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Triangular Fibrocartilage Complex Injuries Treatment & Management

  • Author: James R Verheyden, MD; Chief Editor: Harris Gellman, MD  more...
 
Updated: Nov 17, 2014
 

Medical Therapy

Initial treatment of both symptomatic degenerative and traumatic triangular fibrocartilage complex (TFCC) tears is 8-12 weeks of conservative therapy consisting of the following:

  • Nonsteroidal anti-inflammatory drugs (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,[15] 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 ulnar-positive variance, two thirds of patients worsened over time both symptomatically and radiologically

Palmer classification for TFCC abnormalities

Class 1: Traumatic

  • A - Central perforation (see the first, second, and third images below)
  • B - Ulnar avulsion (see the fourth, fifth, and sixth images below) with or without distal ulnar fracture
  • C - Distal avulsion
  • D - Radial avulsion with or without sigmoid notch fracture
    A Palmer class 1A tear of the triangular fibrocart A Palmer class 1A tear of the triangular fibrocartilage complex that is being probed.
    A Palmer class 1A tear of the triangular fibrocart A Palmer class 1A tear of the triangular fibrocartilage complex after debridement, being treated with an electrothermal wand.
    Palmer class 1A tear of the triangular fibrocartil Palmer class 1A tear of the triangular fibrocartilage complex after debridement with a shaver and thermal treatment.
    A traumatic, ulnar side Palmer class 1B tear of th A traumatic, ulnar side Palmer class 1B tear of the triangular fibrocartilage complex.
    Palmer class 1B tear of the triangular fibrocartil Palmer class 1B tear of the triangular fibrocartilage complex treated with an outside-in technique using 2-0 polydioxanone sutures and a wire loop.
    Completion of an outside-in repair for a Palmer cl Completion of an outside-in repair for a Palmer class 1B tear of the triangular fibrocartilage complex.

Class 2: Degenerative (ulnocarpal abutment syndrome) stage

  • 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

Acute isolated TFCC disruption with dislocation or instability of distal radioulnar joint

Isolated TFCC disruptions may be associated with distal radioulnar (DRU) joint 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 DRU joint 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 DRU joint instability is reduced with the forearm in supination. Palmar DRU joint 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.

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Surgical Therapy

If the DRU 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 DRU joint is recommended for 4-6 weeks.

Instability of the DRU joint 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 DRU joint instability after open reduction and internal fixation (ORIF) of the radial shaft fracture.[16]

In individuals with radial head fracture and tenderness over the DRU joint, every attempt should be made to preserve the radial head to prevent proximal migration of the radius. DRU joint 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 DRU joint who were treated with ORIF of the radial head.[17]

Arthroscopic compared with open repair

In a study of 16 competitive athletes with wrist TFCC injuries from 2001 through 2005, McAdams et al found that arthroscopic debridement or repair of TFCC injury provided pain relief and allowed patients to return to play. There was slower recovery in patients with concomitant ulnar-side wrist injuries.[18]

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 decreased operative time; reduced postoperative immobilizations; and decreased irritation from suture knots below the skin.[19, 20]

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 between the two approaches to 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.[21]

Reiter et al performed a retrospective study of 46 patients who underwent arthroscopic repair of Palmer class IB tears to assess functional and subjective outcomes, as well as to determine 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. Ulnar neutral or positive variance was not a contraindication for repair and did not necessitate simultaneous ulnar shortening.[22]

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Intraoperative Details

Open repair

Make a dorsal ulnar incision between the fourth and fifth extensor compartments. Carry the dissection down to the DRU ligament. Reflect the DRU ligament and the periosteum over the lunate fossa. Place horizontal mattress sutures in the TFCC through drill holes placed in the dorsoulnar aspect of the distal radius.

Wrist arthroscopy

Indications for wrist arthroscopy include acute unstable tears, acute tears that fail to respond to conservative management, and chronic tears for which conservative management fails.[18, 23, 24, 25]

General arthroscopic principles are as follows:

  • Debride to a stable smooth rim of tissue
  • Maintain a 2-mm peripheral rim
  • Excise less than two thirds of the central portion of the TFCC
  • Maintain the integrity of the DRU ligament, the palmar radioulnar (PRU) ligament, and the disk carpal ligaments

Traumatic central tears (Palmer class 1A)

Perform debridement as above.

Traumatic ulnar-side tears (Palmer class 1B) with outside-in technique

Debride the synovitis and the edges of the tear.[26] Make a 1-cm incision just radial to the extensor carpi ulnaris (ECU) tendon. Open the radial aspect of the ECU tendon sheath for 1 cm. Retract the ECU palmarly.

