Triangular fibrocartilage complex (TFCC)

Introduction

• TFCC: Load-bearing structure; stabilizes ulnar wrist.
• Injuries: Acute/chronic; linked to forced ulnar deviation, positive ulnar variation.
• Symptoms: Ulnar-sided wrist pain, clicking, point tenderness.
• Diagnosis: MRI, arthroscopy.
• Treatment: Conservative and operative options.

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Etiology

• Load compression on TFCC in ulnar deviation.
• Common causes: Swinging a racket/bat.
• Positive ulnar variance: Articular surface of ulna more distal than radius.

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Epidemiology

• Prevalence increases with age.
• High prevalence in patients aged 70+ and those with ulnar-sided pain.

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History and Physical Examination

• Symptoms: Ulnar-sided wrist pain, worse with activity, grip weakness, instability, clicking.
• Sports-related injury history: Activities involving forced ulnar deviation such as swinging a racket or bat.
  • Acute (forced wrist extension)
  • chronic (heavy wrist load).
• Exam: Palpation best in pronation

Tests:

• TFCC Compression Test
  • Procedure: The patient’s forearm is placed in a neutral position with the wrist in ulnar deviation.
  • Positive Result: Reproduction of ulnar-sided wrist pain suggests TFCC injury.
• TFCC Stress Test:
  • Procedure: Applying a force across the ulna with the wrist in ulnar deviation.
  • Positive Result: Pain indicates TFCC injury.
• Press Test:
  • Procedure: The patient lifts themselves out of a chair using the wrists in an extended position.
  • Positive Result: Pain indicates a TFCC tear.
• Supination Test:
  • Procedure: The patient grabs the underside of a table with the forearms supinated.
  • Positive Result: Pain from loading the TFCC and dorsal impingement suggests a peripheral, dorsal tear.
• Piano Key Test:
  • Procedure: The patient places both hands on an exam table and presses the palms down.
  • Positive Result: Prominent distal ulna on the affected side suggests distal radioulnar joint instability, associated with TFCC injury. If the ulnar head returns to normal position when the palms are relaxed, the test is positive.
• Grind Test:
  • Procedure: Compressing the radius and ulna while rotating the forearm.
  • Positive Result: Pain indicates a possible degenerative process or TFCC injury.

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Evaluation

• Radiographs: Evaluate for fracture, ulnar variance.
• MRI: Standard diagnostic tool.
• Arthroscopy: Most accurate diagnosis method.
• Important: Assess lunotriquetral ligament integrity.

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Treatment/Management

• Conservative: Rest, physical therapy, corticosteroid injections (up to 6 months).
• Limited evidence for bracing.
• Surgery: For failed conservative treatment or DRUJ instability.
  • Options: Arthroscopic repair, debridement, ulnar shortening, Wafer procedure.
  • Based on Palmer classification.
• Elite athletes: Tailored treatment; options to delay surgery.