What is the treatment for a partial thickness tear of the styloid attachment of the Triangular Fibrocartilage Complex (TFCC) near the base of the meniscal homologue in the right wrist?

Treatment of Partial Thickness TFCC Tear at Styloid Attachment

For a partial thickness tear of the styloid attachment of the TFCC near the base of the meniscal homologue, initial conservative management with above-elbow immobilization for 6 weeks is the recommended first-line treatment, with arthroscopic repair reserved for cases that fail conservative therapy or present with DRUJ instability. 1

Initial Conservative Management

Conservative treatment should be attempted first for all partial thickness TFCC tears without frank DRUJ instability:

• Immobilization protocol: Use an above-elbow custom-molded thermoplastic splint in neutral forearm rotation for 6 weeks, as this achieves good outcomes in 76% of traumatic TFCC tears compared to only 29% with short-arm splints 1
• Activity modification: Complete abstinence from sporting activities, gym exercises, and yoga maneuvers that stress the wrist joint 2
• Pharmacologic adjuncts: NSAIDs for pain control, with consideration of corticosteroid injection in conjunction with physical therapy for grossly symptomatic patients 2

Critical pitfall: Short-arm immobilization is associated with significantly worse outcomes and should be avoided—above-elbow immobilization is essential to prevent forearm rotation that stresses the healing TFCC 1

Indications for Surgical Intervention

Proceed directly to arthroscopic treatment if any of the following are present:

• DRUJ instability: Dorsal subluxation of the ulnar head on physical examination or imaging is an independent predictor of poor conservative outcome and warrants early surgical consideration 1
• Failed conservative management: Persistent ulnar-sided wrist pain after 6 weeks of appropriate immobilization and rehabilitation 3, 2
• Mechanical symptoms: True mechanical locking or inability to fully extend the wrist (though less common with partial tears) 2

Note on imaging sensitivity: Conventional arthrography is insensitive to partial-thickness tears, so MRI or MR arthrography should be used for diagnostic confirmation if surgery is being considered 4

Surgical Treatment Algorithm

When conservative management fails, arthroscopic intervention is the preferred approach:

• Arthroscopic debridement: For stable partial thickness tears without peripheral detachment, arthroscopic debridement of the torn fibers provides pain relief and good functional outcomes 3, 2
• Arthroscopic repair: For tears involving the foveal or peripheral attachments (even if partial thickness), arthroscopic capsular repair or foveal reattachment with suture anchor restores DRUJ stability and prevents progression 5, 6
• Concurrent pathology: Arthroscopic evaluation allows identification and treatment of associated ligament injuries that may be missed on standard imaging 5

Post-Operative Protocol (If Surgery Required)

Structured rehabilitation is critical to prevent repair failure:

• Immobilization phase: 4 weeks in neutral forearm rotation and neutral wrist position 5
• Early motion: Gentle active wrist motion begins at 4 weeks post-operatively 5
• Strengthening: Progressive strengthening exercises at 8-12 weeks 5
• Return to activity: Minimum 3 months before return to heavy tasks and sports 5
• Radiographic follow-up: At 3 weeks and at cessation of immobilization to confirm healing 5

Expected Complications and Outcomes

Realistic expectations should be set with patients:

• Conservative treatment success: 76% good outcome rate with proper above-elbow immobilization in traumatic TFCC tears 1
• Surgical outcomes: Significant pain reduction or complete pain relief expected following arthroscopic treatment and rehabilitation 3
• Neurologic complications: Dorsal sensory branch of ulnar nerve neuropraxia occurs in approximately 10% of arthroscopic cases, with full spontaneous recovery expected 5
• Immobilization complications: Minor skin irritation and muscle atrophy occur in 14.7% but are less significant than risks of inadequate treatment 5

Key decision point: The presence of DRUJ subluxation on physical examination (positive ulnar head ballottement test with dorsal instability) or imaging is the single most important predictor of conservative treatment failure and should prompt early surgical referral 1, 6