Triangular Fibrocartilage Complex Tears in the Athlete

doi:10.1016/S0278-5919(05)70253-2

Clinics in Sports Medicine

Volume 20, Issue 1, 1 January 2001, Pages 155-166

https://doi.org/10.1016/S0278-5919(05)70253-2 Get rights and content

Injury to the triangular fibrocartilage can occur as a result of athletic activity ranging from racquet sports to baseball to contact sports. The basic principles of treatment of triangular fibrocartilage complex (TFCC) tears in the athlete are similar to those applied to the general population. The postoperative rehabilitation, however, must be tailored to the patient's sport.

Section snippets

ANATOMY OF THE TRIANGULAR FIBROCARTILAGE COMPLEX

The goal of treatment of TFCC tears is restoration of anatomy and function. The anatomy of the TFCC has been well studied. The base of the triangular fibrocartilage attaches to the distal radius at the distal edge of the sigmoid notch. Its distal surface blends imperceptibly with the hyaline cartilage of the lunate fossa of the distal radius. The triangular fibrocartilage narrows as it passes from radial to ulnar. Its deep fibers (ligamentum subcruatum) insert in the fovea at the base of the

DIAGNOSIS

The diagnosis of a triangular fibrocartilage tear is not always easy. The classic complaint is ulnar-sided wrist pain associated with popping or clicking. Pain at the ulnar aspect of the ulnocarpal joint just palmar to the extensor carpi ulnaris (ECU) often is associated with a peripheral rather than central tear of the TFCC.

Physical examination can demonstrate tenderness over the TFCC. Ulnar deviation of the wrist combined with supination and pronation and the application of an axial load will

TEAR CLASSIFICATION

Palmer⁹ and associates devised a classification scheme for TFCC tears, which divides them into traumatic tears, type 1, and degenerative tears, type 2. This article deals with those tears (1A–D and 2C–D) that lend themselves to arthroscopic treatment (Fig. 2).

DÉBRIDEMENT

Before starting arthroscopic treatment of TFCC tears, the ulnar variance must be evaluated. This is done by taking an x-ray with the shoulder abducted to 90° and the elbow flexed to 90° with the hand flat on the x-ray cassette (90 × 90 view of Palmer¹⁰). Triangular fibrocartilage débridement in the presence of an ulnar plus variance is doomed to fail, as the simple débridement of the TFCC is insufficient to decompress the ulnar side of the wrist. In such cases of ulnar abutment syndrome, an

MECHANICAL DÉBRIDEMENT

The patient undergoing a TFCC débridement is placed on the operating room table in the supine position. The arm is prepped and draped and the wrist is distracted using traction applied through sterile finger traps and a commercially available wrist distraction device. The distraction device should be solid. Improvised traction systems are unreliable and can fail during the procedure.

A viewing portal is established at the 3–4 portal (the portal is placed at the interval between the extensor

REPAIR

Radial (Palmer 1D) and ulnar (Palmer 1B) detachments of the triangular fibrocartilage can be repaired arthroscopically. Two methods are used routinely for repair of detachment of the TFCC from the ulna. One involves repair techniques similar to those developed for meniscorrhesis.³ The other uses a Tuohy needle as popularized by Dr. Gary Poehling.

The technique popularized by Whipple involves the placement of the scope in the 3–4 portal while the repair is accomplished through the 4–5 or 6R

POSTOPERATIVE REGIMEN

The postoperative regimen after the débridement of triangular fibrocartilage tears includes the application of a bulky dressing and a volar splint. The patient gradually is weaned from this splint over a 6-week period. The author's experience has been that premature return to activities can aggravate the postsurgical synovitis. Return to full activity can be expected by the 12th postoperative week.

With repair of a peripheral tear of the triangular fibrocartilage, the arm must be held in a cast

ARTHROSCOPICALLY ASSISTED ULNAR SHORTENING

The ulnar abutment syndrome (the combination of an ulnar plus variance and a triangular fibrocartilage tear) is the most common indication for arthroscopically assisted ulnar shortening. Simple débridement of the TFCC in the presence of an ulnar plus variance is inadequate treatment of an ulnar abutment syndrome. The ulnar aspect of the wrist must be decompressed, and arthroscopically assisted ulnar shortening has proven to be effective in this situation.¹⁵ Arthroscopic ulnar shortening is

SUMMARY

The treatment of triangular fibrocartilage tears in the athlete presents more of a rehabilitation challenge than a surgical technique challenge. The rehabilitation regimen is a function of the sport. Although injuries to the shoulder and knee can be career ending, injuries to the TFCC usually, but not always, can be treated successfully.

