Pain on the pinky side of the wrist, clicking, weakness with gripping, instability when rotating the forearm — these are the hallmarks of a TFCC tear. Most TFCC tears can be managed without surgery. When surgery is needed, Dr. Graham prioritizes repair over debridement whenever the tear is repairable — and in his experience, patients who undergo TFCC repair do extremely well.
Cause: acute injury (fall on outstretched wrist, twisting injury) or chronic overuse (repetitive forearm rotation, racquet sports, gymnastics). Both patterns are treated.
Understanding the Condition
The triangular fibrocartilage complex (TFCC) is a cartilage and ligament structure on the ulnar side of the wrist — the pinky side. It fills the space between the end of the ulna and the carpal bones, forming a cushion that absorbs load across the wrist and simultaneously acting as the primary soft tissue stabilizer of the distal radioulnar joint (DRUJ) — the joint where the radius and ulna meet at the wrist.
The TFCC is under load during virtually every wrist activity that involves gripping or forearm rotation. Opening a jar, swinging a racquet, turning a screwdriver, pushing up from a chair — all of these load the ulnar wrist and the TFCC. When the TFCC is torn, these activities become painful, and the DRUJ can become unstable — the ulna feels loose or clunks relative to the radius with rotation.
Tears occur in two patterns. Acute traumatic tears typically follow a fall on an outstretched hand with the wrist loaded and rotated, or a sudden twisting injury. Chronic degenerative tears develop gradually with repetitive loading and are common in racquet sports, gymnastics, and manual occupations. Both types are treated at JOI Jacksonville Beach.
The anatomy of the TFCC is also relevant to understanding why some tears are repairable and others are not. The peripheral portion of the TFCC — the part that attaches to the ulna and the surrounding capsule — has a blood supply and can heal when repaired. The central portion — the disc itself — is avascular and cannot reliably heal with suture repair. This distinction determines whether a patient is a candidate for repair or debridement.
The TFCC disc (red) cushions the ulnar wrist and stabilizes the DRUJ. Central tears are in an avascular zone — they do not reliably heal with repair and are typically debrided. Peripheral tears at the ulnar attachment (blue) have a blood supply and can be repaired with suture — the preferred treatment when technically feasible.
Treatment Pathway
TFCC tears are worked up and treated in a logical sequence. The goal is to confirm the diagnosis before committing to surgery, and to give conservative treatment a genuine opportunity to work first.
The starting point for most patients presenting with ulnar wrist pain. A corticosteroid injection into the wrist joint reduces inflammation and pain — and serves a diagnostic purpose as well: significant relief from the injection confirms that the pain generator is inside the joint, which is consistent with a TFCC tear. Physical therapy is offered but not mandatory at this stage — some patients prefer to try the injection alone first and see how much it helps.
If the injection provides meaningful and lasting relief, further workup may not be needed. If symptoms return or persist after 6 to 8 weeks, the next step is imaging.
Therapy: offered but not mandatory at initial presentationIf symptoms persist after the initial injection, Dr. Graham obtains an MRI arthrogram — an MRI performed after contrast is injected directly into the wrist joint. Standard MRI frequently underestimates or fails to identify TFCC tears, particularly partial tears and peripheral tears. MRI arthrogram is significantly more sensitive and is the study Dr. Graham relies on to confirm tear location, extent, and whether peripheral repair may be possible.
The arthrogram MRI is obtained at JOI, where Dr. Graham can coordinate the injection and coordinate imaging interpretation. He reviews the images himself before making treatment recommendations.
Standard MRI alone is often insufficient — arthrogram is the diagnostic standardOnce a TFCC tear is confirmed on MRI arthrogram, Dr. Graham offers a second cortisone injection targeted specifically at the confirmed pathology. Simultaneously, a custom-molded Munster brace is fabricated by JOI's occupational therapists — a thermoplastic orthosis that immobilizes the wrist and forearm while allowing finger motion. The Munster brace prevents the forearm rotation that most stresses the TFCC, giving the tear an opportunity to settle or partially heal.
