eMedicine Specialties > Orthopedic Surgery > Hand & Upper Extremity

Triangular Fibrocartilage Complex Injuries: Treatment

Author: James R Verheyden, MD, Consulting Surgeon, Department of Orthopedic Surgery, The Orthopedic and Neurosurgical Center of the Cascades
Coauthor(s): Andrew K Palmer, MD, Chair, Professor, Department of Orthopedics, State University of New York-Upstate Medical University
Contributor Information and Disclosures

Updated: Jun 23, 2009

Treatment

Medical Therapy

Initial treatment of both symptomatic degenerative and traumatic 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 is as follows¹⁸ :

• 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 triangular fibrocartilage complex abnormalities

Class 1: Traumatic

• A - Central perforation (see Images 8-10)
  
  

  

  A Palmer class 1A tear of the triangular fibrocartilage complex that is being probed.

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  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.

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  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.

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  Palmer class 1A tear of the triangular fibrocartilage complex after debridement with a shaver and thermal treatment.

• B - Ulnar avulsion (see Images 11-13) with or without distal ulnar fracture
  
  

  

  A traumatic, ulnar side Palmer class 1B tear of the triangular fibrocartilage complex.

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  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.

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  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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  Completion of an outside-in repair for a Palmer class 1B tear of the triangular fibrocartilage complex.

• C - Distal avulsion
• D - Radial avulsion with or without sigmoid notch fracture

Class 2: Degenerative (ulnocarpal abutment syndrome) stage

• A - TFCC (triangular fibrocartilage complex) 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 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 the distal radioulnar joint

Isolated TFCC disruptions may be associated with distal radioulnar joint (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. On physical examination, 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 Therapy

If the distal radioulnar joint (DRUJ) 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 fractures -dislocations. Anatomic reduction of these fractures often stabilizes the DRUJ. When fixation of these fractures does not stabilize the DRUJ, stabilization can be obtained with either long arm casting in a reduced position, open reduction and TFCC repair, or 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 of the radial shaft fracture.¹⁹

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 open reduction and internal fixation of the radial head.²⁰

Intraoperative Details

Open repair

• Make a dorsal ulnar incision between the fourth and fifth extensor compartments.
• Carry the dissection down to the dorsal radioulnar ligament (DRUL).
• Reflect the DRUL and the periosteum over the lunate fossa.
• Place horizontal mattress sutures in the triangular fibrocartilage complex (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.^2,21

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 DRUL, palmar radioulnar ligament (PRUL), and disk carpal ligaments.

Treatment of traumatic central tears (Palmer class 1A)

• Debridement as above

Treatment of traumatic ulnar-side tears (Palmer class 1B) with outside-in technique²²

• Debride the synovitis and the edges of the tear.
• 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 2 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 2 to 4 sutures may be required.
• Reconstruct the ECU tendon as needed.
• Immobilize the wrist and elbow for 4 weeks in a splint or Muenster cast.

Treatment of 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.

Treatment of 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 DRUJ in neutral rotation with a single 0.062-inch 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.

Treatment of degenerative tears (Palmer classes 2A and 2B)

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

Treatment of 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. The arthroscopic wafer procedure is performed as follows:
  • 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.²³
  • Patients with an arthroscopic wafer procedure may have a more prolonged postoperative course than those with open ulnar shortening.

Treatment of degenerative tears (Palmer class 2D)

• Treatment is similar to that for Palmer class 2C tears.
• Carefully assess lunotriquetral (LT) instability.
• If the LT is stable, perform debridement.
• If the LT 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.²⁴
• An arthroscopic wafer procedure is contraindicated, as it leads to more laxity in the ulnar extrinsic and LT ligaments.

Treatment of degenerative tears (Palmer class 2E)

• Degenerative tears have an unpredictable response to arthroscopic debridement.
• These tears usually require a salvage operation.
• Address the DRUJ and LT joint.
• A limited ulnar head excision can be performed.
• The Sauve-Kapandji procedure involves radioulnar joint arthrodesis and proximal ulnar pseudoarthrosis.
• 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:

• Extra-articular
• Maintains the mechanical integrity of the DRUJ
• Maintains the origins and insertions of the ligamentous tissue and capsule forming the peripheral aspect of the TFCC; may result in tightening of the ulnocarpal complex, including the LT ligament, with shortening
• Potentially less painful than an arthroscopic resection

Postoperative Details

• 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.

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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