TFCC Tears & Distal Radioulnar Joint Instability
The distal radioulnar joint (DRUJ)
When we rotate our forearm, the radius rotates around the ulna. The DRUJ is a pivot joint which allows this motion to occur whilst simultaneously keeping the two bones stable.
The triangular fibrocartilage complex, commonly called the TFCC, is the principle stabiliser of the DRUJ. A TFCC injury can cause pain, clicking, weakness, loss of confidence in the wrist and difficulty rotating the forearm.
A comprehensive approach to TFCC and DRUJ disorders
TFCC and DRUJ problems exist on a broad spectrum.
TFCC problems present differently in different people. An acutely painful but stable TFCC injury may settle with immobilisation and rehabilitation. A repairable peripheral or foveal tear may be treated arthroscopically. A more complex injury may require open repair, particularly when there is static subluxation, a bony correction or revision surgery.
An irreparable TFCC may require tendon-graft reconstruction. Ulnar impaction may require a wafer procedure or ulnar shortening osteotomy. Sigmoid notch deficiency or post-traumatic deformity may require corrective osteotomy and patient-specific planning. Advanced DRUJ arthritis may be treated with arthroscopic procedures, matched ulnar resection, tendon interposition, hemi-joint resurfacing or constrained total joint replacement.
Dr Xuan Ye has a particular interest in the comprehensive treatment of TFCC and DRUJ disorders in adults and children. His practice includes arthroscopic TFCC repair, open repair, arthroscopic and arthroscopically assisted ligament reconstruction, ulnar shortening osteotomy, arthroscopic wafer procedures, corrective osteotomy, sigmoid notch reconstruction and the management of DRUJ arthritis. For advanced or previously failed conditions, treatment may include ulnar head resurfacing or an Aptis, also known as a Scheker, constrained DRUJ replacement.
What is the TFCC?
The TFCC is not a single ligament. It is a complex arrangement of cartilage, ligaments and supporting soft tissues between the end of the ulna and the small bones of the wrist.
It acts as both a cushion and a stabiliser. It helps distribute load across the ulnar side of the wrist, supports the wrist during gripping and weight-bearing, and stabilises the relationship between the radius and ulna as the forearm rotates.
What causes a TFCC tear?
A TFCC tear may be an acute traumatic tear like a sporting injury, or develop gradually through repeated loading over time (twisting and ulna deviation).
Traumatic tears commonly occur after a fall onto an outstretched hand, a forceful twisting movement, a sporting injury or an accident involving the wrist or forearm. A sudden injury can detach the TFCC from its peripheral or foveal attachment and may result in DRUJ instability.
Degenerative tears develop more gradually. They may be associated with repetitive wrist loading, age-related tissue change, inflammatory arthritis, previous fractures or abnormal alignment between the radius and ulna.
How is a TFCC injury diagnosed?
The objective is not simply to treat an MRI abnormality. It is to understand how the TFCC functions, determine why the wrist remains painful or unstable and address each relevant soft-tissue, bony and joint component of the problem.
Diagnosis begins with a careful history and clinical examination. The examination evaluates tenderness over the TFCC and ulnar fovea, wrist and forearm movement, grip strength and DRUJ stability in different positions of forearm rotation. Associated conditions involving the extensor carpi ulnaris tendon, lunotriquetral ligament, cartilage or other parts of the wrist must also be considered.
The stability of the affected DRUJ is usually compared with the opposite wrist. Some people naturally have more movement in both DRUJs than others, so the diagnosis cannot be made from the amount of movement alone. The quality of the endpoint, reproduction of pain and difference between sides are also important.
X-rays and assessment of bony anatomy
X-rays are used to assess for any bony deformity as well as the relative length of the radius and ulna. This is known as the ulna variance. The relationship between the radius and ulna is important because a technically successful soft-tissue repair may still fail if abnormal bone alignment continues to overload or destabilise the joint.
A previous distal radius or forearm fracture may alter the length, rotation, tilt or shape of the bones. These changes can modify DRUJ mechanics and may need to be corrected as part of treatment.
The role of MRI
MRI is useful for examining the TFCC, cartilage, tendons and other wrist ligaments. It may identify a tear, inflammation, degeneration or associated wrist pathology. However, MRI findings must be interpreted in the context of the patient’s symptoms and examination. TFCC abnormalities can be present in asymptomatic wrists, while clinically important instability may exist despite an MRI report that does not identify a definite tear.
A detailed review of the MRI may reveal subtle evidence of previous injury or scarring even when the formal report does not describe an active tear. In these cases arthroscopy can provide a more accurate real time assessment of the tissue quality (example below) for the treatment of TFCC pain that has not impoved despite maximal non-operative management.
