simultaneous arthroscopic or open repair of both the scapholunate ligament and TFCC complex, as this combined injury pattern represents a severe wrist instability that will not heal with isolated treatment 3.

Scapholunate Ligament Repair

• Direct arthroscopic repair using bone anchors for the dorsal scapholunate ligament (the biomechanically critical component), complemented by dorsal capsular reinforcement to reconstruct the dorsal capsulo-scapholunate septum 4
• Temporary K-wire or transosseous screw fixation of the scaphoid and lunate in reduced position to maintain carpal alignment during healing 5, 6
• The dorsal band is the most important component for stability and must be addressed 4

TFCC Repair

• Arthroscopic foveal repair with suture anchor for peripheral tears with foveal detachment, as this restores anatomic TFCC attachment critical for distal radioulnar joint stability 2
• This technique allows concurrent treatment of the scapholunate injury during the same procedure 2

Post-Operative Protocol

Immobilization is critical for healing:

• Immobilize forearm rotation for 4 weeks in neutral rotation and wrist in neutral position 2
• Wrist immobilization for 3 weeks, then dart-throwing motion permitted until temporary fixation removal 6
• Remove K-wires or screws at 2-3 months post-operatively 6
• Gentle active wrist motion begins at 4 weeks, strengthening exercises at 8-12 weeks 2
• Return to heavy tasks and sports at minimum 3 months 2
• Wrist brace recommended for 3-6 months depending on occupation and activity level 6

Radiographic Monitoring

• Obtain radiographs at 3 weeks post-operatively and at immobilization cessation to confirm healing and assess carpal alignment 2
• Monitor for maintenance of scapholunate interval and absence of dorsal intercalated segmental instability pattern 7

Expected Outcomes and Complications

Combined repair shows good success rates:

• Statistically significant pain reduction (VAS from 8.9 to 5.0) and functional improvement (DASH from 63 to 40) at mean 54-month follow-up 3
• Only 7% require supplemental procedures for persistent instability 3
• Dorsal sensory branch of ulnar nerve neuropraxia occurs in approximately 10% but fully recovers spontaneously 2
• Immobilization-related complications (skin irritation, muscle atrophy) occur in 14.7% but are generally minor 2

Critical Pitfalls to Avoid

• Do not treat these injuries in isolation—combined scapholunate and TFCC injuries represent a "combined wrist injury" with worse outcomes if not addressed together 8
• Do not delay surgical intervention—chronic injuries have worse outcomes than acute repairs 3
• Do not rely on standard MRI alone—it has only moderate sensitivity (65-89%) for scapholunate tears and may miss the full extent of injury 1
• Ensure adequate immobilization duration—premature mobilization leads to repair failure and persistent instability 2, 6