Non-Surgical Triangular fibrocartilage complex tear and distal radioulnar instability

Ross Hauser, MD., Caring Medical Florida
Danielle R. Steilen-Matias, MMS, PA-C., Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
David N. Woznica, MD., Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois

Triangular fibrocartilage complex tear of the wrist TFCC

You have a lot of pain on the outside of your wrist. After a few weeks or months of anti-inflammatories and other over-the-counter painkillers, you go online or to the nearest pharmacy and buy yourself a wrist brace. After continued self-managed care and the fact that your wrist is still painful and nothing you are doing is helping, you go to your doctor. After an examination, your doctor refers you onto the orthopedist. An eventual MRI reveals that you have a Triangular fibrocartilage complex tear or a TFCC. What you hear is something in your wrist is torn. You ask the doctor, “will it require surgery?” “Maybe not,” is the reply. “But you will need to rest your wrist to allow it to heal.”

Your orthopedist will probably ask you if you have been putting ice on your wrist? Most people do.

Then you may be asked, “Do you keep your hand elevated on a pillow when you are trying to sleep?” Because of the wrist pain, you may tell the doctor that you are having difficulty in getting a good night’s sleep. You may be one of the people who wraps their hand up in a pillow and makes a soft cast out of it with the help of an ace bandage. This is usually not effective.

At this time a cortisone injection may be recommended to you. For many people, this will work fine. For others, the wrist pain will continue and more options will need to be considered. You may be reading this page because you are on the hunt for more options.

Now I have to wait another 2 months maybe more for the surgery and then it could be a 2 to 6 months recovery beyond that

Some people will wind up here at Caring Medical. When we first meet them they are sitting on our examination table. They will usually be grasping their “bad” wrist with their other hand and rubbing the pinky side area. They will say things like this:

“My wrist has been bothering me for a long time now. I play a lot of tennis, it has been getting worse and worse. I went to my doctor, he referred me to the orthopedist, I had a nerve test and an MRI and everything came back pointing to a Triangular fibrocartilage complex tear. If I have the surgery it will be months before I can do anything with that hand.”

– or –

“I am thinking about getting the surgery now, I have been icing and bracing and resting for months now. I had cortisone, nothing helps. Now I have to wait another 2 months maybe more for the surgery and then it could be a 2 to 6 months recovery beyond that. I am frustrated and would like to get something done now.”

Some people are in our office because they need to work and their job is physically demanding.

Not everyone is a weekend warrior, a sports enthusiast who goes all out on the weekend. Some people are in our office because they need to work and their job is physically demanding. They find that their wrist is catching, getting stuck, and they are not only in pain but they are losing hand function. Some of these people are close to making a surgical decision.

“My MRI came back that I had a triangular fibrocartilage tear. My orthopedist gave me a very sound opinion based on his experiences. Since I had a lot of inflammation, we can try to put my wrist in a cast for 4 weeks and see if the forced inactivity and rest would calm everything down, or, I could have the surgery. It would be 2 or 3 or 4 months of recovery, AND, there is no guarantee that the surgery would help me.”

For some people, surgery may be beneficial. Some surgeons, as we will discuss below in new research, do not think surgery is a “sure thing.”

The path to surgery and what surgery may look like when you get there

A February 2020 paper (1) sought to offer surgeons a less complicated surgical option that may work. In the introduction to this paper, the research surgeons gave a look at the familiar path people take to surgery and some of the problems they may encounter when they get there.

“Nowadays, arthroscopy plays an important role in providing treatment as well as in establishing the diagnosis. (of Triangular fibrocartilage complex tear). Arthroscopic repair of a TFCC tear is indicated after the failure of non-surgical treatments such as cast immobilization, splinting, and administration of nonsteroidal anti-inflammatory drugs for more than 3 months. Several arthroscopic therapeutic methods have been described, including the inside-out, outside-in, and all-arthroscopic techniques. However, these arthroscopic procedures are time-consuming and technically demanding.”

