History

The history of triangular fibrocartilage complex (TFCC) injuries includes ulnar-side wrist pain (frequently accompanied by clicking), a fall or trauma, and/or mechanical symptoms that improve with rest and worsen with activity.

Physical Examination

In the physical examination, it is important to look for the following:

Painful grinding or clicking with wrist range of motion (ROM)
Weakness
Ulnar deviation of the wrist with the forearm in neutral produces ulnar wrist pain and occasional clicking (perform a TFCC compression test)
Instability of the distal radioulnar joint (DRUJ) joint with shucking the distal radius and ulna between the examiner's fingers (perform a DRUJ stress test; always compare this with the opposite wrist)
Piano key sign, which is a prominent and ballottable distal ulna with full pronation of the forearm
Ulnar carpal sag
Lunotriquetral (LT) interval tenderness
Positive LT ballottement or shuck test
Extensor carpi ulnaris (ECU) tendon subluxation

Workup

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Media Gallery

Triangular fibrocartilage complex suspends distal radius and ulnar carpus from distal ulna. T=triquetrum; L=lunate; S=scaphoid. (Reprinted with permission from Palmer AK and Werner FW: The Triangular Fibrocartilage Complex of the Wrist - Anatomy and Function. J Hand Surg; 1981; 6:153)
Triangular fibrocartilage complex provides continuous gliding surface across entire distal face of radius and ulna to allow for flexion-extension and translational movements.
Distally, triangular fibrocartilage complex inserts into lunate triquetrum via ulnolunate and ulnotriquetral ligaments. Triangular fibrocartilage complex solidly connects ulnar axis to volar carpus. Unlabeled arrow points to prestyloid recess. (Reprinted with permission from Palmer AK and Werner FW: The Triangular Fibrocartilage Complex of the Wrist - Anatomy and Function. J Hand Surg; 1981; 6:153)
Relation of triangular fibrocartilage complex to distal radius and ulnar styloid.
Ulnocarpal portion of triangular fibrocartilage complex (TFCC) is composed of discus articularis, ulnolunate ligament (ULL), and ulnotriquetral ligament (UTL). Distally, TFCC inserts into lunate via ULL and into triquetrum via UTL.
Sigmoid notch of distal radius with distinct dorsal, palmar, and distal margins and indistinct proximal margin; triangular fibrocartilage complex arises from ulnar margin of lunate fossa of radius. (Reprinted with permission from Fernandez D and Palmer AK. Fractures of the Distal Radius. In: Green's Operative Hand Surgery. Vol 1. 1999)
Seat of ulnar head articulates with sigmoid notch of distal radius. Radially, triangular fibrocartilage complex (TFCC) arises from ulnar margin of lunate fossa of radius. Ulnarly, TFCC inserts into base of ulnar styloid. (Reprinted with permission from Fernandez D and Palmer AK. Fractures of the Distal Radius. In: Green's Operative Hand Surgery. Vol 1. 1999)
Palmer class 1A tear of triangular fibrocartilage complex that is being probed.
Palmer class 1A tear of triangular fibrocartilage complex after debridement, being treated with electrothermal wand.
Palmer class 1A tear of triangular fibrocartilage complex after debridement with shaver and thermal treatment.
Traumatic ulnar-side Palmer class 1B tear of triangular fibrocartilage complex.
Palmer class 1B tear of triangular fibrocartilage complex treated with outside-in technique using 2-0 polydioxanone sutures and wire loop.
Completion of outside-in repair for Palmer class 1B tear of triangular fibrocartilage complex.

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Author

James R Verheyden, MD Consulting Surgeon, Department of Orthopedic Surgery, The Orthopedic and Neurosurgical Center of the Cascades

James R Verheyden, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Society for Surgery of the Hand

Disclosure: Nothing to disclose.

Coauthor(s)

Andrew K Palmer, MD Chair, Professor, Department of Orthopedics, State University of New York-Upstate Medical University

Andrew K Palmer, MD is a member of the following medical societies: American Osteopathic College of Physical Medicine and Rehabilitation

Disclosure: Partner received salary from Del Palma Orthopedics for board membership.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

N Ake Nystrom, MD, PhD Associate Professor of Orthopedic Surgery and Plastic Surgery, University of Nebraska Medical Center

Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine; Clinical Professor of Surgery, Nova Southeastern School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, Arkansas Medical Society, Florida Medical Association, Florida Orthopaedic Society

Disclosure: Nothing to disclose.

Additional Contributors

Joseph E Sheppard, MD Professor of Clinical Orthopedic Surgery, Chief of Hand and Upper Extremity Service, Department of Orthopedic Surgery, University of Arizona Health Sciences Center, University Physicians Healthcare

Joseph E Sheppard, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Orthopaedics Overseas, American Society for Surgery of the Hand

Disclosure: Nothing to disclose.

Sections Triangular Fibrocartilage Complex Injuries
Overview
Presentation
Workup
Treatment
Media Gallery
References

Triangular Fibrocartilage Complex Injuries Clinical Presentation

History

Physical Examination

References

Tables

Contributor Information and Disclosures

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