The wrist joint consists of 8 small bones and numerous, fine joint surfaces between them. It is arguably one of the most complex of all joints in the body. Intricate anatomical arrangement allows fascinating joint mobility and intriguing biomechanics. Wrist provides great hand mobility, an asset fully appreciated only when injury or disease unfavourably affect our dexterity.

Triangular fibro-cartilage complex (TFCC) is a complicated anatomical structure, located inside the wrist joint. It is a large cartilage-ligament formation suspended between the ends of two forearm bones (radius and ulna) and often referred to as “a hammock” of the wrist (Picture 1; Gallery below). It allows gliding action inside the joint, but at the same time, it acts as the most important wrist stabilizer. It is however, prone to tears and disruptions; unfortunately often diagnosed late due to sparse availability of wrist expertise.

Mild injuries of the triangular fibro-cartilage complex are often referred to as a wrist sprain. More extensive tears, acquired through injury or degeneration can, however lead to ongoing pain and frustrating hand disability.

There are two main groups of causes leading to the triangular fibro-cartilage complex abnormalities – injuries and chronic, long standing abnormal biomechanics.

Traumatic injury is the most common mechanism of TFCC injury. Tearing or rupture occurs when enough force is transmitted through the joint which then overcomes the tensile strength of the TFCC. A fall onto an outstretched hand when we slip and/or strenuous loading of the hand whilst wrist rotates (high-demand athletes such as, tennis players or gymnasts) most commonly lead to TFCC injuries. Traumatic tear is usually peripheral (Picture 2; Gallery below). Abnormalities of the central portion of the TFCC (Picture 3; Gallery below) usually happens in chronic, long-standing imbalances, although in rare circumstances, those can be result of injury too.

Triangular fibro-cartilage complex (TFCC) tears can also occur gradually, over the time, via degenerative changes i.e. repetitive movements which transmit high load and/or griping forces across the structure. Degenerative changes in the TFCC structure also increase in frequency and severity as we get older. Thinning soft tissue structures can result in a TFCC tearing with minor force or minimal trauma and in such long standing cases, is usually located in the centre of the TFCC disc (Picture 3; Gallery below).

There may be some anatomical risk factors too i.e. that some people have a predisposition to develop TFCC problems because of unfavourable variations in wrist anatomy.  Studies show that patients with a torn triangular fibro-cartilage complex often have a greater forward curve in the ulnar bone or ulna is slightly longer than the radius, condition known as “positive ulna variance”. Causes for above anatomical variations remain unclear. More details on this condition are described in a separate “Ulno-Carpal Abutment” section.

Wrist pain along the ulnar (little finger) side is the main symptom (Picture 4). Some patients report diffuse pain throughout the entire wrist area. The pain is made worse by any activity or position that requires forearm rotation and movement in the ulnar direction. This includes simple activities like turning a doorknob or key in the door, or lifting a heavy objects with one hand. Other symptoms include weakness on hand rotation, swelling; clicking, as if something is “catching inside the joint”. Many patients report on feeling of instability – as if the wrist is going ‘to give in’, especially when loaded.

The grading of TFCC tears is usually based on severity of ligament disruption i.e. minimal, partial or complete.

As TFCC is a soft structure and is not ‘visible’ on the X-rays. X-rays may suggest TFCC disruption only if it is associated with bone fracture; ligamentous disruption without bone fracture might appear normal on standard X-rays especially early and soon after injury. More specific imaging is required in order to detect ligament trauma, usually a MRI. X-rays with a dye injected is called a wrist arthrography. It is positive for a TFCC tear if the dye leaks into any of the joints. Ultrasound can also be useful.

Wrist arthroscopy is really the best way to accurately assess the severity of damage, but equally, it is the most invasive and requires highly specialised surgical expertise. This key hole assessment allows us to look inside the joint and not only clearly visualise suspected tears and abnormalities, but also check on possible other associated ligaments and/or cartilage injuries too (Picture 5). There are special indications when wrist arthroscopy is essential, but it is not always mandatory.

Decisions as to which method would be best to ascertain condition of suspected TFCC pathology, is based on clinical facts gathered during the consultation and physical examination of the joint by a wrist expert.

Advise on the best treatment option should be based on highly individual circumstances and clinical facts: 1) your perception of disability 2) objective clinical signs 3) exact anatomical damage and 4) rehabilitation needs against a patient’s specific circumstances. No two patients are the same and this is why consultation and ‘hands-on’ assessment are crucial.

Non-surgical Treatment

If TFCC tear is small/limited and wrist joint remains stable, mainstream treatment is usually conservative (non-operative). Immobilisation with long or short splint (4-8 weeks) is started and supported by hand therapy. Splint immobilises bones and supports healing ligament whereas the supervised therapy maintains muscle power, tendon gliding and suppleness of the small joints in the hand.

