Triangular Fibrocartilage Complex (TFCC) Injury
1. Introduction
The triangular fibrocartilage complex (TFCC) is a structure on the ulnar side of the wrist (the little finger side) and it is composed of an intra-articular disc of cartilage as well as a group of ligaments and tendons that support this part of the wrist (3, 5, 6, 7). The triangular fibrocartilage complex plays an important role in wrist biomechanics (5, 7). Its main function is to stabilise the wrist joint during activities that bend or twist the wrist joint (3, 6, 7). It helps to absorb shock and transmit forces across the wrist to protect it from impact (3, 5, 6, 7). The structure allows the wrist to move through a complex range of motion (3, 5). Due to its stabilising function, it is more susceptible to injury which can be either caused by trauma or wear and tear (5, 6).
Frequently Asked Questions
A common cause of pain on the ulnar side (little finger side) of the wrist (7). It involves an irritation or tear to the cartilage that helps to stabilise this side of the wrist. Â
- TFCC is a common form of wrist pain although in the general population it is a very rare condition.
- These injuries often occur with radial fractures at the wrist end of the bone (2).
- Incidence of these injuries with this type of fracture is between 35% and 78% (4).
- No.
- An accurate and early diagnosis will lead to an appropriate management plan aiming to reduce pain and improve function of the wrist (11).
- These injuries are rarely linked to more complex trauma or more worrying medical conditions.
- Females and younger individuals are more at risk of this injury (8).
- Athletes that frequently load the wrist (8); including gymnasts (3), and those who play racket sports (6,7).
- Manual workers who often load the wrists such as groundworkers and builders (8).
- Ulnar sided wrist pain (side of the little finger) near to wrist crease (3, 4, 5, 6, 11).
- Grinding, clicking or popping (3, 5, 6, 7, 11).
- Reduced grip strength (4, 6, 7).
- Instability of the wrist (4, 5, 6, 11).
- Reduced range of movement/function in the forearm, especially rotation (4).
- Pain reproduced with loading/movement of the wrist or forearm, especially with rotation during activities like turning door handles and opening jars (6, 3).
- Swelling around the joint.
- Initially, adapt or refrain from the activities and movements that aggravate your symptoms (6).
- Alongside this, rest or immobilisation of the wrist in a splint for a short period of time can be helpful to reduce pain (3,6, 9).
- Appropriate strengthening exercises can also help accelerate recovery.
- Recovery is dependent on the type and severity of injury.
- Following your rehabilitation programme will help you progress with your recovery safely and effectively.
- Total recovery could take anywhere between 6-12 weeks or up to 6 months (6).
We recommend consulting a musculoskeletal physiotherapist to ensure exercises are best suited to your recovery. If you are carrying out an exercise regime without consulting a healthcare professional, you do so at your own risk. Book online with us today to get a programme tailored to your specific needs.
2. Signs and Symptoms
Symptoms can vary with cause and severity of injury, but these are the main signs of a triangular fibrocartilage complex injury include:
- Ulnar-sided wrist pain (side of the little finger) experienced near the wrist crease (3, 4, 5, 6, 11).
- Pain that is reproduced with loading and movement of the wrist or forearm, especially with rotational activities such as turning door handles and opening jars (6, 3).
- A grinding, clicking, or popping sensation on movement of the wrist joint (3, 5, 6, 7, 11).
- Weakened grip strength (4, 6, 7).
- Reduced range of movement in the forearm, especially on rotation (4).
