What is a triangular fibrocartilage complex tear?

A TFCC tear is a tear in the triangular fibrocartilage complex, a structure found in the little finger side of the wrist.

Within the forearm are 2 bones, the radius (thumb side) and the ulna (little finger side), and within the wrist there are 8 wrist bones (carpals). The TFCC sits between the ulna and 2 carpal bones, the triquetrum and lunate.

The triangular fibrocartilage complex is made up of, and connects with a number of structures within the wrist including:

• articular disc
• meniscus homologue,
• ulnar collateral ligament
• volar/palmer (palm side) & dorsal (back side) radioulnar ligaments,
• sheath of the extensor carpi ulnaris tendon.
• ulnolunate and ulnotriquetral ligaments

Fig 1. Palm sided view (palmer) and back of hand sided view of the triangular fibrocartilage complex (1).

What are the signs and symptoms of a TFCC tear?

The main complaint and symptom people present with is pain in the little finger side (ulnar side) of the wrist. Sometimes the pain is very localised and one may be able to pin point the exact location of the pain, whereas other times, it is less obvious and harder to pin point. Usually pain is accompanied by a clicking, snapping or catching feel upon wrist movement.

In people with type II TFCC tears, or tears resulting from a degenerative joint disease, or 'crepitus' (a crackling, grating and/or popping sensation) may be felt during wrist movement.

People with TFCC tears often complain of feeling weak in the wrist (ie/ they can’t grip as hard or lift heavy things) or that their wrist is unstable and is going to collapse when they put a lot of force on it (ie/ lean on it).

Depending on the severity of the tear, the wrist may also present bent slightly to the little finger side (ulnarly deviated), and the bony prominence on the ulnar side of the wrist may appear to stick out more than usual. This is indicative of Ulnar dislocation and often presents in complete TFCC tears.

What causes a TFCC tear?

The specific structures most often torn in TFCC tears are the meniscal homologue and articular disc (2). This is usually caused by forced or over extension (hyperextension) and pronation of the wrist which is the position most often assumed when falling onto an outstretched arm (3,4, 6). Forces that pull the wrist away from the ulna (distraction forces) can also tear the TFCC (7). This type of injury is more often seen in tennis players and baseballers because of the great distraction forces felt by the wrist when the bat/racquet contacts the ball. TFCC injuries are also common amongst gymnasts whose wrists often move into these extreme positions. Tears to the TFCC can also occur with fractures of the radius or ulna (22), as indicated in Palmer’s classification of TFCC tears (below).

TFCC tears do not always occur as a result of a trauma and may occur as a result of degenerative changes in the wrist. A degenerative tear may occur as a result of ‘ulnocarpal impaction syndrome’ – when the end of the ulnar chronically ‘impacts’ on the TFCC and the 2 wrist bones it connects with (lunate and triquetrum). This often occurs as a result of ulnar variance (when the ulnar is longer than the radius). Ulnar variance can occur as a congenital defect (defect from birth) or as a result of trauma, which may, for example, hinder growth of the radius. Ultimately these conditions lead to increased wear and subsequently degeneration of the TFCC. However, degenerative changes in the wrist do not always need a specific trigger to occur and may result as a natural progression in the ageing process (22).

Palmer (1989) classified TFCC tears into 2 classes according to their mechanism of injury. Class 1 tears are those that occur as a result of a trauma, while Class 2 tears are those that are a result of degenerative changes in the wrist. The subtypes are further classified according to the severity and/or location of the tear.

Class 1 : Traumatic cause
A : central perforation (tear)
B : ulnar avulsion with or without distal ulnar fracture
C : distal avulsion
D : radial avulsion with or without sigmoid notch fracture

Class 2 : Degenerative cause
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 LT ligament perforation
E : TFCC perforation with lunate and/or ulnar chondromalacia, LT ligament perforation, and ulnocarpal arthritis

What tests can I take to see if I have a TFCC tear?

