5 TFCC MRI From Easy to Hard

Added: 2026-06-03

[00:00:00]Most radiologists struggle to report the TFCC on MRI scans and they're often completely wrong. In one study of over 800 MRI reports by over 100 radiologists, the TFCC was incorrectly called normal in 45% of the time when in fact there was a pathology. These missed tears [music] mean delayed treatment or surgery for the patient. The study also found that one in three reported tears [music] was wrong, like there was no tear at all. These false positives [clears throat] can lead to unnecessary surgery and an angry surgeon.

[00:00:31]And we don't want it, right? I'm Dr. Kristoff Acton. I'm a skeletal radiologist and founder of the virtual MSK fellowship where I have been coaching and giving feedback to over 400 radiologists on thousands on their own MSK MRI cases to increase their confidence and speed in MSK MRI reporting. So, today I'm going to walk you through five messy real world TFCC cases that my fellows shared with me in our coaching sessions. By the end, you will have a framework for reading the TFCC that goes beyond the disk. We will start with a complete peripheral tear that any radiologist should be able to report. Then the cases get harder. I show you a more deceptive case and explain the anatomy of the peripheral TFCC you need to know to make the right call. Third, a misleading arthrogram.

[00:01:18]Fourth, a wrist MRI with many findings where your job is to tell the surgeon which one is driving the pain. And finally, a fracture that most radiologists just call a fracture and move on but miss the findings that decide whether the patient needs [music] a cast or surgery. Let's get into it.

[00:01:35]Now, let's have a look at the first case.

[00:01:37]Ulnar attachment tear. When we look at this image here, we have resolution is not great. Maybe if you can reduce the field of view to something like this, you might get a little bit more resolution out of an image like or a scan like this.

[00:01:52]Uh when we go in, so what I would see here and what's the age? Just want to confirm. 39, so there is probably a central perforation that's happening in the disc itself. We see here on the 3D also very at least very thin thinning maybe questionable perforation.

[00:02:09]And then I think you're right the foveal attachment is torn. The fovea itself would be somewhere here.

[00:02:16]Uh you can see this here better the J shape. But there is a lot of fluid like signal here and there is nothing really that's connecting the disc here with the fovea itself. This might be a remnant of the foveal attachment, but it's not attached. So this is torn.

[00:02:33]So contrast would most likely leak in there. And now the question is do we call or what do we call this here? So this one this layer here is meniscus homolog and then this one here would be part of the styloid attachment. And I also it's too irregular. I wouldn't really I mean it's at least partially torn and I think I would be okay by calling this a complete tear of both now with granulation tissue in the subacute phase making it even harder. But there is edema, there is abnormality uh here and I don't think there was much else going on. So I think yeah, peripheral TFCC tear uh with the injury here. So this is styloid process. And if you look at other wrist MRIs, you will often see the black styloid attachment. And here this is just torn with granulation tissue synovitis here. So yeah, I agree.

[00:03:28]Okay, hi Shobha. Thanks for this case wrist MRI.

[00:03:32]And the suspicion is a TFCC injury. And what we can see here on the axial is the disc itself is fine.

[00:03:40]We see a little bit of the styloid attachment here. This one here is part of the foveal attachment. We'll see this on the coronals better. So going back here, we see centrally the disc is fine. There's nothing wrong here. This is the styloid detachment. This is the I just This is the volar attachment. This is the styloid detachment like this. So, this one looks quite okay. But, then we have this edema here. I think this is the main problem in this case.

[00:04:05]Now, this depends now on the clinical information. I you know, if there was a trauma, I would call this like a a sprain or even like a severe focal sprain of the dorsal you know, peripheral attachment of TFCC, meaning part of the radioulnar joint or radioulnar ligament. Although, the actual attachment here is fine, and you can see on the axial how this part here, this is still okay. So, it's not it's not torn. It's more like this perifocal tissue, the peripheral attachment of the TFCC ring that's involved. So, we can also see here. We follow this. You can see a nice sharp triangular meniscus-like structure. But, then there is this edema here at the dorsum here, and this one here is the styloid attachment, which is continuous.

