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Management of isolated triangular fibrocartilage complex perforations of the wrist
(SCIENTIFIC/CLINICAL ARTICLES
J
Management of Isolated Triangular Fibrocartilage Complex Perforations of the Wrist Bonnie Trainor Lucio, LOTR The Hand Center of Louisiana, Inc. 2622 lena Street, New Orleans, Louisiana
Harold M, Stokes, MD Hand Surgical Associates, New Orleans, Louisiana
Gary G. Poehling, MD Professor and Chairman, Department of Orthopaedic Surgery, Bowman Gray School of Medicine, Winston-Salem, North Carolina
Sabrina Lemoine-Smith, LOTR Metairie, Louisiana
Elizabeth Crook, MS 1 Winston-Salem, North Carolina
triangular fibrocartilage complex (TFCC) T ofhe the wrist is unfamiliar to many, yet it is
both biomechanically and anatomically significant for normal wrist and hand function. It is a complex structure interposed between the distal ulna and the ulna carpus and is composed of the articular disc, the meniscus homologue, the ulnar collateral ligament, the dorsal radioulnar ligament, the volar radioulnar ligament, and the sheath of the extensor carpi ulnaris (Fig. lA). The TFCC arises from the ulnar aspect of the lunate fossa of the radius and extends to the base of the ulnar styloid. 1 It inserts distally into the triquetrum, hamate, and base of the fifth metacarpal (Fig. 18). The average thickness of the volar and dorsal aspects of the TFCC is 4 or 5 mm. 2 Centrally, the TFCC is thinner and at times is found to be perforated.! Abnormalities of the TFCC have been classified by Palmeil into traumatic and degenerative lesions. Traumatic lesions are less common and are classified by location of the perforation. Degenerative changes are a result of repetitive loading and ulnoThis paper is adapted from a scientific paper presented at the Thirteenth Annual Meeting of The American Society of Hand Therapists, 19-23 September 1990, Toronto, Ontario, Canada. Correspondence and reprint requests to Bonnie Trainor Lucio, LOTR, The Hand Center of Louisiana, Inc., 2622 Jena Street, New Orleans, LA 70115.
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ABSTRACT: The purpose of this study was to examine surgical and therapeutic management of patients with triangular fibrocartilage complex perforations of the wrist. Anatomy, symptoms, diagnosis, surgical treatment, and therapeutic intervention were examined. Twenty-three patients with symptomatic triangular fibrocartilage complex tears were followed after arthroscopic debridement. Emphasis of hand therapy was placed on decreasing edema and obtaining maximum range of motion, strength, and function. Twenty-two of the 23 patients had been employed at the time of their injuries. Seventeen patients (77%) were asymptomatic following triangular fibrocartilage complex debridement and hand rehabilitation. The mean time for return to work was 5.5 weeks after arthroscopy and therapy. Retrospective, post-operative functional results compared with those of the opposite unaffected limbs were: grip strength, 71'}'o; lateral pinch, 79%; three jaw-chuck, 83%; pronation, 94%; supination, 85%; wrist palmar flexion, 87%; wrist dorsiflexion, 86%; radial deviation, 91 %; and ulnar deviation, 95%. This study suggests favorable functional results follOWing arthroscopic triangular fibrocartilage complex debridement and hand rehabilitation.
carpal abutment. This paper focuses on traumatic TFCC perforations. The TFCC receives its blood supply from the ulnar artery through its dorsal and palmar radiocarpal branches and the dorsal and palmar branches of the anterior interosseous artery. l-listologic sections of the TFCC reveal vascularity in the outer 15% to 20% of the disc, with the rest being avascular.4 In exalT),ining 34 wrists, Palmer and Werner found 18 (53%) perforated wrists, located in the central horizontal portion of the complex. 1 Mikic evaluated 180 cadaver wrists, ranging in age from premature infancy to 97 years. There was no evidence of degenerative change or perforations of any part of the disc in any of the specimens before the third decade of life. He also noted a linear progression of degeneration with age so that over the age of 50, all specimens showed degenerative changes, many with the horizontal portion of the TFCC being affected. s Biomechanically, the TFCC serves to: 1) stabilize the distal radioulnar joint; 2) act as a cushion for the ulnar carpus, carrying approximately 20% of the axial load of the forearm in a cadaver specimen; and 3) stabilize the ulnar carpus.1.6-!2 Variable transmission loads are placed on the ulnar aspect of the wrist by the TFCC as the forearm moves through pronation and supination.s 13 Supination results in a negative ulnar variance and, conversely, pronation results in
Schematic representation of the components of the triangular fibrocartilage complex. MH = mpniscus homologue; AD = articular disc; UCL == ulnar collateral ligament; RUL = dorsal dnd volar radioulnar ligaments. The extensor carpi ulnaris sheath is not shown. Other structures shown are: the metacarpal bones 12,3,4, and .5); the carpal bones (5 = scaphoid, L = lunate, TQ == triquetrum, H = hamate, C = capitate, TZ = trapezoid, TP = trapezium); the radius (R); and the ulna (U). B, right: Cross-sectional view of the wrist showing the triangular fibrocartilage complex (TFCe; arising from the radius and inwrUng into the ulnar styloid and ulnar carpal bones IT = triquetrum, L = lunate, 5 -, scaphoid). Reprinted with permission from Palmer AK, Werner FW: The triangular fibrocartilage complex of the wrist: Anatomy and function. I Hand Surg 6: 15.3, 1981. fiGURE 1.