It is difficult to differentiate TFCC tears with other wrist complications as ulnar sided wrist pain is the common complaint for many wrist conditions. A number of tests and imaging techniques exist to diagnose a TFCC lesion, but the best and most accurate way to do this is to use multiple diagnostic methods and compare each the findings.

Some diagnositic tests that can be performed during a physical examination include:

The McMurray’s test: when the examiner glides the lunate and triquetrum up and down in the wrist, while the wrist is bent on the little finger side (ulnarly deviated). Usually if there is a TFCC tear, the patient should feel pain, crepitus and or a painful snapping. (8)

Piano key test: the examiner gently moves up and down the wrist end of the ulnar, while holding onto the radius. The ulnar is pressed down, like a piano key and normally the ular should spring back like a piano key, but in the event of a TFCC tear the ulna may move more than usual and may not spring back up like normal.


Load Test: the examiner grips the patient’s hand in a ‘hand shake position’ and ulnarly deviates the wrist, thereby squashing the TFCC. While still compressing the complex, the examiner rotates the wrist through an arc to feel for crepitus, clicking and see whether the patient feels an pain.

A more functional test is the "press test," in which the patient is instructed to lift themselves out of a chair by pushing off the chair’s arm rests. This test is very sensitive in picking up TFCC tears and is an easy technique to perform (5).


Some other imaging techniques that may be used to complement wrist arthroscopy:

Research today suggests wrist arthroscopy is the best imaging technique to determine the presence and severity of a TFCC tear.(6, 12). To read more information on wrist arthroscopy, view post on 'surgical management' below.

Xray - may illustrate TFCC disruption, in the presence of a fracture, otherwise TFCC tears will go unnoticed on a plain film. Changes associated with a TFCC tear such as ulnar variance or dislocations may be evident from a plain film X-ray, which may suggest a TFCC lesion, but is not conclusive on its own.

MRI - can be used to indicate the presence of a TFCC tear and was used alot in the past, but more recent research suggests it is not as good as an arthrogram or arthroscopy in diagnosing TFCC tears. MRI images can be useful in differentiating the class of TFCC tear as class 1 tears (traumatic in origin) appear more obvious in T2 or fat saturated images, while class 2 tears appear as a high signal area in all T1, T2 weighted and fat saturated images (8).

Fig 4. Class 2B. T2 weighted MRI indicates thinning and perforation of the central segment (arrows).

Arthrogram – Dye is injected into the wrist joint to see whether there is a tear of the TFCC. If there is a tear, dye will leak into the surrounding joints. There are 3 main joints and normally these joints are closed off from one another. Nonetheless this method has its faults. In the presence of severe scarring after a TFCC tear, an arthrogram may appear negative, as the scar tissue blocks the tear, stopping the dye from leaking into the other joints. Also some people’s wrist joint are normally not completely closed off from eachother and therefore may falsely indicate a positive arthrogram. Today arthrography is being replaced by arthroscopy, which is the standard by which other techniques used to diagnose ulnar sided wrist pain, are be compared (12).

How can Physiotherapy help?

MANAGEMENT

The progression of management for an individual with a triangular fibrocartilage complex (TFCC) tear is the same for injuries diagnosed as either traumatic or degenerative. You should expect to begin with conservative treatments and rehabilitation overseen primarily by a physiotherapist and your general practitioner (GP). If your injury fails to respond to such conservative measures there are several more invasive orthopaedic surgical management strategies available that repair the TFCC tear directly and restore stability amongst the bones and ligaments that form your wrist. Ultimately all management strategies for TFCC tears aim to restore the greatest amount of function back to your injured wrist whilst preventing any further or future injury.

