Author: Murphy, M P.
Figure 1: A computer-generated image of the DRUJ and TFCC by MD Toye (1)
Abstract
Within the context of sports medicine, specifically ice hockey, reports have discovered that injuries to the wrist, hand, and finger account for the majority the of ER department visits for adolescents’ hockey players (2).
Therefore, the aim of this manuscript is to investigate a common injury of the wrist, specifically tearing of the TFCC and/or its individual components.
Within the introduction, it is the goal to describe the anatomical significance of this structure, briefly mention common mechanisms of injury, as well as typical clinical presentations. The body of the manuscript will describe conservative treatment options to manage this acute injury with PT modalities such as joint mobilizations, therapeutic exercises and extra-vertebral manipulation techniques.
Introduction
The Triangular Fibrocartilage Complex, also known as the TFCC, is vitally important for wrist, hand, and finger arthrokinematics.
This complex is comprised of four unique components, The TFC proper, ulnar component, volar component, and dorsal component.
All of which contain, one, sometimes more, significant ligamentous anatomical structures. Together these components stabilize the distal radius & ulna and enable the homo sapiens to freely rotate the wrist and grip objects tightly, which are essential for sport participation and activities of daily life.
| TFC Proper | Central Aspect Peripheral Aspect |
| Ulnar Component | Meniscus homologue (MH) Ulnar Collateral Ligament (UCL) |
| Volar Component | Volar radioulnar ligament Ulnotriquetral ligament Ulnolunate ligament |
| Dorsal Component | Dorsal radioulnar ligament (dRUL)Extrensor Carpi Ulnaris tendon sheath Dorsal Ulnotriquetral ligament (dUT) |
Table 1: A listing of the four TFCC components and their corresponding anatomical ligamentous structures (1).
The triangular fibrocartilage proper (TFC) is widely described in professional literature to be the most important. It functions as a shock absorber and possesses a unique triangular shape that sits within the medial aspect of the distal radius and articulates with the carpal bone Os lunate. With the help of ultrasound, the central aspect of the TFC proper has been measured to be 1-2 mm thick and is relatively avascular compared to the peripheries (1).
Within kinesiology and skeletal biomechanics, it understood that this structure, as a whole, transmits mechanical forces from the DRUJ through the Os lunate & Os triquetrum and functions to stabilize the ulnar aspect of DRUJ and proximal aspect of the pinky finger.
When damaged, as in the cases described below, this can lead to pain that is localized to the ulnar aspect of the distal forearm, clicking and/or popping within the wrist, grip strength weakness, and lack of finger dexterity.
Most commonly, the TFCC is damaged in the following ways.
The first is a degenerative process that is associated with biological senescence, otherwise known as aging. This anatomical structure contains collagen, which provides compressive and tensile integrity to the DRUJ. Over time these physical properties begin to atrophy and are replaced with fibrin, which is thick fibrotic connective tissue with an increased coefficient of friction.
The second is the result of a traumatic fall on an outstretched hand, which will be referred to as a FOOSH for the remainder of this manuscript. A study published in 2021 discovered that TFCC injuries accompanied distal radius fractures in 39-84% of reported cases (3).
The third is a result of a rapidly occurring compressive shear force, at the distal radioulnar joint, as in cases of when pronation to supination is performed. This biomechanical action is commonly performed in the sport of ice hockey as a means to perform a wrist, snap, or slap shot. To illustrate this claim, the left hand serves as the anchor point to the hockey stick for a right-handed player. When one of these shots is performed the left wrist must undergo rapid acceleration and deceleration moving arthrokinematically from pronation to supination. A study published in 2018 reported that the greatest strain to the dorsal lunotriquetral ligament, which belongs to the dorsal component of the TFCC, occurred when the wrist was flexed, pronated and radial deviated (4). If done repeatedly, throughout a season, tissue breakdown and remodeling may occur, predisposing the athlete to long term injury reserves. This is not only cost in-effective for professional markets such as the NHL, but dangerous to the long-term health of the athlete.
Despite the initial insult, when this anatomical structure is damaged, a patient will often speak to a chief complaint of distal ulnar forearm pain and/or weakness, point tenderness to the triquetrum and/or pisiform, and possible joint crepitus depending on the duration of the complaint.
Physical Examinations to screen for this injury include (5).
- TFCC Compression test
- TFCC Stress Test
- Press Test
- Supination Test
- Piano Key Test
- Grind Test
If positive physical examination findings are discovered, the patient could progress to radiographic medical imagining in order to evaluate for the presence of a positive ulnar variance, retroversion of the Os lunate, and fractures.
If any of these abnormalities are identified, this would be an indication to recommend MRI imaging to evaluate the four soft tissue components of the TFCC.
The current grading system for TFCC injuries is known at the Palmer Classification, which was a guideline put forth in 1989 (6). Within this classification system, Type I designates traumatic injuries while type II classifies degenerative lesions.
Body
For discussions sake, when an acute injury occurs and is non-degenerative in nature, the patient and clinician should first discuss the importance of bracing the injury site until pain and inflammation have decreased. One model that is frequently utilized in clinical practice is Universal Tripod Wrist Lancer (7).
Once in the subacute phase of healing, the patient should immediately progress to PT modalities, in order to avoid deconditioning of the muscular, ligamentous, and tendinous tissues.
Mobilizations
- Posterior to Anterior & Anterior to Posterior Glide of the Lunate and Triquetrum.