The role of CT scanning
CT scans are not necessary for diagnosing simple TFCC tears. They can be useful in revision cases and for complex instability to assess for radial deformity or a deficient sigmoid notch. A shallow, flattened or deficient sigmoid notch may provide inadequate containment of the ulnar head and contribute to persistent DRUJ instability (Case example below of a shallow notch corrected with a sigmoid notchplasty).
In selected cases, both forearms may be scanned in neutral rotation, pronation and supination. This allows the symptomatic wrist to be compared with the opposite side and can demonstrate abnormal translation or incongruity that may not be apparent on a standard static scan.
Wrist arthroscopy has revolutionised TFCC treatment
Wrist arthroscopy has revolutionised the diagnosis and treatment of soft-tissue wrist conditions, including TFCC injuries. Arthroscopy allows for direct visualisation of the joint and repair of previously difficult to reach areas of the wrist in a soft tissue sparing and minimally invasive fashion. The procedure is performed through several small incisions around the wrist. A narrow camera is introduced into the joint, allowing the TFCC, cartilage and intrinsic wrist ligaments to be inspected directly.
Arthroscopy does much more than confirm whether a tear is present. It allows the surgeon to probe, tension and dynamically assess the TFCC. This provides information about how the tissue functions rather than simply how it appears on a static scan. A TFCC that appears continuous on MRI may be found at arthroscopy to be scarred, elongated or inadequately attached. Conversely, an apparent tear on MRI may prove stable and not require repair.
Arthroscopy also allows different components of the TFCC to be examined individually. The superficial and deep fibres, peripheral attachment, foveal attachment and relationship with the DRUJ can be assessed. Associated synovitis, unstable cartilage, ulnar impaction and other ligament injuries can be treated during the same procedure. Wrist arthroscopy remains the most direct method of assessing the functional integrity of the TFCC.
A targeted approach based on arthroscopic findings
TFCC surgery is not a single operation. The appropriate treatment depends on which component is injured, whether the tissue remains repairable, whether the DRUJ is unstable and whether abnormal bony anatomy is contributing to the problem. Arthroscopy allows surgery to be targeted according to the actual intraoperative findings. A stable area of tissue does not need to be disturbed simply because it appears abnormal on MRI. Conversely, a scarred but functionally lax attachment can be repaired or reconstructed even when the scan describes it as healed.
Treatment may involve synovectomy, stabilisation of an unstable flap, peripheral repair, foveal repair, reconstruction with a tendon graft, treatment of ulnar impaction or correction of abnormal bone anatomy. This tailored approach avoids treating every TFCC injury in the same way.
Non-operative treatment
Not every TFCC injury requires surgery. Treatment is guided primarily by pain, function and the presence or absence of mechanical instability. Pain following an acute injury may settle with time. Initial treatment may include a wrist or forearm splint, temporary restriction of lifting and rotation, anti-inflammatory medication when medically appropriate, and hand therapy.
The duration and type of immobilisation depend on the suspected injury. When the deep TFCC attachment is involved, a brace that controls forearm rotation may be more useful than a short wrist splint. Therapy is introduced gradually and focuses on restoring movement, improving dynamic muscular control and returning safely to normal activities. Injection may be considered when inflammation or synovitis is contributing to the symptoms, although an injection cannot restore a mechanically incompetent TFCC.
A period of non-operative treatment is reasonable when the DRUJ is clinically stable, symptoms are improving and there is no major mechanical obstruction. However, persistent symptomatic instability that has not healed during the early recovery period is less likely to respond to prolonged observation alone.
Arthroscopic debridement
Dr Ye rarely performs isolated TFCC debridement as the principal treatment for a symptomatic TFCC injury.
Debridement may be useful when there is inflamed synovium, an unstable central flap or damaged tissue causing mechanical irritation. However, removing tissue does not restore a deficient foveal attachment and cannot correct DRUJ instability.
When debridement is performed, it is often part of a broader procedure. For example, it may accompany an arthroscopic wafer procedure or an ulnar shortening osteotomy when ulnar impaction is the underlying mechanical problem.
The objective is not simply to remove abnormal tissue. It is to address the combination of synovitis, unstable tissue, excessive loading and instability responsible for the patient’s symptoms.
Arthroscopic TFCC repair
When the TFCC is repairable, Dr Ye generally uses sutures to restore the injured tissue to an appropriate anatomical attachment. The repair technique is selected according to the location and pattern of the injury. Arthroscopic options include inside-out, outside-in, peripheral capsular and foveal repair techniques.
A peripheral tear may be repaired to the surrounding capsule when this restores appropriate tension and stability (soft tissue to soft tissue). A deeper foveal tear requires restoration of the principal stabilising fibres to their attachment at the ulna (soft tissue to bone). The arthroscope allows the repair to be assessed immediately. The TFCC can be retensioned, probed and tested, and the stability of the DRUJ can be reassessed before the operation is completed.
