Triangular Fibrocartilage ComplexTriangular Fibrocartilage Complex

Manny MooreManny MooreClinic IIIClinic III

Triangular Fibrocartilage ComplexTriangular Fibrocartilage Complex

What Structures are InvolvedWhat Structures are Involved• Anatomy?

• Stability?

• Mechanism of injury?

• Predisposing Factors?

InjuryInjury AssessmentAssessment

•History•Inspection

•Palpation

•Range of Motion

•Neurological Testing •Special Test

Conservative Treatment GuidelinesConservative Treatment Guidelines

• Rest• Avoid Stressful Motions• Rehabilitation• Splints or brace • NSAIDS

•Surgical intervention is suggested if the patient symptoms are not alleviatedWithin 4-6 weeks depending on the type of lesion.

Nonoperative versus Nonoperative versus Operative ManagementOperative Management

Refer out for ImagingRefer out for Imaging

Palmer Classification for TFCC LesionsTraumatic Lesions

• Class IA: Central rupture• Class IB: Ulnar avulsion with/without disruption of the ulnar styloidprocess• 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

Diagnostic ImagingDiagnostic Imaging

•MRI?

•CT Scan?

•Arthroscopy?

The Golden Standard?The Golden Standard?

Which Surgical Procedure? Which Surgical Procedure? •Open Dissection, Arthroscopy,or Direct Repair

• Central Tears

• Peripheral Tears

• Preoperative Rehabilitation?• Postoperative Rehabilitation?

Deciding Factors?Deciding Factors?

Goals?Goals?

• Ulnar Varience

Phase I for Central Debridement (3-5 days)Phase I for Central Debridement (3-5 days)

Goals:Goals: • Control edema• Pain• Protect repair• Minimize deconditioning

Intervention: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

Phase II for Central Debridement (10-14 days)Phase II for Central Debridement (10-14 days)

Goals:Goals:

• Control edema• Pain• Continue to protect repair• Minimize deconditioning• Scar management

Intervention:Intervention:

• Scar management begun within 48 hours of suture removal• Initiation of active-assist ROM for wrist and forearm

Phase III for Central Debridement Weeks 3-4Phase III for Central Debridement Weeks 3-4Goals:Goals:

• Control edema• Pain• Improve ROM

Intervention: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

Phase IV for Central Debridement Week 6Phase IV for Central Debridement Week 6

Goals:Goals:

• Continue with ROM gains• Begin strengthening

Intervention:Intervention:

• Progressive strengthening may be begun using putty or a hand exerciser• The wrist immobilization splint may be discontinued if the patient is asymptomatic

Phase I for Peripheral Repair (Week 1)Phase I for Peripheral Repair (Week 1)

Goals:Goals:• Edema control• Protect repair

Intervention:Intervention:• Patient remains in bulky post-op dressing• Instructions in edema control

Phase II for Peripheral Repair (Week 2)Phase II for Peripheral Repair (Week 2)Goals:Goals: • Edema and pain control• Continue to protect repair

Intervention: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 splintfabricated• 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

Phase III for Peripheral Repair (Week 3-6)Phase III for Peripheral Repair (Week 3-6)

Goals:Goals:

EdemaPain Increase ROMScar managementImprove strength

Intervention: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

Goals:Goals:

• Continue to improve ROM• Continue to increase strength• Simulate work requirements

Intervention:Intervention:

• Dynamic splinting as necessary to increase ROM• Progress strengthening with putty, hand exerciser, free weights• Simulate work tasks as able

Phase IV for Peripheral Repair (Week 8)Phase IV for Peripheral Repair (Week 8)

• 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.

PrecautionsPrecautions

ConclusionConclusion

• 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.

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 ofOrthopedics 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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