Therapist and Physician Information on Treatment and Repair of TFCC Tears

The Weight Bearing Test (WBT) is a differential diagnosis tool. It is the only way to accurately and objectively measure the severity of a TFCC injury and change over the course of time. 

It MUST be performed with a non-digital analog scale.  Elbow must be STRAIGHT and over the wrist. 

There are three ways to assess wrist stability using the Weight Bearing Test:

1. Weight Bearing Test at 90 degrees

 

2. Weight Bearing Test at 45 degrees (Scapholunate Load Test)

If the patient experiences pain with wrist extension, perform the 45 Degree Angle/Scapholunate Load Test.

We use this test to better understand the load bearing tolerance of the wrist. This angle is harder to perform, and drops weight bearing tolerance 30% in normal healthy wrists. This position does not require full wrist extension and is valuable in our assessments. It is very important NOT to push beyond pain. 

 3. Weight Bearing Test at 30 degrees (Modified Grip Test)

The modified grip weight test is valuable in understanding the weight load tolerance of the wrist. This test requires grip strength and wrist extension at 30 degrees.

Research articles

Increase of weight-bearing capacity of patients with lesions of the TFCC using a wrist brace

Wrist Weight Bearing Tolerance in Healthy Adults

Wrist weight bearing reasearch indicates:

  1. Wrist weight bearing (WWB) is largely defined by age and height.
  2. WWB is typically between 60 and 120 lbs.
  3. There is no difference in WWB between right and left, dominant and non-dominant
  4. If TFCC is torn, you will see painful and diminished weight bearing tolerance AND a clear and objective improvement with the WristWidget® immediately.
  5. WWB is typically 15% less than grip except in cases where heavy use of forearms - elite athletes, carpenters, weightlifters etc. 

 

Conservative treatment of TFCC tears

Research articles

The use of WristWidget®s as a non-surgical alternative to repairing TFCC tears

Increase of Weight-Bearing Capability of Patients with Lesions of the TFCC using the WristWidget® brace

As discussed in the video and paper above, peripheral AND central tears of the TFCC can fully heal without surgery when the recommended TFCC healing protocol is followed. The severity of the injury is determined using the Weight Bearing Test.  Over 40,000 patient cases are supported by this research.

Cortisone injections for TFCC tears

Cortisone injections skew weight bearing tolerance- falsely negative- or pain-free.  Do not test weight bearing tolerance for 10 days after a cortisone injection. Patients with a TFCC tear who get a cortisone injection develop an immediate ability to bear weight.  At the end of 10 days, the weight bearing tolerance plummets.  NOTE: after a cortisone injection, instruct patients to protect their wrist and do not load it!

 

Differential diagnosis

Often Abductor Digiti Quinti is a cause of clicking.  

Test resisted abduction.  If painful, tape pinky to the ring finger during the day.   The patient complains of pain with typing, mousing or writing. Clicking is not always present in every case.  Remember, the wrist has many small bones which are all disrupted when the radius and ulna spread from a TFCC tear. 

 

Often Flexor Policis Longus is involved and causes slightly volar (palm sided) ulnar pain.  

Simply stretch FPL and resist flexion of DIP- if painful- will respond beautifully to stretching exercises.  These patients report pain with mousing and typing - a complaint atypical for TFCC only problems.  

 

ECU-only tendonitis presents with pain-free and normal weight bearing tolerance.  Often though, both TFCC tears and ECU tendonitis present together.  If ECU is painful to touch at the insertion at the base of the 5th metacarpal and 6th dorsal compartment, it really helps to splint patient at night in a wrist-cock up which does not compress the ulna head.  If wb is over 65 lbs, night time use of WristWidget® is not required but recommended.  Wear this wrist-cock up splint over the WristWidget®.  

45 lbs of wrist weight bearing are necessary for function.  If below, the patient will have simple functional pain. 65 lbs of wrist weight bearing are required for heavier tasks.  The patient can return to heavy activities when weight bearing is over 65 lbs.  Patients need to wear the WristWidget® 24/7 until weight bearing is over 65 lbs.  In patients who are not active and their normal is 65 lbs, they typically are not loading the wrist functionally beyond 50.  In this case- the WristWidget® can be removed at night.  

The goal is 100% of weight bearing tolerance.  Most patients will stop treatment prematurely because they do not know their 100%.  

 

The Gut and the TFCC

There is a high correlation between ulnar-sided wrist pain and stomach/gut/intestine weakness.  Data gathered based on Chinese Medicine reports and worth noting in your own experience.

 

Surgical treatment of TFCC tears 

Research article

Triangular Fibrocartilage Complex Injuries Treatment & Management 

 

Highlights from the article

History

It was only in 1981 that 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 the image below). The TFCC is the major ligamentous stabilizer of the distal radioulnar (DRU) joint and the ulnar carpus.