a more positive ulnar variance. The ulnar head becomes exposed dorsally in full pronation and palmarly in full supination. The horizontal portion of the TFCC is thicker in a more negative ulnar variance, and thinner in a more positive ulnar variance. 14 In full supination and pronation, the dorsal and palmar portions of the TFCC become tense, thus stabilizing the distal radioulnar joint. 15 Palmer and Werner l found that 17% of the specimens examined with ulna-minus wrists were found to have TFCC perforations, whereas 730/[ ulna-neutral or ulna-plus wrists had TFCC perforations. Disruptions of the TFCC are often overlooked and misdiagnosed. Traumatic injuries usually result from a fall on the outstretched pronated hand, an acute rotational injury to the forearm, or an axial load and distraction injury to the ulnar border of the forearm.3.h· 9 Clinical symptoms of TFCC disruption include a "clicking," "popping," or "locking" of the wrist, pain upon rotation of the forearm associated with discomfort in the area of the ulna styloid, and complaints of weakness of grip strength. Diagnostic tools utilized to identify TFCC disruptions may involve a careful history and thorough examination including stress testing and palpation, radiography, arthrography, triple injection arthrography, cinearthrography, and wrist arthroscopy. Cinearthrograms are helpful in that they allow the examiner to dynamically visualize whether the TFCC is intact. Contrast material is injected into the radiocarpal joint, and the wrist is passively mobilized (Fig. 2A). An intact TFCC (Fig. 28) does not permit the contrast material to invade the radioulnar joint, in comparison with a perforated TFCC (Fig. 2C). Traumatic tears of the horizontal portion of the TFCC that do not respond to conservative care are felt to be best treated with limited TFCC arthroscopic
debridement. l With arthroscopy, excision of the entire TFCC would lead to instability of the distal ulna and would be expected to lead to increased ulnolunate abutment, erosion of cartilage, and wrist pain. I Prior to arthroscopic surgery, the structures relevant to portal entry are marked so that they remain apparent after the wrist is distended (Fig. 3A). The major landmarks and the position of the five portals used in wrist arthroscopy are identified (Fig. 3B).11> The primary radiocarpal portal, the 3-4, is located 1 cm distal to Lister's tubercle and just over the distal radius. It is here where the arthroscope is placed for viewing the internal structures. The 6-R portal lies radial to the extensor carpi ulnaris (ECU) and distal to the ulnar head. This portal is used for insertion of different instruments. The 6-U portal is just ulnar to the ECU, and allows inflow of Ringer's solution. Examination is begun on the radial side, moving along the volar aspect to the ulnar side, then returning along the dorsal aspect (Fig. 4A). The probe is used to identify structural characteristics. A perforated TFCC is detected when the probe is abJc to pass through the fibrocartilage. Debridement of the rough, jagged edges of the perforation using a suction radial shaver is desired, in order to create a smooth, oval window in the TFCC (Fig. 48). Palmer et al. found that removal of the central one-third of the TFCC produced no significant alteration of load patterns on the ulnar aspect of the wrist. Removal of two-thirds and all of the horizontal portions of the TFCC significantly increased the load through the distal ulna, leading to ulnolunate abutment. 17 Making contact with the articular surfaces of the ulna and carpal bones is avoided. The wrist is placed in a bulky dressing following arthroscopy until the therapeutic initial evaluation. October-December 1991
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FIGURE 2. A, left: Cinearthrogram of a right wrist with contrast material being inserted into the radiocarpal jOint. B, below left: Intact triangular fibrocartilage complex (TFCC)no extravasation. C, below: Extravasation of dye into the distal radioulnar joint indicating a triangular fibrocartilage complex (TFCC) perforation.
Intact TFCC
METHOD Twenty-three patients, 11 women and 12 men, ranging in age from 21 to 57 years (mean age = 38 years; 40.5 years for women, 36.7 years for men) with symptomatic isolated TFCC perforations were fol164
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Dye extravasation lowed after arthroscopic debridement. All 23 patients were right-handed (i.e., they had a tendency to use the right hand in preference to the left). Fifteen dominant hands were affected as compared with eight nondominant hands. The mechanism of injury varied, with the most common injury resulting from a fall on the outstretched pronated hand (6 patients),
fiGURE 3. A, left: Surgical positioning for wrist arthroscopy. B, right: The 3-4, 6-U, and 6-R portals provide the acce s and vi ibility needed for wrist arthroscopy. The midcarpal portals (MCR = midcarpal radius and MCU = midcarpal ulna ) provide a view of the midcarpal joint. Reprinted with permission from Poehling GG: An illustrated guide to small joint arthroscopy. Wrist arthroscopy; portals to progress. Andover, MA: Smith and Nephew D yonics, Inc., 1989 .