CONSERVATIVE MANAGEMENT

Conservative management of TFCC tears involves eight to twelve weeks (or greater depending on the extent of injury) of progressive phases of treatment that aim to enhance natural healing processes and prevent further damage at the injury site. Conservative management of TFCC tears consists of:

Immobilisation (cast or splinting)
Anti-Inflammatory Medication (NSAIDS)
Physiotherapy Rehabilitation

These three important features of conservative management are involved throughout the four phases that begin at immobilisation at the time of TFCC tear diagnosis and then progress through to the return of function. These phases are summarised below:

Immobilisation ( 3 – 6 weeks )

After diagnosis of a TFCC tear your wrist will be immobilised in a Sugar Tong Splint (http://emedicine.medscape.com/article/80127-media) that places your wrist in a protective position that places minimal stress on your TFCC and prevents forearm movements that stress the TFCC. Immobilisation occurs for a period of four to six weeks for traumatic tears and three to four weeks for degenerative tears, so to allow for optimal uninterrupted healing at the site of your injury. During this time it will be recommended to you to take anti-inflammatory medications such as NSAIDS (neurofen), that should be overseen by your GP and self-administered depending on your level of pain or symptoms.

Physiotherapy management forms an important role during the immobilisation period, particularly in educating you about the importance of movement exercises for your fingers and thumb to prevent significant muscle loss (atrophy) whilst your wrist is in the splint. You should move your fingers and thumb as much as pain permits during the day, for at least ten sets of repetitions per day. Movement of your fingers and thumb also promotes fluid movement and clearing of any swelling at your wrist or tissues back through the blood vessels in your forearm. Maintaining strength in such muscles will make functional rehabilitation after the splint is removed easier as it will assist the muscles that move your wrist that will have lost strength after being disused in the splint. During this phase your physiotherapist will gain an understanding of your injury that will optimise their planning of a rehabilitation program for you to regain your wrist function after the splint is removed (phase two).


Splint Removal & Early Physiotherapy Rehabilitation ( 4 – 6 weeks)

Once your splint has been removed after the approval and satisfaction of your medical professional in the results of the period of immobilisation healing, physiotherapy becomes the most important influence on your rehabilitation. Your physiotherapist should conduct a full physical examination of your wrist in particular and the other joints of your arm before any treatment is started to identify your main functional losses such as active range of movement of your wrist (AROM), muscle strength and length in your forearm whilst assessing for stiffness, scarring and swelling in your joints and any areas or movements that are painful. Assessment of the wrist and arm’s function is vital in developing the exercise program that will form the core of your rehabilitation as well as indicating other treatment techniques such as massage or electrical physical agents (such as ultrasound).

Your physiotherapy rehabilitation should involve exercises that regain movement, strength, flexibility, coordination and function of your wrist, improve circulation, decrease swelling and ease discomfort whilst also incorporating functional tasks relevant to your goals or occupation. Education is again an important feature of this phase as your physiotherapist should inform you how to protect your joints during certain activities or job duties, whilst also advocating the importance of now wearing a removal splint for such protection, especially during sleeping.

Recommendations for exercises/techniques in your initial rehabilitation program should include:

AROM and Assisted AROM exercises – wrist (flexion / extension, ulnar / radial deviation), fingers/thumb (flexion / extension), forearm (pronation / supination), elbow (flexion/extension)
Tendon Glide exercises – differentiate wrist from finger tendons, increase their movement
Functional exercises – fist formation, opposition and grip
Massage – reduce swelling and scarring/adhesion formation
Passive Accessory Movement Glides – particularly wrist (AP, PA and Med/Lat) and DRUJ (AP/PA)
Pain management – GP may inject cortisone / steroids

These techniques aim to achieve the main goals of initial physiotherapy rehabilitation of decreasing swelling and increasing ROM. Such exercises should be prescribed in sets of 3-5/day with the amount of repetitions and sets adjusted according to your level of function. AROM exercises should performed slowly with the physiotherapist applying a gentle stretch at the end of movement to encourage stretching. Finger movement should be encouraged to remain at as often as possible with pain permitting to maintain hand function. It is important that your physiotherapist educates you about why you are performing these exercises and should supplement your therapy sessions with handouts that demonstrate the exercises and also about how swelling is a normal and necessary response to injury and the way to best manage it. This initial phase of rehabilitation should typically last four weeks, progressing in the range of exercises from gentle AROM to beginning strengthening exercises (phase three).