Functions of the TFCC:

  • It provides a continuous gliding surface across the entire distal face of the two forearm bones for flexion-extension and translational movements
  • It provides a flexible mechanism for stable rotational movements of the radiocarpal unit around the ulnar axis
  • It suspends the ulnar carpus from the dorsal ulnar face of the radius
  • It cushions the forces transmitted through the ulnocarpal axis
  • It solidly connects the ulnar axis to the volar carpus

Injuries to the TFCC present as ulnar-side wrist pain, frequently with clicking. Torn TFCCs constitute 35% of intra-articular fractures and 53% of extra-articular fractures. There is no correlation between ulnar styloid fractures and TFCC injuries. Patients with a torn TFCC display ulnar variance (radial shortening) that is on average 4.6 mm (vs 2.5 mm for no tear) and dorsal angulation of 24° (vs 12° for no tear).

Since 1777, when DeSault's original dissertation first described DRUJ injuries, much has been written about this joint and the TFCC. As Palmer pointed out,[1, 2, 3]  humans are differentiated from lower primates by a radiocarpal joint with a TFCC interposed between the ulna and carpus. [1]  This TFCC improves wrist functional stability and allows six degrees of freedom at the wrist—flexion, extension, supination, pronation, and radial and ulnar deviation.

As interest in the TFCC evolved, open repair techniques for this structure were devised. Small-joint arthroscopy provides the opportunity for new techniques in the debridement or repair of these structures.

Anatomy

As the name suggests, the TFCC is triangular in shape. Palmer found an inverse relation between ulnar variance and TFCC thickness of the TFCC: The TFCC is thicker in individuals who are ulnar minus. [4]Generally, the TFCC is 1-2 mm thick at its center. This may thicken to 5 mm where the TFCC inserts into the eccentric concavity of the ulnar head and projecting styloid.

 

The TFCC extends ulnarly to insert into the base of the ulnar styloid. Distally, it inserts into the lunate via the ulnolunate (UL) ligament and into the triquetrum via the ulnotriquetral (UT) ligament, the hamate, and the base of the fifth metacarpal. Radially, the TFCC arises from the ulnar margin of the lunate fossa of the radius.

Underneath the TFCC is the ulnar head. The seat, or the convex portion of the ulnar head, articulates with the sigmoid notch of the radius (see the image below). The cartilage-covered nonarticular pole of the ulnar head is deep to the articular disk.

The ulnocarpal portion of the TFCC is composed of the discus articularis and the UL and UT ligaments (referred to by some as the disk carpal ligaments). Embryologic studies have demonstrated that these ligaments arise from the disk and are critical to the carpal suspensory function of the TFCC.

The dorsal and palmar branches of the anterior interosseous artery and dorsal and palmar radiocarpal branches from the ulnar artery supply blood to the periphery of the TFCC. These vessels supply the TFCC in a radial fashion, with histologic sections demonstrating that the vessels penetrate the peripheral 10-40% of the disk. The central portion and radial attachment are avascular.

Mikic demonstrated that the percentage of the peripheral disk that is vascularized is reduced from one third in a young patient to one fourth in patients of advanced age. [5]

Because the periphery of the TFCC has a good blood supply, tears in this region can be repaired. By contrast, tears in the central avascular area must be debrided because they have no potential for healing.

>>Wendy notes: It has taken me 14 years to be able to confirm with great confidence that the central portion of the TFCC heals beautifully.

I have articulated a protocol for use as a guide to healing.

Take special note of the pronator stretch of the elbow and diet. Central tears have more problems with supination with load which require a different protocol than peripheral tears. 

We are here to help guide you and your patient along your path to full, 100% recovery.

The richly vascularized dorsal radioulnar (DRU) ligament and palmar radioulnar (PRU) ligament are composed of thick, longitudinally oriented collagen fiber bundles that blend in with the central avascular fibrocartilaginous portion.

When the TFCC is viewed during wrist arthroscopy, the styloid attachment appears folded. Some of the blood vessels to the TFCC enter between these folds. This fold, combined with the vascular hilum, is termed the ligamentum subcruentum, which actually is the confluence of the TFCC and the V-shaped ligament (disk ligament) as it extends from the hilar area of the styloid to its twin insertions on the lunate and triquetrum.

From a distal perspective, the TFCC has two distinct insertions into the ulna—a superficial portion and a deep portion. The superficial components, the DRU and PRU ligaments, insert into the base of the styloid. The deep portion, the ligamentum subcruentum, inserts into the fovea near the axis of forearm rotation.

A large controversy exists concerning the biomechanical changes of the TFCC during pronation and supination. A number of authors claim that the DRU ligament tightens during pronation and relaxes with supination; other authors claim the exact opposite.

Nakamura et al may have solved this question by using a custom-made surface coil allowing complete freedom of wrist motion. From magnetic resonance imaging (MRI) of the wrist in coronal and sagittal planes at maximal pronation and neutral and maximal supination, they showed that during pronation and supination, the TFCC twists at its origin. [6]  This should result in friction between the proximal side of the disk proper and the ulnar head during rotation. The friction may increase in ulnocarpal abutment syndrome because of ulnar variance, potentially explaining the degeneration seen in Palmer class 2 TFCC tears.