[00:04:50]And then, we have got these fibers coming down into the volar attachment. And I I think also they for me would be intact. I don't see a tear.

[00:04:59]And I think the second thing on the volar aspect that you mentioned, as there is also some edema, we can see uh a little bit here and a little bit here. I think one of them would be the prestyloid recess. I think this one here for me would be the prestyloid recess here.

[00:05:15]So, this is just a a pouch of the joint space.

[00:05:19]I here you can see homolog here, and this is where the prestyloid recess goes down. I think this bulges just down here volarly to the styloid process.

[00:05:27]And I'm not so sure whether or maybe this is a ganglion cyst arising from this area. And then, we've got another pocket of fluid here, which goes kind of like under the or close to the styloid process. Maybe this is still part of the prestyloid recess. I think I wouldn't make this a tear.

[00:05:48]Now, when we look at the location of this one, so this is a quite a pronated position. The ulnar styloid of the normally is here, or in supination it's up here. So, this is supination, down here is pronation, and this would be neutral.

[00:06:02]Um that also twists a little bit the 4-wheel attachments to here, styloid attachments to here. So, there's some variability here.

[00:06:12]Um but yes, so I think there is a definitely a sprain of the dorsal radioulnar ligament or dorsal peripheral TFCC attachment, no central perforation.

[00:06:20]I don't see a distinct tear. So, if we would give contrast into the distal radioulnar joint, I think it would stay contained.

[00:06:26]Uh and I don't see how Well, potentially the The question is, what happens if we give contrast into the radiocarpal compartment? Would it go in between here, which would make then maybe this styloid attachment partially torn. But I think, you know, this one's covered.

[00:06:44]Ulnocarpal ligament come up here, like this.

[00:06:48]I think it's just the edema mainly that's here the issue. Maybe small tears at the peripheral thing might be okay.

[00:06:54]Um But yeah, this depends on the story.

[00:06:57]Let's say if he is not a post-traumatic case and it's a chronic situation, then I would call this like some peripheral irritation here.

[00:07:06]I don't think I would call synovitis per se because, you know, the joint We can have synovitis in the prestyloid recess, which would be maybe somewhere like here.

[00:07:18]But there is This is extra-articular.

[00:07:21]Uh so, this one is not inside the joint.

[00:07:22]The joint You can see this is This is the joint line here, joint capsule here. And then, of course, we have the recess here.

[00:07:31]And then, we have the meniscal homolog.

[00:07:32]We've got These are the compartments that we fill up with contrast in arthrograms. So, whatever this is, it's outside of the joint. That's why I don't like the term synovitis for this area. I would just call it like soft tissue irritation.

[00:07:43]Uh or like chronic irritation. Or if you want to go with the sprain route, like chronic sprain of the dorsal digital ulnar ligament or dorsal TFCC peripheral attachment.

[00:07:52]Um yeah, so I mean it doesn't look like super cute, but it could be more like a subacute injury. So, I think sprain is would be my preferred terminology here.

[00:08:04]Uh we're looking at the TFCC injury question, and this was an arthrogram.

[00:08:08]The first comment that I would make is I find it's slightly weird that the radiocarpal compartment was injected only. I would have preferred a first distal radioulnar joint injection and see what we can see. But, when we look at this here, we can see the surface is intact. There's nothing going down. So, we don't have a communicating injury somewhere. And even at the periphery here, we can see the meniscus homolog outline nicely and pre-styloid recess here. And there's no contrast leaking into the attachments or somewhere. So, we have to rely really on the PD fat sat here more for this case. And when we look here, again, we can confirm the disc is intact. We see the dorsal radioulnar ligament here intact. We see the volar radioulnar ligament intact here. And then, the disc itself is fine as well.