The combination of a targeted injection and structured immobilization resolves symptoms in a meaningful proportion of patients — even with a confirmed tear on MRI. Surgery is not inevitable just because imaging shows a tear.
Munster brace fabricated by JOI occupational therapists — custom molded to the patientFor patients with partial TFCC tears who have not achieved adequate relief from cortisone and bracing, or who want to maximize conservative treatment before committing to surgery, platelet-rich plasma (PRP) is a meaningful option. PRP delivers concentrated growth factors directly to the tear site, potentially stimulating the healing response — particularly relevant for peripheral tears where a blood supply already exists.
Dr. Graham is happy to discuss PRP with any patient who asks. It is not a guaranteed resolution, but for the right patient — particularly those with partial peripheral tears and good tissue quality — it represents a reasonable biologic step between conventional conservative treatment and surgery.
PRP particularly relevant for partial peripheral tears with existing blood supplyWhen conservative management has failed to resolve symptoms despite injection, bracing, and adequate time, surgery is offered. The surgical decision — whether to repair or debride — is determined by tear location confirmed on MRI arthrogram and by intraoperative findings at the time of arthroscopy. Peripheral tears are repaired when possible. Central tears are typically debrided. Some patients have both peripheral and central components — in those cases, Dr. Graham debrides the central portion and repairs the peripheral tear in the same arthroscopic setting.
Repair vs. debridement determined by MRI arthrogram findings and intraoperative assessmentStandard MRI of the wrist can suggest a TFCC tear, but it frequently misses or underestimates the injury — particularly partial tears and peripheral tears at the ulnar attachment. The TFCC is a thin, complex structure with small dimensions; without intra-articular contrast to outline its surfaces and highlight defects, standard MRI sequences often cannot characterize the tear precisely enough to guide treatment decisions.
MRI arthrogram — performed after a small volume of contrast is injected directly into the wrist joint under fluoroscopic guidance — outlines the TFCC from the inside. Contrast that leaks through a tear clearly identifies its location and extent. Peripheral tears can be distinguished from central tears. The presence of DRUJ involvement can be assessed. This information directly determines whether the patient is a candidate for repair and influences the surgical approach.
At JOI, MRI arthrogram is coordinated through the same system — the injection and imaging are arranged together, and Dr. Graham reviews the images himself before discussing surgical planning with the patient. If you have already had a standard MRI of your wrist that did not show a definitive tear but you still have ulnar-sided wrist pain, an arthrogram MRI may provide the answer.
Platelet-rich plasma (PRP) is a particularly logical treatment option for partial TFCC tears — especially peripheral tears where a blood supply already exists at the tear site. PRP delivers a concentrated dose of growth factors drawn from the patient's own blood directly to the tear, potentially amplifying the biological repair process that the tissue is already attempting on its own.
For patients with partial tears on MRI arthrogram who have had some but not enough relief from cortisone and bracing, PRP represents a meaningful next step before committing to surgery. The injection is performed with fluoroscopic or ultrasound guidance to place the concentrated platelets precisely at the tear site. It is a cash-pay procedure — insurance does not cover PRP — but for patients who want to exhaust biologic options before an operation, it is a well-reasoned choice.
Dr. Graham does not proactively push PRP in every TFCC case, but he is enthusiastic about discussing it with patients who are interested. For complete information on the PRP procedure, see the PRP treatment page.
When Surgery Is Needed
Not all TFCC tears are the same — and the surgical decision between repair and debridement depends on tear location, tissue quality, and what is found at the time of arthroscopy. Dr. Graham repairs when repair is possible.
When the tear is in the peripheral vascular zone — where a blood supply exists — repair is possible and preferred. Arthroscopic sutures are passed through the torn TFCC tissue and secured to restore the anatomy and allow biological healing. Dr. Graham performs arthroscopic repair using inside-out or outside-in suture techniques depending on tear location and accessibility.