- A feeling of instability of the joint (4, 5, 6, 11)
3. Causes
Triangular fibrocartilage complex injuries have been classified into two categories to distinguish between causes- class 1 and class 2 (5).Â
Class 1 injuries are caused by trauma, so they are acute injuries (6, 7). They are further divided into types 1A to D depending on the specific location of the injury within the triangular fibrocartilage complex injuries (6, 7). These injuries are usually caused by a compression force on the wrist joint structures. For example, after a fall onto an outstretched and rotated hand leading to the wrist being forced into hyperextension (3, 6, 7). They can also occur during sports, especially racket/bat sports like tennis or cricket, when the wrist is loaded in an ulnar deviated position (6, 7). Â
Class 2 injuries are degenerative and subdivided according to the severity of the injury (9). This means there is no clear traumatic mechanism of injury (7), so symptoms usually develop because of repetitive loading of the wrist joint. For example, during manual work or activities that frequently involve the hands (8).Â
4. Risk Factors
This is not an exhaustive list. These factors could increase the likelihood of someone developing triangular fibrocartilage complex injuries. It does not mean everyone with these risk factors will develop symptoms. Â
- It has been found that females are more likely to experience symptoms of triangular fibrocartilage complex injuries (8).Â
- Younger individuals are more at risk of this injury (8). It has been reported that those who are less than 30 years old are more likely to experience acute TFCC injuries (class 1) (3). Â
- It therefore follows that those older than age 30 are more commonly affected by degenerative TFCC injury (3).
- Athletes such as gymnasts (3) or racket sports players (6, 7).
- Manual workers (8) develop this injury more frequently. This is due to repeated loading demands on the wrist joints (3).Â
- Congenital (problems as you grow and develop) differences is also more likely to occur if the lengths of the ulna and radius bones are different (3, 6). Â
5. Prevalence
Triangular fibrocartilage complex injuries injury is a common cause of pain on the ulnar side of the wrists (7), which is the side of the little finger. Â
TFCC injuries are also often linked with distal radius fractures, fractures that occur at the wrist end of the radius bone. Incidence of TFCC injuries with these fractures is between 35% and 78% (4).Â
6. Assessment & Diagnosis
Your physiotherapist will obtain a detailed history of your presentation before completing a thorough physical assessment. This could involve observation of the wrist and how it moves, palpation of the structures to feel for tenderness and any specific tests to rule out differential pathologies (3). They will then use the findings to determine an accurate diagnosis that will inform an appropriate and personalised management plan. Your rehabilitation journey can then begin.Â
In more severe cases, an MRI may be required to assess and evaluate the extent of your injury. This could lead to an Orthopaedic or consultant review to establish if surgical intervention is required for the best outcomes. This will be based on if structural instability in the area is present and your goals for treatment and future function. Â
7. Self-Management
Your physiotherapist will talk you through your injury and how best you can self-manage it to promote recovery. Initially, rest or immobilisation of the wrist in splint for around 4-6 weeks (3, 7, 9) will be recommended. This can help reduce pain in the early stages. Alongside this, ways you can modify the activities and movements that aggravate your symptoms will be included in your management plan (6, 10). To reduce inflammation and manage pain, the application of ice and use of non-steroidal anti-inflammatory medication (NSAIDS) will be suggested.
8. Rehabilitation
Depending on the severity of the injury, a progressive physiotherapy rehabilitation programme is likely to be beneficial to mitigate symptoms and restore function. Usually conservative treatments, such as physiotherapy, are given a trial for up to 6 months (6) because positive outcomes are expected. You will be provided with a personalised exercise plan that will continue to be modified and updated after re-assessment, to best suit your progress and achieve your goals.
Rehabilitation will initially aim to increase range of movement and flexibility to avoid stiffness (6) after potential immobilisation. As you progress, exercises to build strength will then become the focus. These will then be progressed with resistance bands or weights (3) to increase load on the wrist joint.
Below are a series of rehabilitation programmes with varying degrees of intensity, made to target the above in a progressive and safe way.
9. Triangular Fibrocartilage Complex (TFCC) Injury
Rehabilitation Plans
Our team of expert musculoskeletal physiotherapist have created rehabilitation plans to enable people to manage their condition. If you have any questions or concerns about a condition, we recommend you book an consultation with one of our clinicians.
What Is the Pain Scale?
The pain scale or what some physios would call the Visual Analogue Scale (VAS), is a scale that is used to try and understand the level of pain that someone is in. The scale is intended as something that you would rate yourself on a scale of 0-10 with 0 = no pain, 10 = worst pain imaginable. You can learn more about what is pain and the pain scale here.