and twisting injuries to the forearm (5 patients) as the second most common cause. Duration of therapy for treatment ranged from 1-26 weeks (mean = 9.2 weeks). Time elapsed from surgery to initiation of rehabilitation ranged from 1 day to 5 weeks postoperative. Delay of initiation of therapy was due to patient scheduling conflicts and physician referral. Therapy guidelines were established for treating these patients, however it must be emphasized that patients should be progressed according to their degrees of pain tolerance. Frequency of exercises: 10 repetitions/4 times a day. Week 1
• Patient is kept in bulky dressing • Instructions in edema control
Week 2
• Bulky dressing removed
• Edema control-retrograde massage, elevation, Coban wrapping, and Isotoner glove 1H • Wrist cock-up splint • Active range of motion (AROM) exercises 10 repetitions/4 times a day (Fig. 5), including supination/pronation, radial and ulnar deviation, wrist palmar flexion and dorsiflexion, and tendon gliding exercises (waving, full fist, and hook fist) • Isometric (contract-relax) injured forearm/hand 10 repetitions/4 times a day • Low-grade isotonic exercises, if edema is not present l9 (i.e., least resistant putty exercises 2-3 minutes 4 times a day) October-December 1991
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• Light activities of daily living (ADLs) with a maximum 5-pound limit (Note: this is an upper limit placed on patients who are not experiencing pain. No literature was found to discourage a maximum of 5 pounds while performing ADLs. No adverse reaction was noted with patients in this study.) • Paraffin utilized for 20 minutes with hand elevated (If severe edema persists, high-voltage Galvanic stimulation for 20 to 30 minutes has been recommended to treat pain, edema, and assist in wound healing. 20) • Wrist cock-up splint discontinued at end of week 2 Weeks 3-5 • Continue same regimen as week 2 except: • Increase isotonic exercises up to 10 pounds maximum (i.e., to strengthen upper arm, forearm). Wrist mobility using less than 5 pounds with free weights, performed within pain-free range of motion. • ADLs and leisure activities involving less than 10 pounds
fiGURE 4. A, leit: Arthroscopic appearance o( a triangular fihrocartilage complex (TrCC) perforation. Erosion o( the ulna, triquetrum, and lunate are evident. Suction punch, arthroscope, and 18-gauge needle are shown. B, right: A 2.S-millimeter suction punch is utiliLed to remove jagged edges of the perforation. Reprinted with permission (rom Poehling CC: An illustrated guide to small joint arthroscopy. Wrist arthroscopy; Portals to progress. Andover, MA: Smith and Nephew O)'onics, Inc., 1989.
Week 5• Isotonic exercises performed using the Discharge BTE and work simulation tasks to maximum exercise level within painfree range (Fig. 6) • Discharge-return to work and continue with home exercise program
RESULTS The average length of follow-up ranged from 6 to 43 months, with an average of 21 months. Subjective pain analog: mean = 2.1 on a scale from a to 10. Table 1 shows the functional results as compared with those of the opposite unaffected limb. Seventeen patients (77%) had good/excellent results following TFCC debridement and hand rehabilitation. Rating of results was based upon a pain analog scale and loss of ROM. Twenty-two of the 23 patients had been employed at the time of their injuries; 17 patients (77%) returned to work. Mean time for return to work was 5.5 weeks after arthroscopy. No complication resulted from TFCC debridement. Four patients required additional surgery, and 1 of these patients subsequently returned to work. Nine women had been employed prior to surgery; 8/9 (89%) returned to work following surgery. Mean age for women was 40.5 years. Six women were ~40 years old. Thirteen men had been employed prior to surgery; 9/13 (69%) returned to work following surgery. Mean age for men was 36.7 years. It is also noted that 4/6 patients with poor results (>3 on pain analog scale with loss of >10° ROM) were over 40 years old. Three patients were :s30 years old. Two of 3 166
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fiGURE 5. Active range of motion exercises are performed within a pain-free range and gradually progressed to include resistive exercises.
patients returned to work after debridement. The other patient required additional surgery and returned to work after the second surgery. There were 4 patients ~50 years of age. One patient had not been employed prior to surgery. Of the three patients who had been employed, two did not return to work and one did. Types of employment ranged from
FIGURE 6. Functional tasks are utilized to increase range of motion and increase independence. TABLE 1.
Posttherapy Functional Results ('!'o) as Compared with the Opposite Unaffected Limb
Grip strength Lateral pinch Three jaw chuck Pronation Supination Wrist palmar flexion Wrist dorsiflexion Radial devation Ulnar deviation
71 79 83 94 85 87 86 91 95
professional careers (9 patients), requiring minimal strength and range of motion of the wrist, to heavy labor (13 patients), which often required heavy lifting and carrying intermittently/consistently throughout their workdays. All patients who returned to work returned to their original positions.
