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Triangular fibrocartilage complex (TFCC) injuries of the wrist affect the ulnar (little finger) side of the wrist. Mild injuries of the triangular fibrocartilage complex may be referred to as a wrist sprain. As the name suggests, the soft tissues of the wrist are complex. They work together to stabilise the very mobile wrist joint. Disruption of this area through injury or degeneration can cause more than just a wrist sprain. A TFCC injury can be a very disabling wrist condition.

The TFCC suspends the ends of the radius and ulna bones over the wrist. It is triangular in shape and made up of several ligaments and cartilage. The TFCC makes it possible for the wrist to move in six different directions (bending, straightening, twisting, and side-to-side).The entire TFCC sits between the ulna and two carpal bones (the lunate and the triquetrum). The TFCC inserts into the lunate and triquetrum via the ulnolunate and ulnotriquetral ligaments. It stabilises the distal radioulnar joint while improving the range of motion and gliding action within the wrist.

High-demand athletes such as tennis players or gymnasts (including children and teens) are at greatest risk for TFCC injuries. TFCC injuries in children and adolescents occur more often after an ulnar styloid fracture that does not heal.  Power drill injuries can also cause TFCC rupture when the drill binds and the wrist rotates instead of the drill bit. TFCC tears can also occur with degenerative changes.  Repetitive pronation (palm down position) and gripping with load or force through the wrist are risk factors for tissue degeneration.  Degenerative changes in the TFCC structure also increase in frequency and severity as we get older. Thinning soft tissue structures can result in a TFCC tear with minor force or minimal trauma.

 

Symptoms

Wrist pain along the ulnar (little finger) side is the main symptom. Some patients report pain throughout the entire wrist area. It cannot be pinpointed to one area.  The pain is made worse by any activity or position that requires forearm rotation and movement in the ulnar direction. This includes simple activities like turning a doorknob or key in the door, using a can opener, or lifting a heavy pan or bottle of milk with one hand. Other symptoms include swelling, clicking, snapping, or crackling (crepitus), and weakness. Some patients report a feeling of instability – like the wrist is going to give out on them. You may feel as if something is catching inside the joint. There is usually tenderness along the ulnar side of the wrist. If a fracture at the distal end of the ulna bone (at the wrist) is present along with soft tissue instability, then forearm rotation may be limited. The direction of limitation (palm up or palm down) depends on which direction the ulna dislocates.

MRI and wrist arthroscopy are the best ways to accurately assess the severity of damage of the TFCC injury. At wrist arthroscopy the surgeon looks for other associated injuries of ligaments and cartilage. The surgeon performs the wrist arthroscopy by inserting a long thin probe into the joint. A tiny camera on the end of the instrument allows the surgeon to look directly at the ligaments. 

 

Treatment

If the wrist is still stable, then conservative (nonoperative) care is advised. You may be given a temporary splint to wear for four to six weeks. The splint will hold your wrist still and allow scar tissue to help heal it.

Anti-inflammatory drugs and physiotherapy may be prescribed.

You may benefit from one or two steroid injections spaced a part by several weeks.  If the wrist is unstable but you do not want surgery, then the surgeon may put a cast on your wrist and forearm. It may be possible to use a splint for six weeks (instead of casting) and then start physiotherapy.

Surgery

Surgical treatment is based on the specific injury present. Instability as a result of complete ligamentous ruptures, especially with bone fracture, requires surgery as soon as possible.  The outside perimeter of the TFCC has a good blood supply. Tears in this area can be repaired. But there is no potential for healing when tears occur in the central area where there is no blood supply. Arthroscopic debridement (smoothing or shaving) of the damaged tissue is then required. 

Your surgeon may wish to perform an open repair of TFCC injury.  Although they are few, there are some complex tears that require open repair. Open repair means the surgeon makes an incision and opens the tissues to perform the operation. This gives the surgeon a better view and better access of the area. 

The specific procedure depends on the tissues injured and the extent of the injury, e.g. detachment of the radioulnar ligaments usually requires open repair. Instability of the distal radioulnar joint may require the use of wires to hold the area together until healing occurs. 

In other cases, surgery has been delayed long enough that the torn ligament has retracted (pulled back) so far that direct repair cannot be done. In these cases, a tendon graft may be needed to help strengthen the repair.

Chronic and degenerative TFCC may require a different surgical approach. Debridement is not as successful with this group as it is with acute TFCC injuries. Sometimes it is necessary to shorten the ulnar bone at the wrist to obtain pain relief. There are two procedures used to shorten the ulna and unload the ulnocarpal joint. These are the ulnar (diaphyseal) shortening method and the distal ulnar head shortening osteotomy (Feldon wafer method). If lunate-triquetrum instability is present, ulnar shortening can be done to tighten the ulnocarpal ligaments and decrease the motion between the lunate and triquetrum.  When making the decision as to which procedure, the surgeon weighs the amount of shortening needed and the conformation of the distal radioulnar joint - which will affect the joint loading. Diaphyseal Shortening method (using internal fixation - plate/screws) - higher complication rate (delayed union, nonunion, hardware removal).

Distal ulnar head shortening osteotomy (i.e. Feldon wafer method) arthroscopic or open method (only 2-3mm of shortening) – less invasive and equal relief to diaphyseal shortening.

After Surgery

Your wrist will be immobilised in a bulky dressing or cast. The type of immobilising device used and the position your wrist is placed in depends on the type of surgery you had. Motion exercises are usually started five to seven days after the operation.

Pain relief, improved motion, and increased function are the main goals of surgery for most patients. The surgeon is also interested in restoring wrist stability and the load bearing function of the wrist.

After the initial soreness from the surgery is gone, you should experience a significant decrease in pain, many patients report being pain free.

The follow-up plan after surgery may vary depending on the type of procedure used by your surgeon. Some patients to return to full, unrestricted activity as early as six weeks post-op. One week after surgery, the splint will be replaced with a fiberglass type cast (still in a supinated position). The elbow is left free to move fully. The cast will be removed six weeks after the operation. Cast removal is followed by physiotherapy for six to eight weeks.  This will help you regain full joint motion, strength, and normal movement patterns. Some patients have difficulty regaining pinch and grip strength.  The specialist hand therapist’s goal is to restore full motion, strength, and function. The rehab program will be geared toward your needs at home, work, and leisure. Many patients are able to return to work with no restrictions.