The early plan will be aimed at improving range of motion and flexibility of the joints and soft tissues in the wrist and forearm. The exercises are simple and light in intensity to introduce the wrist back to movement after potential immobilisation. Complete 2-3 times a day if possible.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
Finally, the advanced programme is a greater challenge as even more emphasis is put on loading and strengthening. This will help to improve the overall function of your wrist and forearm, hopefully allowing you to perform functional movements, such as gripping, more easily. Complete 2-3 times a day as strength and pain allow.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
10. Return to Sport / Normal life
If you wish to return to sport, your physiotherapist will discuss ways in which you can progress further than in the advanced programme. This is so that you can achieve the higher level of function required to safely resume the activity. These more challenging and complex exercises will progressively and carefully load the wrists further, to build greater strength. It is reported that an athlete should be able to resume their sport in around 12-14 weeks after injury (3). Â
11. Other Treatment Options
Corticosteroid injections can be used alongside physiotherapy (6). They can provide short-term pain relief in those with more severe symptoms that are limiting function and adherence to exercises. If conservative treatment is unsuccessful in providing symptom relief after a 6–month trial, or if there is clear instability of the distal radioulnar joint, then surgical interventions may be recommended (6). Â
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References
- Chen, Z. et al. (2018) A novel staged wrist sensorimotor rehabilitation program for a patient with triangular fibrocartilage complex injury: A case report. Journal of Hand Therapy. Hanley & Belfus. Elsevier Inc. https://doi.org/10.1016/j.jht.2018.04.003
- Kasapinova, K. and Kamilosk, V. (2016) The correlation of initial radiographic characteristics of distal radius fractures and injuries of the triangular fibrocartilage complex. The Journal of Hand Surgery (European Volume). 41(5). SAGE. DOI: 10.1177/1753193415624669
- Mcllvain, G. et al. (2013) Recognition and Management of Triangular Fibrocartilage Complex Injury. International Journal of Athletic Therapy & Training. Human Kinetics Publishers Inc.
- Kasapinova, K. and Kamiloski, V. (2017) Outcomes of surgically treated distal radial fractures with associated triangular fibrocartilage complex injury. Journal of Hand Therapy. Hanley & Belfus. Elsevier Inc. https://doi.org/10.1016/j.jht.2017.09.002
- Skalski, M. et al. (2015) The Traumatized TFCC: An Illustrated Review of the Anatomy and Injury Patterns of the Triangular Fibrocartilage Complex. Current Problems in Diagnostic Radiology. Mosby, Inc. Elsevier. 45(1) http://dx.doi.org/10.1067/j.cpradiol.2015.05.004.
- Jawed, A. et al. (2020) TFCC injuries: How we treat? Journal of Clinical Orthopaedics and Trauma. Journal of Clinical Orthopaedics and Trauma. Delhi Orthopedic Association. https://doi.org/10.1016/j.jcot.2020.06.001
- Doarn, M. and Wysock, R. (2016) Acute TFCC Injury. Oper Tech Sports Med. Elsevier Inc. http://dx.doi.org/10.1053/j.otsm.2016.02.001
- Roh, Y. et al. (2018) Prevalence and clinical characteristics of radiographic central triangular fibrocartilage complex tears in symptomatic and asymptomatic individuals younger than 50 years. Archives of Orthopaedic and Trauma Surgery. Springer-Verlag. https://doi.org/10.1007/s00402-018-2969-y
- Barlow, S. (2016) CASE REPORT: A Non-surgical Intervention for Triangular Fibrocartilage Complex Tears. Physiotherapy Research International. John Wiley & Sons, Inc. DOI: 10.1002/pri.1672
- Dunn, J. et al. (2020) Surgical Repair of Acute TFCC Injury. HAND. SAGE. AAHS. 15(5). DOI: 10.1177/1558944719828007
- Soreide, E. et al. (2017) A long-term (20 years’) follow-up after arthroscopically assisted repair of the TFCC. Journal of plastic surgery and hand surgery. Taylor and Francis. 51(5). http://dx.doi.org/10.1080/2000656X.2016.1256296.
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