Continued Physiotherapy Rehabilitation

Once ROM has begun to sufficiently improve from the initial assessment values, your physiotherapist should start to focus more on improving the strength and endurance of the muscles that move your wrist depending on level of healing of your TFCC healing as indicated by your GP and physiotherapist. If ROM improvement has plateaued before reaching functional ROM, it is recommended that a dynamic or static progressive splint should be used, that promotes increases in movement in desired directions by placing the targeted joint in a gentle stretch. Typically such splints are applied in a forearm supination or wrist extension position.

Strengthening prescription should begin after twelve weeks post diagnosis with isometric exercises for the wrist, forearm, hand, elbow and shoulder against the physiotherapist then progressing onto more resistance-based exercises as tolerated starting at minimal weight. In particular grip strength should be addressed due to its critical functional value in most daily activities and occupational duties. Weight bearing on hands should be avoided at all times, your physiotherapists will eventually incorporate weight bearing on gym balls under supervision if it is a functional activity involved in your occupation or sport after sufficient resistance strengthening.

Recommendations for strengthening program:

Pronation / Supination – hold a hammer in your hand and perform movement both concentric and eccentrically
Wrist Flexion / Extension – Small dumbbell (500g then progress to higher masses) perform movement
Elbow / Shoulder Strengthening – Start minimal weight and progress to larger mass, in ROM that require strengthening

Prescription of such exercises should be based on initially building muscle mass, using moderate repetitions (6-10 reps) and eccentric loading (3 seconds down and 1 second up phase) for initially 3-5 sets/day, depending on progression of increases in strength. For endurance you should be performing high repetitions (>10 reps) of a low weight, pain permitting, in between or after strength exercise sets.

The use of removal splinting should continue to be encouraged during sleeping and daily activities that may re-injure the TFCC, as protecting your injury also continues to facilitate your healing and also rests your wrist and forearm.

Another focus of this phase is the incorporation of more functional activities as apart of exercise prescription, in preparation for returning you back to normal independent functioning depending on your goals. Such more functional activities can involve:

Folding washing
Using cutlery
Using tools such as screwdrivers
Other occupational/sport specific tasks

These activities should progress the rehabilitation of your wrist to a level of pain free function that can enable your integration back into independent living (phase four), depending upon the approval of your physiotherapist’s assessment of your wrist.


Return to Function

This is the end phase of your rehabilitation journey with your physiotherapist under conservative management where hopefully your injury has responded sufficiently and your function permits you to return to work, sport or independence. Throughout this phase education and reassessment of your wrist are the main management focuses that your physiotherapist will use to ensure that the activities you are participating are not causing reinjury of your TFCC and that you know how to protect your wrist.

However if the TFCC tear fails to respond to conservative management, surgery is the next and final option available to repair your injury. There are several surgical procedures available ranging from key hole surgery to full open surgery to repair your TFCC. Selection of your procedure depends on the nature of your injury (traumatic or degenerative) as based upon the TFCC tear classification system, whether there is any bony or ligamentous instability and the preference of your surgeon.

The recommendations for protocols for conservative management of TFCC tears was interpreted from the text, Fundamentals of Hand Therapy: Clinical reasoning and treatment guidelines for common diagnoses of the upper extremity, Cooper, C. (2007).

EVALUATION

Conservative measures have been shown to be a successful management strategy for TFCC tears post functional physiotherapy rehabilitation, as a study of 133 individuals with TFCC tears who undertook conservative management were asymptomatic 9.5 years post injury (Osterman et al., 1991). However they are highly dependent on the extent of the tear and several factors specific to the individual involving their level of motivation, healing ability, comorbidities and adherence to the rehabilitation programs. Due to the relatively avascular nature of the TFCC surgical procedures are more highly preferred strategies for repairing TFCC tears with the success of conservative measures being more attributed to post surgery rehabilitation using the same progression of management.