[00:08:55]So, the area where we see a little bit of fluid is here, and we know there is no contrast in there. And this is the processus styloideus ulna. And because we have fluid here in a location where we wouldn't expect it to be, I would also give a high-grade partial tear. I wouldn't call it a complete tear, otherwise I would have suspected the contrast to go in because it was quite overblown. And there should have been enough pressure to go in here on the arthro T1 fat sat, and it's not the case. So, some of these fibers might still be intact or at least scarred and and uh kind of like prevents the contrast from communi- communicating. So, I would say high-grade partial tear foveal attachment.

[00:09:29]And then, I think you are correct that there is some interstitial tear component into the disc periphery here.

[00:09:38]And I think the foveal attachment is a bit hard to assess. I don't see fluid, you know, transacting it somewhere here.

[00:09:45]Um so, that's why I would probably also go, as you said, you know, that it's intact. Uh unfortunately, we cannot really use this T1 here because it was very, very much movement in here. And the T1 is either like And this one is also not much better.

[00:10:05]Sorry for the phone. Because, you know, we don't have an injection into the distal ulnar joint, which might have helped us in assessing this area here.

[00:10:14]So, we have a wrist MRI TFCC tear or UCL tear is the question.

[00:10:20]You can see a perforation and something on the volar aspect ligament and the lunotriquetral ligament is intact. And your question is UCL wave it torn and partial thickness of the dorsal radioulnar ligament. And whether to discuss the meniscus homolog or the triangular ligament. But, so the meniscus homolog, I used to look at it, but I never really see any pathology there. So, I just stopped even mentioning it.

[00:10:44]Um but, let's have a look at your case.

[00:10:46]So, this is the image.

[00:10:48]And yeah, there's a small perforation here at the disc.

[00:10:51]Here, that's okay. We can see there is quite a large, you know, high signal here in the foveal attachment with these cysts here indicating there is a high-grade partial tear and synovitis going into this area here creating this ganglion cyst and the perifocal edema here. And also, when we look at the styloid attachment, there is at least some fraying. Often, we see the covering of the ulnar styloid. I'm not sure whether this is just anatomically variant or whether I would even go with a partial tear also for the styloid attachment.

[00:11:24]Uh meniscus homolog, we don't really see much. It's probably this one here. So, I would not mention this, but we can see there is this dirty stuff here in the prestyloid recess, which we will call synovitis.

[00:11:35]Um the dorsal and this is the dorsal radioulnar ligament also shows some degeneration. Uh the volar one, I think it's better.

[00:11:44]And for the ulnar collateral ligament, you know, we don't really see it as a distinct structure for the most part.

[00:11:51]It's a and you know enforcing the tendon sheath of the ECU tendon, there's just a mild tenosynovitis.

[00:12:00]And I cannot really show you where that ligament would be. It's going to It's going to run somewhere along here, but I would not mention this here as a sprain or tear or anything. So, we got enough stuff already happening here as is.

[00:12:14]Uh LT ligaments, we don't really know. I think the resolution is not really giving us enough information to be sure about the membranous portion here. This bit here is still disc.

[00:12:25]And I wouldn't be surprised if there is a perforation of the LT ligament membranous portion.

[00:12:31]Now, let's try to find the LT ligament dorsal and volar one. So, we got the dorsal one.

[00:12:38]Uh we see somewhere here the volar one.

[00:12:41]I think LT ligament the two main components, maybe some degeneration of the dorsal one. Volar one, I think we just go with okay, membranous portion not well seen.

[00:12:49]And then for the SL ligament, yeah, it looks too high.

[00:12:54]Um I wouldn't make a tear out of it yet here. I would just say some signal increase and degeneration of the dorsal SL ligament and also here the volar one.

[00:13:03]I think we can probably be okay with a advanced degeneration or even if you want to go with a partial tear, I think I would also be okay. We can see there's some fraying happening even here something linear that goes into the ligament itself. But I think that's quite a a subtle case. Um clinically, I mean, there are these things are probably more important, osteoarthritis, and then the changes on the owner carpal side here.

