MRIs and Triangular Fibrocartilage Complex (TFCC) tears

Over the past 12 years, I have had the incredible luxury of following thousands of cases.  One of the most frustrating aspects of this injury is the lack of reliable MRI results.   There have been so many positive MRI’s that show TFCC tears yet when surgically treated, later show no pathology to the Triangular Fibrocartilage Complex (TFCC).   Dr. Richard Berger describes this beautifully in his work with UT (ulnotriquetal ligament) tears. 

It is well known in the medical community that MRI’s have many false-negative and false-positive results. Add to this the variety of MRIs themselves.  MRI machines are not all the same. 


As published in 1995, "As verified by arthroscopy, the press test had 100% sensitivity in preoperative tear detection compared with 79% for magnetic resonance imaging. The press test is recommended as a useful, free, noninvasive clinical test for triangular fibrocartilage complex tears of the wrist."

You can find information on the Weight Bearing Test here. 

For the consumer, this is difficult to navigate.

I am hopeful that I can share some insight that will help you navigate through these variables. If you are going to have an MRI test on your wrist, ask for the following:

Minimum requirements of magnetic strength for the Triangular Fibrocartilage Complex (TFCC)

3.0 Testa—widely available but I still see the 1.5 Tesla readings. 

Dedicated Wrist Receiver Coil

Resolution 0.2-0.4

Slice thickness 2 mm or less

These MRI machines cost over 1 million dollars and radiologists have to be able to understand the latest technology.  All of it takes time and money.   The owners of the MRI machines, largely hospitals, want to get every penny out of their investments so they try not to update their technology until their machines are paid for.  The reimbursement rate for MRIs does not change based on the quality of the machine.  The only motivator for good MRI’s is an accurate diagnosis and treatment, which can save money in the long run.

Let's say you go out and but the best TV for $5000.  In one year, a better one comes out that has greater resolution and sound.  Most people will continue to use the $5000 TV for a while before upgrading to a newer TV.  Technology moves very fast.  MRIs are the same.

Most of these advanced machines are found closer to the research and for-profit hospitals. Ask your doctor to send you to the right MRI! 

Access to these is difficult for most people around the globe. 

Even if you find the best MRI with the best-trained radiologist, the tool is limited. The research below was written in 2005 and discusses MRI technology for diagnosing TFCC tears.

“The diagnosis of Triangular Fibrocartilage Complex (TFCC) lesions is not always simple. Noninvasive techniques have been reported to allow for a better understanding and a sharper diagnosis before planning arthroscopy or any other (surgical) treatment. MRI is a powerful tool for imaging soft tissue. The first surveys confirmed the usefulness of this technique, giving the wrong impression that MRI should be the gold standard in the diagnosis of chronic wrist pain (1, 11).

However, with standardly available scanners and less sophisticated coils, the lower resolution was reflected in lower sensitivity and specificity of this imaging technique in the diagnosis of TFCC and other ligamentous lesions of the wrist (2-9). Some comparative series are summarized in Table I (1-9,11). Interpretation of MRI images should be done with caution and especially the high number of false negatives should be a warning. In fact the ss and the sp were not superior to arthrography (ss =0.72 sp = 0.92) (10). This and other surveys have in common a rather modest sensitivity, indicating that a negative MRI is not an endpoint, and a relatively high specificity, indicating that a positive MRI should be trusted and is a good base for further treatment. The small size of the TFCC and even smaller signals of a rupture requires special techniques and adapted coils. This allows making slices as thin as 2 to 3 mm. Standard coils cannot provide enough details to detect such small lesions. An interesting evolution is MRI-arthrography which can considerably increase the specificity and sensitivity (3).” 

Dr. Kimberly K Amrami wrote Chapter 5  in the recent publication of Ulnar-Sided Wrist Pain: A Master Skills Publication.  The book can be purchased here.

Her discussion is worth reading.  I would recommend printing it out and handing it to your doc.  I mean this seriously. These summarize the challenges and value of MRI technologies. 

Because this is such a challenge in the medical community, I searched to define a better way to analyze every case. 

The Weight-bearing test must be performed by every patient with a diagnosis of a Triangular Fibrocartilage Complex (TFCC) tear.  In 100% of the cases I have seen over the past 12 years, every TFCC tear presented with painful and diminished weight bearing tolerance.  They all show changes with the tape or WristWidget® donned. 

This is not the case for tendonitis, fractures, UT tears and much more.  The Weight-bearing test is reliable, affordable and specific. 

Now you know… enjoy the knowledge. 


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