Triangular Fibrocartilage Complex (TFCC) Tear – Treatment by Arthroscopy


Wrist Arthroscopy for TFCC Tear (Ulnar-Sided Wrist Pain)

What Is TFCC?

  • Triangular Fibro Cartilage Complex
  • Found in the wrist joint
  • It is the ligamentous and cartilaginous structures that suspend the distal radius and ulnar carpus from the distal ulna

Causes of TFCC Tears

  • Falls onto pronated hyperextended wrist
  • Power-drill injuries in which the drill binds and rotates the wrist instead of the bit
  • Distraction force applied to the volar forearm or wrist
  • Distal radius fractures

Symptoms of TFCC Tear

  • Ulnar sided (i.e. little finger side) wrist pain
  • Associated with clicking

Clinical Signs

  • Painful grinding or clicking with wrist range of motion (ROM)
  • Weakness
  • Ulnar deviation of the wrist with the forearm in neutral produces ulnar wrist pain and occasional clicking (Perform a TFCC compression test.)
  • Instability of the distal radioulnar joint (DRUJ) with shucking the distal radius and ulna between the examiner’s fingers
    Piano key sign, which is a prominent and ballottable distal ulna with full pronation of the forearm
  • Ulnar carpal sag
  • Lunotriquetral (LT) interval tenderness
  • Positive LT ballottement or shuck test
  • ECU tendon subluxation

Treatment

  • Wrist arthroscopy
  • Done under General Anaesthesia or Regional Anaesthesia
  • 2 to 3 Small Incisions at the Wrist level
  • Minimally invasive

Case Example

  • Right handed lady who fell off a bicycle onto her right outstretched hand 2 months ago.
  • Has ulnar sided wrist pain.
  • Treated with wrist splint for 6 weeks but not better.
  • MRI scan of her wrist showed a TFCC tear.

Right Wrist MRI showing TFCC Tear Type IB

Treatment

  • Wrist arthroscopy under regional block.
  • Right Hand and Wrist was suspended with 8 lbs of traction.

Right Wrist Arthroscopy

  • The joint is entered using a 1.9mm arthroscope at the 3/4 portal.
  • An outflow is achieved by inserting a 21G needle at the 6U.
  • A working portal is created at 4/5 portal.
  • The TFCC repair is done through a 6R portal which is enlarged.

Right Wrist Arthroscopy Portals

    The tear is repaired with an outside in technique with PDS 3/0 suture. The Smith & Nephew’s TFCC Mender device is used to pass the sutures through the torn TFCC. The sutures are tied outside the capsule while the ECU tendon is being protected by an assistant.

TFCC Mender Device from Smith & Nephew

 

 

 

TFCC Tear – Palmer Type IB

TFCC Tear in a Right Wrist

The TFCC Mender Curved Cannula is passed through the TFCC from the exposed 6R portal

A PDS 3/0 suture is passed into the joint and retrieved through the 4/5 portal using a small arthroscopic grasper

The cannula is passed into the joint again to pass a suture shuttle. I use the PDS 3/0 as a suture shuttle.

The 1st PDS suture that was passed through the TFCC is shuttled back into the joint and out of the capsule.

The 1st repair suture is tied to the capsule, closing the TFCC tear

A 2nd suture is passed into the joint.

The 2nd repair suture is shuttled.

The 2nd repair suture is tied to complete the repair of the torn TFCC.

The wrist is immobilised in a backslab from above elbow to below the wrist with elbow at 90 degrees flexion and forearm in neutral rotation.

The wrist is immobilised in a backslab and an arm sling is applied.

The plaster backslab is changed to a thermoplastic splint which is used to 3 weeks.

This is changed to a wrist brace for another 3 weeks.

Gentle range of motion exercises are started thereafter.

For more information on TFCC tears and wrist injuries, please contact Dr HC Chang at 683 666 36 or visit our website at http://www.ortho.com.sg

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