TFCC injuries

What are TFCC injuries?

TFCC (triangular fibrocartilage complex) is a ligamentous-cartilaginous structure that lies in the little finger side of the wrist. As the name implies it’s a complex structure that comprises of meniscus homologue (like meniscus in knee joint), central articular disc, ulnolunate ligament, ulnotriquetral ligament, radioulnar ligament (dorsal and volar), and sheath at the floor of the extensor carpi ulnaris. TFCC provides cushion and support to the small carpal bones of the wrist and plays an important role to stabilize the forearm bones namely radius and ulna at the wrist joint while loading, grasping anything or rotating the forearm. Any injury to TFCC can destabilise the wrist joint resulting in chronic pain and instability of the wrist.

 TFCC tears are of two types-

  1. Type 1 TFCC tears- this type of TFCC tears occur due to an injury resulted from falling onto an outstretched hand especially when wrist is pronated (palm facing the floor). This may happen due to sport activities like playing racquet or tennis, cricket, boxing, fall on an outstretched hand etc. Repetitive overuse of hand while lifting heavy luggage or gardening can cause tears in the TFCC.
  2. Type 2 TFCC tears- this type of TFCC tears occur due to degenerative wear and tear as a result of rheumatoid arthritis or gout, long ulna, old age etc.

 

What are the symptoms of TFCC injuries?

The most common symptom of TFCC injuries is pain in the wrist typically on the little finger side or ulnar side of your wrist. The pain may spread to the whole wrist. It is felt more when you load your wrist, normal activities rarely causes any symptoms. A clicking or popping sound is also heard when the wrist is moved in certain directions.  You may feel weakness in grasping anything and find it difficult lifting yourself out of the chair using your affected wrist. You may also notice that one of your bone on the little finger side of your wrist being more prominent.

 

How is it diagnosed?

TFCC injuries are commonly missed or misdiagnosed as wrist sprain. Your orthopaedic surgeon will assess your complete medical history, history of trauma or injury and careful physical examination. He will perform a TFCC tear test to diagnose the injury.  He will ask for X- ray to start with and MRI scan is essential to confirm the diagnosis and plan for the management.

 

What happens if nothing is done?

If TFCC tear is left untreated, you may feel persistent pain, stiffness, clicking and most commonly weakness at the wrist joint. The joint may become unstable and could end up with arthritis of the joint.

 

How is it treated?

Management of TFCC tears is based on the symptoms, patient expectations, activity level, extent of tear and stability of the wrist joint. Most TFCC tears can be treated conservatively, that involves splinting, cold application, anti-inflammatory medicines, steroid injection, and hand therapy.

Surgery is indicated in-

  • Type 1- acute unstable injury
  • Complete symptomatic tear
  • Type 2 with ulnar positive variance >2 mm
  • Weakness and unstable distal radio-ulnar joint
  • Large tears
  • Instability of wrist joint
  • Persistent pain and clicking
  • Ulnar impaction syndrome

 

What are the non-operative treatments?

The non-operative treatments involve –

  • Immobilization/Activity modification- your wrist is immobilized in a splint for 4- 6 weeks to allow proper healing and prevent new injury to the affected area. The splint usually involves immobilising your elbow to prevent forearm rotation.
  • Ice packs (frozen peas bag)– you can also apply ice on the joint for 20 -30 minutes in every 2 to 3 hours in first two days of the injury as it can relieve pain and swelling.
  • Medications– anti-inflammatory medicines like ibuprofen or aspirin may be given to regulate pain and swelling in the wrist for few days, as long-term consumption of these medicines can delay healing and may cause damage to your kidneys and stomach.
  • You have to keep your hand and wrist elevated (above the level of your heart) and keep moving your fingers, elbow and shoulder to maintain the flexibility and prevent stiffness of its joints.
  • Hand therapy- early range of motion exercises is started after 1 to 2 weeks of immobilization to prevent stiffness and maintain the good mobility in your elbow. Your wrist and elbow is prone for getting stiff and the splint is removed 3 times a day for exercises (20mins each –wrist and elbow flexion and extension, no forearm rotation). They are started with gentle exercises and are slowly progressed to strenuous and strengthening exercises to improve the range of motion, strength and prevent stiffness. Early hand therapy under the supervision of your surgeon is paramount for optimal outcome.

