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Triangular Fibrocartilaginous Injuries of the Hand

Doug Charters, Mark Demme, Krista Derry, Lindsay Desaulniers

Triangular Fibrocartilaginous Complex (TFCC)

The nonmuscular structure

supporting the distal radioulnar joint

of the wrist carpals

It is referred to as the meniscus

Cushions the ulna against the Allows axial loading of the

ulnar aspect of the forearm carpus itself

Stabilizes the ulnar side of the

Anatomy of the TFCC

Connected to the carpus by

the ulnolunate ligament

Comprised of the triangular

fibrocartilage, ulnar meniscus homologue, ulnar collateral ligament, dorsal and volar radioulnar ligaments, ulnolunate and ulnotriquetral ligamnets, and extensor carpi ulnaris tendon sheath

Triangular Fibrocartilage Dorsal and Volar Radioulnar Ligaments

Subjective Assessment

Swelling and tenderness on the medial aspect of the wrist

Discomfort with ulnar deviation as it compresses the TFCC

(this distinguishes TFCC injuries from other wrist injuries)

Pain is aggravated by rotation, ulnar deviation and

compression

Crepitous may or may not be present

Tears are often tender just distal to ulna styloid process

Mechanisms of Injury

Hyperextension of the wrist Acute or chronic trauma

Fall onto an outstretched arm/hand Racquet sports Golf/baseball swing Weightlifting Use of powertools

Hyperpronation of the wrist Causes a dislocation or subluxation of the ulna dorsally Hypersupination of the wrist Causes a dislocation or subluxation of the ulna volarly

Objective Assessment and Diagnosis

Signs of a TFCC injury include:

Decreased strength Pain with range of motion and gripping

Palpable tenderness to touch the ulnar side of the wrist Tests are needed to make a more conclusive diagnosis as the

majority of symptoms for a TFCC injury can also signify other wrist injuries

Objective Assessment

Compression Test The examiner places his/her thumb on the ulnar side of the wrist with the patients forearm in neutral and check for pain and any clicking or crepitus Supination Lift Test The patient places his/her palms on the undersurface of a table and attempts to lift. Onset of pain upon stabilizing body weight indicates a positive supination Lift test. Piano Key's Test Patient sits with both hands in pronation. Examiner stabilizes the patients arm with one hand so his or her finger can push down on the distal ulna. The other hand supports the patients hand. Positive test produces pain and tenderness and indicates DRUJ instability.

Watson Test

Assesses the scapholunate ligament stability by palpating the scaphoid anteriorly and posteriorly on the distal aspect the examiner moves the wrist from ulnar to radial deviation. Test is positive if there is pain or palpable displacement

Lunotriquetral Ballotment Test Integrity of the lunotriquetral ligament is tested by immobilizing the lunate and moving the triquetrum and pisiform up and down on the lunate. Test is positive if pain is produced.

Watson Test

Lunotriquetral Ballotment Test

Wrist Arthroscopy

Non surgical tests are used

primarily to narrow down the possibility of a TFCC injury but an accurate diagnosis in almost all cases needs to be confirmed by performing a wrist arthroscopy allows a physician to view inside of the wrist joint through a thin arthroscope. Arthroscopes can be used to make a diagnosis as well as providing therapeutic treatment.

This is a surgical procedure that

Palmar Classifications

Class 1 ­ Traumatic Type 1A ­ Avascular articular disc

A tear of the central portion of the TFCC The most common type of tear

Type 1B ­ Base of the styloid Avulsion of the TFCC from its attachment to the ulnar styloid Type 1C ­ Carpal detachment Tears involve the ulnotriquetral or ulnolunate ligaments Peripheral tear adjacent to the lunate and/or triquetrum Rare, high energy injuries Type 1D ­ Detachment from radius Tears involve the another avascular area The attachments of the TFCC are avulsed from the radius

