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. Nonoperative versus Operative Management
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.
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
Deciding Factors?
Central Tears
Peripheral Tears
Ulnar Varience
Goals?
Preoperative Rehabilitation?
Postoperative Rehabilitation?

8. Phase I for Central Debridement (3-5 days)
Goals:
Control edema
Pain
Protect repair
Minimize deconditioning
Intervention:
• 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 management
Intervention:
• 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 ROM
Intervention:
• 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 strengthening
Intervention:
• 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 repair
Intervention:
• 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 repair
Intervention:
• 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 strength
Intervention:
• 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. Phase IV for Peripheral Repair (Week 8)
Goals:
Continue to improve ROM
Continue to increase strength
Simulate work requirements
Intervention:
• Dynamic splinting as necessary to increase ROM
• Progress strengthening with putty, hand exerciser, free weights
• Simulate work tasks as able
Precautions
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.

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.

18. ?
Questions