Management of TFCC Injuries
Start with conservative management for 3 months in all acute TFCC injuries with stable DRUJ, and proceed to arthroscopic foveal repair with suture anchor only if conservative treatment fails or if there is DRUJ instability. 1, 2, 3, 4
Initial Conservative Management (First-Line Treatment)
Conservative treatment is the appropriate initial approach for most TFCC injuries, particularly those with stable distal radioulnar joint (DRUJ). 4
Treatment components include:
- Immobilization: Use wrist orthoses to protect the TFCC during the initial healing phase 3
- Activity modification: Avoid provocative movements involving forearm rotation and ulnar deviation 5, 6
- Progressive rehabilitation program: Implement a structured 5-phase protocol incorporating strengthening and proprioception exercises 3
- Pain management: Use analgesics as needed, avoiding prolonged narcotic use 5
Expected timeline and outcomes:
- Most patients show significant improvement within 8-12 weeks of structured conservative treatment 3
- Conservative management achieves pain reduction from 5.3/10 to 0.5/10, with 35% improvement in ROM and 59.5% increase in grip strength 3
- Outcomes after conservative treatment are statistically equivalent to arthroscopic debridement for stable DRUJ injuries (DASH score 16.8 vs 22.1, grip strength 88% vs 89%) 4
Indications for Surgical Intervention
Proceed to surgery if any of the following criteria are met:
- Failure of conservative treatment after 3 months of appropriate management 2, 5, 4
- DRUJ instability on clinical examination, indicating peripheral tear with foveal detachment (Palmer 1B) 1, 2
- Persistent severe ulnar-sided wrist pain that limits activities of daily living despite conservative measures 5, 7
Surgical Management
Arthroscopic foveal repair with suture anchor is the preferred surgical technique for Palmer 1B peripheral tears with disrupted deep fibers and foveal detachment. 1, 2
Key advantages of this approach:
- Restores anatomic TFCC attachment to the foveal insertion site, which is critical for DRUJ stability 1, 2
- Allows concurrent treatment of associated ligament injuries that may be missed on standard imaging 1
- Lower morbidity compared to open repair techniques 7
Post-operative protocol:
- Weeks 0-4: Immobilize forearm rotation in neutral position and wrist in neutral 1, 2
- Week 4: Begin gentle active wrist motion 1, 2
- Weeks 8-12: Progress to strengthening exercises 1, 2
- 3 months minimum: Return to heavy tasks and sports 1, 2
- Radiographic follow-up: Obtain imaging at 3 weeks post-operatively and at immobilization cessation to confirm healing 1, 2
Diagnostic Imaging Considerations
When conservative treatment fails and surgery is being considered:
- MR arthrography provides the best diagnostic accuracy for TFCC tears and associated ligament injuries 2
- CT arthrography is superior to standard MRI and similar to MR arthrography for TFCC lesions 2
- 3.0T MRI without contrast has variable accuracy (sensitivity 63-100%, specificity 42-100%) but can be useful 2
Expected Complications
Be aware of these potential complications:
- Dorsal sensory branch of ulnar nerve (DSBUN) neuroapraxia occurs in approximately 10% of surgical cases, with full spontaneous recovery expected 1, 2
- Immobilization-related complications (skin irritation, muscle atrophy) occur in 14.7% of cases but are generally minor 1, 2
Critical Clinical Pitfalls to Avoid
- Do not rush to surgery for TFCC injuries with stable DRUJ—conservative management achieves equivalent outcomes in these cases 4
- Do not use simple arthroscopic debridement for Palmer 1B tears with DRUJ instability—these require foveal repair to restore stability 1, 2
- Do not allow patients to return to sports or heavy activities before 3 months post-operatively—premature loading risks repair failure 1, 2
- Do not skip the structured rehabilitation protocol—progressive strengthening and proprioception training are essential for re-establishing DRUJ stability 3