Treatment of Full Thickness Central TFCC Disc Tear (4mm)
Begin with a minimum 6-month trial of conservative management including immobilization in neutral wrist and forearm position for 4 weeks, followed by progressive rehabilitation, as approximately 50% of patients achieve complete recovery by 1 year with nonsurgical treatment alone. 1, 2, 3
Initial Conservative Management
- Immobilize the wrist and forearm in neutral position for 4 weeks to allow healing of the central disc tear 1, 2
- Initiate gentle active wrist motion at 4 weeks post-immobilization 1, 2
- Progress to strengthening exercises at 8-12 weeks 1, 2
- Delay return to heavy tasks and sports until minimum 3 months 1
The natural history data demonstrates that 30% of patients with TFCC tears without DRUJ instability achieve complete recovery by 6 months, increasing to 50% by 1 year with conservative treatment 3. This supports an extended trial of nonsurgical management before considering surgery.
- Consider NSAIDs for pain management during the conservative treatment period 4
- Avoid complete immobilization beyond the initial 4-week period, as relative rest with progressive loading promotes proper healing 4
Surgical Indications
Proceed to arthroscopic intervention only after failure of conservative treatment for at least 6 months, as this represents the evidence-based threshold for determining treatment failure 3.
- Surgery is indicated when ulnar-sided wrist pain persists despite adequate conservative management 4, 5
- Confirm diagnosis with MR arthrography prior to surgery, as it provides superior diagnostic accuracy compared to standard MRI for TFCC tears 1, 2
- Alternative imaging with CT arthrography offers similar or superior accuracy to MR arthrography and may be considered 1, 2
Surgical Technique for Central Disc Tears
Arthroscopic debridement is the primary surgical treatment for Palmer 1A central disc tears, as these tears occur in the avascular central portion and cannot heal with repair 4, 6, 5.
- Perform arthroscopic debridement of the torn central disc tissue 4
- The 4mm tear size falls within the range amenable to debridement, as the central disc is avascular and repair is not feasible 5
- Arthroscopic approach allows concurrent evaluation and treatment of associated injuries 1
Critical distinction: If the tear extends to involve peripheral attachments or foveal insertion (converting to Palmer 1B), arthroscopic foveal repair with suture anchor becomes necessary to restore DRUJ stability 1, 2. Careful arthroscopic assessment is essential to distinguish pure central disc tears from those with peripheral extension.
Post-Operative Protocol
- Immobilize forearm rotation for 4 weeks in neutral rotation following surgical intervention 1
- Obtain radiographs at 3 weeks post-operatively to confirm healing 1
- Begin gentle active motion at 4 weeks, strengthening at 8-12 weeks, return to sports at minimum 3 months 1, 2
Expected Complications
- Dorsal sensory branch of ulnar nerve (DSBUN) neuroapraxia occurs in approximately 10% of cases, with full spontaneous recovery expected 1
- Immobilization-related complications (skin irritation, muscle atrophy) occur in 14.7% of cases but are generally minor 1
Common Pitfalls to Avoid
- Do not rush to surgery before 6 months of conservative treatment, as half of patients will recover without surgical intervention 3
- Do not attempt repair of central disc tears, as the avascular nature of this tissue precludes healing; debridement is the appropriate technique 5
- Ensure accurate classification of the tear type (central vs peripheral) through arthroscopic evaluation, as this fundamentally changes the surgical approach from debridement to repair 1, 6, 5