TFCC & Ulnar-side wrist injuries

Ulnar-side wrist pain can be caused by injury to the various tissues found between the radiocarpal joint and distal radioulnar joint. The term triangular fibrocartilage complex (TFCC) is used to describe a complex of fibrocartilage and ligamentous tissue located on that lateral aspect of the wrist (Nakamura, Yabe & Horiuchi., 1996). It consists of  “the disc proper, the meniscus homologue, the ulnolunate ligament, and the ulnotriquetral ligament” (Nakamura, Yabe & Horiuchi., 1996, p.582)

• The TFCC originates from the distal radius (sigmoid notch on the ulnar border of the articular surface of the distal radius) and ulnar head (ulnar styloid and fovea of the ulnar head) binding the distal radioulnar joint together.
• It travels distally to the proximal row of carpal bones (lunate, triquetrum, hamate, and base of fifth metacarpal) (Ko & Wiedrich., 2012, p.308).

The articular disc

The articular disc is a “horizontally oriented structure that is avascular, thin, and triangular in shape, lying between the ulnar head, the lunate, and the triquetrum.” (Ko & Wiedrich., 2012, p.308). Only the peripheral 10-40% of the disc receive a vascular supply from the dorsal and palmar radiocarpal branches of the ulnar anterior, and the palmar branch of the anterior interosseous artery. “Therefore, the palmar, ulnar, and dorsal components of the TFCC possess inherent healing potential, whereas the central and radial portions of the TFCC are largely avascular, which significantly limits the ability of these regions to heal in the setting of injury.” (Ko & Wiedrich., 2012, p.308).

Representation of the anatomy of the ulnar side of the wrist (Ko & Wiedrich., 2012, p.308).

Dynamic stability

• The function of the TFCC is to stabilize the ulnarcarpal and distal radioulnar joints (DRUJ).
• The TFCC is a load-bearing structure between the ulnar head, and lunate and triquetrum bones, which makes it susceptible to acute traumatic and degenerative overload injuries (Ko & Wiedrich., 2012, p.308).
• It is believed to take about 18-20% of the load of the wrist (Ko & Wiedrich., 2012, p.309).

Not all of the TFCC contributes equally to stability of the DRUJ. The central and avascular portion of the disc is not a major stabiliser of the DRUJ (Ko & Wiedrich., 2012, p.308).

• The part of the TFCC which inserts into the ulnar carpal bones is hammock-like in shape and structure, and allows smooth motion of the bones during flexion, extension, radial deviation and ulnar deviation by accomodating twisting movements. (Nakamura, Yabe & Horiuchi., 1996)
• There is little deformity seen in the disc proper during pronation and supine” (Nakamura, Yabe & Horiuchi., 1996, p.585).
• During supination & pronation the deep dorsal and superficial volar radio-ulnar ligaments tighten to prevent further dorsal displacement of the ulna. These extrinsic ligaments (ulnotriquetral and ulnolunate) act as stabilizers between the distal ulna and volar carpus.” (Sachar., 2008, p. 1669).
• Don't forget that pronator quadratus and the extensor carpi ulnaris are also dynamic stabilizers of the distal part of the ulna.

Clinical presentation

“To make an accurate diagnosis of the etiology of ulnar-sided wrist pain, one must take an adequate history, perform a detailed physical exam, and accurately interpret appropriate diagnostic tests.” (Sachar, 2008., 1670). Specifically, try to isolate information about the following factors.

1. Location of pain

“TFCC injury should be suspected when an athlete presents with vague ulnar-sided wrist pain or
tenderness, possibly associated with an audible or palpable click on forearm rotation.”  (Ko & Wiedrich., 2012, p.307). 

2. Mechanism of injury 

The wrist moves through flexion, extension, radial and ulnar deviation, and various degrees of forearm pronation and supination. Each of these movements can be performed with varying levels of grip force. Therefore, knowing the motion of the wrist, the amount of weight bearing or grip loading is important to understanding the MOI and structures involved. 

“Ulnar deviation, grip, and pronation are all movements that stress the TFCC when swinging a baseball bat, tennis racquet, or golf club" Other sports that stress the TFCC through axial loading include gymnastics, and boxing. (Ko & Wiedrich., 2012, p.309)

Acute injuries are generally accompanied with a specific event that the patient can remember such as swinging a bat, falling onto a pronated outstretched hand, and usually have a degree of wrist extension and hyperpronation (Sachar, 2008, 1670).