DISCUSSION Extraneous variables that may have been factors in the functional outcomes in this stydy include: age, in relation to degenerative changes of the TFCC after the third decade, which supports previous work by Mikic, and prolonged healing time as age increases; compensable injuries-workman's compensation versus private patients-possible motivational factors; poor results noted with articular cartilage damage to the lunate and ulnar head, as shown by Palmer and Werner1 and Mikic5; and dominance versus nondominance in the injured limbs when compared functionally (i.e., the dominant upper extremity shown to be on the average 5.4% stronger in males and 8.9% stronger in females).21 Ulnar-sided wrist pain has often been referred
to as "the low back pain of the wrist."3 Barring extraneous variables, patients less than 40 years old exhibited favorable functional results, i.e., in the areas of pain, motion, grip, and return to work. It is noted that 4 of the 6 patients with poor results were over the age of 40. Early mobilization (AROM exercises one week post-op) appeared to contribute to the favorable outcome of this study, unlike prolonged immobilization following other procedures. Menon et al. reviewed 16 patients following arthrotomy where the patients remained immobilized for 6 weeks in a long arm cast. Eleven patients (69%) had no symptom at follow-up, but 5 (31 %) required further surgery. 22 McDonough reported that immobilization of articular surfaces may lead to changes and potentially a decrease in matrix and cellular components, disorganization of the various strata of cartilage, and potential irreversible damage if immobilization is prolonged. 23 Qualification that a cookbook protocol for management of these patients cannot be adhered to, and that the patient's pain tolerance dictates the progression of therapy, cannot be overemphasized. One issue that necessitates resolution is the treatment of patients over 40 years old with TFCC perforations. While many advances have taken place in the management of TFCC lesions, further research is needed to address this dilemma.
REFERENCES 1. Palmer AK, Werner FW: The triangular fibrocartilage complex of the wrist-Anatomy and function. J Hand Surg 6:15362:563-82, 1981. 2. Dell PC: Distal radioulnar joint dysfunction. Hand Clin 3(4), 1987. 3. Palmer AK: Triangular fibrocartilage complex lesions: A classification. J Hand Surg 14A:594-606. 4. Thiru-Pathi RG, Ferlic DC, Clayton ML, McClure DC: Arterial anatomy of the triangular fibrocartilage complex of the wrist and its surgical significance. J Hand Surg llA:258-63, 1986. 5. Mikic ZD: Age changes in the triangular fibrocartilage of the wrist joint. J Anat 126:367-84, 1978. 6. Bowers WHo Problems of the distal radioulnar joint. In Advances in Ohhopaedic Surgery. Baltimore, Williams & Wilkins, 1984, pp. 289-303. 7. Bowers WHo The distal radioulnar joint. In Green DP (ed.): Operative Hand Surgery. Vol. II. New York, Churchill livingstone, 1988, pp. 939-89. 8. Palmer AK. The distal radioulnar jOint. In Lichtman DM (ed.): The Wrist and Its Disorders. Philadelphia, W.B. Saunders, 1988, pp. 222-31. 9. Palmer AK. The distal radioulnar jOint. In Talesnik J (ed.): Hand Clinics-Management of Wrist Problems. Philadelphia, W.B. Saunders, 1987, pp. 31-40. 10. Palmer AK, Werner FW. Biomechanics of the distal radioulnar joint. Clin Orthop 187:26-34, 1984. 11. Werner FW, Glisson RR, Murphy DJ, Palmer AK. Force transmission through the distal radioulnar carpal joint: Effect of ulnar lengthening and shortening. Hand Surg 18:304-8, 1986. 12. Ekenstam F, Palmer AK, Glisson RR. The load on the radius and ulna in different positions of the wrist and forearm. Acta Ortho Scand 5S:363-5, 1984. 13. Kauer JMG. The articular disc of the hand. Acta Anat 93:590605, 1985. 14. Palmer AK, Glisson RR, Werner FW. Relationship between ulnar variance and triangular fibrocartilage complex thickness. J Hand Surg 9A:681-3, 1984. 15. Ekenstam FW, Hagert CG. Anatomical studies on the geom-
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16. 17. 18. 19.
etry and stability of the distal radioulnar joint. Scand J Plast Reconstr Surg Hand Surg 19:17-25, 1985. Poehling GG. An illustrated guide to small joint arthroscopy. Wrist arthroscopy; portals to progress. Andover, MA: Smith and Nephew Dyonics, Inc., 1989. Palmer AK, Werner FW, Glisson BS, Murphy OJ. Partial excision of the triangular fibrocartilage complex. J Hand Surg 13A:403-6, 1988. Hunter jM, Mackin EJ. Management of edema. In Hunter JM, Schneider LH, Mackin EJ, et al (eds.): Rehabilitation of the Hand. 3rd ed. St. Louis, C.V. Mosby, 1990, pp. 187-94. McEntree PM. Therapist's management of the stiff hand. liz Hunter JM, Schneider LH, Mackin EJ, et al (eds.): Rehabilitation of the Hand. 3rd ed. St Louis, C.V. Mosby, 1990, pp. 328-41.
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20. Taylor Mullins PA. Use of therapeutic modalities in upper extremity rehabilitation. In Hunter JM, Schneider LH, Mackin EJ, et al (eds.): Rehabilitation of the Hand. 3rd ed. St. Louis, C.V. Mosby, 1990, pp. 195-220. 21. Swanson AB, Swanson GG, Coran-HageTt C. Evaluation of impairment of hand function. In Hunter JM, Schneider LH, Mackin EJ, et al (eds.): Rehabilitation of the Hand. 3rd ed. St. Louis, C.V. Mosby, 1990, pp. 109-38. 22. Menon J, Wood VE, Shoene HR, Frykman GK, Hohl JC, Bestard EA. Isolated tears of the triangular fibrocartilage of the wrist: Results of partial excision. J Hand Surg 9A:527 -30, 1984. 23. McDonough AL. Effects of immobilization and exercise on articular cartilage-A review of literature. J Orthop Sports Phys Ther 9:2-5, 1981.
