Triangular Fibrocartilage Complex Injuries Workup

Updated: Oct 13, 2022
  • Author: James R Verheyden, MD; Chief Editor: Harris Gellman, MD  more...
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Imaging Studies

Plain radiography

Obtain neutral forearm rotation posteroanterior (PA) and lateral x-rays of the wrist to allow assessment of ulnar variance and to assess for chondromalacia of the lunate or ulnar head, degenerative joint disease of the distal radioulnar joint (DRUJ), lunotriquetral (LT) or scapholunate (SL) instability, dorsiflexed intercalated segment instability (DISI), or volarflexed intercalated segment instability (VISI).

Wrist arthrography

The accuracy and diagnostic capability of triple-injection wrist arthrograms have been challenged over the past decade. The test is not specific, with a high incidence of findings on the contralateral asymptomatic side. Wrist arthrography has poor diagnostic agreement with chronic wrist pain.

Positive wrist arthrograms are obtained in 27% of asymptomatic adults. Palmer class 1B tears have positive arthrograms with a DRUJ injection but not with a radiocarpal injection. Palmer class 1C tears have variable findings. Palmer class 1D tears usually have positive arthrograms.

Magnetic resonance imaging

Magnetic resonance imaging (MRI) can predict triangular fibrocartilage complex (TFCC) lesions with 0.8 sensitivity and 0.7 specificity using a dedicated wrist coil. [32, 33, 34] Fat-suppression MRI scans best exhibit the complex structure of the TFCC.

A prospective study by Lee et al suggested that the addition of axial traction during wrist magnetic resonance arthrography may significantly improve the ability of this modality to detect and visualize tears of the TFCC. [35]  

A study by Thomsen et al found postcontrast 3T indirect magnetic resonance arthrography to have better diagnostic performance than precontrast imaging for the overall detection of class 1B TFCC tears. [36]  

A study by Zhan et al suggested that the more detailed injury patterns detectable with high-resolution 3T MRI may indicate the need for refinement of the classic Palmer classification of TFCC injuries. [37]


Ultrasonography (US) has not been as widely employed for imaging TFCC lesions as the preceding modalities have. However, high-resolution US may be useful for diagnosing these injuries. [38]  A study by Yuine et al found that using force-monitor US to assess DRUJ instability may help identify TFCC-injured wrists. [39]



Wrist arthroscopy has been the criterion standard for diagnosis of these injuries; it can be a diagnostic tool or a therapeutic tool. When compared with other imaging studies, wrist arthroscopy has typically been found to be more accurate. It also allows assessment of the size of the tear, determination of whether an unstable flap is present, and detection of associated synovitis and chondral and ligamentous lesions. However, one study suggested, on the basis of relatively low interrater correlation, that the status of arthroscopy as the reference standard should be reconsidered. [40]  

With the trampoline test, normally a probe should bounce off of the TFCC. If a probe sinks into the TFCC as if it is on a feather bed, a tear is usually present.

Wrist arthroscopy is used in the diagnosis of TFCC tears associated with distal radius fractures. Richards examined 118 fractures [41] ; these fractures had wrist arthroscopy that required reduction and fixation because of a failure to obtain or maintain a reduction.

Lee Master et al undertook a study to determine the accuracy of the wrist insufflation test on the basis of mean radiocarpal and midcarpal joint space volumes in 29 patients who underwent three- or four-portal radiocarpal and radial midcarpal portal insufflation before wrist arthroscopy. [42]  They concluded that the test allowed detection of complete SL interosseous ligament and TFCC tears and complete SL interosseous ligament and LT interosseous ligament tears.