Type 1A Injury ­ TFCC Tear

Palmar Classifications Continued

Class 2 ­ Atraumatic or Degenerative Type 2A

Thinning of the articular disc without frank perforation

Type 2B Tears involve the same thinning with chondromalacia of the lunate or ulna Type 2C Lesions involve a central perforation of the disc in addition to chondromalacia Type 2D Involve frank perforation, chondromalacia, and lunotriquetral ligament disruption Type 2E Same as Type 2D but also includes ulnocarpal arthritis

Treatment

Class 1 Begin with immobilization in acute period If immobilization fails surgery is the option Type 1A ­ arthroscopic debridement because it is avascular and will not heal Type 1B and C ­ an open or arthroscopic repair because it is a favourable environment for healing due to its vascularization Type 1D ­ debridement of the central portion of the radial attachment

Class 2 Type 2A and B ­ these injuries are viewed as ulnar impaction injuries and are therefore treated with ulnar shortening to decrease the load Is beginning to be treated as Type 2C Type 2C ­ ulnar shortening or a "wafer procedure" Type 2D ­ if there is no instability then the ligament can be debrided and an arthroscopic wafer resection can be performed If instability exists formal ulnar shortening should be performed Type 2E ­ ulnar resection

Surgical Intervention

Wafer Procedure Arthroscopic Repair

Role of the Kinesiologist

Subjective and objective assessment working with a

physiotherapist

Exercise progression for rehabilitation post surgery

Range of motion exercises (unweighted)

Flexibility

Isotonic

Strength

Functional

Exercises for Rehabilitation

Wrist range of motion

Flexion Extension Ulnar and radial deviation

Wrist Stretching

Flexion and extension Forearm pronation and

supination

Strengthening Exercises

Wrist flexion and extension Grip strengthening

QUESTION 1

What does TFCC Stand for

A) Triple Fibrous Cartilage Complex B) Triangular Fibrocartilaginous Complex C) Trigger Finger Carpal Contusion

D) Triangular Flexor Carpi Compression

Correct Answer is...

B ­ Triangular Fibrocartilaginous Complex

Question 2

What are the two classes of TFCC injuries according to the

Palmar classifiction system?

A) Traumatic and Chronic B) Treatable and Degenerative C) Traumatic and Atraumatic D) Treatable and Untreatable

Correct Answer is...

C ­ Traumatic and Atraumatic

Question 3

Which of the following symptoms distinguishes TFCC injuries

from other injuries?

A) Crepitous B) Swelling and tenderness on the medial aspect of wirst C) Pain with rotation D) Discomfort with ulnar deviation

Correct Answer is...

D ­ Discomfort with ulnar deviation

References

Ahn, A. K., Chang, D., & Plate, A. M. (2006). Triangular fibrocartilage complex tears: A review. Bulletin of the NYU Hospital for Joint Diseases, 64(3-4), 114-118

Higgins, R., English, B. & Brukner, P., (2006) Essential Sports Medicine. Malden, Mass. : Blackwell Publishing Oatis, C. A. (2004). Kinesiology: The Mechanics & Pathomechanics of Human Movement . Philadelphia, Pennsylvania: Lippincott Williams & Wilkins.

Anderson, M. K., Parr, G. P., & Hall, S. (2009). Foundations of Athletic Training (Fourth Edition ed.). Baltimore, Maryland, USA: Lippincott Williams & Wilkins, a Wolters Kluwer business. Houglum, P. A. (2005). Therapeutic Exercises for Musculoskeletal Injuries (2nd Edition ed.). Champaign , IL, USA: Human Kinetics. University of Michigan, Triangular Fibrocartilage Complex (TFCC) Injuries, retrieved Oct 21, 2009 from: http://www.med.umich.edu/1libr/sma/sma_trifibcc_sma.htm Zachee, B., De Smet, L., & Fabry, G. (1992). Lesions of the triangular fibrocartilaginous complex. Acta Orthopaedica Belgica, 58(4), 429-435.

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Triangular Fibrocartilaginous

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