Pathophysiology

Palmer and Werner looked at the axial load distribution through the distal radius and ulna [7] and demonstrated that with normal axial loading, 20% of the force is transmitted through the ulna and 80% through the radius. Their data also illustrated that small changes in relative ulnar length can significantly alter load patterns across the wrist. For example, with a distal radius fracture that settles 2.5 mm, an increase in ulnar axial load of approximately 40% can be expected.

Palmer, Werner, Glisson, and Murphy demonstrated that the percentage of axial force transmitted through the ulna decreases by sequential removal of the horizontal portion of the TFCC. [4] This percentage decrease is accentuated with more positive ulnar variance.

In a cadaver study, Adams demonstrated that no significant kinematic or structural changes resulted from an excision that did not violate the peripheral 2 mm of the disk and that constituted less than two thirds of the disk area. [8]

TFCC tears are associated with a positive ulnar variance. Ulnar variance increases with pronation and grip and decreases with supination.

The floor of the extensor carpi ulnaris (ECU) tendon sheath broadly connects with the TFCC. After release of the TFCC from its distal ulna attachment, Tang demonstrated a 30% increase in ECU tendon excursion during wrist extension. [9] This suggests the following:

  • The TFCC is an important pulley for the ECU tendon
  • Disruption of the normal ECU excursion may contribute to abnormal loading and force transmission through the ulnar wrist and TFCC

Palmer classification for TFCC abnormalities

The Palmer classification divides TFCC abnormalities into two main classes, which are then further divided into several subtypes.

Palmer class 1 (traumatic) TFCC abnormalities are divided into the following subtypes:

  • A - Central perforation
  • B - Ulnar avulsion with or without distal ulnar fracture
  • C - Distal avulsion
  • D - Radial avulsion with or without sigmoid notch fracture

Palmer class 2 (degenerative [ulnocarpal abutment syndrome] stage) TFCC abnormalities are divided into the following subtypes:

  • 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 lunotriquetral (LT) ligament perforation
  • E - TFCC perforation with lunate and/or ulnar chondromalacia, LT ligament perforation, and ulnocarpal arthritis

In a small series, Nance et al described eight patients who were presumed to have solitary TFCC tears but were found on wrist arthroscopy to have a combination of 1A and 1B injuries. [10]  They suggested that this combined pattern, which is not currently categorized in the Palmer classification system and is not reliably diagnosed preoperatively, might usefully be considered a new subtype in this system.

Etiology

Causative conditions for TFCC injuries include the following:

  • Falls onto pronated hyperextended wrist
  • Power-drill injuries in which the drill binds and rotates the wrist instead of the bit
  • Distraction force applied to the volar forearm or wrist
  • Distal radius fractures

Epidemiology

Mikic looked at 180 wrist joints in 100 cadavers, ranging in age from fetuses to 94 years. [5] He demonstrated that degeneration of the TFCC begins in the third decade of life and progressively increases in frequency and severity in subsequent decades. After the fifth decade of life, he noted no normal-appearing TFCCs. Viegas and Ballantyne found similar results. [11]

Prognosis

Arthroscopic repair

A review by de Araujo et al of 17 patients after arthroscopic repair of Palmer class 1B tears, with an average patient age of 33 years, showed that at 8 months' follow-up, 16 patients (48%) were satisfied or very satisfied; one patient was not satisfied. At 16-24 months' follow-up, 70% of the patients were satisfied.[12]

Reiter et al performed a retrospective study of 46 patients who underwent arthroscopic repair of Palmer class IB tears to determine patients' functional and subjective outcomes, as well as whether clinical outcomes were related to ulnar length. Good-to-excellent results were achieved in 63% of the patients, including increased range of motion and grip strength and pain relief. Neutral or positive ulnar variance was not a contraindication for repair and did not necessitate simultaneous ulnar shortening. [13]

Sagerman and Short reviewed 12 patients after arthroscopic repair of Palmer class 1D tears, with an average follow-up of 17 months, and found good or excellent results in 67% of patients. [14]

Trumble et al reviewed 24 patients after arthroscopic repair of Palmer classes 1B, 1C, and 1D tears. The average patient age was 31 years. Treatment occurred within 4 months after injury, with a follow-up of 34 months. Postoperative range of motion was 89%, and grip strength was 85%. Thirteen of 19 patients returned to their original jobs or sports. Follow-up studies demonstrated that the TFCC was intact in 12 of 15 patients. [15]

Corso et al reviewed 44 patients (average age, 32.5 years) and 45 wrists with zone-specific repair and follow-up of 37 months and found excellent results in 29 patients, good results in 12, fair results in one, and poor results in three. [16]

In a study from 2001 through 2005 of 16 competitive athletes with wrist TFCC, McAdams et al found that arthroscopic debridement or repair of TFCC injury provided pain relief and allowed patients to return to play, with slower recovery in patients with concomitant ulnar-side wrist injuries. [8] .

