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Tfcc Management

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Submitted By Keno1993
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Tear of the Triangular Fibrocartilage Complex (TFCC): The TFCC can be acutely injured if the wrist is subjected to a large compressive load in a position of extension and ulnar deviation as this causes increased load and impinges the TFCC between the distal ulnar and the proximal carpal row. Whilst Degenerative changes have most commonly been associated with increased age, overuse injuries or positive ulnar variance which causes ulnocarpal impaction during wrist movements and degradation of the TFCC
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Typical patient features and presenting history: Populations most at risk of TFCC tears are gymnasts and racquet sport players due to the large compressive forces applied to the wrist in extension and ulnar deviation or patients with the degenerative conditions listed above. Patients with a TFCC tear will present with ulnar sided wrist pain and a “clicking” sensation during movements such as wrist extension and ulnar deviation. The mechanism of injury will normally be a traumatic incident (i.e. A fall onto on outstretched hand) or a history of repetitive compressive activities applied to the wrist, such as tennis. When describing their symptoms the patient should describe symptoms that are aggravated by activity and improve with rest. They may also report generalized weakness and swelling over the dorsal ulnar aspect of the wrist.

Top 3 differential diagnoses:
The top 3 differential diagnoses for a TFCC tear are arthritis of the distal radio-ulnar joint, Kienbock’s disease (Avascular Necrosis of the Lunate) and Extensor Carpi Ulnaris tendinopathy.

Objective Assessment findings required to confirm or negate the diagnosis:
Key physical examination findings are pain with resisted wrist extension and ulnar deviation, decreased grip strength and crepitus and clicking with movement. Positive results in provocative tests such as TFCC load test and the Ulnar Fovea sign can help diagnose a tear. To eliminate other potential sources of pain compression would be applied both in radial and ulnar deviation If it is truly a TFCC injury pain will be decreased in radial deviation. Static muscle test of the ECU and positioning the wrist into flexion and radial deviation should also not exhibit pain if it is a TFCC injury.
Common management strategies and treatment suggestions:
Level 5 Evidence by Sachar (2008) indicated that acute tears can be managed conservatively though the application of rest, ice, avoidance of aggravating activities and a 3 to 6 week splinting period. This is followed by physiotherapist intervention which aims to restore movement via soft tissue massage, passive mobilisations of the affected joints as well as active and passive movements of the wrist, fingers and elbow. If the patient has sustained a degenerative injury or does not respond to treatment, surgical management can be used. Level 4 evidence by Reiter et al., (2008) and Miwa et al., (2004) suggest arthroscopic repair and debridement of acute TFCC injuries as they achieve good outcomes in 63 – 92% of patients. Whilst for degenerative tears Level 3 evidence by Constantine et al., (2000) found the Wafer resection procedure to be the most viable option with 71-100% of patients recording good to excellent outcomes.
Prognosis:
In most acute cases conservative management relieves symptoms within a 4 to 6 week period. If the patient has a degenerative tear due to positive ulnar variance or ulnocarpal impaction surgical intervention is the best course of action to relieve symptoms though recovery time is longer.
Must Read Reference: Sachar, K. (2008). Ulnar-sided wrist pain: evaluation and treatment of triangular fibrocartilage complex tears, ulnocarpal impaction syndrome, and lunotriquetral ligament tears. The Journal Of Hand Surgery, 33(9), 1669--1679.

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