Under arthroscopic visualization, pass two needles through the capsule and across the tear using a meniscus mender or similar TFCC repair device. Use a wire loop passed through one needle to retrieve a 2-0 polydioxanone suture (PDS) passed through the other needle. This creates a loop. Tie the suture over the dorsal wrist capsule, approximating the tear. From two to four sutures may be required.

Reconstruct the ECU tendon as needed. Immobilize the wrist and elbow for 4 weeks in a splint or Muenster cast.

Ulnar extrinsic ligament tears (Palmer class 1C)

Perform a mini open or arthroscopic repair using zone-specific cannulas. Stay between the ECU and flexor carpi ulnaris (FCU) to avoid the neurovascular bundle.

Traumatic radial-side tears (Palmer class 1D)

Debride as with a Palmer class 1A tear, or repair as follows:

  • Debride the edge of the sigmoid notch with a shaver down to bleeding bone
  • Make drill holes through the distal radius with a K-wire passed percutaneously into the joint from the sigmoid notch across the distal radius
  • Pass a 2-0 PDS double-ended suture on long needles through the TFCC and into the drill holes
  • Tie the suture on the surface of the radius through a small incision while protecting the superficial radial nerve
  • Pin the DRU joint in neutral rotation with a single 0.062-in. K-wire
  • Immobilize the wrist and elbow for 8 weeks in a splint or Muenster cast
  • Transosseous suture anchors can be used in place of drill holes

Degenerative tears (Palmer classes 2A and 2B)

Gently debride. If the patient is ulnar-positive and symptomatic, use open ulnar shortening.

Degenerative tears (Palmer class 2C)

Gently debride in patients who are ulnar-neutral or ulnar-negative. For patients who are ulnar-positive, consider the arthroscopic wafer procedure.

Wnorowski demonstrated almost a 50% unloading of the ulnar side of the wrist after excision of the central portion of the TFCC and resection of the radial two thirds of the width of the ulnar head to a depth of subchondral bone.[27] Patients with an arthroscopic wafer procedure may have a more prolonged postoperative course than those with open ulnar shortening.

Degenerative tears (Palmer class 2D)

Treatment is similar to that for Palmer class 2C tears. Carefully assess lunotriquetral (LT) instability. If the LT joint is stable, perform debridement. If it is unstable, consider an open shortening osteotomy to unload the ulnar head and tighten the ulnar extrinsic ligaments. Then, consider an LT fusion or pinning or an LT ligament repair.[28] An arthroscopic wafer procedure is contraindicated, because it leads to more laxity in the ulnar extrinsic and LT ligaments.

Degenerative tears (Palmer class 2E)

Degenerative tears have an unpredictable response to arthroscopic debridement. These tears usually require a salvage operation. The DRU and LT joints must be addressed. A limited ulnar head excision can be performed. The Sauve-Kapandji procedure involves radioulnar joint arthrodesis and proximal ulnar pseudarthrosis. The Darrach procedure is a resection of the distal end of the ulna.

Ulnar-shortening osteotomy

Consider ulnar-shortening osteotomy for patients with ulnar-positive variance, patients in whom debridement fails, and/or patients who present with a delay in treatment of longer than 6 months.

Advantages of an ulnar-shortening osteotomy are as follows:

  • It is extra-articular
  • It maintains the mechanical integrity of the DRU joint
  • It maintains the origins and insertions of the ligamentous tissue and capsule forming the peripheral aspect of the TFCC; it may result in tightening of the ulnocarpal complex, including the LT ligament, with shortening
  • It is potentially less painful than an arthroscopic resection
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Postoperative Details

See the list below:

  • All patients are immobilized immediately following surgery.
  • 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 triangular fibrocartilage complex (TFCC) repairs.
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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)
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Outcome and Prognosis

Arthroscopic repair

A review by de Araujo et al of 17 patients after arthroscopic repair of Palmer class IB 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.[29]

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. Ulnar neutral or positive variance was not a contraindication for repair and did not necessitate simultaneous ulnar shortening.[22]

Sagerman and Short reviewed 12 patients after arthroscopic repair of Palmer class ID tears, with an average follow-up of 17 months, and found good or excellent results in 67% of patients.[30]

Trumble et al reviewed 24 patients after arthroscopic repair of Palmer classes IB, IC, and ID 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.[31]

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.[32]

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-sided 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 decreased operative time; reduced postoperative immobilizations; and decreased irritation from suture knots below the skin.[33, 34]

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 of 39 patients with open technique, vs 8 of 36 patients with arthroscopy). Females had a higher rate of reoperation.[35]

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.[36] 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 5 patients. Of the 16 patients, 13 returned to their previous jobs. Ulnar positive 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.[37]

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 8 patients, fair results in 2 patients, and poor results in 5 patients.[38]

De Smet et al conducted a retrospective survey of 46 patients who underwent debridement with or without wafer distal ulna resection.[39] 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 8 patients; 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.[40]

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.[41]

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.[42]

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.[43] 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.

