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Triangular Fibrocartilage Complex Manny Moore Clinic III.

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Presentation on theme: "Triangular Fibrocartilage Complex Manny Moore Clinic III."— Presentation transcript:

1 Triangular Fibrocartilage Complex Manny Moore Clinic III

2 Triangular Fibrocartilage Complex What Structures are Involved Anatomy? Stability? Mechanism of injury? Predisposing Factors?

3 Injury Assessment History Inspection Palpation Range of Motion Neurological Testing Special Test

4 Conservative Treatment Guidelines Rest Avoid Stressful Motions Rehabilitation Splints or brace NSAIDS Surgical intervention is suggested if the patient symptoms are not alleviated Within 4-6 weeks depending on the type of lesion. Nonoperative versus Operative Management Refer out for Imaging

5 Palmer Classification for TFCC Lesions Traumatic Lesions Class IA: Central rupture Class IB: Ulnar avulsion with/without disruption of the ulnar styloid process Class IC: Distal avulsion Class ID: Radial avulsion with/without osseous lesion of the radius Degenerative Lesions Class IIA: Superficial degenerative lesion Class IIB: Degenerative tear with cartilage lesion of the lunate or the ulna Class IIC: Degenerative disc perforation with cartilage lesion of the lunate or the ulna Class IID: Degenerative disc perforation with cartilage lesion of the lunate or the ulna and lunotriquentral instability Class IIE: Degenerative disc perforation with cartilage lesion of the lunate or the ulna, lunotriquentral instability and ulnocarpal arthrosis

6 Diagnostic Imaging MRI? CT Scan? Arthroscopy? The Golden Standard?

7 Which Surgical Procedure? Open Dissection, Arthroscopy,or Direct Repair Central Tears Peripheral Tears Preoperative Rehabilitation? Postoperative Rehabilitation? Deciding Factors? Goals? Ulnar Varience

8 Phase I for Central Debridement (3-5 days) Goals: Control edema Pain Protect repair Minimize 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

9 Phase II for Central Debridement (10-14 days) Goals: Control edema Pain Continue to protect repair Minimize deconditioning Scar managementIntervention: Scar management begun within 48 hours of suture removal Initiation of active-assist ROM for wrist and forearm

10 Phase III for Central Debridement Weeks 3-4 Goals: Control edema Pain Improve 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

11 Phase IV for Central Debridement Week 6 Goals: Continue with ROM gains Begin strengtheningIntervention: Progressive strengthening may be begun using putty or a hand exerciser The wrist immobilization splint may be discontinued if the patient is asymptomatic

12 Phase I for Peripheral Repair (Week 1) Goals: Edema control Protect repairIntervention: Patient remains in bulky post-op dressing Instructions in edema control

13 Phase II for Peripheral Repair (Week 2) Goals: Edema and pain control Continue 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 splint fabricated 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

14 Phase III for Peripheral Repair (Week 3-6) Goals: Edema Pain Increase ROM Scar management Improve 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

15 Goals: Continue to improve ROM Continue to increase strength Simulate work requirementsIntervention: Dynamic splinting as necessary to increase ROM Progress strengthening with putty, hand exerciser, free weights Simulate work tasks as able Phase IV for Peripheral Repair (Week 8) Aggressive PROM or Strengthening that increases pain Increased ulnar-sided wrist pain If ulnar shortening in addition to the TFCC repair or Debridement, the course of post-operative therapy will be altered. Precautions

16 Conclusion Rehabilitation ranges from 6-8 weeks depending on surgical methods used Arthroscopic 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.

17 References Usama Albastaki, MD," Dimitris Sophocleous, MD,^ Jan Gothlin, MD, PhD. MRI Imaging in TFCC injuries. Journal of Munipulotive and Physiological Therapeutics Volume 30, Number 7 Jui Tien Shih, Huung Maan Lee. Functional Results of TFCC. Department of Orthopedics and Hand Surgery, Vol 10, Cuong Pho DPT, Joe Godges DPT. Triangular Fibrocartilage Complex (TFCC) Repair and Rehabilitation. Indiana Hand Therapy Protocols Jan-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.

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