Triangular Fibrocartilage Complex Injuries Treatment & Management

If a congruent reduction cannot be achieved or if the dorsal instability is unstable in 30° of supination, then arthroscopic evaluation of the triangular fibrocartilage complex (TFCC) is recommended with repair as needed.

Repairing TFCC tears is contraindicated in the presence of infection or degeneration. Palmer class 2 degenerative TFCC tears (see Pathophysiology) represent a pathologic progression of disease associated with ulnar impaction syndrome.

Degeneration of the TFCC is found with repetitive pronation and axial grip loading in association with positive ulnar variance and impaction between the ulnar head and the proximal pole of the lunate. Treatment of degenerative TFCC tears associated with ulnar impaction syndrome consists of nonoperative treatment first with immobilization, avoidance of aggravating activities, and nonsteroidal anti-inflammatory drugs (NSAIDs).

Palmer class 2A and 2B lesions that fail to respond to conservative treatment are treated with gentle debridement. If the patient is ulnar-positive and symptomatic, a formal ulnar shortening is considered. An arthroscopic wafer is contraindicated, in that this would require resection of intact TFCC to perform the procedure or require performing the procedure entirely through the distal radioulnar joint (DRUJ) portals.

The surgical indications for an arthroscopic wafer procedure are a Palmer class 2C or 2D lesion in a positive ulnar variance of not more than 2 mm without evidence of lunotriquetral (LT) instability. If LT instability is present, this is addressed with formal ulnar shortening in an attempt to tighten the ulnocarpal ligaments and decrease the motion between the lunate and triquetrum.

For patients with a positive ulnar variance of more than 2 mm, formal ulnar shortening is performed. For patients with neutral or negative ulnar variance and a Palmer class 2C lesion, arthroscopic debridement is performed. Palmer class 2E lesions respond unpredictably to arthroscopic debridement. They are usually treated with a salvage procedure such as a limited ulnar head resection, a Sauve-Kapandji procedure, or a Darrach procedure that addresses the DRUJ and LT joint pathology.

Initial treatment of both symptomatic degenerative and traumatic TFCC 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, ^[43] 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 positive ulnar variance, two thirds of patients worsened over time both symptomatically and radiologically

Over a 3-year period, Lee et al treated 117 patients with TFCC tears who did not have DRUJ instability. ^[44]  They found nonsurgical treatment to be moderately successful in treating these patients and recommended a minimum of 6 months of nonsurgical treatment as the first-line treatment for this injury.

A study by Sander et al compared the outcomes of symptomatic TFCC lesions with a stable DRUJ after conservative treatment and arthroscopic debridement and found the two approaches to yield similar results. ^[45] In view of their finding that conservative treatment was a sufficient and reliable option, the authors proposed it as first-line treatment for TFCC lesions with a stable DRUJ.

Acute isolated TFCC disruption with dislocation or instability of DRUJ

Isolated TFCC disruptions may be associated with 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. 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 (ROM), 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.

If the DRUJ joint remains unstable, open reduction is required to remove interposed structures. When instability persists with forearm ROM, 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 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 DRUJ instability after open reduction and internal fixation (ORIF) of the radial shaft fracture. ^[46]

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 ORIF of the radial head. ^[47]

Arthroscopic vs 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. ^[48]

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 operating time, reduced postoperative immobilizations, and decreased irritation from suture knots below the skin. ^{[49, 50]}

In a study of 75 patients who underwent TFCC repair by arthroscopic (n = 36) or open technique (n = 39), Anderson et al found that there was no statistical difference in clinical outcome between the two approaches to repair. ^[51] They did note an increased rate of postoperative superficial ulnar pain in patients who underwent open repair (14/39 with open technique vs 8/36 with arthroscopy). Females had a higher rate of reoperation.

Reiter et al performed a retrospective study of 46 patients who underwent arthroscopic repair of Palmer class 1B tears to assess functional and subjective outcomes, as well as to determine whether clinical outcomes were related to ulnar length. ^[16] Good-to-excellent results were achieved in 63% of the patients, including increased ROM and grip strength and pain relief. Neutral or positive ulnar variance was not a contraindication for repair and did not necessitate simultaneous ulnar shortening.

A systematic review by Andersson et al examined the outcomes of open and arthroscopic repair of TFCC injuries. ^[52] The primary outcome measure was the rate of postoperative DRUJ reinstability; secondary outcome measures were ROM, grip strength, residual pain, functional wrist scores, complication rate, and reoperation rate. The two repair approaches yielded comparable results in terms of DRUJ reinstability and functional outcome scores. The evidence was insufficient to allow recommendation of one technique over the other in clinical practice.

A study by Yeh et al (N = 201; mean age, 26.7 y; mean follow-up, 32.6 mo) evaluated the functional outcomes of patients who underwent arthroscopic repair of foveal TFCC tears with suture anchors and adjuvant platelet-rich plasma (PRP) injections after the surgical procedure. ^[53] Mean modified Mayo wrist score improved (from 48.5 ± 2.6 to 82.4 ± 2.5), and mean Disabilities of the Arm, Shoulder, and Hand (DASH) score decreased (from 39.2 ± 6.7 to 10.6 ± 7.5). Overall, 92.5% of the patients achieved satisfactory wrist function according to the modified Mayo wrist score, and patients with satisfactory scores returned to sports or work activities, retaining normal range of motion (ROM).

Open repair

Make a dorsal ulnar incision between the fourth and fifth extensor compartments. Carry the dissection down to the dorsal radioulnar (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. ^{[48, 54, 55, 56]}

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. ^[57] 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 passed through the other needle. This creates a loop. Tie the suture over the dorsal wrist capsule, approximating the tear; 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 miniopen or arthroscopic repair using zone-specific cannulas. Stay between the ECU and the 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 double-ended polydioxanone 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-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. ^[58] 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 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. ^[59] 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 DRUJ and the LT joint 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 positive ulnar variance, patients in whom debridement fails, and 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 DRUJ
• 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

After surgery, all patients are immobilized immediately. 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 TFCC repairs.

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)