TFCC injury

Triangular Fibrocartilage Complex – TFCC injury: Understand it before seeing doctors

TFCC stands for Triangular fibrocartilage complex – this little complex in the wrist shocks many people.

I often call it: Small element big impact.

The impact is not function, this means you have total mobility – you can do everything.

To a normal eye it looks like you have nothing, but it is only you who can feel it.

If you are reading this article right now, I want to tell you one thing:

The sooner you act, the better. This is an injury that needs fast action (ignore everyone who tells you different). If it hurts after a week, it is a red sign.

Ignore the opinion of non-experts (including doctors, sorry to say).

Do not ignore your pain.

Introduction: TFCC Injury

This is the first article on a series of TFCC articles.

This article will be kept quite general – there won’t be a deep dive into this topic.

It is very complicated to an extent that even

• 95% of doctors don’t understand it (thus there is a lot wrong treatments)
• 90% of orthopedic surgeons only understand half of the matter

There is only a small percentage of very specialized wrist doctor and surgeons who understand this matter and know how treat it.

The reason why many oversea it is because most people take bone fracture seriously but not a TFCC – it turns out that a TFCC heals much slower and worse than a bone.

Who is this article for:

If you are suffering a wrist injury or have wrist pain, then this article is good to understand whether you can rule out a TFCC or it may be a potential cause.

If you already know, it is a TFCC injury this article will give you good overview of guidlines.

What this article will disucss:

In this article we will discuss:

• the cause of a TFCC injury 

• the symptoms of a TFCC injury (where is the pain, what other things may happen)
• the treatment from simple to more severe that can lead to surgery

TFCC injury: Causes

There can be many causes that can lead to a TFCC injury.

The cause can be simple things such as:

• boxing
• lifting weights
• arm wrestling
• etc.

Or it can be an accident – which in medical terms is called “trauma”, this usually a fall on an outstreched hand, e.g.

• you trip and fall
• you fall from your bicycle or scooter
• you fall during skiing or snowboarding
• etc.

All of those actions can cause TFCC injuries.

This makes a TFCC injury very dangerous because non-medical people and even many doctors underestimate it.

They have seen it before for another patient (which was caused through arm wrestiling) and they compare it to another patient with a more serious cause such as a trauma.

The severity of a TFCC injury can be very different depending of the force of impact.

The severity will indicate its symptoms – but be aware: The symptoms also hide sometimes. 

I will give some real case studies later.

TFCC injury: Symptoms

We will go through all the symptoms that I have heard from doctors (when I say ‘doctors’ I am referring to specialized wrist doctors who know a lot about TFCCs) and other people have told me of.

Here is a list of symptoms:

• pain on the pinky side of your wrist. Sometimes constant pain, sometimes only when moving, e.g. 
• clicking when you move your wrist horizontally 
• swelling of the bone on your wirst (it is called the ulnar styloid – google for some pictures)

The most relevant symptom is usually:

Pain around the bone on your wrist.

We will discuss each of those symptoms in more detail.

TFCC injury: Ulnar wrist side pain

The pain is usually on the ulnar side of your wrist.

Medical people say: Ulnar side of the wrist.

The naming comes from the two bones in your arm: The radial bone and the ulnar bone. Touch your foream and you feel that there are two bones.

For example, if you touch your right forearm, then your radial bone is on the left and the ulnar bone is on the right.

We will also add videos and pictures at a later stage and show you more.

This pain can be very different in severity depending on the severity of impact (see causes above) from pain just when doing heavy sports (tennis, weight lifting) to constant pain all day.

Let us discuss the pain a bit more.

Location of the pain:

Usually, you will feel the pain starting on the bony part of your wrist (ulnar styloid).

You may feel it is inside of it, but you also know that it is not the bone as there is no fracture.

The location may vary over time, e.g.

• aggregating along to your pinky finger
• aggregating to your forearm
• be on the ulnar side of the ulnar styloid
• be below the ulnar styloid

If you have constant pain this is probably the worst.

Some people have when they don’t move it, but pain starts with activities. 

Those who have pain they will feel that activities aggregates the pain.

The activities that will make the pain worse:

• pain when opening a door
• pain when turning a doorknob
• pain when opening a water bootle
• pain when doing pushups
• pain when pushing yourself off the bed with two hands
• etc.