Yao et al compared an all-arthroscopic TFCC repair technique with an outside-in technique in 10 matched pairs of fresh-frozen cadaveric wrists and found that the all-arthroscopic technique resulted in decreases in operating time, postoperative immobilizations, and irritation from suture knots below the skin. [17, 18]

In a study of 75 patients with TFCC repair by arthroscopic or open technique between 1997 and 2006, Anderson et al found that there was no statistical difference in clinical outcome for arthroscopic and open techniques for TFCC repair. They did note an increased rate of postoperative superficial ulnar pain in patients who underwent open repair (14/39 patients with open technique vs 8/36 patients with arthroscopy). Females had a higher rate of reoperation. [19]

In a cadaveric study comparing the biomechanical strength of knotless suture anchor repair and the traditional outside-in repair of peripheral TFCC tears, Desai et al concluded that the all-arthroscopic suture anchor TFCC repair was biomechanically stronger than the outside-in repair and that the former allowed repair of both superficial and deep layers of the articular disk directly to bone, thereby restoring native TFCC anatomy. [20]  They suggested that the absence of knots might prevent irritation to the surrounding soft tissues.

Arthroscopic debridement

Minami et al reviewed 16 patients (average age, 30 years) with a follow-up of 35 months. Palmer class 1 tears were found in 11 patients, and Palmer class 2 tears were found in five. Of the 16 patients, 13 returned to their previous jobs. Positive ulnar variance and LT tears were associated with a poor outcome; Palmer class 1 tears were associated with excellent results; and Palmer class 2 tears were associated with poor results. [21]

Westkaemper et al reviewed 28 patients (average age, 30 years) with a follow-up of 15.4 months. Excellent results were found in 13 patients, with good results in eight, fair results in two, and poor results in five. [22]

De Smet et al conducted a retrospective survey of 46 patients who underwent debridement with or without wafer distal ulna resection. [23]  Patients were sent a questionnaire on pain, disability, and time off from work. Mean scores on the Disabilities of the Arm, Shoulder, and Hand (DASH) scale decreased from 42 to 28. The pain was considered severe in 12 patients; 32 patients were satisfied. There were significant differences in the outcome between use of debridement only and use of debridement with wafer resection of the distal ulna.

Ulnar shortening

Minami and Kato reviewed 25 patients (average age, 32 years) with follow-up of 35 months. Ulnar variance averaged more than 3.5 mm. Ulnar-shortening osteotomies of 3 mm, fixed with a 6-hole 3.5-mm dynamic compression plate (DCP), were performed. Twenty-three patients also had arthroscopy. Palmer class 1 tears were found in 15 patients; only the flap was removed. Palmer class 2 tears were found in eight; no debridement was performed.

Complete relief or only occasional mild pain was found in 23 patients. Of the 25 patients, 23 returned to their original work. Osteotomies healed at an average of 7 weeks. This research suggests that ulnar shortening is indicated in both traumatic and degenerative tears associated with ulnar positive variance. [24]

Trumble et al reviewed 21 patients with treatment delays longer than 6 months and follow-up of 29 months. Palmer class 1 tears were repaired. Ulnar-shortening osteotomies of 2-3 mm fixed with 6-hole 3.5-mm DCPs were performed. Complete pain relief was found in 19 of 21 patients. Grip strength was 83%; range of motion was 81% of normal. Treatment delays longer than 6 months from the time of injury resulted in a higher recurrence of symptoms; in these situations, the authors recommended combining arthroscopic repair with ulnar shortening. [25]

Hulsizer et al reviewed 97 patients (average age, 34 years; average ulnar variance, 0.4 mm) with central or nondetached ulnar peripheral tears initially treated with debridement. Persistent pain more than 3 months after surgery was reported by 13 patients. A 2-mm ulnar-shortening osteotomy, fixed with a 6-hole 3.5-mm DCP, was performed on these 13 patients. Complete pain relief at 2.3-year follow-up was reported by 12 of the 13 patients. An ulnar-shortening osteotomy of 2 mm was recommended for patients in whom arthroscopic debridement failed. [26]

In a retrospective study involving 256 patients, Yamanaka et al compared preoperative and postoperative TFCC thickness and TFCC angle, using magnetic resonance imaging (MRI) to quantitatively evaluate the effect of ulnar-shortening osteotomy on disk regeneration and the suspension effect on the TFCC. [27]  They found that ulnar-shortening osteotomy yielded a high residual potential for regeneration in the disk proper. There was no correlation between disk regeneration or the suspension effect on the TFCC and the Mayo wrist score.

Seo et al assessed the results of arthroscopic peripheral repair (n=15) against those of arthroscopic debridement (n=16) for treatment of chronic unstable TFCC tears in 31 ulnar-positive patients undergoing ulnar-shortening osteotomy (minimum follow-up, 24 months). [28] Improvements were noted in both groups; however, grip strength, DASH, and Patient-Rated Wrist Evaluation (PRWE) scores were better in the repair group than in the debridement group. Recovery from DRUJ instability noted during preoperative evaluation was superior in the repair group as well.