• ** Wrist extension injuries will impact the lunotriquetral ligament
• ** Dislocation of the DRUJ may be associated with a pop or noise and immediate visible deformity (Sachar, 2008, p1670).

Chronic injuries due to repetitive overload won’t have the same recognisable moment in time.

Physical examination

Given the complex anatomy of the TFCC described above, it is important to identify what structures are likely to be contributing to ulnar-side wrist pain. This requires the clinician to perform a battery of tests. It is important to note though that there remains "little evidence of the accuracy of these tests” (Prosser, et al., 2011, p. 247). As clinicians you will need to rely on your clinical reasoning to understand the meaning of the findings from your physical exam. 

Observe for swelling and deformity first, to rule out a fracture or dislocation. When observing both wrists, if the ulna is more prominent dorsally this may indicate an injury to the DRUJ. (Sachar, 2008)

Range of movement of wrist flexion, extension, radial deviation, ulnar deviation, pronation & supination.

Blue (TFCC), green (lunotriquetral interval), pink (scapholunate interval), and orange (DRUJ).

Palpation:

• “The lunotriquetral interval (lime green) is palpated dorsally between the fourth and fifth compartments one finger breadth distal to the DRUJ and with the wrist in 30 degrees of flexion” (Sachar, 2008, p. 1671).
• The TFCC (light blue) is best palpated in the soft spot between the ulnar styloid, FCU and volar surface of the ulnar head. This is known as the ulna fovea sign (Ko et al., 2012; Sachar, 2008; Tay et al., 2007). 
• The fovea sign test has a 95.2% sensitivity and 86.5% specificity (Sachar, 2008, p.1671; Tay et al., 2007, P483). That is, it is sensitive and specific in detecting foveal disruption of the distal radioulnar ligament and ulnotriquetral ligament injuries (Tay et al., 2007).
• UT ligament injuries are typically associated with a stable DRUJ and foveal disruptions are associated with an unstable DRUJ (Tay et al., 2007, p. 438).

Pain provocation tests

Prosser et al (2011) suggest the following provocative tests to diagnose wrist ligament injuries:

1. The scapholunate ligament is tested by applying pressure through the examiner’s thumb to the scaphoid tubercle.
2. The lunotriquetral joint/ligaments can be evaluated with 3 tests (Sachar., 2008, p. 1671; Sachar., 2012, p.1491-1492)
   1. The Regan shuck - a sheering test between the lunate and triquetrum. Move the lunate in a volar and dorsal direction while moving the remaining wrist in the opposite direction.
   2. The Kleimman Shear test - a similar sheering test for the LT ligament but with more fine hand placement than the Regan shuck test. One thumb and index finger is placed over the pisiform and triquetrum while the other hands stabilises the lunate and radial column of the wrist.
   3. LT ligament ballottement /compression. Stabilise the hand while the thumb applies a radial force driving the triquetrum into the lunate.
3. The arcuate ligament is tested with the midcarpal stress test and considered positive if there was a catch up clunk in the midcarpal joint in the addition to pain reproduction.
4. The distal radioulnar joint (DRUJ) - piano key test
   1. “This test is performed with the patient's palp flat on the table. The test is performed by applying a dorsal to volar load across the ulna 4cm proximal to the DRUJ. Pain should be reproduced at the DRUJ joint level.” (Sachar, 2012., p. 1492).
   2. If the deep dorsal fibers have been severely sprained or detached from the fovea, performing this maneuver may cause subtle subluxation or gross instability of the DRUJ (and pain).
   3. Laxity in both supination and pronation potentially represents a multiplanar tear of both deep dorsal and palmar fibers of the ligamentum subcruentum. (Ko et al., 2012, 310)
5. The TFCC is tested with a stress test (wrist is in ulnar deviation while applying a shear force across the ulnar complex of the wrist) and compression test (as per stress test but with compression). 
6. The GRIT test is used to evaluate the integrity of the lunate cartilage (ulnar impaction syndrome) using a grip measurement in neutral, pronation and supination.  
7. ECU (extensor carpi ulnaris) is examined by resisted movement into ulnar deviation (MMT). This is performed with the forearm in supination and elbow flexed to 90 degrees.
8. Weight bearing on the wrist in extension - the press test.
9. Combined pronation, ulnar deviation and compression - reproduce clicking sounds.

