In this case report, hand surgeons from the University of Pittsburgh School of Medicine (Department of Orthopedic Surgery) use the patient example of a 49-year-old man with a triangular fibrocartilage complex tear (TFCC) to discuss current concepts of treatment for this condition. The patient had chronic wrist pain for seven months. Conservative (nonoperative) care did not relieve his pain.
Surgery was a consideration but the surgeons had questions whether the surgery would give any better results than the cortisone injections, immobilization, and hand therapy he had already tried. They looked to see what evidence current research had to offer in making this treatment decision. Let's take a look at the condition and what is known about it and see what they decided to do.
Triangular fibrocartilage complex (TFCC) injuries of the wrist affect the ulnar (little finger) side of the wrist. The triangular fibrocartilage complex (TFCC) suspends the ends of the two bones of the forearm (radius and ulna) over the wrist.
It is triangular in shape and made up of several ligaments and cartilage. The TFCC makes it possible for the wrist to move in six different directions (bending, straightening, twisting, side-to-side). It stabilizes the distal radioulnar joint while improving the range of motion and gliding action within the wrist.
This is a simple explanation of a very complex injury. Mild injuries of the TFCC may be referred to as a wrist sprain. As the name suggests, the soft tissues of the wrist are complex. They work together to stabilize the very mobile wrist joint.
Disruption of this area through injury or degeneration can cause more than just a wrist sprain. A TFCC injury can be a very disabling wrist condition. For a more detailed description and understanding of this wrist problem, see A Patient Guide to Triangular Fibrocartilage Complex (TFCC) Injuries.
TFCC injuries can be difficult to accurately diagnose. X-rays may show a difference in length between the two forearm bones (called variance). When one of these two bones is longer (or shorter) than the other, it is considered a risk factor for wrist pain and disruption of the triangular fibrocartilage complex. The surgeon may also be able to see something called the sag sign on X-rays. One of the carpal bones has shifted in position (sagged); this is an indication of instability.
In addition to X-rays, imaging with magnetic resonance arthrography (MRA) may be needed. A special dye is injected into the joint to show areas of damage and especially disruption of the joint. The most accurate way to diagnose TFCC is with arthroscopic examination.
Even with a complete diagnosis, treatment decisions aren't easy. Each case of TFCC injury must be examined one-by-one. The exact location of the injury and extent of damage are important factors. Whether the injury is the result of trauma or degeneration will also be taken into consideration. The presence of other associated injuries (e.g., torn ligaments, bone fractures) can influence both the treatment and results.
Taking a close look at the current evidence available was a challenge. Most of the studies are based on small series of case studies. Large studies comparing different treatment approaches for similar TFCC injuries just aren't available. That leaves surgeons lacking the evidence they need to guide treatment.
The authors of this case report suggest the need for studies to compare nonoperative care with sham treatment and operative treatment. They also point out the fact that different operative approaches must be compared (e.g., debridement, use of open incision versus minimally invasive technique). Other factors that might affect outcomes (e.g., age, cause: traumatic or degenerative) must also be investigated.
What did they decide in the end to do for this patient? The patient had not responded to conservative care but the wrist was stable and the surgeon felt there was potential for healing. With no known trauma, it seemed best to try another round of immobilization for four to six weeks. If there's no improvement at the end of that time, further evaluation (probably with diagnostic arthroscopy) was planned. Any further treatment decisions would have to wait pending the results of these first two steps.
Reference: Kevin Roenbeck, MD, and Joseph E. Imbriglia, MD. Peripheral Triangular Fibrocartilage Complex Tears. In The Journal of Hand Surgery. October 2011. Vol. 36A. No. 10. Pp. 1687-1690.