That is the patient journey to TFCC surgery.

Triangular fibrocartilage complex tear – more than a cartilage tear – it is a problem of the hypermobile wrist and grinding instability

In our experience, patient/athletes with triangular fibrocartilage complex (TFCC) injury suffer from complex ligament degenerative problems that are contributing to the grinding wrist instability, carpal instability. Using the term “grinding instability,” is probably something that you can relate to because your wrist is grinding, making cracking, popping noises, and it feels like things in your wrist are being rubbed the wrong way.

Some of you with a more advanced problem may have been suggested to an ulnar shortening osteotomy because of this grinding. This is a surgery to shave down the ulna, the pinky side forearm bone that forms the ulnocarpal complex or triangular fibrocartilage complex. Simply, where the forearm and wrist meet. A simple surgical answer to if the bones are rubbing against each other is to shave down the bone so they don’t.

Distal radioulnar instability


It was not until recently that surgeons discovered the vast complexity and interaction between the distal radioulnar joint, the wrist’s outer joint where the ulnar and radius bones meet, and triangular fibrocartilage complex tears.

This was acknowledged in the surgical journal Hand clinics. (2) here surgeons offered guidance on understanding the relationship between distal radioulnar joint instability and TFCC ligaments.

“During the last two decades, increased knowledge of functional anatomy and pathophysiology of the triangular fibrocartilage complex (TFCC) have contributed to a change in surgeons’ perspective toward it. The earlier concept of the TFCC as the “hammock” structure of the ulnar carpus has updated to the “iceberg” concept, whereby the much larger “submerged” part represents the foveal (the ligament complex) insertions of the TFCC and functions as the stabilizer of the distal radioulnar joint and the ulnar carpus, thus lending it greater functional importance.”

The ligament complex is really important.

In the journal Geriatric Orthopaedic Surgery & Rehabilitation, (3) surgeons described distal radioulnar instability, this way, with emphasis on the ligament structure

“Distal radioulnar joint instability is a common clinical condition but a frequently missed diagnosis. Both surgical and nonsurgical treatments are possible for chronic cases of Distal radioulnar instability. Nonsurgical treatment can be considered as the primary therapy in less active patients, while surgery should be considered to recover bone and ligament injuries if nonsurgical treatment fails to restore forearm stability and function. The appropriate choice of treatment depends on the individual patient and specific derangement of the Distal radioulnar joint instability.”

In this video, Ross Hauser, MD discusses distal radioulnar instability. Summary learning points are:

  • Distal radioulnar joint instability is often overlooked even though the patient will have loud clicking and popping noises coming from the wrist.
  • In this video at 0:48, Dr. Hauser demonstrates wrist rotation and how radioulnar joint instability can cause pain, reduced strength, and popping and clicking in the wrist.
  • The radius bone and the ulnar bone are supposed to stay together with wrist rotation, the two bones are not supposed to move apart.
  • At 1:10 of the video, under Digital Motion X-ray, a patient’s radius bone and ulnar bone are seen to clearly move apart
  • The patient in the video was treated with Prolotherapy injections to strengthen the ligaments of the wrist. This is discussed below.
In this image from the video Dr. Hauser demonstrates a case of severe distal radioulnar instability, a condition that is routinely overlooked in wrist pain examinations. Here the ulnar and radius, the two forearm bones that meet at the wrist as seen to be greatly separated at the wrist when the are suppose to stay together. This is a tell tale sign of ligament damage causing wrist instability.

In this image from the video, Dr. Hauser demonstrates a case of severe distal radioulnar instability, a condition that is routinely overlooked in wrist pain examinations. Here the ulnar and radius, the two forearm bones that meet at the wrist are seen to be greatly separated at the wrist when the are supposed to stay together. This is a tell tale sign of ligament damage causing wrist instability.

