3 Triangular Fibrocartilage Complex Triangular Fibrocartilage Complex (TFCC)Similar to the meniscus in the knee.Evolutionary theorist- Used to be more bony for weight-bearing. As we evolved the ulna retracted and was replaced with the TFCC.Triangular Fibrocartilage ComplexPalmar and Werner introduced term TFCC 1981Structures include:Articular discMeniscus homologuePrestyloid recessDorsal & volar radioulnar ligaments
4 Central disc is avascular and aneural. TFCCCentral disc is avascular and aneural.InnervationVolar, ulnar portions: Ulnar NDorsal portion: PIN, dorsal sensory branchCentral disc relatively aneuralVascularityAnterior interosseous & ulnar arteriesCentral disc relatively avascularPeripheral 15-20% well vascularized, will healAttachmentsOriginates from medial border of distal radiusInserts into base of ulnar styloid (fovea)
5 Conservative management 0-6 WeeksSplinting in a long arm cast or splint with the elbow in 90° flexion and the forearm neutral for 0-6 weeks to reduce the symptoms6 weeksActive and active-assistive ROM exercises are initiated to the wrist and forearm. A wrist immobilization splint is fabricated for comfort and protection.8 weeksIf patient is asymptomatic, progressive strengthening to thehand and wrist, avoiding a torsion load at the wrist.If the patient’s symptoms are not alleviated in 4-6 weeks surgicalrepair or debridement is suggested.
6 Central DebridementCentral and radial injuries are avascular and won’t heal thus they are debrided.3-5 day post- op bulky dressing removed and gentle AROM exercises initiated. Splint worn between exercise sessions.10-14 days-scar massage initiated within 48 hours following suture removal3-4 weeks – PROM initiated.6 weeks progressive strengthening as long as the patient is pain free. Splint discontinued.Desensitization of scar often needed
7 TFCC Peripheral Tear Surgical repair 10-14 day post op bulky dressing removed and a long arm cast or splint is fitted with elbow in 90 degrees of flexion and forearm in neutral-AAROM and PROM of digits.6 weeks post op-cast removed and splint fabricated if not already. Splint worn between AROM exercises of elbow, wrist and forearm. Scar management and desensitization may be started at this time if patient was casted.8 weeks post op. PROM can be initiated. Dynamic splinting as needed as long as pain does not increase. DO not torque wrist.10-12 weeks. Progressive strengthening with putty, hand exerciser and hand weights
8 Contribution of the ECU ECU only motor unit w/ a relationship to the TFCCTendon sheath blends with TFCCECU held close to center of rotation of wrist by the TFCCTFCC is an important pulley for the ECUDisruption of the ECU may contribute to abnormal loading & force transmission through TFCCPainful snap wrist with rotation if sheath is damagedECU only motor unit w/ a relationship to the TFCCTendon sheath blends with TFCCECU held close to center of rotation of wrist by the TFCCTFCC is an important pulley for the ECUDisruption of the ECU may contribute to abnormal loading & force transmission through the TFCC.
9 Long arm elbow splints Sugar tong Muenster Long arm static Should prevent pronation and supination
11 ECU Snap wrist Damage to the ECU sheath. TendonitisImmobilize with splint for 6 weeksGentle PROM twice a day(FCU tendonitis similar)Snap wristDamage to the ECU sheath.Painful snapping with forearm rotation.Immobilize-sugar tong/long arm elbow.
15 Growth Plate-Epiphyseal Plate 15% to 30% of all childhood fractures occur at the growth plateGrowth plates are the softer parts of children’s bones, where growth occurs.Located at each end of a bone, growth platesare weakest sections of the skeleton, sometimes evenweaker than surrounding ligaments and tendons.Injury that would result in a joint sprain for an adult can cause a growth plate fracture in a child.
16 Growth Plate-Epiphyseal Plate During adolescence, the growth plate is replacedby solid bone. The long bones inthe body include:The bones of the hand and fingersBoth bones of the forearm (radius and ulna)The bone of the upper leg (femur)The lower leg bones (tibia and fibula)The foot bones (metatarsals and phalanges).If any of these areas become injured, it’s important to seek professional help from a qualified surgeon.
23 Tendon Injuries in the Finger “Jersey finger”—laceration of the flexor digitorumprofundus (FDP)FDP flexes the DIP jointsCan occurs during tackling in footballHistory of failure to grab an object (e.g., football jersey or car door handle)Painful, swollen finger, especially of the volar DIPJRing finger commonly involved
24 Jersey Finger Inability to flex at the DIPJ PIPJ and MCPJ flexion preservedRadiographs (AP, lateral, oblique) to assess for tendinous rupture or bony avulsion fracture.Surgical repair requiredImmobilization 3 to 4 weeks for younger children.Rosalyn Evans or Indiana Flexor tendon protocol for older children if compliant. Surgical repair should be strong…Four to 6 strand core stitch. New, stonger suture techniques are being developed (see references).
27 Football Mallet Finger Flexion deformity of the DIPJ secondary to the inability to extend. Terminal extensor tendon rupture.Painful, swollen fingertipMay have occurred when trying to catch a ballInability to extend the distal phalanx at the DIPJRadiographs (AP, lateral, oblique)Two forms of mallet finger:Tendinous--extensor tendon ruptureBony--bony avulsion fracture of the distal phalanx
30 Football Mallet Finger Treatment Continuous splinting 6 to 8 weeks Wear splint in between exercises and gradually decrease wearing time up to 10 weeks. Children heal faster then adults. Monitor extension lag..wear at night.DIPJ must not be allowed to drop in flexionBony avulsions < 1/3 of articular surface can be reduced with dorsal pressure and dorsal splinting - 6 to 8 weeks.Post-reduction radiographs are essentialRefer failed non-surgical treatment, bony avulsions that are irreducible or involve 1/3 or more of the articular surface, or volar subluxation of the distal phalanx
34 Dorsal Dislocations of the PIPJ Collateral ligament and volar plate injuries Dorsal extension block at 30 degrees. Full flexion allowed. Extension block is decreased to 20 degrees at week 4 and to 10 degrees at week 5. Splint is discontinued at week 6. Extension gutter splint at night if patient unable to extend PIP to neutral. Seriel casting if needed.
41 Resources/References Cannon, N., Beal, B., Walters, K., Roscetti, S., Brandenburg, G., Lewis, S. et al. Diagnosis and treatment manual for physicians and therapists: Upper extremity rehabilitation. Fourth Edition. The Hand Rehabilitation Center of Indiana. Skirvin, T., Osterman, L. Fedorczyk, J.,Amadio, P. (2011). Rehabilitation of the hand and upper extremity, sixth edition. Elsevier. Roslyn B Evans. (2005). Zone I Flexor Tendon Rehabilitation with Limited Extension and Active Flexion. Journal of Hand Therapy, 18(2), Retrieved January 29, 2012, from ProQuest Nursing & Allied Health Source. (Document ID: ).
42 Pearls Orficast Dr. Roy Meals : mallet splintpatternWrist Widget: Sammons and Preston