- Goal = Restore gliding properties of proximal carpal row.
- Elbow Extension Mobilization.
- Goal = Restore gliding properties of olecranon, and muscle length to biceps brachia.
- Carpal Back Bend.
- Goal = Restore extension gliding properties of DRUJ and proximal carpal row.
- General Wrist Axial Traction: Dorsal/Volar & Ulnar/Radial Glides.
- Goal = Restore gliding properties of DRUJ in two degrees of freedom.
Discussion: Joint mobilizations such as those proposed by Mulligan, E P are defined as the “passive movements of articular surfaces… (8)” by a licensed physical medicine practitioner to decrease pain or increase joint mobility. In regard to the TFCC, the DRUJ, carpal bones, and elbow are all locations of clinical interest and may be mobilized to ensure the smooth gliding of articular surfaces and muscular/ligamentous/tendinous structures.
Resistance Training
- Flexbar Wrist Extensions:
- Goal = Eccentric strengthening & lengthening of the Extensor carpi radials brevis.
- Weighted pronation & supination ROM
- Goal = Concentric strengthening of Biceps Brachi & Supinator.
- Goal = Concentric strengthening of Pronator Teres & Pronator Quadratus.
- Isometric holds in radial deviation.
- Goal = Isometric strengthening of Flexor carpi radialsis, Extensor carpi radialsis longus, Extensor carpi radialsis brevis.
- Isometric holds in ulnar deviation
- Goal = Isometric strengthening of Flexor carpi ulnaris & Extensor carpi ulnaris.
Discussion: The goal of a resistance training regiment is to strengthen the skeletal musculature that permits wrist flexion/extension, pronation/supination, and radial/ulnar deviation. These exercises should be performed at a frequency of three days per week for a total of 10-15 repetitions per bout.
Manipulations
- PA & AP subluxated carpal techniques
- Goal = Remove subluxation from carpal rows.
Discussion: Extravertbal spinal manipulation techniques are utilized to clear subluxations or air pockets that are present within joints. These subluxations can not only serve as pain drivers but can also restrict normal arthrokinematics. Once removed with a high velocity low amplitude thrust, normal biomechanically properties and axonal nerve flow can be temporarily restored. However, it is important to note that this procedure should not be used in patients with osteoporosis or patients who are in the early acute stages of healing (9).
Review Questions
- The diagnosis of an injury to the TFCC is made possible with the use of MRI imaging. What is the classification system used to classify the severity and type of TFCC injury?
- Palmer Classification
- Life Classification
- Dorsal Classification
- Logan Classification
- The TFCC is a load bearing cartilaginous structure that functions to stabilize the radial aspect of the wrist.
- True
- False
- Patients with this condition will typically present with ulnar sided wrist pain that worsens with prolonged activity.
- True
- False
- Which of the answers below is/are orthopedic procedures used to screen for TFCC injuries
- Piano Key Test
- Press Test
- Grind Test
- All of the Above
- In the context of biomechanics, how many degrees of freedom does the radiocarpal joint possess?
- One
- Two
- Three
- Four
References
- Toye, L. January 2020. A Case Study: Displaced Triangular Fibrocartilage Complex Tears. Radsource MRI Web Clinics. Accessed October 10th, 2024. https://radsource.us/displaced-triangular-fibrocartilage-cartilage-complex-tears/
- Tedesco, L J. Swindell, H W. Anderson, F L. Jang, E. Wong, T T. Kazam, J K. Kadiyala, R K. Popkin, C A. 2020. Evaluation and Management of Hand, Wrist, and Elbow Injuries in Ice Hockey. Dovepress Journal of Sports Medicine; 11: 93-103.
- Im, J. Kang, S J. Lee, S L. March 2021. A Compartive Study between Conservative and Surgical Treatments of Triangular Fibrocartilage Complex Injury of the Wrist with Distal Radius Fractures. The Jounral of Clinical Orthopedic Surgery; 13(1): 105-109. A comparative study between conservative and surgical treatments of triangular fibrocartilage complex injury of the wrist with distal radius fractures
- Sandman, E. Boily, M. Martineau, P A. “Hockey wrist: dorsal ulnotriqueteral ligament injury.” December 2018. The Canadian Journal of Surgery; 61)6: 398-404. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6281460/
- Triangular Fibrocartilage Complex Injuries. Physiopedia. Accessed October 10, 2024. https://www.physio-pedia.com/Triangular_Fibrocartilage_Complex_Injuries
- Teunis, T. Ring R. November 2017. Review of Palmer and Wener (1981) on the triangular fibrocartilage complex of the wrist anatomy and function. Journal of ISAKOS; 2(6): 350-354. Review of Palmer and Werner (1981) on the triangular fibrocartilage complex of the wrist anatomy and function – ScienceDirect
- Medspec Universal Tripod wrist lancer. DME Direct The Orthopedic & Sports Brace Experts. Accessed October 10th, 2024. https://www.dme-direct.com/medspec-universal-tripod-wrist-lacer
- Joint Mobilization. Physiopedia. Accessed October 10, 2024. https://www.physio-pedia.com/images/c/c0/Principles_of_Joint_Mobilization.pdf
- Krik, C R. Lawernece, D J. Valvo, N. L. 1998. States Manual of Spinal, Pelvic, and Extravertebral Techniques: 2nd edition. Waver;y Press Inc, Baltimore MD; Part 3: 184-192.
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