Chronic triangular fibrocartilage complex (TFCC) injury

[flemma]

Hi

Im after a little bit of help and advice please. I have just come across this site and already i have read some great threads. So i hope there is someone out there that can help me. I would really appreciate it.

I fell in Feb 08 and put both hands out behind me to brace my fall - big mistake! I had immediate left wrist pain so went for an x-ray. I was advised the x-ray was clear and it was just soft tissue/ligament damage so used a wrist splint for a while. Anyway to cut a long story short, i had months of physio and spent 4.5 months off sick.

I have constant aching pain, with shooting pains done the ulna side of my wrist to my little finger and ring finger, i also experience pins and needles and numbness in the same area. I can't lift much weight and i have a poor grip.

The symptoms continued and recently got a lot worse again depsite no new injury occuring. I got referred for an orthopaedic consult who looked back at my original x-ray and noticed a chip off the ulna which can no longer be seen on my latest x-ray and also is fairly confident i have damaged the triangular fibrocartilage complex (TFCC). I have a bone scan and MRI booked for the end of the month. If TFCC is confirmed then apparently i will need surgery.

Seeing as it is almost a year old i am interested to hear anyones advice or experience of the surgery required and also if the physio treatment will be changed due to the possible new diagnosis. At present, i am trying to build the muscle up as my wrist is apparently fairly unstable.

I am keen to get the most appropriate treatment as quickly as possible as i have now been off 7 weeks and am not allowed back untill it is totally resolved as they can't manage the pain, which is going to take months.

Thanks in advance for anyones help. Sorry for the essay!

Em

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[physiobob]

Hi there, thanks for your posting. Unfotunately I don't have any recent experience with this type of surgery but i did see some information from the emedicine part of medscape. Some of that and a few images to perhaps spark some discussion is posted below. You can read more by searching on their website.

In 1981, Palmer and Werner introduced the term "triangular fibrocartilage complex" (TFCC) to describe the ligamentous and cartilaginous structures that suspend the distal radius and ulnar carpus from the distal ulna (see Image 1). The TFCC is the major ligamentous stabilizer of the distal radioulnar joint (DRUJ) and the ulnar carpus.

Functions of the TFCC are as follows:

* Provides a continuous gliding surface across the entire distal face of the 2 forearm bones for flexion-extension and translational movements (see Image 2)
* Provides a flexible mechanism for stable rotational movements of the radiocarpal unit around the ulnar axis
* Suspends the ulnar carpus from the dorsal ulnar face of the radius
* Cushions the forces transmitted through the ulnocarpal axis
* Solidly connects the ulnar axis to the volar carpus (see Image 3)

Treatment

Medical Therapy

Initial treatment of both symptomatic degenerative and traumatic tears is 8-12 weeks of conservative therapy consisting of the following:

* NSAIDs
* Immobilization in slight flexion and ulnar deviation in a short arm cast for 4-6 weeks, followed by removable wrist splints and physical therapy
* Initial treatment with long arm casting for 4-6 weeks for traumatic tears and 3-4 weeks of short arm casting for degenerative tears recommended by some

The natural history of symptomatic tears according to Osterman's (1991) study of 133 patients is as follows:

* Traumatic tears with neutral ulnar variance did not worsen over time, and one third of patients were asymptomatic at 9.5 years of follow-up.
* In persons with traumatic tears with ulnar positive variance, two thirds of patients worsened over time both symptomatically and radiologically.

Palmer classification for triangular fibrocartilage complex abnormalities

Class 1: Traumatic

* A - Central perforation (see Images 8-10)
* B - Ulnar avulsion (see Images 11-13) with or without distal ulnar fracture
* C - Distal avulsion
* D - Radial avulsion with or without sigmoid notch fracture

Class 2: Degenerative (ulnocarpal abutment syndrome) stage

* A - TFCC wear
* B - TFCC wear with lunate and/or ulnar chondromalacia
* C - TFCC perforation with lunate and/or ulnar chondromalacia
* D - TFCC perforation with lunate and/or ulnar chondromalacia and LT ligament perforation
* E - TFCC perforation with lunate and/or ulnar chondromalacia, LT ligament perforation, and ulnocarpal arthritis

Acute isolated TFCC disruption with dislocation or instability of the distal radioulnar joint

Isolated TFCC disruptions may be associated with DRUJ instability. These injuries are often associated with distal radius and forearm fractures. Forced hyperpronation usually results in dorsal dislocation. On physical examination, the ulnar head is prominent dorsally and the patient has limited forearm supination. Less commonly, volar dislocation results from forced supination. On physical examination, dorsal skin dimpling is often observed and pronation is limited. The volarly displaced ulnar head is often not felt because of the overlying soft tissues. When dislocation of the ulnar head is not present, subluxation and instability are more difficult to diagnose. Subluxation and instability of the DRUJ are assessed on physical examination by shucking the radius and ulna past each other to determine the amount of dorsal/palmar laxity. This should be performed in neutral, pronation, and supination and compared to the opposite side.