Physical Exam

The history of triangular fibrocartilage complex (TFCC) injuries includes ulnar-side wrist pain (frequently accompanied by clicking), a fall or trauma, and/or mechanical symptoms that improve with rest and worsen with activity.

In the physical examination, it is important to look for the following:

  • Painful grinding or clicking with wrist range of motion (ROM)
  • Weakness
  • Ulnar deviation of the wrist with the forearm in neutral produces ulnar wrist pain and occasional clicking (perform a TFCC compression test)
  • Instability of the distal radioulnar joint (DRUJ) joint with shucking the distal radius and ulna between the examiner's fingers (perform a DRUJ stress test; always compare this with the opposite wrist)
  • Piano key sign, which is a prominent and ballottable distal ulna with full pronation of the forearm
  • Ulnar carpal sag
  • Lunotriquetral (LT) interval tenderness
  • Positive LT ballottement or shuck test
  • Extensor carpi ulnaris (ECU) tendon subluxation

Work Up

Imaging Studies

Plain radiography

Obtain neutral forearm rotation posteroanterior (PA) and lateral x-rays of the wrist to allow assessment of ulnar variance and to assess for chondromalacia of the lunate or ulnar head, degenerative joint disease of the distal radioulnar joint (DRUJ), lunotriquetral (LT) or scapholunate (SL) instability, dorsiflexed intercalated segment instability (DISI), or volarflexed intercalated segment instability (VISI).

Wrist arthrography

The accuracy and diagnostic capability of triple-injection wrist arthrograms have been challenged over the past decade. The test is not specific, with a high incidence of findings on the contralateral asymptomatic side. Wrist arthrography has poor diagnostic agreement with chronic wrist pain.

Positive wrist arthrograms are obtained in 27% of asymptomatic adults. Palmer class 1B tears have positive arthrograms with a DRUJ injection but not with a radiocarpal injection. Palmer class 1C tears have variable findings. Palmer class 1D tears usually have positive arthrograms.

Magnetic resonance imaging

Magnetic resonance imaging (MRI) can predict triangular fibrocartilage complex (TFCC) lesions with 0.8 sensitivity and 0.7 specificity using a dedicated wrist coil. [29, 30, 31] Fat-suppression MRI scans best exhibit the complex structure of the TFCC.

A prospective study by Lee et al suggested that the addition of axial traction during wrist magnetic resonance arthrography may significantly improve the ability of this modality to detect and visualize tears of the TFCC. [32]  A study by Thomsen et al found postcontrast 3T indirect magnetic resonance arthrography to have better diagnostic performance than precontrast imaging for the overall detection of class 1B TFCC tears. [33]

Procedures

Wrist arthroscopy has been the criterion standard for diagnosis of these injuries; it can be a diagnostic tool or a therapeutic tool. When compared with other imaging studies, wrist arthroscopy has typically been found to be more accurate. It also allows assessment of the size of the tear, determination of whether an unstable flap is present, and detection of associated synovitis and chondral and ligamentous lesions. However, one study suggested, on the basis of relatively low interrater correlation, that the status of arthroscopy as the reference standard should be reconsidered. [34]  

With the trampoline test, normally a probe should bounce off of the TFCC. If a probe sinks into the TFCC as if it is on a feather bed, a tear is usually present.

Wrist arthroscopy is used in the diagnosis of TFCC tears associated with distal radius fractures. Richards examined 118 fractures [35] ; these fractures had wrist arthroscopy that required reduction and fixation because of a failure to obtain or maintain a reduction.

The Weight Bearing Test as developed by Wendy Medeiros, OT, CHT (retired 2014) has proven to provide an accurate, and reliable diagnosis for TFCC tears.  

Treatment

If a congruent reduction cannot be achieved or if the dorsal instability is unstable in 30° of supination, then arthroscopic evaluation of the triangular fibrocartilage complex (TFCC) is recommended with repair as needed.

As discussed in the video and paper above, peripheral AND central tears of the TFCC can fully heal without surgery when the recommended healing protocols are followed as determined by the severity of the injury.  Over 40,000 patient cases are supported by this research. 

Repairing TFCC tears is contraindicated in the presence of infection or degeneration. Palmer class 2 degenerative TFCC tears represent a pathologic progression of disease associated with ulnar impaction syndrome.

Degeneration of the TFCC is found with repetitive pronation and axial grip loading in association with positive ulnar variance and impaction between the ulnar head and the proximal pole of the lunate. Treatment of degenerative TFCC tears associated with ulnar impaction syndrome consists of nonoperative treatment first with immobilization, avoidance of aggravating activities, and nonsteroidal anti-inflammatory drugs (NSAIDs).