Removing cartilage? Shaving down bone? How much does triangular fibrocartilage surgery help an athlete return to sport? A worker back to the job?

In June 2019, researchers in Scotland looked to provide information on return rates and times to return to sport following surgical management of triangular fibrocartilage tears. They published their paper in the British Medical Bulletin (4) in which they examined 10 previously conducted studies where the patient followed conservative management for 6 weeks to 6 months as the first-line treatment. If symptoms persisted following this period, surgical management was advised. Arthroscopic debridement was recommended for central tears, and arthroscopic repair was recommended for peripheral tears.

  • The researchers noted that surgery and conservative care treatments remain controversial because of limited success. They write: “The optimal treatment modalities for triangular fibrocartilage tears remain to be defined.”

The researchers did find that Traumatic central tears can be treated with arthroscopic debridement alone. Arthroscopic repair with an all-inside repair can improve return rates to sport over an outside-in technique for ulna-sided tears. But these were not conclusive, writing: “Future prospective studies should aim to establish the optimal treatment modalities for triangular fibrocartilage tears.

As with any medical treatment, some people will benefit, some people will not. The controversy surrounding surgery for triangular fibrocartilage tears comes from papers like that published in the medical journal Arthroscopy (5) (November 2018). This from Wake Forest University School of Medicine.

“After ruling out additional potential pain generators for ulnar-sided wrist pain, arthroscopic debridement for triangular fibrocartilage complex pathology can be an effective means for decreasing pain and improving function in the short term. Arthroscopic skills aside, this procedure will not work for all comers, and establishing realistic patient expectations is essential for optimal outcomes.”

  • In other words, even if you get the triangular cartilage removed or the bone shaved down, there remains the possibility of continuing grinding wrist instability. Don’t take our word for it. Listen to the surgeons.

Surgery made it worse

We would like to stress again that surgery for Triangular fibrocartilage complex tear can help many people. These are typically not the people we see in our office. We see the people after surgery or those whom their surgeon evaluated their situation and could not give a confident expectation that surgery would provide the hoped-for pain relief and increase in function.

This is a February 2019 study that appeared in the Journal of Wrist Surgery (6). It comes from the Department of Orthopaedic Surgery, St. Vincent’s Hospital, Catholic University of Korea. Here are some of the findings.

  • The relationship between a triangular fibrocartilage complex (TFCC) tear and ulnar impaction syndrome has not been fully understood.
    • Ulnar impaction syndrome is when the ulna bone is longer than its companion forearm bone, the radius, and this creates an unnatural impact at the triangular fibrocartilage complex. The idea of surgery of course, as mentioned above, is to correct this problem and alleviate pain and restricted motion of the wrist at the triangular fibrocartilage complex.
  • The researchers of this study hypothesized that a triangular fibrocartilage complex tear could change the ulnar variance, which may be the cause of ulnar impaction syndrome.
    • The ulnar variance is the length differential between the ulnar and the radius bones of the forearm.

Surgeries examined:

  • The researchers examined 72 patients who underwent TFCC foveal repair (ligament and soft tissue repair) between January 2011 and June 2016. Among them, 44 patients diagnosed with TFCC foveal tear with distal (pinky side)  radioulnar joint instability and no ulnar impaction syndrome underwent TFCC foveal repair only (group A) and 28 patients diagnosed with TFCC foveal tear with ulnar impaction syndrome underwent TFCC foveal repair and ulnar shortening osteotomy simultaneously (group B).
  • The researchers measured their ulnar variances in preoperative, postoperative, and last follow-up plain radiography.

Results

  • Once the TFCC was repaired, ulnar variance decreased. (The problem got better). However, it was increased on the last follow-up radiograph. (The problem returned).
  • Conclusion: “Ulnar variance may be changed after a TFCC tear. In our study, it decreased after TFCC foveal repair. However, as time went on, the ulnar variance increased again, which could be one of the causes of ulnar impaction syndrome and ulnar-sided wrist pain.”

