Triangular Fibrocartilage Complex (TFCC) Wrist Injuries

WHAT IS THE TRIANGULAR FIBROCARTILAGE COMPLEX (TFCC)?

Our triangular fibrocartilage complex (or TFCC / TFC, for short), refers to a very complex cartilage structure that's located at the wrist area that's close to your little finger.

The TFCC is made of a mix of

• tendons
• ligaments
• cartilage

that's connected to the extensor carpi ulnaris (ECU).

When we grip something or whenever we rotate our wrist and forearm, our TFCC helps stabilize the wrist and forearm bones.

On top of that, our TFCC also behaves as a "shock absorber" between the ulnar bone (the forearm bone that's closer to the little finger side) and the small carpal bones of the wrist called the triquetrum and lunate.

Unfortunately, some individuals are more at risk / higher tendency to get TFCC injuries due to a problem from birth called ulnar variance, where the ulna is longer than the radius.

COMMON CAUSES OF WRIST TFCC INJURY

The key causes that increases your risk of developing a triangular fibrocartilage complex (TFCC) in your wrist:

1. Sports: wrist injuries are very common in those who play tennis, badminton, basketball and baseball (or cricket). Research shows that 25% of all sports injuries are in the hand or wrist!
2. Age: our risks of injuring our wrist TFCC increases with age predominantly because as the wear and tear (degradation) of the wrist joint and TFCC, it makes it easier to injure it more seriously.
3. Chronic Inflammation: inflammatory diseases such as rheumatoid arthritis or gout as well as repetitive strain injuries (RSI) can cause wrist damage over time. Research showed that TFCC tears were observed in 39% of people with severe rheumatoid arthritis.

HOW DOES TFCC INJURY OCCUR?

Generally, there are two types or forms of triangular fibrocartilage complex tears:

1. Traumatic kind where one falls on outstretch hand, very hard or strong arm rotation or a force or blow to the wrist. People who plays games or sports that involve bats, racquets or place pressure on their wrist (such as weight lifters, dancers, yoga instructors) are often at risk
2. Degenerative kind where the TFCC cartilage wears down with use and time. If their jobs or interest include repeated wrist rotations and squeezing, that can weaken the TFCC such that even minor forces or rotations can tear the TFCC easily.

TFCC INJURY SYMPTOMS

The #1 symptom of a TFCC injury, sprain or tear is ulnar sided wrist pain (which is pain at the wrist level below the little finger).

You may feel the pain constantly (like 24/7) ache, and sharp pains when force is applied through it. Some patient may feel pain in their entire wrist.

Other related pains of TFCC includes:

• A clicking or popping sound when you move your wrist
• Swelling
• Instability
• Weakness
• Limited motion
• Tenderness

TESTS: DIAGNOSING YOUR WRIST PAIN (IS IT TFCC INJURY?)

Ulnar Fovea Sign

The ulnar fovea sign is the most specific and can be the most intense TFCC-specific test, and it's performed with

1. the patient is across the therapist (or orthopedic doctor)
2. their elbow flexed 90 degrees upright on the table
3. ulnar aspect of wrist facing the therapist
4. we stabilize the wrist with our left hand
5. and with the other hand, we palpate and push into the soft region of the ulnar side of the wrist, above the ulnar styloid
6. if tender, then the test is positive and indicates a possible wrist TFCC injury at the styloid and/or foveal attachment sites

Piano key test

This test is to determine wrist stability, where we

1. support the wrist in pronation (palm down)
2. we stabilize the ulnar side of the forearm
3. then we apply gentle force to the ulnar head and release
4. IF the ulnar head pops back to its usual location, then the test is positive

An additional test is to

1. get the patient to sit at a desk
2. place their injured hand face up under the table, pressed against the bottom of the table underside
3. patient to attempt to raise the table by flexing the wrist
4. this action loads the dorsal part of the TFCC, and if this test is painful, that may be indicative of a peripheral dorsal TFCC tear

Ulnocarpal stress test

For this test,

1. we use our left hand to stabilize your injured hand
2. your elbow is flexed at 90 degrees with the hand facing upwards
3. we then hold your elbow in our left hand and your hand in our right hand
4. then we deviate your wrist in full ulnar deviation (means to bend your wrist towards your thumb) AND rotate your wrist at the same time

If there's pain, it's a positive sign.

Press test

The patient sits in a chair or bed and push themselves off with their palms facing down -- this typically causes sharp, intense pain with patients with TFCC tear.

WRIST TFCC INJURY TREATMENT OPTIONS

Conservative / Non-Operative

• Decrease strains on wrist (lifestyle, work and activities)
• Splint specificly: Muenster-type splint, at least eight weeks
• Non-steroidal Anti-inflammatory Drugs to reduce pain and swelling
• Hand & Wrist TFCC Therapy (Pre / Non-surgery)
  • Ultrasound
  • Heat treatment
  • Manual therapy
  • Wrist gentle / gradual strengthening
  • Activity / sports-specific strengthening
• Considerations for injections
  • Hydrocortisone and Lignocaine (cortisone) injections
  • PRP (plasma-rich protein) injections

TFCC Surgery

Arthroscopic

This approach, the surgeon will make a few small incisions around the wrist joint and use a micro-camera (arthroscope) to check the ligaments and measure the impairments before they clean the edges of the injury and remove damaged tissues (debridement) followed by repair with small surgical equipments.

If there is ulnar variance, the surgeon can "trim" the ulnar bone to the right length.

The good thing about arthroscopy is that the surgeon can see the entire wrist without traumatizing the nerves, muscles and other soft tissue inside, and most patients report less pain, less blood loss, less complications and quick recovery time.

Open Surgery

If the TFCC is complex, severe or present with multiple structural tears, the surgeon may recommend for open surgery if there is need to repair the injury with metal pins, screws or other fixation device.

For such cases, patients will need open incision as it's more intensive surgically. Likewise, the surgeon can also fix the ulnar variance too.

WRIST TFCC INJURY RECOVERY TIME

Recovery time for TFCC tears is about 6-8 weeks if very mild, but for more complex injuries it may take 8-24 weeks.

Same thing for surgery, it may take 8-24 or more weeks of hand therapy post wrist TFCC injury or tear surgery followed by hand therapy.