Palmer class 2A and 2B lesions that fail to respond to conservative treatment are treated with gentle debridement. If the patient is ulnar-positive and symptomatic, a formal ulnar shortening is considered. An arthroscopic wafer is contraindicated, in that this would require resection of intact TFCC to perform the procedure or require performing the procedure entirely through the distal radioulnar joint (DRUJ) portals.

The surgical indications for an arthroscopic wafer procedure are a Palmer class 2C or 2D lesion in a positive ulnar variance of not more than 2 mm without evidence of lunotriquetral (LT) instability. If LT instability is present, this is addressed with formal ulnar shortening in an attempt to tighten the ulnocarpal ligaments and decrease the motion between the lunate and triquetrum.

For patients with a positive ulnar variance of more than 2 mm, formal ulnar shortening is performed. For patients with neutral or negative ulnar variance and a Palmer class 2C lesion, an arthroscopic debridement is performed. Palmer class 2E lesions respond unpredictably to arthroscopic debridement. They are usually treated with a salvage procedure such as a limited ulnar head resection, a Sauve-Kapandji procedure, or a Darrach procedure that addresses the DRUJ and lunotriquetral (LT) joint pathology.

Lee Master et al undertook a study to determine the accuracy of the wrist insufflation test on the basis of mean radiocarpal and midcarpal joint space volumes in 29 patients who underwent three- or four-portal radiocarpal and radial midcarpal portal insufflation before wrist arthroscopy. [36]  They concluded that the test allowed detection of complete SL interosseous ligament and TFCC tears and complete SL interosseous ligament and LT interosseous ligament tears.

Medical Therapy

Initial treatment of both symptomatic degenerative and traumatic TFCC 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 study of 133 patients, [37] 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 positive ulnar variance, two thirds of patients worsened over time both symptomatically and radiologically

Over a 3-year period, Lee et al treated 117 patients with TFCC tears who did not have DRUJ instability. [38] They found nonsurgical treatment to be moderately successful in treating these patients and recommended a minimum of 6 months nonsurgical treatment as the first-line treatment for this injury.

Acute isolated TFCC disruption with dislocation or instability of 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. 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 range of motion, 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 Options

If the DRUJ joint remains unstable, open reduction is required to remove interposed structures. When instability persists with forearm range of motion, 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 fracture-dislocations. Anatomic reduction of these fractures often stabilizes the joint. When fixation of these fractures does not stabilize the joint, stabilization can be obtained with either (1) long arm casting in a reduced position, open reduction, and TFCC repair or (2) supplemental K-wire fixation.

Rettig and Raskin 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 (ORIF) of the radial shaft fracture. [39]

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 noted good results in 18 of 19 patients with radial head fracture and pain at the DRUJ who were treated with ORIF of the radial head.[40]

Postoperative Care

After surgery, all patients are immobilized immediately. 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.

Surgical complications

Complications include the following:

  • Infection
  • Stiffness
  • Repair failure
  • Wrist arthroscopy complications
  • Continued pain
  • Decreased strength
  • Hardware failure
  • Nonunion (in cases of nonunion, perform an ulnar-shortening osteotomy)

REFERENCES

  1. Palmer AK, Werner FW. The triangular fibrocartilage complex of the wrist--anatomy and function. J Hand Surg Am. 1981 Mar. 6 (2):153-62. 

  2. Palmer AK. Triangular fibrocartilage complex lesions: a classification. J Hand Surg Am. 1989 Jul. 14 (4):594-606. 

  3. Palmer AK, Glisson RR, Werner FW. Relationship between ulnar variance and triangular fibrocartilage complex thickness. J Hand Surg Am. 1984 Sep. 9 (5):681-2. 

  4. Palmer AK, Werner FW, Glisson RR, Murphy DJ. Partial excision of the triangular fibrocartilage complex. J Hand Surg Am. 1988 May. 13 (3):391-4.

  5. Mikić ZD. Age changes in the triangular fibrocartilage of the wrist joint. J Anat. 1978 Jun. 126 (Pt 2):367-84.

  6. Nakamura T, Nakao Y, Ikegami H, Sato K, Takayama S. Open repair of the ulnar disruption of the triangular fibrocartilage complex with double three-dimensional mattress suturing technique. Tech Hand Up Extrem Surg. 2004 Jun. 8 (2):116-23.

  7. Palmer AK, Werner FW. Biomechanics of the distal radioulnar joint. Clin Orthop Relat Res. 1984 Jul-Aug. 26-35.

  8. Adams BD. Partial excision of the triangular fibrocartilage complex articular disk: a biomechanical study. J Hand Surg Am. 1993 Mar. 18 (2):334-40. 

  9. Tang JB, Ryu J, Kish V. The triangular fibrocartilage complex: an important component of the pulley for the ulnar wrist extensor. J Hand Surg Am. 1998 Nov. 23 (6):986-91. 

  10. Nance E, Ayalon O, Yang S. Combined Palmer Type 1A and 1B Traumatic Lesions of the Triangular Fibrocartilage Complex A New Category. Bull Hosp Jt Dis (2013). 2016 Jun. 74 (2):119-23. 