J
Management of Isolated Triangular Fibrocartilage Complex Perforations of the Wrist Bonnie Trainor Lucio, LOTR The Hand Center of Louisiana, Inc. 2622 lena Street, New Orleans, Louisiana
Harold M, Stokes, MD Hand Surgical Associates, New Orleans, Louisiana
Gary G. Poehling, MD Professor and Chairman, Department of Orthopaedic Surgery, Bowman Gray School of Medicine, Winston-Salem, North Carolina
Sabrina Lemoine-Smith, LOTR Metairie, Louisiana
Elizabeth Crook, MS 1 Winston-Salem, North Carolina
triangular fibrocartilage complex (TFCC) T ofhe the wrist is unfamiliar to many, yet it is
both biomechanically and anatomically significant for normal wrist and hand function. It is a complex structure interposed between the distal ulna and the ulna carpus and is composed of the articular disc, the meniscus homologue, the ulnar collateral ligament, the dorsal radioulnar ligament, the volar radioulnar ligament, and the sheath of the extensor carpi ulnaris (Fig. lA). The TFCC arises from the ulnar aspect of the lunate fossa of the radius and extends to the base of the ulnar styloid. 1 It inserts distally into the triquetrum, hamate, and base of the fifth metacarpal (Fig. 18). The average thickness of the volar and dorsal aspects of the TFCC is 4 or 5 mm. 2 Centrally, the TFCC is thinner and at times is found to be perforated.! Abnormalities of the TFCC have been classified by Palmeil into traumatic and degenerative lesions. Traumatic lesions are less common and are classified by location of the perforation. Degenerative changes are a result of repetitive loading and ulnoThis paper is adapted from a scientific paper presented at the Thirteenth Annual Meeting of The American Society of Hand Therapists, 19-23 September 1990, Toronto, Ontario, Canada. Correspondence and reprint requests to Bonnie Trainor Lucio, LOTR, The Hand Center of Louisiana, Inc., 2622 Jena Street, New Orleans, LA 70115.
162
JOURNAL OF HAND THERAPY
ABSTRACT: The purpose of this study was to examine surgical and therapeutic management of patients with triangular fibrocartilage complex perforations of the wrist. Anatomy, symptoms, diagnosis, surgical treatment, and therapeutic intervention were examined. Twenty-three patients with symptomatic triangular fibrocartilage complex tears were followed after arthroscopic debridement. Emphasis of hand therapy was placed on decreasing edema and obtaining maximum range of motion, strength, and function. Twenty-two of the 23 patients had been employed at the time of their injuries. Seventeen patients (77%) were asymptomatic following triangular fibrocartilage complex debridement and hand rehabilitation. The mean time for return to work was 5.5 weeks after arthroscopy and therapy. Retrospective, post-operative functional results compared with those of the opposite unaffected limbs were: grip strength, 71'}'o; lateral pinch, 79%; three jaw-chuck, 83%; pronation, 94%; supination, 85%; wrist palmar flexion, 87%; wrist dorsiflexion, 86%; radial deviation, 91 %; and ulnar deviation, 95%. This study suggests favorable functional results follOWing arthroscopic triangular fibrocartilage complex debridement and hand rehabilitation.
carpal abutment. This paper focuses on traumatic TFCC perforations. The TFCC receives its blood supply from the ulnar artery through its dorsal and palmar radiocarpal branches and the dorsal and palmar branches of the anterior interosseous artery. l-listologic sections of the TFCC reveal vascularity in the outer 15% to 20% of the disc, with the rest being avascular.4 In exalT),ining 34 wrists, Palmer and Werner found 18 (53%) perforated wrists, located in the central horizontal portion of the complex. 1 Mikic evaluated 180 cadaver wrists, ranging in age from premature infancy to 97 years. There was no evidence of degenerative change or perforations of any part of the disc in any of the specimens before the third decade of life. He also noted a linear progression of degeneration with age so that over the age of 50, all specimens showed degenerative changes, many with the horizontal portion of the TFCC being affected. s Biomechanically, the TFCC serves to: 1) stabilize the distal radioulnar joint; 2) act as a cushion for the ulnar carpus, carrying approximately 20% of the axial load of the forearm in a cadaver specimen; and 3) stabilize the ulnar carpus.1.6-!2 Variable transmission loads are placed on the ulnar aspect of the wrist by the TFCC as the forearm moves through pronation and supination.s 13 Supination results in a negative ulnar variance and, conversely, pronation results in
Schematic representation of the components of the triangular fibrocartilage complex. MH = mpniscus homologue; AD = articular disc; UCL == ulnar collateral ligament; RUL = dorsal dnd volar radioulnar ligaments. The extensor carpi ulnaris sheath is not shown. Other structures shown are: the metacarpal bones 12,3,4, and .5); the carpal bones (5 = scaphoid, L = lunate, TQ == triquetrum, H = hamate, C = capitate, TZ = trapezoid, TP = trapezium); the radius (R); and the ulna (U). B, right: Cross-sectional view of the wrist showing the triangular fibrocartilage complex (TFCe; arising from the radius and inwrUng into the ulnar styloid and ulnar carpal bones IT = triquetrum, L = lunate, 5 -, scaphoid). Reprinted with permission from Palmer AK, Werner FW: The triangular fibrocartilage complex of the wrist: Anatomy and function. I Hand Surg 6: 15.3, 1981. fiGURE 1.
