Basics
Description
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The TFCC:
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A group of ligaments and cartilaginous structures that stabilize the distal radioulnar joint during pronation and supination of the forearm
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Extends from the ulnar styloid to the sigmoid notch of the distal radius
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Central portion:
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More cartilaginous than its periphery
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Acts as a meniscal homolog, similar to the menisci of the knee joint
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Injury to the TFCC may result in acute or chronic wrist pain, often on the ulnar side.
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A few wrists contain a true meniscus with a free edge that can be seen arthroscopically.
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Synonym: Ulnar-sided wrist pain
Epidemiology
Incidence
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Uncommon
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Peak incidence: 30-60 years of age
Risk Factors
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Jobs that require:
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Repeated, loaded pronation and supination of the wrist
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Heavy lifting
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Etiology
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Hyperpronation or dorsiflexion of the wrist may result in a tear of the TFCC, equivalent to a distal dislocation of the ulna (Fig. 1).
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It may be associated with fracture of the distal radius or ulna or both.Fig. 1. TFCC tear may occur with forearm rotation.

Signs and Symptoms
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Most common complaint is ulnar-sided wrist pain, especially with repeated pronation and supination
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Clicking
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History of:
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Hyperpronation or dorsiflexion injury to the wrist (acute cases)
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Repeated pronation and supination (chronic cases)
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Physical Exam
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Localize the area of pain carefully (e.g., use the tip of the index finger to isolate the area of tenderness precisely).
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Examine each joint of the wrist and hand for ROM and to detect crepitus, pain, or snaps.
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TFCC compression test:
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Provocative maneuver, for which elicited pain is a positive test
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Axially load while rotating the ulnar-deviated wrist.
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A click may reproduce the patient’s symptoms, causing pain.
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Palpate the extensor carpi ulnaris while flexing and extending and while pronosupinating the wrist to rule out subluxation.
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Assess the neurovascular status of the hand and forearm.
Tests
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Arthrography of the wrist may be indicated.
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A tear of the TFCC allows dye to extrude into the radioulnar joint, which does not normally communicate with the radiocarpal joint.
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Some patients may require later injections of the distal radioulnar or midcarpal joint for full evaluation.
Imaging
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Radiography:
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AP and lateral radiographs of the wrist
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Radiographs of the wrist in pronation and supination may be helpful in assessing radioulnar joint instability.
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Ulnar height should be assessed on rotation views.
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In the normal wrist, the distal radial and ulnar joint surfaces should be at the same level on the AP radiograph.
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Positive variance of the ulna may result from fracture or instability of the distal radioulnar joint.
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CT scan of both wrists in pronation and supination also can aid in diagnosis of instability.
Differential Diagnosis
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Fracture of the radius, ulna, or any of the carpal bones
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Rupture or tendinitis of the extensor carpi ulnaris, flexor carpi ulnaris, or the carpal ligament
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Extensor carpi ulnaris subluxation
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Arthritis of the ulnocarpal, pisotriquetral, or distal radioulnar joint
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Lunotriquetral ligament injury
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Ulnar artery thrombosis
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Ulnar impaction syndrome

General Measures
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Injury with fractures:
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Reduce and immobilize the fracture.
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Assess the distal radioulnar joint for reduction whenever distal forearm or wrist fractures are manipulated.
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Acutely repair the TFCC when operative care of the fracture is indicated.
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Injuries without fracture:
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Try nonoperative treatment with a below-the-elbow cast in neutral rotation and analgesics for 6 weeks.
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Slowly reintroduce gentle ROM when the cast is removed.
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Patients with continued pain and instability may require additional assessment and subsequent operative repair.
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Special Therapy
Physical Therapy
Patients with reduced ROM after TFCC injury or fracture may benefit from stretching exercises.
Medication
Analgesics are indicated.
Surgery
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Repair of the ruptured TFCC can be attempted arthroscopically or with an open procedure if sufficient tissue is present.
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Tears in the central area of the TFCC without instability may require arthroscopic débridement.
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Variance of the ulnar height may need to be addressed through shortening of the ulna.
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Reconstruction of the distal radioulnar joint with a tendon or band of fascia lata may be used to stabilize the joint.
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In severe cases, with advanced radioulnar arthritis, fusion of the joint (Sauve-Kapandji procedure) may be considered.
P.471

Prognosis
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The prognosis is fair to good.
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Some persistent pain may occur even with adequate repair.
Complications
Posttraumatic arthritis can occur, often delayed by years or even decades.

Codes
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.
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