The more common dorsal DRUJ instability is reduced with the forearm in supination. Palmar DRUJ instability is reduced with the forearm in pronation. If a congruent reduction can be achieved and the forearm is stable through a full ROM, then the forearm is immobilized in a long arm cast in the position of stability for 4-6 weeks. With a dorsal dislocation, the preferred position of immobilization is in approximately 30° of supination for 4 weeks, followed by gradual reduction to neutral over the next 2 weeks. If a congruent reduction cannot be achieved or if the dorsal instability is unstable in 30° of supination, then arthroscopic evaluation of the TFCC is recommended with repair as needed.

Surgical Therapy

If the DRUJ remains unstable, open reduction is required to remove interposed structures. When instability persists with forearm ROM, supplemental Kirschner wire (K-wire) stabilization just proximal to the DRUJ is recommended for 4-6 weeks.

Instability of the DRUJ is often associated with distal radius fractures and Galeazzi fractures-dislocations. Anatomic reduction of these fractures often stabilizes the DRUJ. When fixation of these fractures does not stabilize the DRUJ, stabilization can be obtained with either long arm casting in a reduced position, open reduction and TFCC repair, or supplemental K-wire fixation. Retting and Raskin (2001) noted a high association with Galeazzi fractures within 7.5 cm of the midarticular surface of the distal radius and with DRUJ instability after open reduction and internal fixation of the radial shaft fracture.

In individuals with radial head fracture and tenderness over the DRUJ, every attempt should be made to preserve the radial head to prevent proximal migration of the radius. DRUJ disruption associated with a displaced radial head fracture and proximal migration of the radius is termed the Essex-Lopresti fracture. Geel and Palmer (1992) noted good results in 18 of 19 patients with radial head fracture and pain at the DRUJ, who were treated with open reduction and internal fixation of the radial head.
Intraoperative Details

Open repair

* Make a dorsal ulnar incision between the fourth and fifth extensor compartments.
* Carry the dissection down to the DRUL.
* Reflect the DRUL and the periosteum over the lunate fossa.
* Place horizontal mattress sutures in the TFCC through drill holes placed in the dorsoulnar aspect of the distal radius.

Wrist arthroscopy

Indications for wrist arthroscopy include acute unstable tears, acute tears that fail to respond to conservative management, and chronic tears for which conservative management fails.

General arthroscopic principles are as follows:

* Debride to a stable smooth rim of tissue.
* Maintain a 2-mm peripheral rim.
* Excise less than two thirds of the central portion of the TFCC.
* Maintain the integrity of the DRUL, PRUL, and disk carpal ligaments.

Treatment of traumatic central tears (Palmer class 1A)

* Debridement as above

Treatment of traumatic ulnar-side tears (Palmer class 1B) with outside-in technique

* Debride the synovitis and the edges of the tear.
* Make a 1-cm incision just radial to the ECU tendon.
* Open the radial aspect of the ECU tendon sheath for 1 cm.
* Retract the ECU palmarly.
* Under arthroscopic visualization, pass 2 needles through the capsule and across the tear using a meniscus mender or similar TFCC repair device.
* Use a wire loop passed through one needle to retrieve a 2-0 polydioxanone suture (PDS) passed through the other needle. This creates a loop.
* Tie the suture over the dorsal wrist capsule, approximating the tear.
* From 2 to 4 sutures may be required.
* Reconstruct the ECU tendon as needed.
* Immobilize the wrist and elbow for 4 weeks in a splint or Muenster cast.

Treatment of ulnar extrinsic ligament tears (Palmer class 1C)

* Perform a mini open or arthroscopic repair using zone-specific cannulas.
* Stay between the ECU and flexor carpi ulnaris (FCU) to avoid the neurovascular bundle.