a more positive ulnar variance. The ulnar head becomes exposed dorsally in full pronation and palmarly in full supination. The horizontal portion of the TFCC is thicker in a more negative ulnar variance, and thinner in a more positive ulnar variance. 14 In full supination and pronation, the dorsal and palmar portions of the TFCC become tense, thus stabilizing the distal radioulnar joint. 15 Palmer and Werner l found that 17% of the specimens examined with ulna-minus wrists were found to have TFCC perforations, whereas 730/[ ulna-neutral or ulna-plus wrists had TFCC perforations. Disruptions of the TFCC are often overlooked and misdiagnosed. Traumatic injuries usually result from a fall on the outstretched pronated hand, an acute rotational injury to the forearm, or an axial load and distraction injury to the ulnar border of the forearm.3.h· 9 Clinical symptoms of TFCC disruption include a "clicking," "popping," or "locking" of the wrist, pain upon rotation of the forearm associated with discomfort in the area of the ulna styloid, and complaints of weakness of grip strength. Diagnostic tools utilized to identify TFCC disruptions may involve a careful history and thorough examination including stress testing and palpation, radiography, arthrography, triple injection arthrography, cinearthrography, and wrist arthroscopy. Cinearthrograms are helpful in that they allow the examiner to dynamically visualize whether the TFCC is intact. Contrast material is injected into the radiocarpal joint, and the wrist is passively mobilized (Fig. 2A). An intact TFCC (Fig. 28) does not permit the contrast material to invade the radioulnar joint, in comparison with a perforated TFCC (Fig. 2C). Traumatic tears of the horizontal portion of the TFCC that do not respond to conservative care are felt to be best treated with limited TFCC arthroscopic
debridement. l With arthroscopy, excision of the entire TFCC would lead to instability of the distal ulna and would be expected to lead to increased ulnolunate abutment, erosion of cartilage, and wrist pain. I Prior to arthroscopic surgery, the structures relevant to portal entry are marked so that they remain apparent after the wrist is distended (Fig. 3A). The major landmarks and the position of the five portals used in wrist arthroscopy are identified (Fig. 3B).11> The primary radiocarpal portal, the 3-4, is located 1 cm distal to Lister's tubercle and just over the distal radius. It is here where the arthroscope is placed for viewing the internal structures. The 6-R portal lies radial to the extensor carpi ulnaris (ECU) and distal to the ulnar head. This portal is used for insertion of different instruments. The 6-U portal is just ulnar to the ECU, and allows inflow of Ringer's solution. Examination is begun on the radial side, moving along the volar aspect to the ulnar side, then returning along the dorsal aspect (Fig. 4A). The probe is used to identify structural characteristics. A perforated TFCC is detected when the probe is abJc to pass through the fibrocartilage. Debridement of the rough, jagged edges of the perforation using a suction radial shaver is desired, in order to create a smooth, oval window in the TFCC (Fig. 48). Palmer et al. found that removal of the central one-third of the TFCC produced no significant alteration of load patterns on the ulnar aspect of the wrist. Removal of two-thirds and all of the horizontal portions of the TFCC significantly increased the load through the distal ulna, leading to ulnolunate abutment. 17 Making contact with the articular surfaces of the ulna and carpal bones is avoided. The wrist is placed in a bulky dressing following arthroscopy until the therapeutic initial evaluation. October-December 1991
163
FIGURE 2. A, left: Cinearthrogram of a right wrist with contrast material being inserted into the radiocarpal jOint. B, below left: Intact triangular fibrocartilage complex (TFCC)no extravasation. C, below: Extravasation of dye into the distal radioulnar joint indicating a triangular fibrocartilage complex (TFCC) perforation.
Intact TFCC
METHOD Twenty-three patients, 11 women and 12 men, ranging in age from 21 to 57 years (mean age = 38 years; 40.5 years for women, 36.7 years for men) with symptomatic isolated TFCC perforations were fol164
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Dye extravasation lowed after arthroscopic debridement. All 23 patients were right-handed (i.e., they had a tendency to use the right hand in preference to the left). Fifteen dominant hands were affected as compared with eight nondominant hands. The mechanism of injury varied, with the most common injury resulting from a fall on the outstretched pronated hand (6 patients),
fiGURE 3. A, left: Surgical positioning for wrist arthroscopy. B, right: The 3-4, 6-U, and 6-R portals provide the acce s and vi ibility needed for wrist arthroscopy. The midcarpal portals (MCR = midcarpal radius and MCU = midcarpal ulna ) provide a view of the midcarpal joint. Reprinted with permission from Poehling GG: An illustrated guide to small joint arthroscopy. Wrist arthroscopy; portals to progress. Andover, MA: Smith and Nephew D yonics, Inc., 1989 .
