Basics
Description
-
The TFCC:
-
A group of ligaments and cartilaginous structures that stabilize the distal radioulnar joint during pronation and supination of the forearm
-
Extends from the ulnar styloid to the sigmoid notch of the distal radius
-
Central portion:
-
More cartilaginous than its periphery
-
Acts as a meniscal homolog, similar to the menisci of the knee joint
-
-
-
Injury to the TFCC may result in acute or chronic wrist pain, often on the ulnar side.
-
A few wrists contain a true meniscus with a free edge that can be seen arthroscopically.
-
Synonym: Ulnar-sided wrist pain
Epidemiology
Incidence
-
Uncommon
-
Peak incidence: 30-60 years of age
Risk Factors
-
Jobs that require:
-
Repeated, loaded pronation and supination of the wrist
-
Heavy lifting
-
Etiology
-
Hyperpronation or dorsiflexion of the wrist may result in a tear of the TFCC, equivalent to a distal dislocation of the ulna (Fig. 1).
-
It may be associated with fracture of the distal radius or ulna or both.
Fig. 1. TFCC tear may occur with forearm rotation.
DiagnosisSigns and Symptoms
-
Most common complaint is ulnar-sided wrist pain, especially with repeated pronation and supination
-
Clicking
-
History of:
-
Hyperpronation or dorsiflexion injury to the wrist (acute cases)
-
Repeated pronation and supination (chronic cases)
-
Physical Exam
-
Localize the area of pain carefully (e.g., use the tip of the index finger to isolate the area of tenderness precisely).
-
Examine each joint of the wrist and hand for ROM and to detect crepitus, pain, or snaps.
-
TFCC compression test:
-
Provocative maneuver, for which elicited pain is a positive test
-
Axially load while rotating the ulnar-deviated wrist.
-
A click may reproduce the patient’s symptoms, causing pain.
-
-
Palpate the extensor carpi ulnaris while flexing and extending and while pronosupinating the wrist to rule out subluxation.
-
Assess the neurovascular status of the hand and forearm.
Tests
-
Arthrography of the wrist may be indicated.
-
A tear of the TFCC allows dye to extrude into the radioulnar joint, which does not normally communicate with the radiocarpal joint.
-
-
Some patients may require later injections of the distal radioulnar or midcarpal joint for full evaluation.
Imaging
-
Radiography:
-
AP and lateral radiographs of the wrist
-
Radiographs of the wrist in pronation and supination may be helpful in assessing radioulnar joint instability.
-
Ulnar height should be assessed on rotation views.
-
In the normal wrist, the distal radial and ulnar joint surfaces should be at the same level on the AP radiograph.
-
Positive variance of the ulna may result from fracture or instability of the distal radioulnar joint.
-
-
-
CT scan of both wrists in pronation and supination also can aid in diagnosis of instability.
Differential Diagnosis
-
Fracture of the radius, ulna, or any of the carpal bones
-
Rupture or tendinitis of the extensor carpi ulnaris, flexor carpi ulnaris, or the carpal ligament
-
Extensor carpi ulnaris subluxation
-
Arthritis of the ulnocarpal, pisotriquetral, or distal radioulnar joint
-
Lunotriquetral ligament injury
-
Ulnar artery thrombosis
-
Ulnar impaction syndrome
TreatmentGeneral Measures
-
Injury with fractures:
-
Reduce and immobilize the fracture.
-
Assess the distal radioulnar joint for reduction whenever distal forearm or wrist fractures are manipulated.
-
Acutely repair the TFCC when operative care of the fracture is indicated.
-
-
Injuries without fracture:
-
Try nonoperative treatment with a below-the-elbow cast in neutral rotation and analgesics for 6 weeks.
-
Slowly reintroduce gentle ROM when the cast is removed.
-
Patients with continued pain and instability may require additional assessment and subsequent operative repair.
-
Special Therapy
Physical Therapy
Patients with reduced ROM after TFCC injury or fracture may benefit from stretching exercises.
Medication
Analgesics are indicated.
Surgery
-
Repair of the ruptured TFCC can be attempted arthroscopically or with an open procedure if sufficient tissue is present.
-
Tears in the central area of the TFCC without instability may require arthroscopic débridement.
-
Variance of the ulnar height may need to be addressed through shortening of the ulna.
-
Reconstruction of the distal radioulnar joint with a tendon or band of fascia lata may be used to stabilize the joint.
-
In severe cases, with advanced radioulnar arthritis, fusion of the joint (Sauve-Kapandji procedure) may be considered.
P.471
Follow-upPrognosis
-
The prognosis is fair to good.
-
Some persistent pain may occur even with adequate repair.
Complications
Posttraumatic arthritis can occur, often delayed by years or even decades.
MiscellaneousCodes
ICD9-CM
842.00 Wrist pain
FAQ
Q: Do all TFCC tears need to be repaired?
A: Partial tears may respond well to splint immobilization and anti-inflammatory medicine or corticosteroid injection. Central tears of the TFCC can be treated with arthroscopic bridement. Complete TFCC tears and tears resulting in distal radial ulnar joint instability require repair.
Q: How are TFCC tears repaired?
A: An open repair is performed for a complete peripheral tear. If the distal radial ulnar joint is stable, arthroscopic repair can be considered.
Leave a Reply