Confirming TFCC Injury

Imaging Algorithm

• The American College of Radiology recommends obtaining three-view wrist radiographs first to exclude fractures, then proceeding with 3.0T MRI without contrast as the initial imaging study, reserving MR arthrography for cases where surgical intervention is being considered or when standard MRI is equivocal 1
• 3.0T MRI without contrast has a sensitivity ranging from 63-100% and specificity from 42-100% for TFCC tears, and is more accurate than 1.5T for TFCC lesions 1
• MR arthrography should be reserved for specific situations, including when conservative treatment has failed and surgery is being considered, when standard MRI is equivocal or non-diagnostic, and for surgical planning when precise characterization of tear pattern is needed 1
• MR arthrography has higher sensitivity and specificity than standard MRI for TFCC tears, with sensitivity ranging from 63-100% and specificity 89-97% for single radiocarpal injection 1
• For ulnar-sided detachment of the TFCC, consider additional DRUJ injection 1
• CT arthrography is a useful alternative when MR arthrography is contraindicated, with nearly 100% sensitivity and specificity for TFCC lesions 1
• Conventional arthrography alone should not be relied upon, as it has only moderate sensitivity (76%) for full-thickness tears and is insensitive to partial-thickness tears 2
• MRI with and without IV contrast is not indicated for standard TFCC evaluation and is reserved for suspected infection or inflammatory arthropathy 1
• Arthroscopy remains the gold standard for definitive diagnosis, allowing identification of associated ligament injuries that may be missed on imaging, and can provide both diagnosis and treatment in the same procedure 1

Diagnostic Approach for Ulnar-Sided Wrist Pain

Imaging Guidelines

• The American College of Radiology recommends obtaining three-view wrist radiographs immediately to exclude fractures and assess ulnar variance 3
• For suspected TFCC or ligament injury, MRI without contrast is the appropriate next study, with high accuracy for central TFCC disc lesions 4, 5
• MRI is highly accurate for central TFCC disc lesions using high-resolution fast spin-echo or 3D gradient-recalled sequences 4, 5
• 3.0T MRI may be more accurate than 1.5T for TFCC lesions 4, 5
• Sensitivity for peripheral TFCC attachments and ulnar disc attachments is only fair with non-contrast MRI 4, 5

Diagnostic Accuracy

• MR arthrography has higher sensitivity than standard MRI for complete and incomplete lunotriquetral ligament tears 4, 6, 7
• CT arthrography is an alternative with similar or superior accuracy to MR arthrography for TFCC and intrinsic ligament lesions 4, 6, 7
• CT arthrography has nearly 100% sensitivity and specificity for both scapholunate and TFCC lesions 7

Management Principles

• Immobilization in neutral wrist and forearm position for 4 weeks is recommended for conservative management 6, 7
• Gentle active motion at 4 weeks, strengthening at 8-12 weeks is recommended for conservative management 6, 7
• Arthroscopic foveal repair with suture anchor for peripheral TFCC tears (Palmer 1B) with foveal detachment restores anatomic attachment critical for DRUJ stability 6, 7

Imaging Evaluation of Distal Radioulnar Joint Instability and TFCC Injury

Dynamic Extensor Carpi Ulnaris (ECU) Subluxation

• The American College of Radiology notes that dynamic subluxation of the ECU tendon during forced supination can produce ulnar‑side wrist pain and limit supination, and that static MRI frequently misses this finding; dynamic pronation‑supination sequences are therefore essential for detection. 8
• Ultrasound performed by an experienced operator can directly visualize dynamic ECU subluxation during forced supination, providing a bedside diagnostic alternative. 8

Magnetic Resonance Imaging (MRI) of the TFCC and DRUJ

• According to the American College of Radiology, 3.0 T MRI without contrast accurately depicts the triangular fibrocartilage complex, intrinsic and extrinsic ligaments, DRUJ stability, and ECU tendon pathology, making it the appropriate next imaging modality for persistent symptoms after plain radiographs. [9][10]

Computed Tomography (CT) for DRUJ Stability Assessment

• The American College of Radiology recommends CT as the modality of choice for evaluating DRUJ stability; bilateral wrist scans performed in maximal pronation, neutral, and maximal supination positions allow direct assessment of joint congruity and dynamic instability. [8][9]10

Targeted Injection Technique for TFCC Detachment

• For ulnar‑sided TFCC detachments, the American College of Radiology advises adding a DRUJ injection to the standard radiocarpal injection to improve diagnostic accuracy and guide therapeutic planning. 9