Triangular Fibrocartilage Complex

1. Triangular Fibrocartilage Complex Manny Moore Clinic III

2. Triangular Fibrocartilage Complex What Structures are Involved • Anatomy? • Stability? • Mechanism of injury? • Predisposing Factors?

3. InjuryAssessment • History • Inspection • Palpation • Range of Motion • Neurological Testing • Special Test

4. Nonoperative versus Operative Management • Conservative Treatment Guidelines • Rest • Avoid Stressful Motions • Rehabilitation • Splints or brace • NSAIDS • Surgical intervention is suggested if the patient symptoms are not alleviated Within 4-6 weeks depending on the type of lesion. Refer out for Imaging

5. Palmer Classification for TFCC Lesions • Traumatic Lesions • Class IA: Central rupture • Class IB: Ulnar avulsion with/without disruption of the ulnar styloid process • Class IC: Distal avulsion • Class ID: Radial avulsion with/without osseous lesion of the radius • Degenerative Lesions • Class IIA: Superficial degenerative lesion • Class IIB: Degenerative tear with cartilage lesion of the lunate or the ulna • Class IIC: Degenerative disc perforation with cartilage lesion of the lunate or the ulna • Class IID: Degenerative disc perforation with cartilage lesion of the lunate or the ulna and lunotriquentral instability Class IIE: Degenerative disc perforation with cartilage lesion of the lunate or the ulna, lunotriquentral instability and ulnocarpal arthrosis

6. Diagnostic Imaging • MRI? • CT Scan? • Arthroscopy? The Golden Standard?

7. Which Surgical Procedure? • Open Dissection, Arthroscopy,or Direct Repair Deciding Factors? • Central Tears • Peripheral Tears • Ulnar Varience Goals? • Preoperative Rehabilitation? • Postoperative Rehabilitation?

8. Phase I for Central Debridement (3-5 days) • Goals: • Control edema • Pain • Protect repair • Minimize deconditioning • Intervention: • • Remove post-op dressing • •Edema control with light compressive dressing to hand and forearm • •Active ROM exercises for wrist and forearm are begun 4-8 times a day • •A wrist splint is fabricated to wear between exercises and at night

9. Phase II for Central Debridement (10-14 days) • Goals: • Control edema • Pain • Continue to protect repair • Minimize deconditioning • Scar management • Intervention: • •Scar management begun within 48 hours of suture removal • •Initiation of active-assist ROM for wrist and forearm

10. Phase III for Central Debridement Weeks 3-4 • Goals: • Control edema • Pain • Improve ROM • Intervention: • •Passive ROM of wrist and forearm may be initiated • •Dynamic wrist splinting may be begun to improve ROM • •Weighted wrist stretches may be initiated – also to increase ROM

11. Phase IV for Central Debridement Week 6 • Goals: • Continue with ROM gains • Begin strengthening • Intervention: • •Progressive strengthening may be begun using putty or a hand exerciser • •The wrist immobilization splint may be discontinued if the patient is asymptomatic

12. Phase I for Peripheral Repair (Week 1) • Goals: • Edema control • Protect repair • Intervention: • •Patient remains in bulky post-op dressing • •Instructions in edema control

13. Phase II for Peripheral Repair (Week 2) • Goals: • Edema and pain control • Continue to protect repair • Intervention: • •Removal of bulky dressing • •Edema control with retrograde massage, Isotoner glove, and/or coban wrapping • •Daily pin care as needed • •Long arm cast with 90° elbow flexion and wrist in neutral or wrist cock-up splint • fabricated • •Active and passive ROM for wrist and digits, include tendon glides (lumbrical grip, hookfist, full fist) • •Isometric exercises for forearm/hand: 10 repetitions 4 times/day • •Low-grade isotonic exercises can be initiated if edema is not present (i.e., lightest putty) • •Light ADLs with 5 pound limit

14. Phase III for Peripheral Repair (Week 3-6) Goals: Edema Pain Increase ROM Scar management Improve strength Intervention: •Scar management with massage, scar pad •Discontinue splint (unless patient is still symptomatic) •Increase isotonic exercises up to 10 pounds maximum for upper arm, forearm •Wrist mobility/weighted stretches with less than 5 pounds 3-4 times/day •ADLs with less than 10 pounds

15. Phase IV for Peripheral Repair (Week 8) • Goals: • Continue to improve ROM • Continue to increase strength • Simulate work requirements • Intervention: • •Dynamic splinting as necessary to increase ROM • •Progress strengthening with putty, hand exerciser, free weights • •Simulate work tasks as able Precautions • Aggressive PROM or Strengthening that increases pain • Increased ulnar-sided wrist pain • If ulnar shortening in addition to the TFCC repair or Debridement, the course of post-operative therapy will be altered.

16. Conclusion • Rehabilitation ranges from 6-8 weeks depending on surgical methods used • Arthroscopic and debridment is successful in acute and chronic lesions, however chronic lesions are more successful with ulna shortening. • Arthroscopy is still considered the golden standard when diagnosing lesions and has showed success in pain management function and stability in TFCC repairs. • Despite its high sensitivity of MRI detecting TFCC lesions MRI has its limitations in the detection of peripheral TFCC tears.

17. References Usama Albastaki, MD," Dimitris Sophocleous, MD,^ Jan Gothlin, MD, PhD. MRI Imaging in TFCC injuries. Journal of Munipulotive and Physiological Therapeutics Volume 30, Number 7 Jui Tien Shih, Huung Maan Lee. Functional Results of TFCC. Department of Orthopedics and Hand Surgery, Vol 10, 2005 169-176. Cuong Pho DPT, Joe Godges DPT. Triangular Fibrocartilage Complex (TFCC) Repair and Rehabilitation. Indiana Hand Therapy Protocols Jan-Ragnar Haugstvedt and Torstein Husby.RESULTS OF REPAIR OF PERIPHERAL TEARS IN THE TRIANGULAR FIBROCARTILAGE COMPLEX USING AN ARTHROSCOPIC SUTURETECHNIQUE. Journal of hand Surgery 1999.

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