TFCC injuries

Triangular Fibrocartilage Complex (TFCC) Disorders
(Acute and chronic)

Arpit Jariwala - Upper Limb Fellow - Wrightington

Mike Hayton - Consultant Hand and Wrist Surgeon - Wrightington

Other names
Ulnar sided wrist sprain

What is the TFCC?
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. (Figure 1)

What is its role?
Its main function is to stabilise the joint (distal radio-ulnar 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?
TFCC can be mainly affected by two mechanisms either by injury (traumatic tear) or by wear and tear over time (degenerative changes). Fall outstretched hand or sudden forceful rotation of the forearm such as when using a power drill can lead to traumatic TFCC tears.
High-demand athletes such as tennis players or gymnasts (including children and teenagers) are at greatest risk for TFCC injuries.
In addition, displaced distal radius fractures may be associated with a pull-off fracture of the TFCC from the ulna tip.
Excessive loading of the wrist joint over a long period of time can cause degenerative TFCC tears.

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.
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 iimaging modaility to identify TFCC problems. It helps identify the tears and their location. Radiographs of the wrist are helpful following acute injury where there may be a pull-off fracture of the tip of the distal ulna indicating a TFCC injury (Figure 2).
Increasingly arthroscopy (keyhole surgery) of the wrist is being utilised to identify the problem and in addition, giving the option of its management at the same instance (Figure 3).

Non-operative treatment
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 a period of four-six weeks with the aim of helping the tear to heal and/or the surrounding soft tissues to scar. Usually anti-inflammatories are prescribed to help with pain management. A local anaesthesic 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 displaced wrist fracture.
The operative intervention is usually arthroscopic which primarily involves repair of the TFCC tear done through the arthroscopy (key hole surgery) although open repair may also be undertaken to address complex TFCC tears.

In this video we see a normal TFCC.

In this video we see a small tear

Here we see a large central tear with ragged edges. The ulnar head can be seen through the defect.

Another example of a central tear. In this case I have begun to  shave away the ragged edges to a stable rim.

Cases where the tear is in an area with poor blood supply or in patients with degenerate tears, a trimming (debridement) of the tear may be required.

 

 And in this example the edges are very smooth. Again the ulnar head can be seen through the defect.

 Sometimes the TFCC tear is suitable for repair. Particularly if it has been pulled off the ulnar fovea. Inb this video I reattach the TFCC arthroscopically

 

 
In cases of gross instability of the DRUJ soft tissue reinforcement (ligament reconstruction) may be necessary.
Pull-off fracture of the tip of ulna associated with displaced radius fractures are fixed at the same setting with the radius.

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).