What is the TFCC?
TFCC stands for Triangular Fibro-Cartilage Complex, and consists of 6 different ligamentous and cartilaginous structures located on the ulnar (pinky finger) side of the wrist, between the forearm bones and the carpal bones of the wrist. The TFCC is particularly important in stabilizing the two forearm bones (radius and ulna) at the level of the wrist as well as to help distribute force from the hand up to the elbow.
Why Does It Occur?
Injury to the TFCC can be either be traumatic or degenerative. Traumatic TFCC injuries usually occur after a fall or severe twisting injury to the wrist. Degenerative TFCC injuries usually occur over time and are secondary to repetitive stresses placed on the wrist and to a certain extent, age. TFCC tears can also result from a combination of traumatic tear on top of a degenerative tear.
In many patients the length of the Radius and Ulna bone in the wrist are of equal length. However, in some patients, the Ulna bone is relatively longer than the Radius bone. In these patients (also known as Ulna Positive wrist), patients are more predisposed to getting TFCC tears because the ulna bone can pinch the TFCC against the carpal bones more so than if the two bones were of equal length.
Symptoms and Diagnostic testing
Patients normally experience pain and tenderness along the ulnar (pinky finger) side of the wrist. Pain most commonly occurs with extension of the wrist or rotation of the forearm. Patients may also experience "clicking" or "popping" sensations with wrist movement. Weakness (usually secondary to pain) and swelling may also occur. Many patients complain of pain with motions simulating a push up, carrying heavy objects, or even opening a doorknob.
Dr. Steven Lee will often start with an Xray to evaluate the bone structure and rule out other possible diagnoses. If either the diagnosis is in question, or if needed to determine the next step in the treatment plan, an MRI or other radiologic studies might be ordered.
The choice between non-operative and surgical management of TFCC tears is dependent on a variety of factors. Important considerations consist of severity and duration of symptoms, functional disability, response to non-operative management, location, severity, and chronicity of the tear, Distal Radial Ulnar Joint (DRUJ) instability, as well as specific patient's needs.
Certain TFCC tears can often heal on their own when immobilized in a wrist splint for at least 4 weeks. It is important to consistently wear the splint and to take it off only to wash, but to wear it otherwise at all other times including sleeping. Also, while wearing the splint, patients should also refrain from rotating/twisting their forearm, and otherwise letting pain be their guide to avoiding other activities. Some TFCC tears may not heal even if properly immobilized. Injections such as PRP to increase the body's own healing potential, or corticosteroid injections to decrease the amount of inflammation may also be used as part of the non-operative treatment plan.
Dr. Steven Lee may recommend surgery for those who have failed non-operative treatment, those with particularly large or displaced tears, those that are associated with DRUJ instability, or those with specific functional or time dependent demands.
Wrist arthroscopy is usually the first step in surgical treatment. Arthroscopy involves making a very small incision on the back of the wrist and introducing a tiny video camera into the wrist joint. The image is then projected onto a monitor in real time so that the inside of the wrist and injured TFCC can be examined. Additional small incisions are then made in order to introduce other small arthroscopic instruments for TFCC debridement (removing torn portions of the TFCC that are likely causing symptoms/pain) or repair (suturing the torn ends together arthroscopically). Wrist arthroscopy is minimally invasive and can result in less soft tissue disruption, less pain, and minimal scar formation. It is important to realize that difficult or severe cases may occasionally require an open repair (i.e. not using an arthroscopic camera and instruments).
Dr Steven Lee has over 20 years of experience with wrist arthroscopy. The importance of this statement lies in the fact that all hand surgeons know that there is a significant learning curve in performing wrist arthroscopies. Older hand surgeons have often "missed the boat" in learning how to do the procedure comfortably, while younger surgeons may not be on the "sweet spot" of the learning curve. Dr. Steven Lee is arguably one of the most experienced wrist arthroscopists in NYC. He regularly instructs other hand surgeons from around the world on how to perform the procedure.
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All surgical patients are immediately immobilized after TFCC debridement or repair for 7-10 days in a non-removable splint. During this time, patients are encouraged to keep their hand elevated above their heart level, to keep their dressings clean and dry, to move their fingers, and are allowed to use their fingers to text and type, but not to lift anything heavier than a cup of coffee or causes them any more than a 2/10 pain level.
In the case of a debridement, this is followed by a removable wrist brace for an additional 3-4 weeks followed by formal physical therapy for up to 4-6 weeks. In the case of a repair or open surgery, patients are usually immobilized in a long arm cast or splint for up to 4 weeks, followed additional by use of a removable splint for 2-4 weeks, followed by physical therapy for up to 2-3 months.
Immediate Post-Operative Instructions
Please refer to the following pages for more information:
*It is important to note that all of the information above is not specific to anyone and is subject to change based on many different factors including but not limited to individual patient, diagnosis, and treatment specific variables. It is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopedic advice or assistance should consult Dr. Steven Lee or an orthopedic specialist of your choice.
*Dr. Steven Lee is a board certified orthopedic surgeon and is double fellowship trained in the areas of Hand and Upper Extremity Surgery, and Sports Medicine. He has offices in New York City, Scarsdale, and Westbury Long Island.