Injury: Triangular Fibrocartilage Complex Tear (TFCC)
TFCC injuries typically occur from two primary mechanisms. The first is a repetitive injury to the wrist such as with gymnastics, push-ups or bench press. Secondly, the injury can occur with an acute traumatic event extending the wrist dramatically, which can be associated with a fracture.
Examination & Evaluation
Most individuals will have pain on the back side of the wrist just beyond the tip of the ulna (see below). Other symptoms may include clicking or catching of the wrist as well as issues with grip strength, but this is less common in more mild cases. Typically athletes will have pain with deviating the wrist towards the ulna, which can be performed by the examiner to compress the TFCC and replicate the pain. The patient can be asked to give a thumbs up, make an "Ok" sign, and spread their fingers against resistance to grossly assess nerve function. Also, the pulse should be checked as well as fingertips monitored to check for good blood flow to the area.
Imaging
An x-ray is usually done first in order to detect the presence of an ulna styloid fracture or disruption of the distal radioulnar joint. An MRI is the optimal test to confirm the diagnosis when a fracture is not clear on simple x-ray.
Normal X-ray
MRI Showing TFCC Tear
Treatment
If a TFCC injury is suspected based on pain, and x-rays are negative, it is reasonable to simply treat with immobilization without getting an MRI. My typical protocol is to treat with a removable wrist brace or a short arm cast for approximately 4 weeks. If I do not see improvement, I generally then move on to advanced imaging such as an MRI. However, if the situation calls for a more definitive diagnosis it is appropriate to obtain an MRI at the initial diagnosis. If a large tear is seen or the patient remains symptomatic after immobilization a corticosteroid or biologic (PRP, stem cell) injection can be attempted. Lastly, referral to the hand surgeon may be required in order repair or remove the torn cartilage.
Return to Play
Return to play after a non-operatively treated TFCC injury may require protective padding or bracing due to stiffness or weakness of the wrist. Athletes and activities that would at risk for re-injury would include golf, baseball, weight lifting and boxing.
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