and twisting injuries to the forearm (5 patients) as the second most common cause. Duration of therapy for treatment ranged from 1-26 weeks (mean = 9.2 weeks). Time elapsed from surgery to initiation of rehabilitation ranged from 1 day to 5 weeks postoperative. Delay of initiation of therapy was due to patient scheduling conflicts and physician referral. Therapy guidelines were established for treating these patients, however it must be emphasized that patients should be progressed according to their degrees of pain tolerance. Frequency of exercises: 10 repetitions/4 times a day. Week 1
• Patient is kept in bulky dressing • Instructions in edema control
Week 2
• Bulky dressing removed
• Edema control-retrograde massage, elevation, Coban wrapping, and Isotoner glove 1H • Wrist cock-up splint • Active range of motion (AROM) exercises 10 repetitions/4 times a day (Fig. 5), including supination/pronation, radial and ulnar deviation, wrist palmar flexion and dorsiflexion, and tendon gliding exercises (waving, full fist, and hook fist) • Isometric (contract-relax) injured forearm/hand 10 repetitions/4 times a day • Low-grade isotonic exercises, if edema is not present l9 (i.e., least resistant putty exercises 2-3 minutes 4 times a day) October-December 1991
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• Light activities of daily living (ADLs) with a maximum 5-pound limit (Note: this is an upper limit placed on patients who are not experiencing pain. No literature was found to discourage a maximum of 5 pounds while performing ADLs. No adverse reaction was noted with patients in this study.) • Paraffin utilized for 20 minutes with hand elevated (If severe edema persists, high-voltage Galvanic stimulation for 20 to 30 minutes has been recommended to treat pain, edema, and assist in wound healing. 20) • Wrist cock-up splint discontinued at end of week 2 Weeks 3-5 • Continue same regimen as week 2 except: • Increase isotonic exercises up to 10 pounds maximum (i.e., to strengthen upper arm, forearm). Wrist mobility using less than 5 pounds with free weights, performed within pain-free range of motion. • ADLs and leisure activities involving less than 10 pounds
fiGURE 4. A, leit: Arthroscopic appearance o( a triangular fihrocartilage complex (TrCC) perforation. Erosion o( the ulna, triquetrum, and lunate are evident. Suction punch, arthroscope, and 18-gauge needle are shown. B, right: A 2.S-millimeter suction punch is utiliLed to remove jagged edges of the perforation. Reprinted with permission (rom Poehling CC: An illustrated guide to small joint arthroscopy. Wrist arthroscopy; Portals to progress. Andover, MA: Smith and Nephew O)'onics, Inc., 1989.
Week 5• Isotonic exercises performed using the Discharge BTE and work simulation tasks to maximum exercise level within painfree range (Fig. 6) • Discharge-return to work and continue with home exercise program
RESULTS The average length of follow-up ranged from 6 to 43 months, with an average of 21 months. Subjective pain analog: mean = 2.1 on a scale from a to 10. Table 1 shows the functional results as compared with those of the opposite unaffected limb. Seventeen patients (77%) had good/excellent results following TFCC debridement and hand rehabilitation. Rating of results was based upon a pain analog scale and loss of ROM. Twenty-two of the 23 patients had been employed at the time of their injuries; 17 patients (77%) returned to work. Mean time for return to work was 5.5 weeks after arthroscopy. No complication resulted from TFCC debridement. Four patients required additional surgery, and 1 of these patients subsequently returned to work. Nine women had been employed prior to surgery; 8/9 (89%) returned to work following surgery. Mean age for women was 40.5 years. Six women were ~40 years old. Thirteen men had been employed prior to surgery; 9/13 (69%) returned to work following surgery. Mean age for men was 36.7 years. It is also noted that 4/6 patients with poor results (>3 on pain analog scale with loss of >10° ROM) were over 40 years old. Three patients were :s30 years old. Two of 3 166
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fiGURE 5. Active range of motion exercises are performed within a pain-free range and gradually progressed to include resistive exercises.
patients returned to work after debridement. The other patient required additional surgery and returned to work after the second surgery. There were 4 patients ~50 years of age. One patient had not been employed prior to surgery. Of the three patients who had been employed, two did not return to work and one did. Types of employment ranged from
FIGURE 6. Functional tasks are utilized to increase range of motion and increase independence. TABLE 1.
Posttherapy Functional Results ('!'o) as Compared with the Opposite Unaffected Limb
Grip strength Lateral pinch Three jaw chuck Pronation Supination Wrist palmar flexion Wrist dorsiflexion Radial devation Ulnar deviation
71 79 83 94 85 87 86 91 95
professional careers (9 patients), requiring minimal strength and range of motion of the wrist, to heavy labor (13 patients), which often required heavy lifting and carrying intermittently/consistently throughout their workdays. All patients who returned to work returned to their original positions.