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Future and Controversies

A large controversy exists concerning the biomechanical changes of the TFCC during pronation and supination. A number of authors claim that the dorsal RUL tightens during pronation and relaxes with supination. Others claim the exact opposite.

Nakamura may have solved this question by using a custom-made surface coil allowing complete freedom of wrist motion. From MRI scans of the wrist in coronal and sagittal planes at maximal pronation and neutral and maximal supination, he showed that during pronation and supination, the TFCC twists at its origin.[44] 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.

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Contributor Information and Disclosures
Author

James R Verheyden, MD Consulting Surgeon, Department of Orthopedic Surgery, The Orthopedic and Neurosurgical Center of the Cascades

James R Verheyden, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Society for Surgery of the Hand

Disclosure: Nothing to disclose.

Coauthor(s)

Andrew K Palmer, MD Chair, Professor, Department of Orthopedics, State University of New York-Upstate Medical University

Andrew K Palmer, MD is a member of the following medical societies: American Osteopathic College of Physical Medicine and Rehabilitation

Disclosure: Partner received salary from Del Palma Orthopedics for board membership.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

N Ake Nystrom, MD, PhD Associate Professor of Orthopedic Surgery and Plastic Surgery, University of Nebraska Medical Center

Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine, Clinical Professor, Surgery, Nova Southeastern School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, Arkansas Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

Joseph E Sheppard, MD Professor of Clinical Orthopedic Surgery, Chief of Hand and Upper Extremity Service, Department of Orthopedic Surgery, University of Arizona Health Sciences Center, University Physicians Healthcare

Joseph E Sheppard, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Orthopaedics Overseas, American Society for Surgery of the Hand

Disclosure: Nothing to disclose.

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The triangular fibrocartilage complex suspends the distal radius and ulnar carpus from the distal ulna. T=triquetrum; L=lunate; S=scaphoid. (Reprinted with permission from Palmer AK and Werner FW: The Triangular Fibrocartilage Complex of the Wrist - Anatomy and Function. J Hand Surg; 1981; 6:153)
The triangular fibrocartilage complex provides a continuous gliding surface across the entire distal face of the radius and ulna to allow for flexion-extension and translational movements.
Distally, the triangular fibrocartilage complex inserts into the lunate and triquetrum via the ulnolunate and ulnotriquetral ligaments. The triangular fibrocartilage complex solidly connects the ulnar axis to the volar carpus. The unlabeled arrow points to the prestyloid recess. (Reprinted with permission from Palmer AK and Werner FW: The Triangular Fibrocartilage Complex of the Wrist - Anatomy and Function. J Hand Surg; 1981; 6:153)
Relation of the triangular fibrocartilage complex to the distal radius and ulnar styloid.
The ulnocarpal portion of the triangular fibrocartilage complex is composed of the discus articularis, the ulnolunate (ULL), and the ulnotriquetral (UTL) ligaments. Distally, the triangular fibrocartilage complex inserts into the lunate via the ulnolunate ligament and into the triquetrum via the ulnotriquetral ligament.
Sigmoid notch of the distal radius with distinct dorsal, palmar, and distal margins and an indistinct proximal margin; the triangular fibrocartilage complex arises from the ulnar margin of the lunate fossa of the radius. (Reprinted with permission from Fernandez D and Palmer AK. Fractures of the Distal Radius. In: Green's Operative Hand Surgery. Vol 1. 1999)
The seat of the ulnar head articulates with the sigmoid notch of the distal radius. Radially, the triangular fibrocartilage complex arises from the ulnar margin of the lunate fossa of the radius. Ulnarly, the triangular fibrocartilage complex inserts into the base of the ulnar styloid. (Reprinted with permission from Fernandez D and Palmer AK. Fractures of the Distal Radius. In: Green's Operative Hand Surgery. Vol 1. 1999)
A Palmer class 1A tear of the triangular fibrocartilage complex that is being probed.
A Palmer class 1A tear of the triangular fibrocartilage complex after debridement, being treated with an electrothermal wand.
Palmer class 1A tear of the triangular fibrocartilage complex after debridement with a shaver and thermal treatment.
A traumatic, ulnar side Palmer class 1B tear of the triangular fibrocartilage complex.
Palmer class 1B tear of the triangular fibrocartilage complex treated with an outside-in technique using 2-0 polydioxanone sutures and a wire loop.
Completion of an outside-in repair for a Palmer class 1B tear of the triangular fibrocartilage complex.
 
 
 
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