Treatment of traumatic radial side tears (Palmer class 1D)

Debride as with a Palmer class 1A tear, or repair as follows:

* Debride the edge of the sigmoid notch with a shaver down to bleeding bone.
* Make drill holes through the distal radius with a K-wire passed percutaneously into the joint from the sigmoid notch across the distal radius.
* Pass a 2-0 PDS double-ended suture on long needles through the TFCC and into the drill holes.
* Tie the suture on the surface of the radius through a small incision while protecting the superficial radial nerve.
* Pin the DRUJ in neutral rotation with a single 0.062-inch K-wire.
* Immobilize the wrist and elbow for 8 weeks in a splint or Muenster cast.
* Transosseous suture anchors can be used in place of drill holes.

Treatment of degenerative tears (Palmer classes 2A and 2B)

* Gently debride.
* If the patient is ulnar positive and symptomatic, use open ulnar shortening.

Treatment of degenerative tears (Palmer class 2C)

* Gently debride in patients who are ulnar neutral or ulnar negative.
* For patients who are ulnar positive, consider the arthroscopic wafer procedure. The arthroscopic wafer procedure is performed as follows:
o Wnorowski demonstrated almost a 50% unloading of the ulnar side of the wrist after excision of the central portion of the TFCC and resection of the radial two thirds of the width of the ulnar head to a depth of subchondral bone.
o Patients with an arthroscopic wafer procedure may have a more prolonged postoperative course than those with open ulnar shortening.

Treatment of degenerative tears (Palmer class 2D)

* Treatment is similar to that for Palmer class 2C tears.
* Carefully assess LT instability.
* If the LT is stable, perform debridement.
* If the LT is unstable, consider an open shortening osteotomy to unload the ulnar head and tighten the ulnar extrinsic ligaments. Then, consider an LT fusion or pinning or an LT ligament repair.
* An arthroscopic wafer procedure is contraindicated, as it leads to more laxity in the ulnar extrinsic and LT ligaments.

Treatment of degenerative tears (Palmer class 2E)

* Degenerative tears have an unpredictable response to arthroscopic debridement.
* These tears usually require a salvage operation.
* Address the DRUJ and LT joint.
* A limited ulnar head excision can be performed.
* The Sauve-Kapandji procedure involves radioulnar joint arthrodesis and proximal ulnar pseudoarthrosis.
* The Darrach procedure is a resection of the distal end of the ulna.

Ulnar-shortening osteotomy

Consider ulnar-shortening osteotomy for patients with ulnar positive variance, patients in whom debridement fails, and/or patients who present with a delay in treatment of longer than 6 months.

Advantages of an ulnar-shortening osteotomy are as follows:

* Extra-articular
* Maintains the mechanical integrity of the DRUJ
* Maintains the origins and insertions of the ligamentous tissue and capsule forming the peripheral aspect of the TFCC; may result in tightening of the ulnocarpal complex, including the LT ligament, with shortening
* Potentially less painful than an arthroscopic resection

Postoperative Details

* All patients are immobilized immediately following surgery.
* If debridement alone is performed, patients are placed in a bulky dressing and started on motion exercises at 5-7 days.
* All other patients are placed in a sugar-tong splint.
* Skin sutures are removed at 7-10 days.
* A Muenster-style cast is used for 2 weeks, followed by a short arm cast for 3 weeks for patients who have undergone TFCC repairs.

[wendy howard]

Aloha,

I hope I can be of assistance to you as this injury is my passion.

Dr. Nagle described the push up test as a 100% reliable tool i measuring TFCC tears. Since you already have the diagnosis, I would ask you what your weight bearing tolerance is? You can find the weight bearing test at youtube YouTube - WristWidget

Once you have defined with difference between the weight bearing of the right and left, or injured and non injured, you can determine how bad your injury is. This also helps understand if you have ECU tendonitis vs another injury which is causing your ulnar sided wrist pain.

Then, I would recommend that you tape your wrist with non elastic tape tightly. Do this for a test. Do not cross the wrist, but tape it as if you were putting on a sweat band, except tighter. Now retest the weight bearing. If you notice that there is an objective change in your tolerance to weight without pain, then I would visit http://tfccijury.blogspot.com for more information. This test does not work on a normal wrist as you will note.

This is a difficult injury with many variables which have not been standardized. The objective is to find a good conservative treatment that leads you a complete recovery. This injury also takes a long time to heal. If you decide to go the surgery route, I would spend the time understanding everything about the surgical options and gather as many opinions as possible.

I am free to answer any questions you might have. There are many fine details of your symptoms which, if you understood, would allow you to swim these waters with a good snorkel and wetsuit...

With Warm Aloha,

Wendy Howard, OTR, CHT, Clinical Research Coordinator