Outcome measures

Patient-rated wrist and hand questionnaire is described in further detail here. 

Classification for diagnosis

As you can see from the assessment and anatomy sections above, there are many causes of ulnar-sided wrist pain from structures other that the TFCC. Differential diagnosis of ulnar sided wrist pain includes: “synovitis, lunotriquetral ligament injuries, extensor carpi ulnaris subsheath injuries, ulnar extrinsic ligament injuries, and TFCC tears” (Park, Jagadish, & Yao., 2010, p. 3).

In general, a wait and see approach with immobilisation is used for acute wrist injuries, however in the athletic population, early detection of a TFCC injury is necessary to determine what course of treatment is most appropriate. 

“The gold standard for diagnosing TFCC disorders remains wrist arthroscopy.” (Ko & Wiedrich., 2012, p.311; Prosser et al., 2011). The following classification system is widely recognised and used during arthroscopy to help direct the best course of treatment.

Palmer classification system

Directions for surgical treatment

The role of surgery is dependent on the classification of injury.

• “Arthroscopic debridement is the treatment of choice for IA lesions, with biomechanical studies showing that up to 80% of the articular disc can be removed without creating instability.” (Ko & Wiedrich., 2012, p.312).
  • Splinted for 1 week
  • Most athletes return to sport at 4-5 weeks.
  • Success is 66-87%
• “Lesions of the ulnar, vascular side of the TFCC (IB lesions) are most amenable to arthroscopic or open repair, and early arthroscopic intervention should be encouraged in the elite athlete.” (Ko & Wiedrich., 2012, p.312-313).
  • Splint for 6 weeks
  • ROM for 6 weeks
  • Return to sport around 3 months post surgery
• “Although IC tears are diagnosed arthroscopically, they are generally repaired using an open technique.” (Ko & Wiedrich., 2012, p.313). The postoperative regime is similar to IB repairs.
• “Radial avulsions of the TFCC at the sigmoid notch are often associated with distal radius fractures and can lead to DRUJ instability (ID lesions).” (Ko & Wiedrich., 2012, p.315)
  • ‘A critical step necessary for healing of the repaired ID lesion involves introducing a burr into the sigmoid notch and a 16-mm (0.062-inch) K-wire is advanced through the distal aspect of the sigmoid notch and out through the radial wrist incision.’
  • The postoperative regime is similar to IB repairs.
• “The athlete with a IIA or IIB lesion presents with an insidious onset of ulnar-sided wrist pain that is worse with activity and relieved with rest. Plain radiographs should be obtained to evaluate for DRUJ arthritis and assess ulnar variance, including the pronated grip view. High-performance athletes will most likely not agree to a conservative treatment regimen, so ulnar-shortening osteotomy should be offered to the athlete with ulnar-neutral or ulnar-positive variance.” (Ko & Wiedrich., 2012, p.316-18).
• IIC lesions “should be treated by either arthroscopic debridement and wafer resection or formal ulnar shortening in athletes with ulnar- positive variance.” (Ko & Wiedrich., 2012, p.318).
• IID & IIE lesions are treated similarly to IIC lesions, however there is a focus on determining in lunotriquetral instability exists or not. If there is instability, “then a wafer procedure is not recommended because it does nothing to address the lunotriquetral instability. Instead, the ulna should be shortened, which tightens the ulnocarpal ligaments and thereby helps to stabilize the lunate and triquetrum. If the lunate and triquetrum are still unstable, then a lunotriquetral arthrodesis may be necessary at a later date if the patient does not respond to ulnar shortening.” (Ko & Wiedrich., 2012, p.318).

Patient outcomes long term & RTS:

As you can see from above, the type of surgery performed depends heavily on the injury which is diagnosed. This explains why many athletes with acute injuries with have early arthroscopy to help with diagnosis and determining treatment direction.

