Atzei classification of peripheral TFCC tears

Case contributed by Dr Joachim Feger
Annotated image

Atzei class 1

  • isolated peripheral TFCC tear of the distal (styloid) attachment 

Atzei class 2

  • peripheral TFCC tear of both attachments the styloid and foveal insertion

Atzei class 3

  • isolated peripheral TFCC tear of the proximal (foveal) attachment
  • avulsion fracture of the TFCC insertion

Atzei class 4

  • extensive TFCC tear, which can not be repaired by common capsular repair or foveal fixation
  • degenerative or frayed tear edges which do not hold sutures and show poor healing properties

Atzei class 5

Case Discussion

This is an illustration of the Atzei classification for peripheral triangular fibrocartilage complex (TFCC) tears 1-3, which are classically summarized as Palmer 1b lesions.

Due to better vascularization of the peripheral zone of the triangular fibrocartilaginous complex, peripheral lesions are more amenable to surgical repair than the central mostly avascular zone 4. There are different surgical treatment strategies depending on the exact location and extent of the lesion, which is covered in this classification.

A strength of this classification is that it offers clear therapeutic recommendations for each category:

An Atzei class 1 lesion requires capsular suture class 2 and class 3 tears foveal attachment, class 4 and class 5 lesions require more extensive and sophisticated repair as e.g. tendon graft in case of a class 4 lesion or arthroplasty in case of a class 5 lesion 1-3.


On imaging, it is particularly important to point out isolated lesions of the foveal attachment thus Atzei class 3 lesions, since they also have a normal appearance on arthroscopic inspection. If the hook test is not performed during arthroscopy they can be missed.

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Case information

rID: 76784
Published: 29th Apr 2020
Last edited: 10th May 2020
Inclusion in quiz mode: Included

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