  11. Viegas SF, Ballantyne G. Attritional lesions of the wrist joint. J Hand Surg Am. 1987 Nov. 12 (6):1025-9.

  12. de Araujo W, Poehling GG, Kuzma GR. New Tuohy needle technique for triangular fibrocartilage complex repair: preliminary studies. Arthroscopy. 1996 Dec. 12 (6):699-703.

  13. Reiter A, Wolf MB, Schmid U, Frigge A, Dreyhaupt J, Hahn P, et al. Arthroscopic repair of Palmer 1B triangular fibrocartilage complex tears. Arthroscopy. 2008 Nov. 24 (11):1244-50. 

  14. Sagerman SD, Short W. Arthroscopic repair of radial-sided triangular fibrocartilage complex tears. Arthroscopy. 1996 Jun. 12 (3):339-42.

  15. Trumble TE, Gilbert M, Vedder N. Isolated tears of the triangular fibrocartilage: management by early arthroscopic repair. J Hand Surg Am. 1997 Jan. 22 (1):57-65. 

  16. Corso SJ, Savoie FH, Geissler WB, Whipple TL, Jiminez W, Jenkins N. Arthroscopic repair of peripheral avulsions of the triangular fibrocartilage complex of the wrist: a multicenter study. Arthroscopy. 1997 Feb. 13 (1):78-84. 

  17. Lucky SD, Poehling GG. Arthroscopic treatment of triangular fibrocartilage complex tears. Tech Hand Up Extrem Surg. 1997 Dec. 1 (4):228-36. 

  18. Nakamura T, Yabe Y, Horiuchi Y. Fat suppression magnetic resonance imaging of the triangular fibrocartilage complex. Comparison with spin echo, gradient echo pulse sequences and histology. J Hand Surg Br. 1999 Feb. 24 (1):22-6. 

  19. Skie MC, Mekhail AO, Deitrich DR, Ebraheim NE. Operative technique for inside-out repair of the triangular fibrocartilage complex. J Hand Surg Am. 1997 Sep. 22 (5):814-7. 

  20. Desai MJ, Hutton WC, Jarrett CD. Arthroscopic repair of triangular fibrocartilage tears: a biomechanical comparison of a knotless suture anchor and the traditional outside-in repairs. J Hand Surg Am. 2013 Nov. 38 (11):2193-7. 

  21. Minami A, Ishikawa J, Suenaga N, Kasashima T. Clinical results of treatment of triangular fibrocartilage complex tears by arthroscopic debridement. J Hand Surg Am. 1996 May. 21 (3):406-11. 

  22. Westkaemper JG, Mitsionis G, Giannakopoulos PN, Sotereanos DG. Wrist arthroscopy for the treatment of ligament and triangular fibrocartilage complex injuries. Arthroscopy. 1998 Jul-Aug. 14 (5):479-83. 

  23. De Smet L, Van Nuffel M, Koorneef P, Degreef I. Arthroscopic debridement with and without distal ulnar resection in the treatment of triangular fibrocartilage complex tears. Acta Orthop Belg. 2014 Mar. 80 (1):112-5. 

  24. Minami A, Kato H. Ulnar shortening for triangular fibrocartilage complex tears associated with ulnar positive variance. J Hand Surg Am. 1998 Sep. 23 (5):904-8. 

  25. Trumble TE, Gilbert M, Vedder N. Ulnar shortening combined with arthroscopic repairs in the delayed management of triangular fibrocartilage complex tears. J Hand Surg Am. 1997 Sep. 22 (5):807-13. 

  26. Hulsizer D, Weiss AP, Akelman E. Ulna-shortening osteotomy after failed arthroscopic debridement of the triangular fibrocartilage complex. J Hand Surg Am. 1997 Jul. 22 (4):694-8. 

  27. Yamanaka Y, Nakamura T, Sato K, Toyama Y. How does ulnar shortening osteotomy influence morphologic changes in the triangular fibrocartilage complex?. Clin Orthop Relat Res. 2014 Nov. 472 (11):3489-94.

  28. Seo JB, Kim JP, Yi HS, Park KH. The Outcomes of Arthroscopic Repair Versus Debridement for Chronic Unstable Triangular Fibrocartilage Complex Tears in Patients Undergoing Ulnar-Shortening Osteotomy. J Hand Surg Am. 2016 May. 41 (5):615-23.

  29. Yoshioka H, Tanaka T, Ueno T, Carrino JA, Winalski CS, Aliabadi P, et al. Study of ulnar variance with high-resolution MRI: correlation with triangular fibrocartilage complex and cartilage of ulnar side of wrist. J Magn Reson Imaging. 2007 Sep. 26 (3):714-9. 

  30. Zlatkin MB, Rosner J. MR imaging of ligaments and triangular fibrocartilage complex of the wrist. Radiol Clin North Am. 2006 Jul. 44 (4):595-623, ix.

