Cartilage tear of the wrist – The triangular fibrocartilage complex (TFCC)

Anatomy of the wrist

The triangular fibrocartilage complex (TFCC) is a group of structures (6 ligaments, 2 fibrous discs/cartilages and 1 tendon) located on the ulnar side (inside/little finger side) of the wrist joint. A majority of the injuries to the TFCC involve the cartilage which sits between the two bones of the wrist joint i.e. the ulna and the triquetrum.

The role of the TFCC is to stabilise your wrist joint whilst moving, particularly during supination and pronation. Supination is the term used to describe when you turn your wrist upwards (palm up) and pronation describes turning your wrist down (palm down)(see image below). The TFCC is also responsible for transmitting load safely through your wrist protecting your joint from injury (Doarn et al, 2016).

How is the TFCC injured?

The mechanism of injury for the TFCC does vary. Some of our clients report a specific injury while others cannot recall a specific incident and report a gradual onset of pain.

The most common mechanism of injury is falling onto an outstretched hand. This occurs when tripping over on the pavement or during sporting activities, such as falling onto your wrist when playing football.

Your body’s key protection strategy during a fall is to soften the impact by reaching out with your hands. This results in a high velocity, impact directly through your wrist joint. Impact forces the wrist into hyperextension which can result in a wrist fracture or damage to the TFCC.

The TFCC is also placed under increased risk of injury during a twisting motion of the wrist which causes increased pressure through these small structures.  Twisting motions in the wrist are common during sports such as boxing, tennis or squash.

If there has been no specific incident to trigger the symptoms, pain typically starts with a ‘clicking’ sensation in the wrist which becomes more prevalent over time resulting in pain.

Symptoms of TFCC injuries

The symptoms can vary but the most common signs are pain, swelling and tenderness on the inside of the wrist. Many clients also experience clicking and a sensation of weakness.

How do you diagnose a TFCC injury?

Diagnosing a TFCC injury is clinically challenging. A full and detailed history of the events that preceded your wrist pain is critical in forming a hypothesis of TFCC injury.

Your clinicians will assess your range of movement, wrist strength and grip testing routinely tested.

Your clinician may also palpate (feel) different structures around your wrist and carry out a few specific TFCC tests called compression tests. If you have TFCC, clinical testing will elicit pain and will help your clinician formulate a diagnosis.

Diagnostic imaging

To fully assess whether you have damaged your TFCC and to determine whether it is a partial or a full thickness tear, an MRI scan is required.

The image below shows an MRI scan of the wrist with the location of the TFCC highlighted within the blue circle.

Treiser et al. (2017) conducted a meta-analysis reviewing the most specific and sensitive diagnostic imaging modalities for diagnosing TFCC injury. Results of this study concluded that both MRI (magnetic resonance arthrography) and CT (computed tomographic arthrography) were equally capable of diagnosing TFCC injury.

All our specialists are fully qualified musculoskeletal sonographers and extended scope physiotherapists who have extensive experience of TFCC injuries.

As part of your clinical assessment we also carry out a diagnostic ultrasound (no extra charge). Although the TFCC structures are not well visible on ultrasound imaging, joint swelling (effusion) and inflammation are readily visible.

How is a TFCC injury treated?

Injuries to the TFCC complex are often slow to improve and they can be a very frustrating journey for our clients. The cartilage in the complex has a relatively poor blood supply and consequently takes 4-6 weeks for clients to experience a reduction in symptoms. Unfortunately, from our understanding, it can take 3 months for symptoms to completely reside.

The TFCC is a complex structure that is crucial for wrist stability. When injured it is important that you rest or at least modify your activity to allow it to heal effectively. It is therefore recommended that a brace is worn for up to 4-6 weeks after injury.  There are several braces on the market, the one below is a good option.

Once the pain has settled somewhat you can start a progressive stretching and strengthening home exercise plan under the supervision of a physiotherapist following a comprehensive assessment.

A physiotherapist is able to assess your wrist and provide the correct advice and exercise. However, here are a few tips and tricks that may help;

• Avoid aggravating movements or activities such as racquet sports, weight lifting or press ups. Continued aggravation will prolong your recovery and can even make a tear worse.
• Purchase a wrist brace. The application of a wrist brace will help support your wrist.
• Apply a small bag of peas in a tea towel to the wrist.  This helps reduce local pain and inflammation associated with the injury.
• Try applying a topical non-steroidal anti-inflammatory cream. Talk to your pharmacist before using any medication.
• Adjust your desk space to limit the amount of ulnar deviation (side bending of the wrist). Keeping a neutral wrist position will reduce stress on the TFCC.
• Try some gentle wrist stretches. This will help reduce pain and stiffness associated with inflammation.

What if it is not improving with physiotherapy?

Many TFCC injuries do not settle on their own. If pain is still present 3 months after injury and you are still having trouble returning to full function, then an ultrasound steroid injection is a viable next option.

Ultrasound-guided steroid injection

The use of ultrasound-guided steroid (also known as corticosteroid) injections for the treatment of TFCC tears is routinely suggested as a non-surgical option. Steroid injections help to settle the inflammation associated with TFCC tears (Robba et al (2019).

An ultrasound-guided steroid injection is a highly accurate technique used to target inflammation using real time scanning. Steroid is a potent anti-inflammatory medication and is deposited directly to the injured tissue resulting in reduced pain and inflammation. Steroid injections are used to provide rapid pain relief and to allow you to partake in rehabilitation exercises to help strengthen the muscles around your wrist. This treatment combination i.e. steroid injection and exercise, is a very effective option.

Complete Physio offer a ‘one stop’ clinic for all ultrasound-guided injections. On your first appointment we will confirm your diagnosis and carry an ultrasound guided steroid injection if appropriate. You do not need to be referred via your GP.

We often get asked the question; how many steroid injections can I have?

This depends on many factors and can only be answered on a case by case basis. However, it is recommended that you do not have more than three steroid injections, into the same area, in one year. A majority of our clients only require one injection as this provides a ‘window of opportunity’ to engage in a rehabilitation programme. On occasion we will need to carry out a second injection.

Surgical option

A vast majority of TFCC injuries can be managed with injection therapy and physiotherapy rehabilitation. Surgery is indicated if you are not improving and an injection has not provided adequate pain relief.

Partial tears do not generally need surgical intervention. However, complete tears may require surgery. Surgery is completed using arthroscopic repair (keyhole surgery).  Arthroscopic repair has been shown to produce 93% satisfaction rates patients suffering TFCC tears (Doarn et al, 2016).

Other Wrist & Hand conditions:

Osteoarthritis (OA) wrist joint
Trigger Finger/thumb
Carpal Tunnel Syndrome
Osteoarthritis of the thumb
De Quervain’s Tenosynovitis
Scapholunate ligament injury (pain in the wrist)

If you would like more information or would like to book an appointment please contact us on 0207 4823875 or email injections@complete-physio.co.uk.

References

DOARN, M.C., MD and WYSOCKI, R.W., MD, 2016. Acute TFCC Injury. Operative Techniques in Sports Medicine, 24(2), pp. 123-125.

ROBBA, V.I., KARANTANA, A., FOWLER, A.P.G. and DIVER, C., 2019. Perceptions and experiences of wrist surgeons on the management of triangular fibrocartilage complex tears: a qualitative study. Journal of Hand Surgery (European Volume), 44(6), pp. 572-581.

TREISER, M.D., CRAWFORD, K. and IORIO, M.L., 2018. TFCC Injuries: Meta-Analysis and Comparison of Diagnostic Imaging Modalities. Journal of Wrist Surgery, 7(3), pp. 267-272.