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Cited by (28)

Ulnar Abutment Syndrome in the Athlete
2020, Orthopedic Clinics of North America
Citation Excerpt :
Arthroscopy also allows treatment of any concurrent carpal pathology.17 Arthroscopic debridement of central TFCC tears alone in ulnar positive wrists has been shown to have high failure rates (13%–60%) and some form of ulnar variance correction should be performed.12,18 Arthroscopic debridement alone may be considered in those with ulnar neutral or ulnar negative variance, although patients may require secondary ulnar shortening if they fail debridement alone.18
Triangular Fibrocartilage Complex Injury
2017, Clinical Orthopaedic Rehabilitation: A Team Approach, Fourth Edition
Diagnosis and Treatment of Hand-injuries in Team sports
2016, Sports Orthopaedics and Traumatology
Die Hand gehört aufgrund ihrer exponierten Position und des aktiven Einsatzes im Ballsport zu den häufig verletzten Körperregionen. Im professionellen Sport entfallen sportartübergreifend bis zu 10% der Verletzungen auf den Handbereich. Neben den auch bei anderen Sportarten anzutreffenden Verletzungsmechanismen wie Sturz oder Zugbelastung kommt beim Ballsport zusätzlich die Verletzung durch axiale Stauchungstraumen durch den Ball zum Tragen.
In dieser Übersichtsarbeit liegt der Fokus auf den ballspezifischen Verletzungen, die von distal nach proximal aufgearbeitet werden. Von entscheidender Bedeutung ist nicht nur die Wahl der adäquaten Therapie – konservativ oder operativ – sondern auch, wann der (Profi-) Sportler zurück zum Sport kehren kann.
Injuries of the hand are common sports-injuries. Up to 10% of all injuries in professional ball sports involve the hand and are caused mainly by falls on the finger or dynamic grasping. In ball sports axial compression injuries are common.
This review article focuses on ball-sport-specific hand injuries which are discussed from proximal to distal. It is mandatory to choose the adequate therapy – conservatively or operatively – for a timely return to sport.
Acute TFCC Injury
2016, Operative Techniques in Sports Medicine
Citation Excerpt :
An incision is made and the knot is tied directly on the extensor retinaculum with care to protect dorsal sensory braches of the ulnar nerve.5 Rehabilitation can be challenging in these patients and is important to their ability to return to sport.21 Postoperative protocols for acute TFCC repair are similar and have in common the following: The patient is placed in a long-arm splint in full supination and some degree of wrist extension in the operating room and then transitioned to a custom-molded splint or cast within 1 week postoperatively.
Wrist injuries are common in athletic competition and tears of the triangular fibrocartilage complex (TFCC) are the main source of athletes presenting with acute onset ulnar-sided wrist pain. Treatment for TFCC injuries varies based on the acuity and location of the tear. Degenerative tears are often associated with ulnar positive variance and are best treated with debridement and joint leveling. The focus on athletes encompasses primarily acute injuries, which are often traumatic in nature from twisting such as a torque to the wrist or from a fall on an outstretched hand. Acute tears on the periphery of the TFCC have been shown to have adequate blood supply and potential to heal, and both open and arthroscopic repair techniques have been described. Arthroscopic procedures have shown improved outcomes to open. Athletes and their families should be made aware of the various surgical options available to them and treatment should be tailored to each individual situation.
The Management of Ulnocarpal Abutment and Degenerative Triangular Fibrocartilage Complex Tears in the Competitive Athlete
2012, Hand Clinics
Citation Excerpt :
Many surgeons perform a wrist arthroscopy to address concomitant disorders, followed by a formal USO. An arthroscopic-only approach of either TFCC debridement or the wafer procedure has been shown to be effective and is an attractive option for the midseason athlete secondary to the theoretic benefit of a shorter recovery time.13–15 The effectiveness of arthroscopic debridement of the TFCC lies not only in removing irritative, unstable flaps but excision of the central portion of the TFCC has been shown to unload the ulna by more than 60%.3
Soft-Tissue Injuries of the Hand and Wrist
2008, The Sports Medicine Resource Manual

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: Address reprint requests to Daniel J. Nagle, MD. 448 East Ontario Street, Suite 500, Chicago, IL 60611

^*: Department of Orthopaedics, Northwestern University Medical School, Chicago, Illinois

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Triangular Fibrocartilage Complex Tears in the Athlete

Section snippets

ANATOMY OF THE TRIANGULAR FIBROCARTILAGE COMPLEX

DIAGNOSIS

TEAR CLASSIFICATION

DÉBRIDEMENT

MECHANICAL DÉBRIDEMENT

REPAIR

POSTOPERATIVE REGIMEN

ARTHROSCOPICALLY ASSISTED ULNAR SHORTENING

SUMMARY

J Hand Surg [Am]

Arthroscopy

J Hand Surg [Am]

J Hand Surg [Am]

Arthroscopy

Arthroscopy

J Hand Surg [Am]

J Hand Surg [Am]