 

What does the operation involve?

The main purpose of the operation is to repair the damaged tissue of the TFCC and it can be done with arthroscopy (keyhole surgery) or open surgery.

  • You are admitted to the hospital and the operation is usually performed as a day case.
  • The operation is performed under general anaesthesia or local anaesthesia (Block). In general anaesthesia, the patient does not feel anything and sleeps throughout the operation. In local anaesthesia, the patient remains awake during the operation but he cannot feel whatever is happening in the surgical area. Your anaesthetist can select a combination of both local and general anaesthetic.
  • A tourniquet is tied around your upper arm to reduce blood loss during surgery.
  • Procedure– once anaesthesia is given to the patient, antibiotics are also given to him to prevent any infection during and after the operation. Cut in the skin is made based on the procedure, minor tears are treated by debriding (cleaning/removing) the damaged part. However complex tears are repaired with bone anchors.
  • In some cases, long end of the ulna exerts pressure on the TFCC, this condition is called ulnar impaction syndrome. In such cases, ulnar bone is shortened to appropriate length and fixed with plates and screws
  • The skin is closed with the help of absorbable sutures.
  • The operation takes 1-2 hours to end. Most patients are discharged on the same day.

 

What happens after surgery?

  • The local anaesthetic wears off 4-10 hrs after surgery; patients are encouraged to start taking painkillers before the pain starts i.e. on return home and for at least 48 hours from there. This way most of our patients report little or any pain.
  • Your wrist is rested in a half cast for 2 weeks to protect it from injury and allow proper healing.
  • You should keep your arm elevated (above the level of your heart) most of the times as it prevents swelling. Besides keep moving your fingers, elbow and shoulder.
  • Before discharge, your physiotherapist will teach you gentle exercises of the hand, wrist, elbow and shoulder that you can start soon after the operation from the first day.
  • The patient is reviewed in clinic around 2 weeks following the operation for wound check and physiotherapy.
    • In simple debridement, the wrist is mobilised as tolerated after this brief period of rest.
    • If the TFCC is repaired, the wrist immobilised with splint for 6 weeks and hand therapy
    • Following ulnar shortening osteotomy and ORIF with plates and screw, usually the plaster is changed to splint and hand therapy commenced
  • The wound should be massaged (typically after 2 weeks) using the moisturizing cream by the patient 3 times a day for 3 months once the wound is well healed. This reduces the scar sensitivity and scar-related complications (tenderness; helps scar to mature).
  • You will be guided by your surgeon and hand therapists regarding rehabilitation. In majority of the cases, you could start a gentle range of movement (ROM) exercises at 2 weeks and progress to more strenuous activities (swimming, driving, lightweights in gym etc) around 3 months.. It is advisable to avoid contact sports or any injury to the affected area for 3-6 months. The duration may increase or decrease based on the complexity of the problem and the treatment involved.

 

Are there any risks?

  • Infection
  • Stiffness in the wrist
  • Dorsal sensory nerve injury
  • Persistent instability, weakness
  • Radio carpal / distal radio-ulnar arthritis
  • Injury to ulnar nerve
  • Malunion
  • Non-union
  • Injury to nerves vessels and tendon
  • Tendon irritation
  • Complex regional pain syndrome

 

What are the results of the operation?

The results of TFCC surgery are good with minimum serious complications (<1%). Most patients regain good function and stability of wrist joint after the surgery. The outcome is more predictable under the experience of the author.

 

When can I return to driving and work?

You can get back to work in 2-4 weeks if you have a desk job, however might take upto 3 months if your job involves physical work. Regarding return to contact sports, it usually takes 3-6 months and depends on the severity of injury.  You should be able to resume driving in 6-12 weeks. The above time line could vary based on the severity of injury and the treatment modality.  Your physician will be able to advise you.

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