What is the treatment for a Triangular Fibrocartilage Complex (TFC) fracture?

Treatment of Triangular Fibrocartilage Complex (TFCC) Tears

For peripheral TFCC tears with foveal detachment (Palmer 1B), arthroscopic foveal repair with suture anchor is the preferred surgical approach, while stable tears without DRUJ instability should undergo a trial of conservative management with immobilization and structured rehabilitation before considering surgery. 1, 2

Initial Assessment and Diagnostic Approach

The critical first step is determining whether DRUJ instability is present, as this fundamentally changes management:

• Examine for DRUJ stability by comparing the affected wrist to the contralateral side in neutral, supinated, and pronated positions—frank instability mandates surgical intervention 3
• Obtain MR arthrography (radiocarpal injection, with additional DRUJ injection if ulnar-sided detachment suspected) as it provides superior diagnostic accuracy compared to standard MRI, with sensitivity of 63-100% for TFCC tears 4, 1
• CT arthrography is an alternative with 92-94% sensitivity and specificity for TFCC tears, particularly useful when MRI is contraindicated 4

Conservative Management Algorithm

Initiate non-operative treatment for stable tears without DRUJ instability:

• Immobilize in a munster cast or forearm splint preventing pronation/supination for 4 weeks, followed by 2-4 weeks in a short arm cast 5, 3
• Prescribe NSAIDs and consider corticosteroid injection for symptomatic relief 6, 3
• Implement structured 5-phase rehabilitation combining orthoses with progressive strengthening and proprioception training once immobilization complete 7
• This approach achieves 93% satisfactory outcomes in appropriately selected patients, with pain scores improving from 5.3/10 to 0.5/10 and grip strength increasing 59.5% 7

Surgical Indications and Technique

Proceed to surgery if:

• Conservative management fails after appropriate trial (typically 3-6 months) 6, 3
• DRUJ instability present on initial examination 3
• Peripheral tear with foveal detachment (Palmer 1B) identified on imaging 1, 2

Surgical approach:

• Arthroscopic foveal repair with suture anchor restores anatomic TFCC attachment to the foveal insertion site, which is critical for DRUJ stability 1, 2
• Outside-in suture repair to ulnar capsule is appropriate for superficial fiber tears with intact deep fibers, achieving 90% good-to-excellent results 8
• Arthroscopic debridement alone may suffice for central degenerative tears without instability 6, 3
• Concurrent treatment of associated injuries (scapholunate/lunotriquetral ligament tears present in 60% of cases) can be addressed during the same arthroscopic procedure 5

Post-Operative Protocol

Strict adherence to immobilization prevents repair failure:

• Immobilize forearm rotation for 4 weeks in neutral rotation with wrist in neutral position 1, 2, 5
• Obtain radiographs at 3 weeks post-operatively and again at immobilization cessation to confirm healing 1, 9
• Begin gentle active wrist motion at 4 weeks, progress to strengthening exercises at 8-12 weeks 1, 2
• Return to heavy tasks and sports at minimum 3 months, though athletes bearing weight through hands (gymnasts, wrestlers) have lower return-to-sport rates compared to racquet sport athletes 8

Expected Outcomes and Complications

Surgical repair achieves:

• 93% satisfactory outcomes with return to work/sports activities 5
• Mayo modified wrist scores of excellent in 64% and good in 27% of cases 5
• Grip strength recovery to at least 75% of contralateral hand 5

Common complications to monitor:

• DSBUN neuroapraxia occurs in 10% of cases but fully recovers spontaneously 1, 2
• Immobilization-related complications (skin irritation, muscle atrophy) occur in 14.7% but are minor compared to risks of inadequate treatment 1, 2, 9
• Re-tear rate is low (approximately 3-4%) with proper technique and post-operative immobilization 8

Critical Pitfalls to Avoid

• Do not remove immobilization prematurely without radiographic confirmation of healing—this is the most common cause of repair failure 1, 9
• Do not miss associated ligament injuries on pre-operative imaging; arthroscopic evaluation allows identification of concurrent injuries that standard imaging may miss 2
• Do not assume all ulnar-sided wrist pain with TFCC tear requires surgery—tears with intact deep fibers and stable DRUJ respond well to conservative management 8