Triangular Fibrocartilage Complex Injuries

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Clinically Relevant Anatomy

The Triangular Fibrocartilage Complex is the ligamentous and cartilaginous structures that separate the radiocarpal from the distal radioulnar joint. The TFCC consists of an articular disc, meniscus homologue, ulnocarpal ligament, dosal & volar radioulnar ligament and extensor carpi ulnaris sheath.

• Origin: Medial border of distal radius
• Insertion: Base of ulnar styloid
• Vascular Supply: central disc is avascular, peripheral blood vessels penetrate TFCC margins
• Function of TFCC: Main stabilizer of distal radioulnar joint (volar portion of TFCC prevents dorsal displacement of ulna and is tight in pronation and dorsal portion of TFCC prevents volar displacement of ulna and is tight in supination). Contributes to ulnocarpal stability

Mechanism of Injury / Pathological Process

• Occurs with compressive load on TFCC during marked ulnar deviation
• Commonly associated with positive ulnar variance (radial shortening, average of 4.5 mm)
• Forced ulnar deviance (i.e. swinging bat, racket, etc) causes increased load on TFCC 

Clinical Presentation

• Ulnar sided wrist pain often with clicking/grinding
• Weakness

Diagnostic Procedures

Physical Examination

TFCC Stress Test

• TFCC Compression Test: Reproduction of pain/clicking with ulnar deviation of wrist with forearm in neutral
• Piano Key Sign: Prominent distal ulna with full pronation
• Ulnar Carpal Sag
• Lunotriquetral interval tenderness
• Tenderness on Palpation: The TFCC is located between the os pisiform, the ulnar styloid and the FCU. The best way to palpate the TFCC is with the wrist in pronation.
• Foveal Tenderness: difficult to distinguish from ECU tenderness *TFCC Compression: A combination of ulnar deviation and axial compression while performing repetitive flexion and extension will have an impact on the ulnar styloid and the TFCC. If the TFCC is involved, this test will cause pain and/or clicking.
• Press Test: The patient has to lift himself out of a chair, with the wrists in extension. This will cause pain.
• Supination test: The patient has to ‘lift’ the examination table, with the palmar side of the hand on the underside of the table. This will cause dorsal impingement, as it forces a load on the TFCC with the wrist in supination and extension. It is therefore useful in the diagnosis of a peripheral, dorsal TFCC tear.
• Piano-Key Test: The patient has to place both his hands on the examination table, while pressing the palms on the table. When there is an exaggerated dorsal-palmar translation in comparison with the other hand, this indicates DRUJ instability, which often comes with a TFCC tear. The piano-key test is positive if the ulnar head returns to its normal anatomic position when the force is removed from the ulnar head, there is a difference in mobility and pain compared to the uninvolved side.
• Grind Test: The patient has to perform a rotation of the forearm, while the radius and ulna are compressed. This test might indicate degeneration.
• Trampoline Test: We will probe the TFCC to assess the tension. When there is no normal bounce, there might be a peripheral tear of the TFCC.
• TFCC Stress Test: This is a provocative test. The patient has the wrist in ulnar deviation while applying a shear force across the ulnar complex of the wrist.

Diagnostic Imaging

• Radiographs: may reveal avulsion of ulnar styloid, scaphoid fracture, distal radial fracture, volar tilt of lunate or triquetrum; ulnar variance
• Triple Injection Arthrography: identification of tear (low specificity)
• MRI: identification of tear (high sensitivity and specificity)

Palmar Classification of TFCC Abnormalities

Class 1: Traumatic:

• Class 1A: Central Perforation
• Class 1B: Ulnar Avulsion with or without distal ulnar fracture
• Class 1C: Distal Avulsion
• Class 1D: Radial Avulsion with or without sigmoid notch fracture

Class 2: Degenerative:

• Class 2A: TFCC wear
• Class 2B: TFCC wear with lunate and/or ulnar chondromalacia
• Class 2C: TFCC perforation with lunate and/or ulnar chondromalacia
• Class 2D: TFCC perforation with lunate and/or ulnar chondromalacia and lunotriquetral ligament perforation
• Class 2E: TFCC perforation with lunate and/or ulnar chondromalacia, lunotriquetral ligament perforation, and ulnocarpal arthritis

It is important to distinguish between class 1 and class 2, because a traumatic tear can be repaired, but a degenerative tear is often associated with ulnocarpal impaction syndrome which means that the ulnarpositive variance needs to be assessed. 

