INJURIES TO THE TRIANGULAR FIBROCARTILAGE COMPLEX (TFCC) OF THE WRIST
WHY ARTHROSCOPIC RE-INSERTION?
– Written by Jonny K Andersson, Qatar
Triangular fibrocartilage complex (TFCC) injuries of the wrist are common among athletes as:
· Golfers – do not duff!!
· Racket sports (Tennis, Table tennis)
· Ice Hockey (dorsal ulnotriquetral (UT) ligament injury = “Hockey wrist”)
· Football – goalkeepers
But isolated TFCC injuries can be seen in all sports if the athlete - even in terms of children and adolescents1 - has suffered from a torque trauma or as a concomitant injury together with distal radius fracture. TFCC injury should be suspected if the dorsal angulation of the fractured radius exceeds 32 dgr2 (Figure 1).
Concomitant wrist ligament injuries are not seldom seen together with intraarticular or displaced distal radius fractures among younger non-osteoporotic patients (Figure 2).
Several anatomical structures stabilize the distal radio-ulnar joint (DRUJ), of which the TFCC and especially its foveal insertion is the most important, according to Haugstvedt et al8. Those stabilizing structures include: the floor of extensor carpi ulnaris (ECU) sheath, the ulnocarpal (UC) ligaments, TFCC – especially its foveal insertion, the interosseous membrane – especially the distal oblique band (IOM), the skeleton and joint congruency, as well as the dynamic muscle stabilizers (ECU, flexor carpi ulnaris – FCU, and pronator quadratus - PQ). These stabilizing factors are shown in Figure 3 and 4, and they have to be evaluated in every patient with DRUJ instability by the physiotherapist and the physician, in accordance treating the correct deficits.
Acute TFCC injuries type 1 B (Figure 5a) and 1D (Figure 5b) – according to Palmer9 and Atzei10, are those types of injuries that come with concomitant DRUJ instability and most often need surgical re-insertion.
MEDICAL HISTORY AND CLINICAL EXAMINATION
Dorso-ulnar wrist pain, problems with forced pronation, as well as weak torque and instability are common symptoms, among patients with TFCC injuries. But other conditions such as synovitis, ganglion cysts, lunotriguetral ligament injury, ulnar impaction and other degenerative conditions, have to be rolled out, when the patient complains about dorso-ulnar wrist pain. This area of the wrist is called the “black-box”, as many diagnoses display similar local symptoms.
The foveal sign and DRUJ stability test (Figure 6 a and b), performed during comparison with the non-injured side, are the - among other several tests - the easiest and most consistent. But practice in assessing these patients is necessary as some patients, i.e. the Arabic population and young female athletes, often show habitual laxity, which can confuse the physiotherapist and physician in terms of the diagnostics.
Plain x-rays can sometimes display a widening in the DRUJ on frontal view or a dorsal sub-dislocation of the ulnar head on the lateral view.
Unfortunately, MRI is not sensitive and specific enough to rule out a significant injury to the TFCC11. Wrist arthroscopy is still the gold standard in diagnostics of TFCC injury and the only tool existing to evaluate the grade of instability and the healing capacity.
Tools measuring the torque force (Figure 7) is valuable in the diagnostics and surgical follow-up of TFCC injury with concomitant DRUJ instability. It has been shown that a reduction of 30% of the peak torque force is present in 1B injuries and that the patients gain 16 % after a successful surgery with re-insertion of the TFCC12-14.
I recommend surgery directly, if global DRUJ instability at initial presentation or if sub-dislocation of the ulnar head is present. High demand patients, as athletes, also often need an early surgical intervention.
Otherwise, I prefer to start with 6-8 weeks of physiotherapy including proprioceptive training (neuro-muscular training of the dynamic stabilizing muscles; pronator quadratus, extensor/flexor carpi ulnaris), especially isolated activation of the dynamic DRUJ-stabilizer; FCU (Figure 8)15.
A systematic review in 201813 showed that there are comparable results between open and arthroscopic repair of the TFCC, in terms of DRUJ re-instability incidence and functional outcome scores. The re-instability incidence is approximately 15 % after re-insertion of the TFCC - probably because there are so many DRUJ-stabilizing factors that have to be addressed in terms of this complicated joint. As the arthroscopic technique in my hands is easier, more clarifying in terms of evaluating the healing capacity, grade of instability and possible differential diagnoses, as well as it gives slightly less problems with stiffness and postoperative neuroma of the dorsal sensory nerve branch of the ulnar nerve, I prefer the arthroscopic ulnar tunnel technique, described in Figures 9. But still the method used in re-insertion of the TFCC, is still the surgeon´s choice. If initial global instability or re-instability after re-insertion surgery, I prefer to perform the Adams procedure16, described in Figure 10 or a ulnar shortening osteotomy, if ulnar variance is positive (> +2 mm) with persistent instability in neutral position.
After arthroscopic re-insertion of the TFCC, the postoperative treatment is as follows:
· 3 weeks of above elbow cast in approximately 90° of flexion and 20° of supination, followed by
· 2 weeks of custom made high TFCC-brace (Figure 11), allowing 20° of supination and pronation, and
· 2 weeks of low TFCC-brace.
After 4 months we allow full strength, but in terms of contact sports, the athlete has to wait to attend competition events for approximately 6 months in total.
WHY ARTHROSCOPIC RE-INSERTION?
The arthroscopic technique in my hands is easier compared with the open re-insertion techniques. The arthroscopic technique is more clarifying in terms of assessing the healing capacity of the TFCC, the grade of instability and possible differential diagnoses as well as gives slightly less problems with stiffness and postoperative neuroma of the dorsal sensory nerve branch of the ulnar nerve. The small scars are also preferable. The results are comparable with the open techniques.
Jonny K Andersson M.D., Ph.D.
Senior Consultant Hand Surgery
Aspetar Orthopaedic and Sports Medicine Hospital
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