Surgical Treatment

Surgery is indicated in more serious TFCC disruptions and choice of treatment is based on specific injury pattern. The outside perimeter of the triangular fibro-cartilage complex has good blood supply and this is why surgical repairs in this zone usually heal well (Picture 2). The torn structures can be reattached with sutures. This can be achieved either arthroscopically (key hole surgery) or by open surgical technique. When tears occur in the central area (Picture 3), surgical repairs are usually not possible as torn edges sprung apart. The blood supply to this area is poor, so healing potential is also low. Arthroscopic (key hole) debridement (smoothing) of the centre of the ligament is therefore, usually the best surgical option. Arthroscopic debridement works well for simple tears because much of the damaged tissue can be removed while still preserving joint stability.

There are complex tears that require open repair. Open repair means that TFCC is approached from outside, throught a skin incision on the side of the wrist (Picture 6 below indicates the site of surgical access and consequent scar appearance 4 weeks later). Conventional, open access gives surgeon a better view and wider access to the area, allowing not only a repair of torn TFCC, but tightening of neighbouring ligaments and/or joint capsule if needed. Recovery is however, a bit longer then after key hole repair for obvious reasons.

Chronic, degenerative TFCC problems may require a different surgical approach. Debridement (cleaning) of torn ligament edges might not be as successful with this group as it is with acute TFCC injuries. Sometimes it is necessary to shorten the ulna, one of the forearm bones, in order to decompress the TFCC and obtain adequate pain relief (see Section on Ulno-Carpal Abutment).

It always helps to plan things in advance of surgery and adjust work and life activities accordingly. Therefore, please consider the following issues prior to your operation:

Anticoagulation medication (Aspirin, Brufen, Warfarin, Clopidrogel) should ideally be stopped few days before the operation to reduce the risk of bleeding, but advise from the clinician who prescribed them is wise beforehand. I would strongly advise you to stop smoking prior to surgery as this can badly affect the outcome of surgery and increase complication rates.

Please make sure that you arrange to be collected from the hospital as you will not be able to drive after the surgery

Plan your time off school / work / sports

Allow at least few weeks after surgery before considering holiday

The goal of physiotherapy is to restore full motion, strength, and function of the operated wrist as soon as possible. The rehabilitation program will be geared towards your needs at home, work and leisure preferences.

Plaster of Paris cast applied at the time of surgery is replaced by a custom made, light weight splint few days after surgery by the hand therapist. Splint is secured by Velcro straps and is easy to put on and remove at home. Immobilisation of the operated wrist is required for 6-8 weeks, but supervised wrist movements are encouraged from 10-14 days. For the first 4 weeks long cast which extends from hand to the elbow is required (Picture 7). After one month, this is exchanged for shorter, less cumbersome splint (Picture 8) worn for additional 4-6 weeks. Gentle fingers motion exercises are usually started as early as 5-7 days after the operation.

Many patients with mild triangular fibro-cartilage complex injury are able to return to work and/or return to sports at a pre-injury level. Pain-free movement and full strength are possible.

Residual laxity may remain after non-operative treatment of a TFCC injury. If conservative care is unsuccessful, persistent joint laxity and instability can lead to degeneration of the joint cartilage. Too much force or compression on either side of the joint can lead to pain and altered movement patterns. Surgery may be needed to restore normal wrist movement.

Things to look out for after operation and contact us earlier than planned:

• Disproportionate swelling and pain in your hand
• Signs of infection in vicinity of the operated area i.e. hand/wrist are very hot, prominent redness, pain, swelling, puss collection
• Grazing of the skin (and possibly fluid leaking/oozing from the wounds)
• Increased skin temperature in the scar area
• Offensive wound smell

TFCC surgery is predictably effective and much appreciated by patients. Complications are rare, but as with any surgical procedure, there are general and procedure specific risks which patients should be aware of:

General complications:

• Skin/wound infection
• Hypertrophic (lumpy and itchy) scarring
• Painful scars
• Reflex Sympathetic Dystrophy – RSD (bad reaction to surgery with painful and stiff hands – this can occur with any hand surgery from a minor procedure to a complex reconstruction)

TFCC surgery specific complications:

• Tendon injury
• Nerve injury (with numbness at the back of the wrist)
• Joint infection
• Failure of stabilisation
• Persistent wrist weakness
• Joint stiffness and reduced range of motion
• Repeated or additional surgery

Things to look out for after operation and contact us earlier than planned:

• Disproportionate swelling and pain in your hand
• Signs of infection in vicinity of the operated area i.e. hand/wrist are very hot, prominent redness, pain, swelling, puss collection
• Grazing of the skin (and possibly fluid leaking/oozing from the wounds)
• Increased skin temperature in the scar area
• Offensive wound smell