What treatment options do I have?

MANAGEMENT

The progression of management for an individual with a triangular fibrocartilage complex (TFCC) tear is the same for injuries diagnosed as either traumatic or degenerative. You should expect to begin with conservative treatments and rehabilitation overseen primarily by a physiotherapist and your general practitioner (GP). If your injury fails to respond to such conservative measures there are several more invasive orthopaedic surgical management strategies available that repair the TFCC tear directly and restore stability amongst the bones and ligaments that form your wrist. Ultimately all management strategies for TFCC tears aim to restore the greatest amount of function back to your injured wrist whilst preventing any further or future injury. (For more information on conservative management see next post).

SURGICAL MANAGEMENT

Surgical management of TFCC tears involves three types of procedures that are related to traumatic or degenerative aetiologies and whether are is further involvement of other structures within the joint that are contributing to the TFCC tear or that will cause future damage. These management strategies are summarised below:

Wrist Arthroscopy

Wrist arthroscopy involves key hole surgery of the wrist to either remove worn and damaged cartilage from the TFCC if you are diagnosed with a chronic degenerative TFCC tear that didn’t respond to conservative management or to repair with sutures an acute traumatic tear to the TFCC that did not respond to conservative management. Orthopaedic surgeons aim to be as minimally invasive as possible and aim to only remove the required amount of damaged cartilage, in order to maintain the normal joint mechanics post-surgery.

Physiotherapy involvement follows the same principles as those of conservative management in the post-surgery rehabilitation, however with more focus on scar and swelling management. If removal of damaged cartilage was performed alone, mobilisation with motion exercise can begin 5-7 days post surgery and you will be splinted using a Sugar Tong Splint. Wrist arthroscopy is the most commonly used procedure and has excellent functional results post-surgery after full physiotherapy rehabilitation, with a study by Corso and Colleagues (1997) finding 37 months post wrist arthroscopy of 44 participants, 29 had excellent results and 12 had good results.


Open Surgery

Open surgery is the most invasive surgical procedure used to repair TFCC injuries and is only used if there is instability in the DRUJ or with overlying fractures of bones surrounding the wrist joint that require fixation with plates or K-wires. This management strategy is associated more so with traumatic TFCC tears requiring significant repairs to return the affected wrist joint back to stability in the hope of regaining normal function post-surgery in conjunction with physiotherapy management.

Physiotherapy involvement follows the same principles as those of conservative management in the post-surgery rehabilitation, however with more focus on scar and swelling management. Open surgery and internal fixation has excellent functional outcomes post-surgery, in a study that compared open surgery to wrist arthroscopy, Anderson and Colleagues (2008) found that there was no statistical difference between techniques for clinical outcomes, however it was concluded that wrist arthroscopy has a reduced operation time, reduced cast immobilisation time and lesser skin irritation due to suture knots, indicating why wrist arthroscopies are the preferred surgical management of TFCC tears.

Ulnar-Shortening Osteotomy

Ulnar-shortening osteotomy is the last surgical management option available to repair TFCC tears and is used if the ulna at the affected wrist due to ligamentous instability has a greater length than it should (positive ulnar variance) or if wrist arthroscopy debridement has failed to produce a good functional outcome and/or the began treatment for their injury late (greater than six months). The surgical procedure involves your orthopaedic surgeon removing the necessary amount of your ulna bone that is past its normal position within the wrist joint from the shaft of the ulna. This procedure is important as positive ulnar variance leads to ulnar-carpal osteoarthritis within your wrist due to ulna producing degenerative joint mechanics between it and your carpal bones (abnormal joint loading) that accelerates cartilage wear and is severely functionally limiting.

