CORR Insights®: What is the Natural History of the Triangular Fibrocartilage Complex Tear Without Distal Radioulnar Joint Instability?

Where Are We Now?

Ulnar-sided wrist pain is a common problem; nearly 30 pathological and pathoanatomical entities may cause or contribute to it. While some can be easily identified, others, like lunotriquetral ligament injury, are much more difficult to diagnose because it is located in such a small area.

If no distal radioulnar joint instability is found during clinical examination and the MRI shows a triangular fibrocartilage complex (TFCC) lesion, then the next question is whether to recommend surgery to the patient. Viegas and colleagues [8] found that a TFCC tear was evident in 56% of all cadaver dissections. These results have been supported [3], which leads me to believe that some—perhaps many—TFCC lesions are incidental findings on MRI; other work has shown that diagnostic accuracy of MRI is influenced by a host of technical factors, including variability in the magnetic field strength, use of receiver coils, approaches to image enhancement, and use of contrast [2].

I have observed that many surgeons recommend surgery for ulnar-sided wrist pain if the clinical examination is consistent with a TFCC tear and the tear is visible on MRI. This is more likely to be the recommendation if there is no improvement after a few weeks of nonoperative management. However, there is little evidence to support this recommendation. The current study by Lee and colleagues [4] suggests that many of these patients may not need surgery at all.

Where Do We Need To Go?

I found the findings in this study on congenital ulnar-plus variance especially interesting; future studies need to deal with this, since the procedures in common use for this finding (in particular ulnar shortening operations) could lead to complications [6]. I note that ulnar impaction syndrome is not limited to ulnar-plus wrists; this also occurs in the ulnar-negative and ulnar-neutral wrist [7]. Choosing a specific treatment is made still-more challenging because there may be no difference in the prognosis between a degenerative and a traumatic associated tear [4], and no studies to my knowledge have assessed the accuracy and reproducibility of our clinical tests. It is important that we come to a consensus on this because the causal connection between an MRI-detected tear and the cause of ulnar-sided wrist pain is not certain.

Future studies need to better describe their nonsurgical treatments. Is it that only resting causes improvement in the wrists of patients with ulnar-sided wrist pain? Resting and splinting? A more-detailed account of nonsurgical treatment options is needed.

How Do We Get There?

We would benefit from an evidence-based clinical practice guideline for ulnar-sided wrist pain; I suggest that this could be developed under the auspices of The American Society for Surgery of the Hand and the Federation of European Societies for Surgery of the Hand. In order to develop this, we first need better approaches to classifying TFCC lesions [1], and to determining the difference between a symptomatic lesion and an incidental finding.

Additionally, orthopaedic surgeons should cooperate and consult with physical therapists to better understand the nonoperative treatment options for TFCC such as immobilization or proprioception training [5]. We also need to better understand the pathologies and consequences of the ulnar-plus variance as well as degenerative and traumatic tears. Ideally, future work will help us to better know the strengths and limitations of existing physical examination maneuvers for all patients presenting with signs or symptoms of TFCC tears. But in particular, I think that there is an opportunity to develop dynamic radiographic tests under load in pronation, which may be particularly helpful as we try to care for those patients who have ulnar-sided wrist pain and ulnar-plus variance.