TFCC Tears

Definition

Traumatic or degenerative lesions of the triangular fibrocartilage complex, the primary stabiliser of the distal radioulnar joint and ulnar carpus.

Anatomy

  • Articular disc, dorsal and volar radioulnar ligaments, meniscus homologue, ulnocarpal ligaments and ECU subsheath
  • Deep radioulnar ligament fibres insert into the fovea and stabilise the DRUJ
  • Peripheral 10 to 40% is vascular, while the central disc is avascular
  • Transmits about 20% of axial wrist load with neutral ulnar variance

Classification

  • Palmer Class 1 traumatic lesions
  • 1A. Central perforation of the disc
  • 1B. Ulnar avulsion, with or without an ulnar styloid fracture
  • 1C. Distal avulsion at the ulnocarpal ligaments
  • 1D. Radial avulsion from the sigmoid notch
  • Palmer Class 2 degenerative lesions from ulnocarpal abutment
  • 2A to 2E. Progressive disc wear, chondromalacia, perforation, lunotriquetral tear and ulnocarpal arthritis
  • Atzei classification grades peripheral foveal tears to guide repair

Clinical Features

  • Ulnar wrist pain and clicking, worse with rotation and grip
  • Ulnar fovea sign, with tenderness between the ulnar styloid and FCU
  • Positive ulnocarpal stress test
  • DRUJ ballottement to assess instability

Investigations

  • Radiographs for ulnar variance and ulnar styloid fractures
  • MR arthrography for tear detection
  • Wrist arthroscopy, with the trampoline and hook tests

Differential Diagnosis

Management

  • Splinting. 4 to 6 weeks for acute tears with a stable DRUJ
  • Arthroscopic debridement. Central 1A tears, preserving the peripheral rim
  • Repair. Peripheral 1B tears, with transosseous foveal repair when the DRUJ is unstable
  • Ulnar shortening osteotomy. Degenerative Class 2 tears with positive ulnar variance
  • DRUJ reconstruction. Irreparable foveal tears with instability, see DRUJ Instability

References

  1. Palmer AK. Triangular fibrocartilage complex lesions. A classification. J Hand Surg Am. 1989, 14(4), 594-606. PubMed
  2. Atzei A, Luchetti R. Foveal TFCC tear classification and treatment. Hand Clin. 2011, 27(3), 263-72. PubMed

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 19 October 2026.