Outcome Measures

• DASH Outcome Measure
• Modified Mayo Wrist Score
• Activities of Daily Living Score

Management / Interventions

Conservative Treatment:

• The rehabilitation program should consist of rest, activity modification to remove the inciting force of injury, ice application and splint immobilisation for 3 to 6 weeks
• After the immobilisation, the patient should receive physical therapy

Surgical Intervention

• Open Repair or Arthroscopic Repair 

Post-operative rehabilitation:

For type 1 injuries, the wrist will be immobilised for 1 week after the arthroscopy. After one week, range of motion exercises can be started.
A TFCC tear is a common injury in golf, boxing, tennis, waterskiing, gymnastics, pole vaulting and hockey.
Golf players and tennis players who suffer from a stable TFCC tear are able to start light activity ball contact at 3 weeks after the arthroscopy. They can return to their normal sports activity in 4 to 6 weeks.

When the symptoms remain, ulnocarpal corticosteroid injection can be an option. However, it is unlikely that this will heal the tear, so the symptoms will not subside. An arthroscopic debridement can be an option if the conservative measures fail.

For more severe injuries, post-operative immobilisation in a Muenster cast for 4 weeks may be considered. After 4 weeks the wrist is placed in a short arm splint or Versa wrist splint, which allows progressive motion to the wrist. The immobilisation will decrease the wrist pain and aggravation, which could improve healing. Some types of splints will help stabilise the wrist, which will lead to an improvement in hand function. Patients can then start with range of motion and grip-strengthening exercises. Therapists are more likely to give eccentric grip strengthening exercises, because this will have an influence on the co-activation pattern of the wrist-flexors, which help stabilise the wrist. Other co-activation exercises can also be included to improve the global wrist stability.

Active muscle training should be started 8 weeks post-operation. A graded pain-free exercise program is recommended. Physiotherapy management should include patient education and activity modification. Isometric exercises should be included to help strengthen the area and reduce the risk of instability. In particular, unilateral isometric exercises are beneficial as they have been found to increase voluntary muscle activation bilaterally. This may be because the motor cortex is stimulated, resulting in greater neuromuscular control. In addition, controlled isometric activation of pronator quadratus in supination and neutral wrist position will help to stabilise the distal radioulnar joint (DRUJ). This can be used pre- and postoperatively in patients with TFCC injuries.

These patients are likely to resume normal activity by 3 months postoperatively. It takes 3 to 4 months to return to normal sports activities.

Passive mobilisation

Initially, a traction of the radiocarpal and the midcarpal joints can be used to determine whether this provokes pain.

• To promote the wrist flexion, a dorsal sliding technique can be used.
• To promote the wrist extension, the volar sliding technique can be used.
• To promote the radial deviation the ulnar sliding technique can be used.
• To promote the ulnar deviation, the radial sliding technique can be used.
  
  

General mobility exercises

The patient should perform:

• Wrists rotations.
• Horizontal ulnar and radial deviation.
• Active pronation and supination.
• Stretching flexion and extension of the wrist.

Strengthening exercises

At the end of the therapy, then move on to strengthening exercises. The following exercises are all done with a weight in the hands or with a terra tire.

• Flexion and extension.
• Pronation and supination.

Differential Diagnosis

Differential diagnoses include:

• Osteoarthritis of pisotriquetral/distal radioulnar joint
• Lunotriquetral injuries
• Ulnar extensor muscle tendinitis or subluxation
• Chondral lesions of the distal radioulnar joint
• Ulnar flexor muscle tendinitis
• Pisotriquetral compression syndrome
• Ulnar carpal impingement
• Carpal/Midcarpal Instability
• Hypothenar Hammer Syndrome
  

In the case of acute injury:

• ulnar styloid base fracture
• widening of the distal radio-ulnar joint space