Arthroscopic algorithm for acute traumatic triangular fibrocartilage complex (TFCC) tears

Abstract

The triangular fibrocartilage complex (TFCC) is crucial for stability and acts as a shock absorber and load transmitter at the distal radioulnar joint (DRUJ). It is often injured in wrist trauma, particularly in young athletes. Clinical assessment involves patient history, physical examination, and imaging modalities like MRI, with wrist arthroscopy as the gold standard for diagnosing TFCC tears. Multiple classification systems categorize TFCC tears based on location and arthroscopic appearance, guiding treatment decisions. Surgical options are recommended for tears refractory to conservative management or severe tears. Despite numerous arthroscopic treatments available in the literature, this article aims to simplify the approach. It presents the authors' surgical algorithm for managing acute traumatic TFCC tears arthroscopically. The choice of technique depends on the lesion's location, with various options for peripheral and foveal tears. Post-operative rehabilitation is crucial for optimal recovery. This article provides a comprehensive review of acute traumatic TFCC injuries, covering anatomy, classification, assessment, and treatment options. Emphasis is placed on accurate diagnosis and appropriate arthroscopic management through a structured approach.

Keywords: Distal radioulnar joint (DRUJ); Fovea; Triangular fibrocartilage complex (TFCC); Ulnar-sided; Wrist arthroscopy; Wrist pain.

Fig. 1

Artist's impression of the TFCC anatomy. The retracted ECU tendon and subsheath, highlighted with a red vessel loop, provide a clear view of the complete TFCC anatomy.

Fig. 2

Artist's impression of Herzberg et al. classification of TFCC lesions based on arthroscopic findings, divided into disc (D), reins (R), and wall (W) categories, further subcategorized by tear location.

Fig. 3

Left wrist, DRUJ portal view showing the avulsed radioulnar ligament (yellow arrows from the foveal footprint (black asterisks). Abbreviations: DRUJ, Distal Radioulnar Joint; UH, ulnar head.

Fig. 4

Right wrist, 3–4 portal view showing the arthroscopic probe inserted through the 6R portal, attempting to hook the torn dorsal peripheral TFCC tear (yellow arrows). The black asterisk indicates the triangular fibrocartilage disc. Abbreviations: Tq, triquetrum; SS, extensor carpi ulnaris subsheath; 6U, 6-ulnar portal.

Fig. 5

Left wrist, (A) Two single 3-0 PDS, one radial and one ulnar, and a central 4-0 PDS suture loop (black arrow), are placed to form (B) two loops that secure the lateral and medial portions of the TFCC to the dorsal capsule. Black asterisk depicts the triangular fibrocartilage disc. Abbreviations: Tq, triquetrum; PDS, polydioxanone sutures.

Fig. 6

Right wrist, view from 3 to 4 portal. Figure (A) shows the torn dorsal peripheral edge of the TFCC (yellow arrows) repaired with peripheral capsular sutures (outside-in technique) using 3-0 PDS before tightening the sutures. Figure (B) shows the same area after tightening the sutures, closing the separation between the TFC disc and the dorsal radioulnar ligament and capsule. The black asterisk indicates the triangular fibrocartilage disc. Abbreviations: Tq, triquetrum; SS, extensor carpi ulnaris subsheath; 6U, 6-ulnar portal.

