TFCC Tears



Present with pain but not instability







Different treatment algorithms for each




Ulna side wrist pain

- may be worse with rotation

- opening doors and jars


History of trauma




Local tenderness DRUJ


Supinate / pronate

- pain

- click


Forcibly ulna deviate and pronate wrist

- grinds carpus against TFCC
- generates pain


Check for DRUJ instability / Piano Key


Ulna variance




Xray in neutral supination / pronation


Variance is not static

- Pronation increases ulnar variance

- Supination decreases variance

- May be up to 3 mm




Transverse line of lunate fossa

Transverse line of ulna head




Population is on average 1 mm ulna plus

- wide variation

- 1/4 wrists are ulna negative




Neutral variance

- Takes < 20% of load


Ulna Variance Neutral


2.5mm Ulnar negative

- 4.3% of load


Ulna NegativeUlna Variance Negative


2.5mm Ulnar positive

- 42% of load


Ulna Variance PositiveUlna Positive with abutmentUlna Variance Positive




Ulna Variance


Evidence ulnocarpal abutment / arthritis




Look for discontinuity of TFCC

- radial / ulna / central / carpal


TFCC Tear Ulna Side


Wang et al, J Hand Surg Eur Vol

- 154 patients >20y with assymptomatic wrists had MRI performed

- 44% had full thickness tear

- Worse with age, 17% 20-29y; 77% if > 60y


Palmer Classification TFCC Lesions


Class 1 Traumatic


A. Central perforation

B. Ulnar avulsion 

- With distal ulnar fracture

- Without distal ulnar fracture

C. Carpal / Distal avulsion

- ulno-carpal ligament injury

D. Radial avulsion (+/- sigmoid notch fracture) 


Class 2 Degenerative 




A. TFCC wear

B. TFCC wear

+ lunate and/or ulnar chondromalacia

C. TFCC perforation

+ lunate and/or ulnar chondromalacia 

D. TFCC perforation

+ lunate and/or ulnar chondromalacia

+ Luno-Triquetral ligament perforation

E. TFCC perforation

+ lunate and/or ulnar chondromalacia

+ Luno-Triquetral ligament perforation

+ ulnocarpal arthritis


TFCC Degenerative Tear with Chondromalacia




Diagnose central tears


Trampoline test

- TFCC should bounce on probe

- if very soft, likely has a peripheral tear





- acute repair if DRUJ unstable

- delayed repair if continued symptoms and ulna / radial tear

- debridement of central tears + ulna shortening if ulna positive

- ulna shortening if ulnocarpal abutment / arthritis


Class 1 Traumatic


A.  Ulna


Acute Injury


1.  Stable DRUJ

- immobilise in neutral rotation

- need long arm cast

- surgical repair if continued symptoms / non healing


2.  Unstable DRUJ


A.  Obtain closed reduction / supination

- immobilise


B.  Failure closed reduction

- open / arthroscopic TFCC repair to stabilise DRUJ


Operative repair



- acute instability

- continues pain / late presentation



- good success as very vascular

- 5/6 approach / bed of EDM

- interval between EDM and ECU

- open capsule

- sutures in TFCC, pass  through drill holes in base ulna styloid

- immobilise in cast




B.  Radial



- difficult to access / repair / very avascular


Open repair

- 5/6 approach

- drill holes through dorsal radius into ulna fossa

- use suture retriever

- stabilise with RU K wires if continued instability


C.  Central 



- usually occur along avascular origin from radius 

- usually 1-2mm from origin

- may be traumatic or degenerative


Neutral ulna variance

- Arthroscopic debridement

- 73% success complete pain relief

- Can take central 2/3 of disk without problems


Positive ulna variance

- do worse if debride disc alone

- consider combining with ulnar shortening as well


Class 2 Degenerative 


Class 2A - C



- TFCC wear or perforation

- lunate and / or ulna chondromalacia

- lunate triquetral ligament intact


1.  Positive ulna variance


Shorten ulna +/- arthroscopic debridement TFCC




A.  Ulnar shortening and plate fixation

- specific plates (Trimed)

- have advantage of rotational control throughout procedure

- midportion ulna, apply plate dorsal

- fix distally, sliding screw proximally

- oblique osteotomy through jig

- 5 or 8 mm

- shorten, lag screw through plate

- apply proximal screw


Ulna PositiveUlna Shortening


B.  Wafer / Bower's hemiresection procedure

- open or arthroscopic

- remove 2-3 mm ulna head

- aim to make ulna negative

- not indicated if > 4mm ulna positive

- leave ulna styloid / TFCC intact


2.  Ulna neutral

- arthroscopic debridement

- +/- ulna shortening


Class 2D



- Lunotriquetral ligament perforation



- Arthroscopic debridement / ulna shortening 

- LT fusion if unstable


Type 2E / Ulnocarpal Impaction Syndrome



- LT ligament perforated

- ulnocarpal abutment / arthritis


Associated with positive ulnar variance

- from repetitive loading


Ulnocarpal Abutment




1.  Bower's ulna head hemiresection

- resect 2mm ulna head leaving ulna styloid

- +/- interposition of dorsal capsule


2.  Darrach's

- excision of distal ulan

- +/- stabilisation with tendon transfer


3.  Suave-Kapandji

- distal radioulna fusion