[00:13:28]Where is the symptoms or but they even ask about these things. So, most likely patients really doesn't really have much issues here in terms of the SL ligament and the issue is the synovitis that we can see here, which then also goes into this partial tear of the foveal attachment or even you know, even high grade partial tear. There may be some fibers still intact, so we just go with high grade partial tear and joint space gain information peripheral edema as the main culprit, I think in this case in addition to this one here.

[00:13:57]We got the wrist MRI here in a 40-year-old man. He had an old trauma, no recent injury. And I mean, the obvious finding would be the styloid arthrosis here after an old fracture.

[00:14:07]There may be smaller you know, smaller ossicles close by.

[00:14:11]And the head looks quite big.

[00:14:14]And when we have these styloid arthrosis or these old fractures, especially when they go through the base of the styloid process, what that means is that basically the foveal and styloid detachment are affected. So, you know, this one will go in here. So, both are affected. So, this makes the TFCC or the distal radio-ulnar joint unstable.

[00:14:36]And that's why we see also to some degree like like you mentioned already, dorsal subluxation. If we use these different methods, then the center of rotation would be here.

[00:14:46]You know, it's too high, so dorsal subluxed. And I think the reason for this is mostly injury to the dorsal one, the dorsal radio-ulnar ligament. Um it's not really the volar one. Uh and when we go to the volar one, we can see the volar ulnolunate ligament here very nicely black. We go here, we see part of the ulnar triquetral ligament also quite okayish.

[00:15:11]The disc itself then here is also not perforated or anything like that, but when we go from here, which is still disc, to the next level, which will now show the dorsal radio-ulnar ligament. You can see there is ill ill-definition. You know, it's There's no really nice ligament structure visible here as opposed to the volar side where we have nice and black ligaments here, right? So, this is just uh like scarred uh hardly visible dorsal radioulnar ligament. We've got the bone marrow edema here at the fragment. We've got a bit of fusion in the pisiform triquetrum.

[00:15:46]The attachments are continuous with this fragment.

[00:15:49]Destabilizing this most likely.

[00:15:52]We see a little bit of edema also here.

[00:15:54]Maybe a little bit of a fusion and synovitis in the distal radioulnar joint. And as you said already, dorsal subluxation.

[00:16:00]And yeah, so I think that's the main issue.

[00:16:04]Uh for the ECU tendon, some flattening, maybe a split tear here.

[00:16:09]I see not too much in terms of tenosynovitis, though.

[00:16:15]I I think I would just keep it with a little bit of tendinosis and a split tear.

[00:16:18]Um pisiform triquetral joint is fine. The ulnar nerve here. You can follow my my mouse. This is ulnar nerve. Comes up here.

[00:16:28]Then this is deep branch, superficial branch. Deep branch goes in here.

[00:16:33]Then we lose it. It's fine. Not much to be seen there. Then we've got some smaller dorsal ganglion cysts here at this level.

[00:16:40]Uh and then SL ligament is okay. The other extensor tendons, we don't see much there either. So, we don't see too much. Maybe some subtle degeneration of the dorsal LT ligament. The volar one is fine.

[00:16:52]Volar SL ligament fine. Dorsal SL ligament fine.

[00:16:55]Uh let's go through the extrinsic ligaments here.

[00:17:00]Dorsal intercarpal ligament is fine.

[00:17:01]Maybe some degeneration of the dorsal radiocarpal ligament, which is a bit ill-defined.

[00:17:08]The volar extrinsic ligaments are fine.

[00:17:10]So, I think that will be the assessment here from my side. Now you have seen how subtle TFCC pathology can be in real clinical cases. But, you'll never be able to see what's hidden in plain sight unless you understand this subtle wrist anatomy. Watch this video where I walk you through the full MRI anatomy of the TFCC. It is one of the most popular videos of mine, and according to some surgeons and radiologists in the comments, one of the clearest explanations of the TFCC online.