Focus on strengthening the wrist ligaments and stabilizing the grinding wrist

We are going to briefly summarize Triangular fibrocartilage complex tear symptoms and treatment with Prolotherapy. This is a non-surgical injection technique designed to stabilize the wrist, reduce or eliminate pain, and restore range of motion. Dozens of research studies have documented Prolotherapy’s effectiveness in treating chronic joint pain. Here, Dr. Woznica describes ligament injury in the front, back, and ulnar side of the wrist as causes of wrist instability. This is the most common cause of pain and cartilage degeneration in this area. Most patients with wrist instability and damage to the TFCC have a characteristic clicking sound in the wrist.

The treatment of TFCC injuries includes splinting or casting, ice, rest, and anti-inflammatory medications. In some cases, surgery to remove the cartilage may be recommended. These treatments are pain management techniques that typically do not prompt repair, only suppression of symptoms. We utilize Prolotherapy injections (simple dextrose) to repair damage to the cartilage and the ligaments of the wrist, hand TFCC tear areas.

Prolotherapy treatment demonstrated and described

In the video below, Prolotherapy treatment is being demonstrated on a wrist. A summary of the video is below.

Summary:

As you can see the outer part, pinky-side, of the wrist is being treated.

  • The patient in the video is a personal fitness trainer. She is very physically fit. She does many exercises that put a lot of pressure on her wrists – push-ups, zumba, yoga.
  • The pain in her wrist is making it very difficult for her to demonstrate the various exercises to her classes.
  • We are injecting both rows of the carpal bones. The wrist is comprised of 8 bones and 27 ligaments. It is easy to see why a treatment that focuses on strengthening and repairing the wrist ligaments would be so important to someone with significant wrist pain.
  • We see many people with wrist pain on the ulnar side where Triangular fibrocartilage complex injuries occur.
  • The video shows treatment around the navicular bone and the scaphoid lunate and surrounding ligaments. We see a lot of injuries there.
  • The average person requires 3 to 6 treatments.
  • Prolotherapy injections can be very effective for wrist instability. When we treat the wrist, we treat the entire wrist not only the ulnar side.

If you have questions about triangular fibrocartilage complex tears, Get help and information from our Caring Medical staff


References

1 Tomori Y, Nanno M, Takai S. Quick arthroscopic repair technique for ulnar-sided triangular fibrocartilage complex tears: a technical note [published online ahead of print, 2020 Feb 20]. J Nippon Med Sch. 2020;10.1272/jnms.JNMS.2020_87-209. doi:10.1272/jnms.JNMS.2020_87-209 [Google Scholar]
2 Atzei A, Luchetti R. Foveal TFCC tear classification and treatment. Hand Clin. 2011;27(3):263-272. doi:10.1016/j.hcl.2011.05.014 [Google Scholar]
3 Mirghasemi AR, Lee DJ, Rahimi N, Rashidinia S, Elfar JC. Distal Radioulnar Joint Instability. Geriatr Orthop Surg Rehabil. 2015 Sep;6(3):225-9. doi: 10.1177/2151458515584050. PMID: 26328241; PMCID: PMC4536508. [Google Scholar]
4 Robertson G, Ang KK, Maffulli N, Simpson CK, Rust PA. Return to sport following surgical management of triangular fibrocartilage tears: a systematic review. British medical bulletin. 2019 Jun;130(1):89-103. [Google Scholar]
5 Graves BR. Editorial Commentary: Arthroscopic Triangular Fibrocartilage Complex Debridement May or May Not Help With Ulnar-Sided Wrist Pain. [Google Scholar]
6 Shim JI, Im JH, Lee JY, Kang HV, Cho SH. Changes in Ulnar Variance after a Triangular Fibrocartilage Complex Tear. Journal of wrist surgery. 2019 Feb;8(01):030-6. [Google Scholar]

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