DISCUSSION Extraneous variables that may have been factors in the functional outcomes in this stydy include: age, in relation to degenerative changes of the TFCC after the third decade, which supports previous work by Mikic, and prolonged healing time as age increases; compensable injuries-workman's compensation versus private patients-possible motivational factors; poor results noted with articular cartilage damage to the lunate and ulnar head, as shown by Palmer and Werner1 and Mikic5; and dominance versus nondominance in the injured limbs when compared functionally (i.e., the dominant upper extremity shown to be on the average 5.4% stronger in males and 8.9% stronger in females).21 Ulnar-sided wrist pain has often been referred
to as "the low back pain of the wrist."3 Barring extraneous variables, patients less than 40 years old exhibited favorable functional results, i.e., in the areas of pain, motion, grip, and return to work. It is noted that 4 of the 6 patients with poor results were over the age of 40. Early mobilization (AROM exercises one week post-op) appeared to contribute to the favorable outcome of this study, unlike prolonged immobilization following other procedures. Menon et al. reviewed 16 patients following arthrotomy where the patients remained immobilized for 6 weeks in a long arm cast. Eleven patients (69%) had no symptom at follow-up, but 5 (31 %) required further surgery. 22 McDonough reported that immobilization of articular surfaces may lead to changes and potentially a decrease in matrix and cellular components, disorganization of the various strata of cartilage, and potential irreversible damage if immobilization is prolonged. 23 Qualification that a cookbook protocol for management of these patients cannot be adhered to, and that the patient's pain tolerance dictates the progression of therapy, cannot be overemphasized. One issue that necessitates resolution is the treatment of patients over 40 years old with TFCC perforations. While many advances have taken place in the management of TFCC lesions, further research is needed to address this dilemma.
REFERENCES 1. Palmer AK, Werner FW: The triangular fibrocartilage complex of the wrist-Anatomy and function. J Hand Surg 6:15362:563-82, 1981. 2. Dell PC: Distal radioulnar joint dysfunction. Hand Clin 3(4), 1987. 3. Palmer AK: Triangular fibrocartilage complex lesions: A classification. J Hand Surg 14A:594-606. 4. Thiru-Pathi RG, Ferlic DC, Clayton ML, McClure DC: Arterial anatomy of the triangular fibrocartilage complex of the wrist and its surgical significance. J Hand Surg llA:258-63, 1986. 5. Mikic ZD: Age changes in the triangular fibrocartilage of the wrist joint. J Anat 126:367-84, 1978. 6. Bowers WHo Problems of the distal radioulnar joint. In Advances in Ohhopaedic Surgery. Baltimore, Williams & Wilkins, 1984, pp. 289-303. 7. Bowers WHo The distal radioulnar joint. In Green DP (ed.): Operative Hand Surgery. Vol. II. New York, Churchill livingstone, 1988, pp. 939-89. 8. Palmer AK. The distal radioulnar jOint. In Lichtman DM (ed.): The Wrist and Its Disorders. Philadelphia, W.B. Saunders, 1988, pp. 222-31. 9. Palmer AK. The distal radioulnar jOint. In Talesnik J (ed.): Hand Clinics-Management of Wrist Problems. Philadelphia, W.B. Saunders, 1987, pp. 31-40. 10. Palmer AK, Werner FW. Biomechanics of the distal radioulnar joint. Clin Orthop 187:26-34, 1984. 11. Werner FW, Glisson RR, Murphy DJ, Palmer AK. Force transmission through the distal radioulnar carpal joint: Effect of ulnar lengthening and shortening. Hand Surg 18:304-8, 1986. 12. Ekenstam F, Palmer AK, Glisson RR. The load on the radius and ulna in different positions of the wrist and forearm. Acta Ortho Scand 5S:363-5, 1984. 13. Kauer JMG. The articular disc of the hand. Acta Anat 93:590605, 1985. 14. Palmer AK, Glisson RR, Werner FW. Relationship between ulnar variance and triangular fibrocartilage complex thickness. J Hand Surg 9A:681-3, 1984. 15. Ekenstam FW, Hagert CG. Anatomical studies on the geom-
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etry and stability of the distal radioulnar joint. Scand J Plast Reconstr Surg Hand Surg 19:17-25, 1985. Poehling GG. An illustrated guide to small joint arthroscopy. Wrist arthroscopy; portals to progress. Andover, MA: Smith and Nephew Dyonics, Inc., 1989. Palmer AK, Werner FW, Glisson BS, Murphy OJ. Partial excision of the triangular fibrocartilage complex. J Hand Surg 13A:403-6, 1988. Hunter jM, Mackin EJ. Management of edema. In Hunter JM, Schneider LH, Mackin EJ, et al (eds.): Rehabilitation of the Hand. 3rd ed. St. Louis, C.V. Mosby, 1990, pp. 187-94. McEntree PM. Therapist's management of the stiff hand. liz Hunter JM, Schneider LH, Mackin EJ, et al (eds.): Rehabilitation of the Hand. 3rd ed. St Louis, C.V. Mosby, 1990, pp. 328-41.
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20. Taylor Mullins PA. Use of therapeutic modalities in upper extremity rehabilitation. In Hunter JM, Schneider LH, Mackin EJ, et al (eds.): Rehabilitation of the Hand. 3rd ed. St. Louis, C.V. Mosby, 1990, pp. 195-220. 21. Swanson AB, Swanson GG, Coran-HageTt C. Evaluation of impairment of hand function. In Hunter JM, Schneider LH, Mackin EJ, et al (eds.): Rehabilitation of the Hand. 3rd ed. St. Louis, C.V. Mosby, 1990, pp. 109-38. 22. Menon J, Wood VE, Shoene HR, Frykman GK, Hohl JC, Bestard EA. Isolated tears of the triangular fibrocartilage of the wrist: Results of partial excision. J Hand Surg 9A:527 -30, 1984. 23. McDonough AL. Effects of immobilization and exercise on articular cartilage-A review of literature. J Orthop Sports Phys Ther 9:2-5, 1981.