Triangular Fibrocartilage Complex Disorders (TFCC injuries)
What is the TFCC?
The wrist joint contains cartilage called triangular fibrocartilage complex or TFCC. The carriage is located on the inside or the ulnar aspect of the wrist. Wrist cartilage tears can cause wrist pain and clicking.
The TFCC is an important structure in the wrist. The TFCC is made of tough fibrous tissue and cartilage. This tissue supports the joints between the end of the forearm bones (radius and ulna), adding to their stability. The TFCC also helps connect the forearm with the small bones in the ulnar side (“pinkie finger” side) of the wrist. Several different tissues form the TFCC, and they blend to stabilise the ulnar side of the wrist.
The TFCC also acts as a cushion between the end of the ulna and the small bones (lunate and triquetrum) of the wrist.
In patients whose ulna is longer than the radius at the wrist, the TFCC is usually thinner and more likely to tear.
TFCC is a name given to a soft tissue structure that connects the distal aspects of the two bones in the forearm, namely the radius and ulna, around the wrist.
What is the TFCC?
Its main function is to stabilise the joint (distal radioulnar joint [DRUJ]) between the radius and ulna at the wrist. In addition, it is thought to help to stabilise the wrist joint and share the load going across the wrist.
What pathologies can occur in TFCC?
A TFCC tear can happen in two different locations and is usually caused by different problems. The first type of TFCC tear is due to natural wear, and the other is usually from injury. Tears due to wear are the most common and are usually not seen in younger people. They become more common as one gets older.
Tears from injury can come from:
• A fall on the hand or wrist
• A twisting injury (like a drill bit catching, causing a twist of the arm)
• A fracture at the end of the radius
What are the causes of TFCC tear?
The most common cause of a wrist cartilage tear is a fall directly onto the hand. Other mechanisms include a forced rotation or distraction (pull) such as occurs in boxing, tennis, squash, or weight training.
Sometimes, there is no specific injury to the wrist. Initially, people notice a clicking followed by a gradual onset of pain.
Symptoms
Patients with traumatic tears present with history of injury and pain on the ulnar side (inner side) of the wrist. In addition, they may have pain on forearm rotation, sense of abnormal movement (instability) at the wrist joint, weakness of grip, clicking and swelling around the distal ulna.
Simple activities such as turning a doorknob or lifting heavy objects can be painful.
For some, a TFCC tear may not cause any pain or instability problems in a wrist. Often, MRI studies show tears in people with no pain or problems using the wrist.
Others may experience some or all of the following symptoms:
• Clicking or popping while turning the forearm or moving the wrist from side to side
• Pain
• Weakness
• Limited motion
If there is pain or instability in the wrist, it may be a sign of a problem with the TFCC. In this case, a discussion with your medical provider can help to clarify the issue.
Patients with undiagnosed TFCC problems usually give a history of long-standing ulnar-sided (inner side of the wrist) pain which can be very disabling.
Clinical Examination
The consistent finding on examination by the doctor is pain and tenderness around the distal tip of the ulna. A provocative test by moving the wrist in a specific manner is usually positive in acute presentations. There may be signs of abnormal movement of the DRUJ both in acute and chronic cases.
Investigations
Magnetic resonance imaging (MRI) is probably the best imaging modality to identify TFCC problems. It helps identify the tears and their location. Radiographs of the wrist are helpful following an acute injury where there may be a pull-off fracture of the tip of the distal ulna, indicating a TFCC injury
Increasingly arthroscopy (keyhole surgery) of the wrist is being utilised to identify the problem and in addition, providing the option of its management at the same instance.
Treatments
Only people with the symptoms mentioned above need to be treated for a TFCC tear.
Treatment options that may provide relief are:
• TFCC widgets
• Activity changes
• Anti-inflammatory medicine
• Injections
The wrist widget is a discrete, non-intrusive, velcro brace designed to help treat pain on the ulnar side (little finger side) of the wrist. A good way to determine if the wrist widget will be effective is with the weight-bearing push test. In a seated position place both palms on the chair you are sitting on and gently weight bear through the hands to lift your hips off the seat. Pain in this position, on the ulnar side of the wrist, counts as a positive test. Then provide stability to the wrist joint by either taping or putting on a wrist widget, an immediate reduction in symptoms is a positive finding and indicative of TFCC injury.
If these don’t help, there may be surgical treatments available. Possible surgical treatments are varied depending on the specific, underlying TFCC injury.
Initial treatment for both traumatic and degenerative TFCC tears is nonsurgical if the DRUJ is stable. This involves patients wearing a cast or a splint for four to six weeks to help the tear to heal and/or the surrounding soft tissues to scar. Usually, anti-inflammatories are prescribed to help with pain management. Local anaesthesia and steroid injection may help in chronic settings.
Operative treatment
Operative intervention is undertaken where conservative management has failed, there is instability (abnormal motion) at the DRUJ or there is a pull-off fracture of the TFCC with a displaced wrist fracture.
The operative intervention is usually arthroscopic, which primarily involves repair of the TFCC tear done through the arthroscopy (keyhole surgery), although an open repair may also be undertaken to address complex TFCC tears.
In cases of gross instability of the DRUJ, soft tissue reinforcement (ligament reconstruction) may be necessary.
Post-operative rehabilitation
Post-operative rehabilitation is guided by the patient’s problem and its management.
Patients managed conservatively either in cast or splints undergo physiotherapy to improve the range of motion and gain strength.
Patients who have the TFCC repaired and those who have undergone soft tissue reinforcement (ligament reconstruction) for instability are immobilised for four-six weeks, followed by intensive physiotherapy.
In patients with degenerate tears, physiotherapy is instituted soon after debridement of the tear.
Return to activities of daily living
Most patients with a mild TFCC injury are able to return to work and/or return to sports at a pre-injury level. Pain-free movement and full strength are possible after both conservative and surgical treatments.
Return to driving
The hands need to have full control of the steering wheel, with the left hand having control of the gear stick. It is advisable to delay return to driving until patients are pain-free and can control a car comfortably in an emergency situation. This may take between four-six weeks, although each case is different.
Return to work
People are involved in different working environments. Return to heavy manual labour, for example, should be prevented for approximately 12 weeks and only when the wrist is pain-free. Please ask your surgeon for advice regarding this.
Complications
Problems associated with acute TFCC tears could be due to delay in diagnosis, and this can lead to continued pain, instability or weakness of the wrist.
Operative complications following TFCC repair include infection, injury to nerve or tendons around the operative site, incomplete relief of symptoms and in a few cases, reflex sympathetic dystrophy (painful, stiff hands).