Ulnar-sided wrist pain: classify TFCC tears (Palmer traumatic 1 vs degenerative 2), check the ulnar variance and ulnocarpal abutment, and look at the scapholunate and lunotriquetral ligaments whose tears lead to carpal instability.
Orient first
- Palmer 1A (central), 1B (ulnar peripheral — repairable), 1C, 1D; class 2 degenerative with positive ulnar variance.
- Scapholunate ligament dorsal band is the strongest and most important.
- MR arthrography or 3T MRI improves detection of small tears.
Acquire the study
- MRI wrist (3T preferred, dedicated coil): coronal T1, PD fat-saturated in three planes, 3D gradient-echo; MR arthrography where available. Neutral-rotation PA radiograph for ulnar variance.
The manoeuvre
- Coronal PD fat-saturated: TFCC articular disc — central perforation vs peripheral detachment at the fovea.
- Ulnar variance on the PA radiograph in mm; lunate and ulnar head oedema on coronal images (abutment).
- Scapholunate ligament on coronal and axial images: dorsal, membranous and volar parts.
- Lunotriquetral ligament; carpal alignment on sagittal (DISI/VISI).
- ECU tendon subluxation on axial images.
What confirms it
- Fluid signal through the TFCC or ligament with discontinuity in two planes.
What licenses you to exclude it
- An intact disc and ligaments on 3T or arthrographic MRI make a significant tear unlikely.
The classic misread
- Age-related central TFCC perforations called traumatic.