How to diagnose and treat a Triangular Fibrocartilage Complex (TFCC) injury in a patient with a history of repetitive strain or overuse and potential osteoarthritis?

Confirming TFCC Injury

For confirming TFCC injury, obtain three-view wrist radiographs first to exclude fractures, then proceed with 3.0T MRI without contrast as the initial imaging study, reserving MR arthrography for cases where surgical intervention is being considered or when standard MRI is equivocal. 1, 2

Initial Clinical Assessment

Look specifically for:

• Ulnar-sided wrist pain, particularly during forearm rotation 3, 4
• Positive TFCC compression test, TFCC stress test, grind test, and supination test 5
• Pain with provocation maneuvers 6
• History of repetitive wrist movements, trauma, or distal radial fractures 6, 5

Imaging Algorithm

Step 1: Plain Radiographs

• Obtain three-view wrist radiographs immediately to exclude fractures and assess ulnar variance 2
• This is the mandatory first imaging step per American College of Radiology guidelines 2

Step 2: MRI Without Contrast (3.0T preferred)

• 3.0T MRI without contrast is the appropriate next study for suspected TFCC or ligament injury 2
• Sensitivity ranges from 63-100% and specificity from 42-100% for TFCC tears 1, 7
• 3.0T MRI is more accurate than 1.5T for TFCC lesions 1, 2
• Highly accurate for central TFCC disc lesions using high-resolution fast spin-echo or 3D gradient-recalled sequences 2
• Important caveat: Sensitivity for peripheral TFCC attachments and ulnar disc attachments is only fair with non-contrast MRI 2

Step 3: MR Arthrography (When Needed)

MR arthrography should be reserved for specific situations:

• When conservative treatment has failed and surgery is being considered 7
• When standard MRI is equivocal or non-diagnostic 1
• For surgical planning when precise characterization of tear pattern is needed 1

MR arthrography advantages:

• Higher sensitivity and specificity than standard MRI for TFCC tears 1
• Better diagnostic accuracy for determining complete versus partial tears 1
• Sensitivity ranges from 63-100% with specificity 89-97% for single radiocarpal injection 1
• For ulnar-sided detachment of the TFCC, consider additional DRUJ injection 1

Alternative: CT Arthrography

• CT arthrography is superior to standard MRI and similar to MR arthrography for TFCC lesions 7, 2
• Nearly 100% sensitivity and specificity for TFCC lesions 2
• Useful alternative when MR arthrography is contraindicated 1

Common Pitfalls to Avoid

• Do not rely on conventional arthrography alone - it has only moderate sensitivity (76%) for full-thickness tears and is insensitive to partial-thickness tears 1, 8
• Do not skip plain radiographs - they are essential to exclude fractures and assess ulnar variance, which affects treatment decisions 2
• Do not order MRI with and without IV contrast routinely - this is not indicated for standard TFCC evaluation and is reserved for suspected infection or inflammatory arthropathy 1
• Recognize that standard MRI may miss peripheral tears - if clinical suspicion remains high despite negative standard MRI, proceed to MR arthrography 2

When Arthroscopy is Needed

• Arthroscopy remains the gold standard for definitive diagnosis 1
• Allows identification of associated ligament injuries that may be missed on imaging 8
• Can provide both diagnosis and treatment in the same procedure 6, 3
• Consider when imaging is equivocal but clinical suspicion remains high 3