Fig. 7

Right wrist, 3–4 portal view. (A) A curved 21-G needle loaded with a 3-0 PDS suture is inserted through the 6U portal, passing beneath the TFCC and penetrating the palmar TFCC near the volar sigmoid notch. The suture end is retrieved from the 6R portal, and the needle is retracted just beneath the TFCC and (B) re-penetrates another section of the palmar TFCC at the ulnar edge. Both ends of the suture are retrieved from the 6R portal. (C) The curved hemostat, located between the UCLC and the ulnar NVB, is then used to retrieve the first end of the 3-0 PDS suture so that the suture captures the UCLC out of the 6U portal. (D) The other end of the suture is then retrieved directly from the 6R portal out of the 6U portal. The faded red dotted line indicates the interface between the UCLC/Volar ulnar capsule and the palmar TFCC. The faded green dotted line represents the interface between the ECU SS and the dorsal TFCC. The faded grey dotted line represents the edge of the sigmoid notch. Abbreviations: ECU, Extensor carpi ulnaris; SS, subsheath; Tq, Triquetrum; 6U, 6-ulnar; TFCC, triangular fibrocartilage complex ∗With permission: Chung SR, Merlini L. Arthroscopic repair of combined triangular fibrocartilage complex, lunotriquetral ligament, and ulnocarpal ligament tears. Arthroscopy Techniques. 2024. https://doi.org/10.1016/j.eats.2024.102995.

Fig. 8

Right wrist, 3–4 portal view. The final suture configuration (light blue line and white arrow), reinforcing the palmar TFCC, the UCLC (black asterisk), and the volar LTIL complex. Yellow shaded area represents the 6-U portal. The faded red dotted line indicates the interface between the UCLC/Volar ulnar capsule and the palmar TFCC. Abbreviations: SS, subsheath; Tq, Triquetrum; 6U, 6-ulnar; TFCC, triangular fibrocartilage complex. ∗With permission: Chung SR, Merlini L. Arthroscopic repair of combined triangular fibrocartilage complex, lunotriquetral ligament, and ulnocarpal ligament tears. Arthroscopy Techniques. 2024. doi:10.1016/j.eats.2024.102995.

Fig. 9

The left wrist is shown. (A) The Nakamura target device is inserted through the 6R portal, with the spike placed on the ulnar half of the TFCC. The guide sleeve is advanced to the skin 15 mm proximal to the ulnar styloid tip, where an incision is made. (B) Radiographic appearance of the Nakamura target device, with the tip on the ulnar half of the TFCC. (C) View from the 3–4 portal. A 2-0 FiberWire suture is threaded through the TFCC and out the ulnar cortex via two transosseous tunnels drilled using the target device. The image shows the suture before tightening. (D) The 2-0 FiberWire suture is tightened, securing the TFCC to the fovea. Abbreviations: 6R, 6-radial; TFCC, triangular fibrocartilage complex.

Fig. 10

Artist's impression of Atzei's TFCC foveal suture anchor repair. (A) A suture anchor loaded with a pair of sutures is inserted through the DF portal and passed through each limb of the RUL with a 25-G needle. (C) The sutures are tightened under arthroscopic vision using a small knot-pusher, securing the TFCC to the fovea. (D) Radiographic appearance of Atzei's TFCC foveal suture anchor repair with the suture anchor in the fovea. Abbreviations: DF, direct fovea; RUL, radioulnar ligament.

Fig. 11

Artist's impression of pre-Palmer 1D repair where the RULs were ruptured at mid-substance just before their insertion on the sigmoid notch. (A) A 2/0 or 3/0 monofilament suture is passed through the radial stump tear from the ulnar portion of the TFCC via a 21-G shuttle needle. (B) A second shuttle needle with a suture loop is introduced similarly, parallel to the first needle. The suture loop pulls the nylon suture back through the tear. (C) The procedure is repeated for the DRUL, ensuring both ligaments are securely sutured. Abbreviations: PRUL, palmar radioulnar ligament; DRUL, dorsal radioulnar ligament; RUL, radioulnar ligament.

Fig. 12

Artist's impression of mini-Pushlock anchor repair of radial-sided TFCC avulsion. (A) An 18G needle passes a FiberWire 2-0 suture through the avulsed TFCC end in an all-inside manner. (B) The sutures are retrieved with a mini-arthroscopic suture lasso from the 6U portal. (C) The sutures are threaded into a mini-Pushlock anchor, and a hole is drilled at the sigmoid notch. (D) The TFCC is anchored to the sigmoid notch with the mini-Pushlock anchor. Abbreviations: TFCC, Triangular fibrocartilage complex; 6U, 6-ulnar.