Caring Medical - Where the world comes for ProlotherapyTriangular fibrocartilage complex tear of the wrist TFCC

Ross Hauser, MD., Caring Medical Regenerative Medicine Clinics, Fort Myers, 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

You have a lot pain on the outside of your wrist. After a few weeks or months of anti-inflammatories and other over-the-counter painkillers, you go on line 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 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.

Some people will wind up here at Caring Medical. When we first meet them they are sitting on our examination table. The will usually be grasping their “bad” wrist with their other hand and rubbing the that wrists’ 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 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.”

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 recovery, AND, there is no guarantee that the surgery would help me.”

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

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

In our experience, patient/athletes with Triangular Fibrocartilage complex injury suffer from complex ligament degenerative problems that is 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 a 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.

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 (1) 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 (2) (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 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 (3). 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 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 Ross Hauser, M.D. In this video Dr. Hauser will talk about Prolotherapy treatment. 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. Hauser 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, Ross Hauser MD, demonstrates and describes Prolotherapy to the 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 puts 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.

1 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]
2 Graves BR. Editorial Commentary: Arthroscopic Triangular Fibrocartilage Complex Debridement May or May Not Help With Ulnar-Sided Wrist Pain. [Google Scholar]
3 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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