Basically:

• rotation (turning movements)
• weight lifting 
• gripping (you may avoid shaking hands at some point)

As a summary we can say:

This injury is very notorious because it varies so much and most doctors are not in your body to understand the severity of it.

In comparison to a broken bone, it is invisible until further tests are done.

TFCC injury: Clicking

When doing rotation of your wrist horizontally (medical people call it: radiation), it will cause clicking – not for all people, but for some.

This sometimes feels as if there is something in your wrist.

It is a very awkward feeling to be honest.

TFCC injury: How do you know for sure it is a TFCC?

If you have pain on the ulnar side of your wirst, it can of course be other things than just a TFCC, for example:

• a tendon: ECU, FCU
• the ulnar nerve
• the bone

Usually, a TFCC injury will have impact on your ECU tendon, but the ECU tendon is not the cause of your real pain – it could be the cause of your ulnar styloid being swollen.

Either way, these are just the tests we can do as non-experts.

Let us jump into what real experts do to see whether it is a TFCC.

TFCC injury: Imaging and Tests

So there are two type of test:

• Images: X-ray, MRIs, CT-scans and ultrasound
• Clinicial tests: This means the doctor will touch your wrist and will do certain movements to see how the pain and the wrist movement is

I will explain to you the order of things.

TFCC: Imaging

1 – X-ray:

The very first thing that is done is an X-ray.

A TFCC will not be seen on an X-ray – this is very important to understand.

Why that is?

We have a few anatomical constructs in the wrist:

• bones
• tendons
• cartilage
• ligaments
• nerves
• muscles

X-ray only shows one of these: Bones.

Nothing else. 

A TFCC is made out of cartilage and ligaments, so you will not see it.

An X-ray is still very important for two reasons:

1 – rule out any breaks. 

Sometimes they can be small and go unnoticed.

2 – rule out that you do not have a ulnar variance.

This is a topic for it’s own. But to put it in simple terms:

The ulnar bone may be hitting the TFCC and thus the TFCC is basically getting thinner.

Usually, this can happen, either due to genetics or degenerative over some period of time.

2 – MRI:

After the X-ray, there should be an MRI.

There are two groups of doctors who will not do an MRI:

• 1st group: The generalist (GP, orthopedic surgeons) who think it is “nothing”
• 2nd group: The very highly experienced ones who already know it is a TFCC and know what the next steps are – they will give you a brace (it is called a muenster cast).

As a non-medical it may be hard to distinguish between those two because doctors often try to save money and not do an MRI.

How to know the difference between those two groups:

The first group will let you go home and there is basically no diagnosis and further steps.

The second group will give you their diagnonis (“TFCC”) and they will give you a cast.

Pay attention:

Even MRIs are only 70% accurate.

This means that they sometimes may show

• that you have no tear (although you have one)
• that your tear is not very big (although it is)
• that you only have a central or peripheral tear (but you also have a foveal tear)

Unfortunately, a wrist is so small, that an MRI is not 100% accurate.

There can be a lot of things that can be done to optimize the test results though.

For this, send an email to rt.azimi@gmail.com with Subject “Checklist for MRI” and I will send you a free checklist what to ask for before going to the radiologist for an MRI.

Please go to the radiologist as soon as possible – do not wait. This is urgent.

TFCC: Tests

One of the most common test, doctors do is a clinical test.

A clinical test means they will rotate your wrist to see how it reacts.

Here are a few tests:

1. Try to lift a table (palm up) and see whether you have pain on the ulnar side
2. They will do a DRUJ stress test (sometimes called: Ulnar shift test): They will hold your ulnar and then at your ulnar styloid will pull up and down to see whether it is moving.

TFCC Injury: Treatment

So non-experts usually give you some kind of:

• small brace
• wrist widget
• or nothing at all

Whereas these can help for small TFCC injuries, it can fail for severe TFCC injuries.

The problem is: How will a doctor decide whether it is severe if

• the clinical tests are not 100%
• the imaging test are not 100%

So it is basically just a guess.

One could make a good guess by seeing what the force was (accident or just small force), but it is a very risky game.

Experts will not play this risky game and will give you the right brace: 

This means a soft cast until above your elbow (very important) for 6 weeks.

The problem is: This should be done within a week after the accident.

By the time you find this article, I fear it may be already too late and a brace may not help you (unless it is a very small TFCC tear).

But there is no harm in trying of course and if it is small tear I have seen people to recover from it even after a year.

The one thing you should remember: “Two TFCCs tears are never the same.”