• Generally, a ‘good to excellent’ outcome is achieved in 63% (Reiter et al., 2008).
• 1A debridement specifically achieved a 66% to 87% successful outcome (Ko & Wiedrich, 2012).
• 1B repairs specifically achieved a better result with 94% of patients reporting they were satisfied or very satisfied with their surgery (deAraujo et al., 1996).
• Ulnar shortening osteotomy resulted in 92% complete pain relief or occasional mild pain (Minima & Kato, 1998).
• Traumatic TFCC tears which are frequently seen together with distal radius fractures do not affect the long-term functional results. Therefore, further diagnostic tests and treatment of TFCC tears in patients with stable distal radius fractures may be unnecessary.

Role of Physiotherapy

Conservative management is the best choice for acute cases (Lubiatowski et al., 2006). This includes immobilisation, NSAIDS or CSI and occupational therapy (Ko & Wiedrich., 2012). Immobilisation for a minimum of 4 weeks should be trialled before pursuing further imaging (Park et al., 2010). Don’t rush for an MRI. If you need to rush, send them to an orthopedic specialist who can perform an arthroscopic evaluation. 

Treatment will be directed by degree of pain, severity of injury, competitive level of the athlete and the presence of DRUJ instability. Early diagnosis is of the utmost importance! Clinicians need to understand the sport, position played and level of competition to accurately decided on the best direction for treatment. 

TFCC injuries can often be managed conservatively, however failing this or under some circumstances surgery should be considered as an option. Immobilisation may allow for partial peripheral tears without DRUJ instability to heal. The central disc is avascular and less likely to heal with immobilisation.

There is a need for more research to better direct treatment. From experience, the following are points to consider during treatment planning. 

• Passive mobilisation can help with pain - treat the dysfunction you find!
• Help to restore pain free ROM.
• Need rotational control- pronator quadratus and ECU (attachments into the complex) are important- isometric and dynamic.
• The pronator quadratus actively stabilizes the joint by coapting the ulnar head in the sigmoid notch, particularly in pronation, and it passively stabilizes the joint by viscoelastic forces in supination. An intact extensor carpi ulnaris and fibro-osseous tunnel partially stabilize the distal radioulnar joint even after the triangular fibrocartilage and other ligaments are sectioned (Szabo, 2006).

Sian

References

Cleland, J. (2005). Orthopaedic clinical examination: an evidence-based approach for physical therapists: WB Saunders Co.

Deniz, G., Kose, O., Yanik, S., Colakoglu, T., & Tugay, A. (2013). Effect of untreated triangular fibrocartilage complex (TFCC) tears on the clinical outcome of conservatively treated distal radius fractures. European Journal of Orthopaedic Surgery & Traumatology, 1-5

Ko, J. H., & Wiedrich, T. A. (2012). Triangular fibrocartilage complex injuries in the elite athlete. Hand clinics, 28(3), 307-321.

Nakamura, T., Yabe, Y., & Horiuchi, Y. (1996). Functional anatomy of the triangular fibrocartilage complex. Journal of Hand Surgery, 21(5), 581-586.

Park, M. J., Jagadish, A., & Yao, J. (2010). The rate of triangular fibrocartilage injuries requiring surgical intervention. Orthopedics, 33(11).

Prosser, R., Harvey, L., LaStayo, P., Hargreaves, I., Scougall, P., & Herbert, R. D. (2011). Provocative wrist tests and MRI are of limited diagnostic value for suspected wrist ligament injuries: a cross-sectional study. Journal of physiotherapy, 57(4), 247-253.

Sachar, K. (2008). Ulnar-sided wrist pain: evaluation and treatment of triangular fibrocartilage complex tears, ulnocarpal impaction syndrome, and lunotriquetral ligament tears. Journal of Hand Surgery, 33(9), 1669-1679.

Sachar, K. (2012). Ulnar-sided wrist pain: evaluation and treatment of triangular fibrocartilage complex tears, ulnocarpal impaction syndrome, and lunotriquetral ligament tears. Journal of Hand Surgery, 37(7), 1489-1500.

Szabo, R. M. (2006). Distal radioulnar joint instability. JBJS, 88(4), 884-894.

Tay, S. C., Tomita, K., & Berger, R. A. (2007). The “ulnar fovea sign” for defining ulnar wrist pain: an analysis of sensitivity and specificity. The Journal of hand surgery, 32(4), 438-444.