Presentation on theme: "Triangular Fibrocartilage Complex"— Presentation transcript:
1Triangular Fibrocartilage Complex Manny MooreClinic III
2Triangular Fibrocartilage Complex What Structures are InvolvedAnatomy?Stability?Mechanism of injury?Predisposing Factors?
3Injury Assessment History Inspection Palpation Range of Motion Neurological TestingSpecial Test
4Nonoperative versus Operative Management Conservative Treatment GuidelinesRestAvoid Stressful MotionsRehabilitationSplints or braceNSAIDSSurgical intervention is suggested if the patient symptoms are not alleviatedWithin 4-6 weeks depending on the type of lesion.Refer out for Imaging
5Palmer Classification for TFCC Lesions Traumatic LesionsClass IA: Central ruptureClass IB: Ulnar avulsion with/without disruption of the ulnar styloidprocessClass IC: Distal avulsionClass ID: Radial avulsion with/without osseous lesion of the radiusDegenerative LesionsClass IIA: Superficial degenerative lesionClass IIB: Degenerative tear with cartilage lesion of the lunate or the ulnaClass IIC: Degenerative disc perforation with cartilage lesion of the lunateor the ulnaClass IID: Degenerative disc perforation with cartilage lesion of the lunateor the ulna and lunotriquentral instabilityClass IIE: Degenerative disc perforation with cartilage lesion of the lunateor the ulna, lunotriquentral instability and ulnocarpal arthrosis
6Diagnostic ImagingMRI?CT Scan?Arthroscopy?The Golden Standard?
7Which Surgical Procedure? Open Dissection, Arthroscopy,or Direct RepairDeciding Factors?Central TearsPeripheral TearsUlnar VarienceGoals?Preoperative Rehabilitation?Postoperative Rehabilitation?
8Phase I for Central Debridement (3-5 days) Goals:Control edemaPainProtect repairMinimize deconditioningIntervention:• Remove post-op dressing• Edema control with light compressive dressing to hand and forearm• Active ROM exercises for wrist and forearm are begun 4-8 times a day• A wrist splint is fabricated to wear between exercises and at night
9Phase II for Central Debridement (10-14 days) Goals:Control edemaPainContinue to protect repairMinimize deconditioningScar managementIntervention:• Scar management begun within 48 hours of suture removal• Initiation of active-assist ROM for wrist and forearm
10Phase III for Central Debridement Weeks 3-4 Goals:Control edemaPainImprove ROMIntervention:• Passive ROM of wrist and forearm may be initiated• Dynamic wrist splinting may be begun to improve ROM• Weighted wrist stretches may be initiated – also to increase ROM
11Phase IV for Central Debridement Week 6 Goals:Continue with ROM gainsBegin strengtheningIntervention:• Progressive strengthening may be begun using putty or a hand exerciser• The wrist immobilization splint may be discontinued if the patient is asymptomatic
12Phase I for Peripheral Repair (Week 1) Goals:Edema controlProtect repairIntervention:• Patient remains in bulky post-op dressing• Instructions in edema control
13Phase II for Peripheral Repair (Week 2) Goals:Edema and pain controlContinue to protect repairIntervention:• Removal of bulky dressing• Edema control with retrograde massage, Isotoner glove, and/or coban wrapping• Daily pin care as needed• Long arm cast with 90° elbow flexion and wrist in neutral or wrist cock-up splintfabricated• Active and passive ROM for wrist and digits, include tendon glides (lumbrical grip, hookfist, full fist)• Isometric exercises for forearm/hand: 10 repetitions 4 times/day• Low-grade isotonic exercises can be initiated if edema is not present (i.e., lightest putty)• Light ADLs with 5 pound limit
14Phase III for Peripheral Repair (Week 3-6) Goals:EdemaPainIncrease ROMScar managementImprove strengthIntervention:• Scar management with massage, scar pad• Discontinue splint (unless patient is still symptomatic)• Increase isotonic exercises up to 10 pounds maximum for upper arm, forearm• Wrist mobility/weighted stretches with less than 5 pounds 3-4 times/day• ADLs with less than 10 pounds
15Phase IV for Peripheral Repair (Week 8) Goals:Continue to improve ROMContinue to increase strengthSimulate work requirementsIntervention:• Dynamic splinting as necessary to increase ROM• Progress strengthening with putty, hand exerciser, free weights• Simulate work tasks as ablePrecautionsAggressive PROM or Strengthening that increases painIncreased ulnar-sided wrist painIf ulnar shortening in addition to the TFCC repair or Debridement,the course of post-operative therapy will be altered.
16Conclusion Rehabilitation ranges from 6-8 weeks depending on surgical methods usedArthroscopic and debridment is successful in acute and chronic lesions, however chronic lesions are more successful with ulna shortening.Arthroscopy is still considered the golden standard when diagnosing lesions and has showed success in pain management function and stability in TFCC repairs.Despite its high sensitivity of MRI detecting TFCC lesions MRI has its limitations in the detection of peripheral TFCC tears.
17ReferencesUsama Albastaki, MD," Dimitris Sophocleous, MD,^ Jan Gothlin, MD, PhD.MRI Imaging in TFCC injuries. Journal of Munipulotive and Physiological Therapeutics Volume 30, Number 7Jui Tien Shih, Huung Maan Lee. Functional Results of TFCC. Department ofOrthopedics and Hand Surgery, Vol 10,Cuong Pho DPT, Joe Godges DPT. Triangular Fibrocartilage Complex (TFCC) Repair and Rehabilitation. Indiana Hand Therapy ProtocolsJan-Ragnar Haugstvedt and Torstein Husby.RESULTS OF REPAIR OF PERIPHERAL TEARS IN THE TRIANGULAR FIBROCARTILAGE COMPLEX USING AN ARTHROSCOPIC SUTURETECHNIQUE. Journal of hand Surgery 1999.