Dr Ye’s training has included work with leading wrist arthroscopists from Australia, the United States and Europe, including experience gained during his Australian Hand Surgery Society Travelling Fellowship. This exposure to different schools of wrist arthroscopy allows the repair method to be adapted to the individual tear rather than being limited to a single technique.
When is open TFCC repair used?
Although arthroscopy is central to Dr Ye’s TFCC practice, open repair remains an important option in selected cases.
Dr Ye generally considers open repair when there is static dorsal subluxation of the ulna at the DRUJ, when direct tissue mobilisation is required, when the repair is being combined with an open bony correction, or in selected revision cases.
An open approach may also be appropriate when sigmoid notch reconstruction or notchplasty is required. In this setting, the bony and soft-tissue components of instability can be addressed together.
Open surgery provides direct access to the TFCC and DRUJ when the deformity or tissue injury cannot be corrected reliably through arthroscopy alone.
The distinction is therefore not that arthroscopic repair is modern and open repair is outdated. Both are valuable techniques. The correct approach is the one that most reliably addresses the individual mechanical problem.
Arthroscopic TFCC and DRUJ reconstruction
A chronic TFCC injury may no longer be suitable for direct repair. The tissue may be scarred, elongated, retracted or deficient, or a previous repair may have failed. When the native TFCC cannot be restored, reconstruction may be considered. This involves recreating the stabilising function of the TFCC using a tendon graft.
The graft is positioned to reproduce the function of the principal radioulnar ligaments and control abnormal translation of the DRUJ while preserving forearm rotation.
Dr Ye performs arthroscopic and arthroscopically assisted reconstructions in selected patients. Arthroscopy is used to evaluate the joint, confirm the pattern of instability, assess cartilage and prepare the reconstruction accurately.
Reconstruction is more complex than a primary repair. It is most appropriate when the joint surfaces remain sufficiently preserved and the instability is mainly due to irreparable soft-tissue insufficiency.
Revision TFCC and DRUJ surgery
Revision TFCC surgery, revision DRUJ surgery and complex reconstructive wrist surgery form a substantial part of Dr Ye’s practice. He receives tertiary referrals from other surgical colleagues for patients with persistent pain, instability, deformity or loss of function following previous treatment.
The cause of continuing symptoms may be failure of the TFCC to heal, healing in an elongated or functionally insufficient position, recurrent tearing, persistent foveal detachment, unrecognised DRUJ instability, sigmoid notch deficiency, ulnar impaction, abnormal bone alignment, cartilage damage or progressive arthritis. Some patients have undergone technically appropriate surgery but continue to experience symptoms because another component of the problem was not recognised. Others have developed a new mechanical issue as a consequence of trauma, altered anatomy or previous salvage surgery.
Revision assessment therefore begins again with the diagnosis. The aim is not simply to repeat the previous operation.
Treatment may involve repeat arthroscopy, revision foveal repair, open repair, tendon-graft reconstruction, ulnar shortening, arthroscopic wafer resection, corrective osteotomy, sigmoid notch reconstruction, hemiarthroplasty or constrained DRUJ replacement. The procedure is selected only after identifying the principal source of pain and instability.
Recovery following TFCC surgery
Recovery depends on whether the TFCC has been debrided, repaired or reconstructed and whether an osteotomy or joint procedure has also been performed. Following a TFCC repair, the wrist and forearm generally require protection for approximately six weeks. A cast or splint may be used to restrict forearm rotation while the repair heals.
Hand therapy then focuses on gradually restoring movement without overloading the repair. Strengthening usually begins at approximately three months. Return to heavier work, racquet sports, golf, weight training or contact sport may take approximately four-and-a-half to six months. The timing is adjusted according to the type of repair, tissue quality, associated procedures and the patient’s progress. A tendon-graft reconstruction generally requires more cautious rehabilitation than a primary repair.
Following an ulnar shortening or corrective osteotomy, loading is restricted until the bone has united. Healing is monitored with X-rays, and strengthening is progressed accordingly.
Recovery following DRUJ resurfacing or Scheker replacement is individualised according to the procedure, soft-tissue condition and previous operations.
Risks of surgery
The risks depend on the operation being performed. Potential risks include infection, bleeding, nerve irritation, numbness, scar sensitivity, stiffness, loss of forearm rotation, persistent pain, failure of the TFCC to heal and recurrent instability.
An osteotomy also carries risks of delayed union, non-union, loss of correction and plate irritation. Further surgery may occasionally be required to remove symptomatic hardware after the bone has healed.
Joint resurfacing and replacement carry additional risks, including implant loosening, infection, wear, fracture, mechanical failure and the possibility of revision surgery. The risks, expected recovery and alternatives will be discussed according to the individual diagnosis and proposed treatment.
What does the rehabilitation/recovery involve?
To find out more about rehabilitation and recovery after surgery please see our Rehabilitation Protocols here.
