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Updated: Dec 18 2023

Triangular Fibrocartilage Complex (TFCC) Injury

Images
https://upload.orthobullets.com/topic/6047/images/tfcc mri 2.jpg
  • Summary
    • Triangular Fibrocartilage Complex (TFCC) Injuries, a common cause of ulnar-sided wrist pain, may result from trauma or due to degenerative changes.
    • Diagnosis is made clinically with ulnar sided wrist pain that is worse with ulnar deviation and a positive "fovea" sign. An MRI can help confirm diagnosis.
    • Treatment is generally conservative with NSAIDs and immobilization. Surgical debridement, TFCC repair or ulnar shortening procedures may be indicated depending on severity of symptoms and underlying cause.
  • Etiology
    • Mechanism of TFCC injury
      • Type 1 traumatic injury
        • mechanism
          • most common is fall on extended wrist with forearm pronation
          • traction injury to ulnar side of wrist
        • traction injury to ulnar wrist
      • Type 2 degenerative injury
        • associated with positive ulnar variance
        • associated with ulnocarpal impaction
  • Anatomy
    • TFCC made up of
      • dorsal and volar radioulnar ligaments
        • deep lig, known as ligamentum subcruentum, attach to the ulnar fovea
        • superficial fibers attach to the ulnar styloid
      • central articular disc
      • meniscus homolog
      • ulnar collateral ligament
      • ECU subsheath
      • origin of ulnolunate and ulnotriquetral ligaments
    • Blood supply
      • periphery is well vascularized (10-40% of the periphery)
      • central portion is avascular
    • Origin
      • dorsal and volar radioulnar ligaments originate at the sigmoid notch of the radius
    • Insertion
      • dorsal and volar radioulnar ligaments converge at the base of the ulnar styloid
        • deep fibers insert on to the ulnar fovea
        • superficial fibers insert on the ulnar styloid
  • Classification
      • Class 1 - Traumatic TFCC Injuries
      • 1A
      • Central perforation or tear
      • 1B
      • Ulnar avulsion (without ulnar styloid fx)
      • 1C
      • Distal avulsion (origin of UL and UT ligaments)
      • 1D
      • Radial avulsion
      • Class 2 - Degenerative TFCC Injuries
      • 2A
      • TFCC wear and thinning
      • 2B
      • 2A + Lunate and/or ulnar chondromalacia
      • 2C
      • 2B + TFCC perforation
      • 2D
      • 2C + Ligament disruption
      • 2E
      • 2D + Ulnocarpal and DRUJ arthritis
  • Presentation
    • Symptoms
      • wrist pain
      • turning a door key often painful
    • Physical exam
      • positive "fovea" sign
        • tenderness in the soft spot between the ulnar styloid and flexor carpi ulnaris tendon, between the volar surface of the ulnar head and the pisiform
        • 95% sensitivity and 87% specificity for foveal disruptions of TFCC or ulnotriquetral ligament injuries
      • pain elicited with ulnar deviation (TFCC compression) or radial deviation (TFCC tension)
  • Imaging
    • Radiographs
      • usually negative
      • zero rotation PA view evaluates ulnar variance
      • dynamic pronated PA grip view may show pathology
    • Arthography
      • joint injection shows extravasation
    • MRI
      • has largely replaced arthrography
      • tear at ulnar part of lunate indicates ulnocarpal impaction
      • sensitivity = 74-100%
    • Arthroscopy
      • most accurate method of diagnosis
      • indicated in symptomatic patients after failing several months of splinting and activity modification
  • Differential
    • Ulnocarpal abutment syndrome
    • Ulnar styloid impaction syndrome
    • ECU tendonitis
    • Hook of hamate fracture
    • Ulnar tunnel syndrome
    • Pisotriquetral arthritis
  • Treatment
    • Nonoperative
      • immobilization, NSAIDS, steroid injections
        • indications
          • all acute Type I injuries
          • first line of treatment for Type 2 injuries
    • Operative
      • arthroscopic debridement
        • indications
          • type 1A
          • diagnostic gold standard
      • arthroscopic repair
        • indications
          • type 1B, 1C, 1D
          • best for ulnar and dorsal/ulnar tears
          • generally acute, athletic injuries more amenable to repair than chronic injuries
        • outcomes
          • patient should expect to regain 80% of motion and grip strength when injuries are classified as acute (<3 months)
      • ulnar diaphyseal shortening
        • indications
          • Type II with ulnar positive variance is > 2mm
          • advantage of effectively tightening the ulnocarpal ligaments and is favored when LT instability is present
      • Wafer procedure
        • indications
          • Type II with ulnar positive variance is < 2mm
          • type 2A-C
      • limited ulnar head resection
        • indications
          • type 2D
      • Darrach procedure
        • indications
          • contraindicated due to problems with ulnar stump instability
  • Techniques
    • Arthroscopic debridement
      • approach
        • arthroscopic approach to the wrist
          • performed through combination of 3-4 and 6R portal
      • technique
        • maintain 2 mm rim peripherally otherwise joint can become unstable
      • pros & cons
        • not effective if patient has ulnar positive variance
        • 80% of patients obtain good relief of pain
    • Arthroscopic repair
      • approach
        • arthroscopic approach to the wrist
      • technique
        • many techniques exist such as outside-in and inside-out
        • generally suture based repair
      • pros & cons
        • only works for peripheral tears where blood supply is present
        • patient immobilized for 6 weeks
      • complications
        • ECU tendonitis from suture knot
        • dorsal sensory nerve injury
    • Ulnar diaphyseal shortening
      • approach
        • dorsal approach to the forearm
      • technique
        • osteotomy of the diaphysis or metaphysis followed by plate fixation
      • pros & cons
        • can address > 2 mm ulnar variance
        • requires immobilization and time for fracture healing
        • can help tension the ulnocarpal ligaments
      • complications
        • nonunion
        • hardware irritation necessitating removal
    • Wafer procedure
      • approach
        • dorsal approach to the forearm
      • technique
        • ulnar cortex is not disrupted
        • do not extend bone removal into the DRUJ
      • pros & cons
        • intrinsic stability of ECU, TFCC, and ulnar periosteum obviate need for plate fixation
    • Limited ulnar head resection
      • approach
        • arthroscopic approach to the wrist
      • technique
        • removal of approximately 2-4 mm of bone under the TFCC
        • distal ulnar burred through central TFCC defect
      • pros & cons
        • can be technically difficult to obtain level shortening through TFCC window
        • only applicable when patient has < 2mm of ulnar variance
    • Darrach procedure
      • approach
        • dorsal approach to the forearm
      • technique
        • resection of the distal 1-2cm of the distal ulna
        • TFCC should be approximated to the wrist capsule
      • pros & cons
        • salvage procedure for pain relief only
        • distal joint is unstable
      • complications
        • ECU tendon can sublux over remaining ulna causing pain
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