Physiotherapy rehabilitation is consistent across all three types of surgical procedures however with ulnar-shortening osteotomies, your physiotherapist must also consider bone healing mechanisms in prescribing the types and vigour of exercises post-surgery and post-splint removal, in order to rehabilitate the most optimally for your wrist’s function. The benefit of this procedure however to your physiotherapist is that the surgery does not involve the joint directly and maintains the mechanical integrity of all the wrist’s ligamentous structures and is less painful. Minami and Kato (1998) found that amongst 25 individuals at 35 months post-surgery that 23 had complete pain relief or occasional mild pain, they also found that ulnar shortening osteotomy had efficacy for both traumatic and degenerative TFCC tears.


EVALUATION

Surgical management of TFCC tears in combination with effective physiotherapy rehabilitation show excellent functional outcomes for the affected wrists in comparison to if no intervention was used at all. Surgical procedures show their greatest efficacy if used only after conservative measures have failed and should not be used as the go to management option due to their inherent higher costs, more invasive nature and greater period of rehabilitation.

How long before my wrist returns back to normal?

PROGNOSIS

The prognosis or the time frame that you can expect your triangular fibrocartilage complex (TFCC) tear to take in the long term recovery from diagnosis to return to function depends upon the interaction of several important factors relating to the injury itself and its management. Whether your TFCC tear is the result of a trauma or degenerative changes and the extent of the damage affects it response to the compulsory conservative management you will receive. If your injury does not respond to conservative management then more invasive surgical procedure will be undertaken and the rehabilitation post-operatively will add to the length of time you spend in recovery and unable to participate in your occupation or sport. Factors external to the management strategies can also complicate your TFCC tear healing and act as poor prognostic indicators, these include:

• Infection
• Repair Failure
• Wrist Arthroscopy Complications
• Hardware failure
• Non-union
• Stiffness, decreased strength, continued pain

Another significant indicator for prognostic outcomes is the time from the initial injury (for traumatic) or when degenerative tears become symptomatic that the individual receives treatment for their TFCC tear. With individuals who began management greater than six months post injury or symptoms having a significantly increased rehabilitation period and greater need for more invasive management than individuals who received management for their tear within six months.


PROGNOSIS GUIDELINES


1. Conservative Management – ( 12 – 18+ weeks )

a. Immobilisation – Traumatic ( 4 – 6 weeks )
- Degenerative ( 3 – 4 weeks )

b. Splint Removal and Early Physiotherapy Rehabilitation – ( 4 – 6 weeks )

c. Continued Physiotherapy Rehabilitation – ( 4 – 6+ weeks ) – depends upon response to exercise program and patient’s goals

Surgical management must follow conservative interventions first, therefore the prognosis of recovery after a surgical intervention is on top of the period of time spent in conservative management which may not be the full 12 – 18 weeks.


2. Surgical Management – ( 16 – 20+ weeks )

a. Wrist Arthroscopy – Cast Immobilisation ( 2 weeks )
- Splint immobilisation ( 3 weeks )

b. Open Surgery - K-wire ( 4 – 6 weeks)
- Cast immobilisation ( 4 – 8 weeks) – this is simultaneous with K-wire

c. Ulnar-Shortening Osteotomy – Cast immobilisation ( 6 – 8 weeks ) – replicates normal bone healing time frames

d. Physiotherapy Rehabilitation – ( as required, at least 8 weeks )


Total surgical management time frame depends on the extent of injury, procedure used and individual response to physiotherapy. These figures are estimates that assume no complications, management began less than six months post-injury, physiotherapy response and adherence and non-significant damage to the TFCC.
The American College of Radiology (ACR) recommendations for short and long term goals for post surgical reconstruction of TFCC tears return to specific tasks are that for light duties (42 days post-surgery with extensive physiotherapy rehabilitation) and for heavy, manual tasks duties (180 days post-surgery with ongoing physiotherapy management). Overall however it is the motivation and adherence to the rehabilitation program prescribed by the physiotherapist that will determine how long post management interventions recovery will take. An individual with a TFCC tear has to achieve short term goals such as increasing ROM, reducing pain and stiffness and increasing strength and long term goals such as independence in functional activities and returning to work or sport. Such goals may take a greater or lesser time suggested by the ACR.