  31. Iordache SD, Rowan R, Garvin GJ, Osman S, Grewal R, Faber KJ. Prevalence of triangular fibrocartilage complex abnormalities on MRI scans of asymptomatic wrists. J Hand Surg Am. 2012 Jan. 37 (1):98-103. 

  32. Lee RK, Griffith JF, Ng AW, Nung RC, Yeung DK. Wrist Traction During MR Arthrography Improves Detection of Triangular Fibrocartilage Complex and Intrinsic Ligament Tears and Visibility of Articular Cartilage. AJR Am J Roentgenol. 2016 Jan. 206 (1):155-61. 

  33. Thomsen NOB, Besjakov J, Björkman A. Accuracy of Pre- and Postcontrast, 3 T Indirect MR Arthrography Compared with Wrist Arthroscopy in the Diagnosis of Wrist Ligament Injuries. J Wrist Surg. 2018 Nov. 7 (5):382-388. 

  34. Park A, Lutsky K, Matzon J, Leinberry C, Chapman T, Beredjiklian PK. An Evaluation of the Reliability of Wrist Arthroscopy in the Assessment of Tears of the Triangular Fibrocartilage Complex. J Hand Surg Am. 2018 Jun. 43 (6):545-549. 

  35. Richards RS, Bennett JD, Roth JH, Milne K Jr. Arthroscopic diagnosis of intra-articular soft tissue injuries associated with distal radial fractures. J Hand Surg Am. 1997 Sep. 22 (5):772-6. 

  36. Lee Master D, Yao J. The wrist insufflation test: a confirmatory test for detecting intercarpal ligament and triangular fibrocartilage complex tears. Arthroscopy. 2014 Apr. 30 (4):451-5. 

  37. Osterman AL, Terrill RG. Arthroscopic treatment of TFCC lesions. Hand Clin. 1991 May. 7 (2):277-81. 

  38. Lee JK, Hwang JY, Lee SY, Kwon BC. What is the Natural History of the Triangular Fibrocartilage Complex Tear Without Distal Radioulnar Joint Instability?. Clin Orthop Relat Res. 2018 Oct 22. 

  39. Rettig ME, Raskin KB. Galeazzi fracture-dislocation: a new treatment-oriented classification. J Hand Surg Am. 2001 Mar. 26 (2):228-35. 

  40. Geel CW, Palmer AK. Radial head fractures and their effect on the distal radioulnar joint. A rationale for treatment. Clin Orthop Relat Res. 1992 Feb. 79-84. 

  41. McAdams TR, Swan J, Yao J. Arthroscopic treatment of triangular fibrocartilage wrist injuries in the athlete. Am J Sports Med. 2009 Feb. 37 (2):291-7. 

  42. Yao J, Dantuluri P, Osterman AL. A novel technique of all-inside arthroscopic triangular fibrocartilage complex repair. Arthroscopy. 2007 Dec. 23 (12):1357.e1-4. 

  43. Yao J. All-arthroscopic triangular fibrocartilage complex repair: safety and biomechanical comparison with a traditional outside-in technique in cadavers. J Hand Surg Am. 2009 Apr. 34 (4):671-6. 

  44. Anderson ML, Larson AN, Moran SL, Cooney WP, Amrami KK, Berger RA. Clinical comparison of arthroscopic versus open repair of triangular fibrocartilage complex tears. J Hand Surg Am. 2008 May-Jun. 33 (5):675-82. 

  45. Andersson JK, Åhlén M, Andernord D. Open versus arthroscopic repair of the triangular fibrocartilage complex: a systematic review. J Exp Orthop. 2018 Mar 13. 5 (1):6.

  46. Varitimidis SE, Basdekis GK, Dailiana ZH, Hantes ME, Bargiotas K, Malizos K. Treatment of intra-articular fractures of the distal radius: fluoroscopic or arthroscopic reduction?. J Bone Joint Surg Br. 2008 Jun. 90 (6):778-85. 

  47. Wysocki RW, Richard MJ, Crowe MM, Leversedge FJ, Ruch DS. Arthroscopic treatment of peripheral triangular fibrocartilage complex tears with the deep fibers intact. J Hand Surg Am. 2012 Mar. 37 (3):509-16. 

  48. Geissler WB. Arthroscopic knotless peripheral triangular fibrocartilage repair. J Hand Surg Am. 2012 Feb. 37 (2):350-5. 

  49. Chen AC, Hsu KY, Chang CH, Chan YS. Arthroscopic suture repair of peripheral tears of triangular fibrocartilage complex using a volar portal. Arthroscopy. 2005 Nov. 21 (11):1406. 

  50. Wnorowski DC, Palmer AK, Werner FW, Fortino MD. Anatomic and biomechanical analysis of the arthroscopic wafer procedure. Arthroscopy. 1992. 8 (2):204-12. 

  51. Henry MH. Management of acute triangular fibrocartilage complex injury of the wrist. J Am Acad Orthop Surg. 2008 Jun. 16 (6):320-9.