Central TFCC tears sit in the avascular zone — there is no meaningful blood supply to support healing of a repaired tear. Placing sutures in avascular tissue does not reliably produce union. For isolated central tears, arthroscopic debridement — trimming the torn, unstable flap — is the appropriate procedure. It eliminates the mechanical catching that the flap causes without attempting a repair that the tissue cannot support.
TFCC repair is a technically demanding arthroscopic procedure. It requires more time in the operating room, more technical precision, and a longer post-operative recovery than debridement alone. In Dr. Graham's experience, patients who undergo TFCC repair do extremely well — and that outcome is worth the additional effort.
Not every wrist surgeon shares this philosophy. Repair and debridement reimburse at the same rate — which means there is no financial incentive to choose the more difficult procedure. Dr. Graham's approach is to repair when the anatomy supports it, regardless of the additional technical demands. His conviction is straightforward: when the tissue is repairable and the patient has a peripheral tear, repair gives them the best chance of a lasting result.
If you have been told your TFCC tear cannot be repaired, or that debridement is the only option, it is worth having that conversation with Dr. Graham. He will review your MRI arthrogram and give you an honest assessment of whether repair is technically feasible for your specific tear pattern.
Arthroscopic Technique
TFCC surgery is performed entirely arthroscopically — through small portals into the wrist joint, without open incision. The wrist arthroscope allows direct visualization of the TFCC, the DRUJ, and the surrounding structures. Dr. Graham uses standard radiocarpal and midcarpal portals to access the joint and assess the tear in all zones.
For debridement, a motorized shaver is used to trim the unstable flap of torn central TFCC tissue to a stable edge. The goal is to eliminate the mechanical catching and impingement without destabilizing the peripheral attachment.
For repair, sutures are passed arthroscopically through the torn peripheral tissue using inside-out or outside-in technique depending on the tear's location. The sutures are tied through small additional incisions on the ulnar wrist, pulling the torn tissue back to its attachment and allowing it to heal under tension. The DRUJ is stabilized and confirmed to be congruent at the conclusion of the repair.
Both procedures are performed under regional anesthesia as outpatient cases at Baptist Beaches Hospital or Horizon Surgery Center.
Regional block. Outpatient at Baptist Beaches Hospital or Horizon Surgery Center. Wrist traction applied for arthroscopic joint distraction and portal access.
Arthroscope introduced through standard portals. Full wrist survey performed — TFCC, scapholunate ligament, lunotriquetral ligament, articular surfaces all assessed. Tear location, extent, and tissue quality confirmed intraoperatively.
Any central tear component is debrided with a motorized shaver to a stable edge. The peripheral attachment is preserved and will be repaired in the next step.
Sutures are passed arthroscopically through the peripheral TFCC tear using inside-out or outside-in technique based on tear location. Needles exit through small incisions on the ulnar wrist where the sutures are retrieved and tied, restoring the peripheral attachment under appropriate tension.
DRUJ stability confirmed under arthroscopic visualization and direct manipulation. Repair tension confirmed to be appropriate — not overtightened, restoring anatomic stability without restricting forearm rotation.
Repair: long arm splint or cast for 6 weeks — forearm rotation immobilized to protect the repair during healing. Debridement: short arm splint for 1–2 weeks, then progressive motion. Therapy begins after immobilization period.
Recovery
Recovery after TFCC surgery depends on what was done. Repair requires longer immobilization to allow the repaired tissue to heal — debridement is faster but is appropriate only when repair is not possible.
"I had wrist pain for over a year and two MRIs that showed nothing definitive. Dr. Graham ordered an arthrogram and found the tear immediately. He repaired it arthroscopically and was completely upfront about the six-week recovery. A year later my wrist is better than it's been in years."
Common Questions
Questions from patients who've been told they have ulnar wrist pain, or who've had a normal MRI that didn't explain their symptoms.