The TFCC injury

The Triangular fibrocartilage complex (TFCC) is a group of soft tissues that provides support , load transmission and absorption between the carpal bones and the ulna. Also it stabilises the distal forearm (radius & ulna) during a gripping or rotational movement of the forearm. 

(picture link)

Anatomy

The origin involves the dorsal and volar radioulnar ligaments at the sigmoid notch of the radius. The insertion consists of the dorsal and volar radioulnar ligaments which converge at the base of the ulnar styloid process.

The Triangular fibrocartilage complex is formed by the soft tissues below

• The Dorsal and Volar Radioulnar ligaments (RULs)
• the Central Disc (CD)
• the Meniscus Homolog (MH)
• the Ulnolunate and Ulnotriquetral ligaments (UL & UT)
• the Extensor Carpi Ulnaris subsheath (ECU)

                                                                                                       (picture link)

The Blood supply

The periphery is vascularised by 10-40%

The central portion is avascular

It is very important to mention that the RULs are the main stabilisers of the DRUJ (distal radioulnar joint). There are superficial and deep fibers providing support during rotational movements with current dispute over which of them tighten during pron/supination

( superficial and deep fibers , picture link )

Common Signs

• Pain at the ulnar aspect of the wrist (just above the flexor carpi ulnaris)
• Pain with side to side movement of the wrist
• Painful gripping
• Swelling in the area
• Painful clicking

Causes

The injury of the TFCC can be traumatic (Type I) or degenerative (Type II)

Most common traumatic cause of injury is with the hand outstreched or during excessive rotation of the wrist. However, a traction force to the ulnar wrist might cause this type of injury. It affects mostly athletes in racquet or bat sports as well as gymnasts.

The degenerative injury occurs with time and age, mostly in people over 50 hovewer, it has been found that people can acquire such injury when in their 30s. This injury is associated with a positive ulnar variance or ulnocarpal impaction. Type II TFCC tears can also be caused in people with inflammatory diseases such as rheumatoid arthritis or gout.

Diagnosis

Diagnosing should start with careful examination of the wrist. It should be followed by an X ray to excluded any possible wrist fracture. The MRI provides the most reliable imaging to observe the extent of the TFCC tear as there are mildly useful provocative tests for diagnosing such an injury (link)

Management Non surgical options These can include the use of NSAIDs , CS injections and immobilisation. Immobilisation can take place via a splint, cast or wrap (favourable). There are few techniques that might help however I ve found that gently taping round the wrist  (check for P+Ns, hand / finger colour change after the application in case of nerve and/or blood vessel compression) might prove effective in the acute type I injury (link).Anecdotal Weight bearing on a scale might be a pain assessment tool for people who are doing a lot of hand bearing activities. There is no evidence on the effectiveness of manual therapy in such injuries apart from a case study of wrist bracing (link). Surgical options These include different methods depending on the extent of the TFCC tear (the classification of TFCC tears can be found here, link). Arthroscopic debridement Arthroscopic repain Open surgical repair If you' re interested in learning the literature behind the above then you could check this link. As always, thanks for reading. Art.