Natural History of Traumatic TFCC Tears
23.1 Introduction
The first person known to have mentioned wrist instability and dislocations of the wrist was Hippocrates around 400 BC. After an interlude in scientific activity of a little more than two millennia, Petit in AD 1705 again discussed the difficulties in diagnosing a joint dislocation versus a fracture around the wrist. Abraham Colles reported the clinical entity of a fracture of the lower end of the radius, claiming that no consequences would result, at least in the long term, after a distal radius fracture. Today, it is generally accepted that the most common cause of prolonged pain and disability after distal radial fractures, even after a long interval, is ulnar-sided wrist pain.1 Previously, the dominant explanation had been the relative shortening and subsequently established malunion of the fractured radius in relation to the unfractured ulna, causing an ulnocarpal abutment. Over recent decades we have learned more about the associated soft tissue injuries, which may be responsible for some of the ulnar-sided symptoms.2
Anatomically, the term triangular fibrocartilage complex (TFCC) was coined by Palmer and Werner in 19813 to define the group of structures that stabilize the carpus and the distal radius to the distal ulna. This complex includes the volar and dorsal radioulnar ligaments, the ulnar collateral and ulnocarpal ligaments, and the central part, which has undergone a metaplasia to form a cartilaginous articular disk. Apart from radiographically visible ulnar styloid avulsion fractures, injuries of the TFCC have been detected in up to 80% of patients with displaced distal radial fractures in arthroscopic studies.4,5 In some of these patients, the peripheral TFCC tears caused clinical symptomatic instability of the distal radioulnar joint (DRUJ) but not in others. Although both the pure soft tissue injury of the TFCC and the bony avulsion of the ulnar styloid are part of the same injury pattern, no clear relationship has been established between an ulnar styloid fracture or a peripheral TFCC tear and the resulting objective hyperlaxity and subjective symptomatic instability. Although there is an increased incidence of TFCC tears when the ulnar styloid is fractured,2 there are also tears when it is not. Arthroscopic or open repair of TFCC has been demonstrated with good clinical results up to 2 years later.6–8
Comparative studies, randomized or merely prospective, in which one group is not treated and the other is treated are rare or altogether missing and we are left without clear guidelines for what to do when we find a laxity of the DRUJ while surgically treating a distal radius fracture. There is interindividual variation of the DRUJ anatomy and therefore varying susceptibility to bony malunion, in addition to the soft tissue injury, that influences which patients do become symptomatic. In the era of the new volar angle stable fixation devices, it is believed that achieving and retaining a better reduction of the fracture and perhaps the soft tissue is now less important for the final outcome in the absence of malunion. It remains unclear when TFCC injuries should be repaired or styloid fractures reattached in the acute treatment of distal radius fractures, and the natural course of a TFCC injury in a distal radius fracture cohort becomes increasingly interesting.
23.2 Our Experience
In a prospective arthroscopic study in 51 young adults with displaced distal radial fractures between 1995 and 1997, the morphological presence of a TFCC tear at the time of the fracture was correlated with the presence of objectively recorded laxity (ulnar stress test) and the presence of subjective instability9 at 1 year after the fracture/injury.2 Seventy-eight percent of the patients had complete or partial TFCC injury. The distal radius fracture was treated according to the standard treatment at that time, but the TFCC injury was left untreated in order to study the long-term natural course of these previously unknown associated injuries. Twenty-one patients were treated with closed reduction and cast, 11 with arthroscopically assisted reduction and cast, 5 with closed reduction and external fixation, 6 with arthroscopically-assisted reduction and external fixation, and 8 with open reduction and internal fixation. In a follow-up study 1 year after the TFCC tears were arthroscopically diagnosed but left untreated, complete peripheral TFCC tears in 10/11 patients were found to cause objective DRUJ laxity, which in turn was found to worsen the subjective outcome after the fracture, independently of other parameters.2
23.2.1 Objective Outcome
At the initial arthroscopic examination, the TFCC tears were classified according to Palmer and Werner.3 A bleeding point and/or a loss of the collagen continuity was interpreted as a partial tear. A peripheral tear in the ligament was defined as complete if it caused a loss of tension in the TFCC during the hook and trampoline test at the initial arthroscopic assessment.4
Both at the 1-year follow-up2 and at the 13- to 15-year follow-up10 the patients were evaluated regarding DRUJ stability with both a physical examination and an interview. Stability testing was carried out using the DRUJ stress test at the 1-year follow-up and by another examiner at the 13- to 15-year follow-up. The stability of the DRUJ was compared with the uninjured, opposite side for reference and it was recorded whether the DRUJ was deemed lax and whether or not the test caused pain.
23.2.2 Subjective Outcome
In the initial 1-year study; the Gartland and Werley9 demerit point system was used to evaluate the subjective/functional outcome. For comparison, the same score was used again in the 13- to 15-year follow-up study. The examiner completed the score after the patient was examined, and the outcome was classified as excellent, good, fair, or poor. In the 13-year to 15-year follow-up, the subjective outcome was also evaluated using the Quick-Disabilities of the Arm, Shoulder, and Hand (Quick-DASH) questionnaire11 and the patient’s subjective experiences of pain at rest, pain with activity, overall function, and appearance were recorded on a visual analog scale.
23.3 Results
Thirty-eight of the 51 originally treated patients (75%) participated in both the clinical examination and radiographic investigation at the late follow-up. Twenty-three of the 38 patients were female, and the mean age was 57 years (range 38–73 years). Eight of the 38 patients had had a complete peripheral tear at the initial presentation, 25 a partial peripheral or central tear, and 5 patients had no TFCC tear at all.
Complete peripheral tears In the original group of 51 patients, 11 patients were diagnosed with an arthroscopically complete peripheral TFCC tear, out of which 8 patients were assessed at the present follow-up. Of these 8 patients with initial complete peripheral TFCC tear, the median DASH score after 13 to 15 years was 25 compared with a score of 7 in the patients with no, central, or partial peripheral TFCC injury (P = 0.14). The grip strength was 88% of the contralateral side in patients with a complete peripheral TFCC tear compared with 95% (P = 0.53) in patients without (▶ Table 23.1).
Complete peripheral tear | Partial peripheral or central tear | P | |
DASH | |||
Median (range) | 25 (0–59) | 7 (0–70) | 0.14 |
Mean (SD) | 26 (23) | 14 (18) | 0.12 |
Gartland and Werley score | 5 (0–15) | 4 (0–13) | 0.73 |
VAS at rest | 0 (0–4) | 1 (0–5) | 0.63 |
VAS in activity | 3 (0–6) | 1 (0–8) |
