The New York State Workers Compensation Board provides foundational principles for addressing injuries related to the Triangular Fibrocartilage Complex (TFCC). These guidelines are formulated to assist healthcare professionals in determining appropriate interventions for TFCC injuries as part of a comprehensive assessment.
Healthcare experts specializing in managing Triangular Fibrocartilage Complex Tears can rely on the guidance outlined by the Workers Compensation Board to make well-informed decisions about the most suitable therapeutic approaches for their patients.
It is essential to underscore that these guidelines are not intended to replace clinical judgment or professional expertise. The ultimate decision regarding interventions for Triangular Fibrocartilage Complex Tears should involve collaboration between the patient and their healthcare provider.
Triangular Fibrocartilage Complex (TFCC) Tears
Triangular fibrocartilage complex (TFCC) tears are common wrist injuries involving the cartilaginous meniscus situated between the radius and ulna, with symptoms typically reported on the ulnar side of the wrist joint.
Physical Exam
During the examination, dorso-ulnar wrist joint tenderness may be observed, which is not specifically tender over an extensor compartment. Swelling is generally absent, although it may be present in the case of an acute, large tear. The examiner should aim to reproduce catching or snapping in the ulnar wrist joint.
Medical History
Patients often report non-radiating ulnar-sided pain and clicking. It is crucial to correlate these symptoms with the physical examination and the mechanism of injury, as MRI studies indicate that TFCC tears are both common and frequently asymptomatic. Ulnar deviation with axial loading tends to exacerbate pain, and a “click” or “clunk” in the ulnar wrist joint may be reproduced with forearm rotation (supination/pronation). Occupational cases may exhibit symptomatic onset after a specific traumatic event, such as a slip and fall. The patient’s history should encompass ulnar wrist joint pain and sensations of catching, snapping, or popping during wrist movement.
Initial Assessment
The primary focus of the patient history is to determine the extent of TFCC tearing and whether it is symptomatic enough to necessitate intervention. Monitoring the patient’s symptoms for healing without immediate surgical intervention is generally the most common approach. Some cases may not heal, persist with symptoms, and respond well to surgical repair or removal.
Diagnostic Studies
X-rays are recommended to diagnose TFCC tears, especially when there is suspicion or to rule out other sources of wrist pain. One set of x-rays is typically sufficient.
MRI is recommended for diagnosing Triangular Fibrocartilage Complex (TFCC) Tears.
Arthroscopy is recommended in select patients with persistent wrist pain unresponsive to conservative management when MRI findings do not reveal the etiology. Diagnostic arthroscopy can be performed independently or combined with surgical repair.
Medications
For the majority of patients, initial recommendations for medication involve ibuprofen, naproxen, or other traditional NSAIDs. Acetaminophen (or its analog, paracetamol) might be a reasonable alternative for individuals not suitable for NSAIDs, although evidence generally suggests that acetaminophen is slightly less effective. Studies indicate that NSAIDs are comparable in efficacy to opioids (including tramadol) for pain relief but with less impairment.
Non-Steroidal Anti-inflammatory Drugs (NSAIDs) for Treatment of Acute, Subacute, or Chronic TFCC Tears
Recommended for treating acute, subacute, or chronic TFCC tears. Indications include using NSAIDs for the treatment of acute, subacute, or chronic TFCC tears. Over-the-counter options may be tried initially. The frequency and duration of use can be as needed, and discontinuation may be warranted in case of symptom resolution, lack of efficacy, or the development of adverse effects.
NSAIDs for Patients at High Risk of Gastrointestinal Bleeding
Recommended for concurrent use with cytoprotective drug classes, including misoprostol, sucralfate, histamine Type 2 receptor blockers, and proton pump inhibitors, for patients at a high risk of gastrointestinal bleeding. Indications involve considering cytoprotective medications, especially if longer-term treatment is contemplated, for patients with a high-risk factor profile such as a history of prior gastrointestinal bleeding, elderly individuals, diabetics, and cigarette smokers. The recommended frequency, dose, and duration follow manufacturer guidelines. Discontinuation may be necessary in cases of intolerance, adverse effects, or discontinuation of NSAID use.
NSAIDs for Patients at Risk for Cardiovascular Adverse Effects
Patients with known cardiovascular disease or multiple risk factors for cardiovascular disease should discuss the risks and benefits of NSAID therapy for pain. First-line therapy with acetaminophen or aspirin is considered the safest regarding cardiovascular adverse effects. If NSAIDs are needed, non-selective options are preferred over COX-2 specific drugs. In patients taking low-dose aspirin for cardiovascular disease prevention, timing adjustments are recommended to minimize potential interference with aspirin’s beneficial effects.
Acetaminophen for Treatment of TFCC Tears Pain
Recommended for managing pain associated with TFCC tears, especially in patients with contraindications for NSAIDs. All patients experiencing TFCC tears pain, whether acute, subacute, chronic, or post-operative, are indicated for its use.
The dosage and frequency should adhere to the manufacturer’s recommendations and may be employed on an as-needed basis. Caution is advised against exceeding four grams per day due to evidence of potential hepatic toxicity. Discontinuation is warranted upon pain resolution, adverse effects, or intolerance.
Not recommended for acute, subacute, or chronic TFCC tears. However, limited use (up to seven days) is recommended for postoperative pain management as adjunctive therapy to more effective treatments. Prescribing opioids is often necessary for postoperative pain management, especially at night, as an adjunct to more efficacious treatments such as NSAIDs and acetaminophen.
The prescription frequency involves as-needed usage throughout the day, eventually tapering off at night before complete discontinuation. The rationale behind this recommendation is that some patients may find insufficient pain relief with NSAIDs, making judicious use of opioids helpful, particularly for nocturnal use. Opioids are advised for brief, selective use in postoperative patients, primarily for nighttime use to facilitate postoperative sleep.
Rehabilitation
Rehabilitation, in the context of a work-related injury, should concentrate on reinstating the functional capacity required for the patient’s daily and occupational activities, ultimately aiming to return the injured worker to the pre-injury state as much as possible. Active therapy demands internal effort from the patient to complete specific exercises or tasks, while passive therapy involves interventions not requiring patient exertion, relying on modalities delivered by a therapist.
Generally, passive interventions are considered to support progress in an active therapy program, facilitating objective functional gains. Emphasis should be placed on active interventions over passive ones. Patients are encouraged to continue both active and passive therapies at home to extend the treatment process and sustain improvement levels. Assistive devices may be incorporated into the rehabilitation plan as adjunctive measures to enhance functional gains.
Therapy: Active
Therapeutic Exercise
Recommended for specific patients, particularly during the recovery or post-operative phases. Exercise is generally not recommended acutely but may be necessary post-operatively. Functional objectives should encompass enhanced grip strength, key pinch strength, range of motion, and improved work-related capabilities.
The frequency, dosage, and duration of therapeutic exercise sessions may range from as few as two to three visits for patients with mild functional deficits to up to 12 to 15 visits for those with more severe deficits. Continuous assessment of ongoing objective functional improvement is essential.
If persistent functional deficits are present, exceeding 12 to 15 visits may be warranted, provided there is documented progress toward specific functional goals. A home exercise program should be developed and performed in conjunction with therapy as part of the rehabilitation plan.}
Therapy: Passive
RICE (Rest, Ice, Compression, Elevation)
Recommended for relative rest in the treatment of acute, subacute, or chronic triangular fibrocartilage complex (TFCC) tears. Relative rest may obviate the need for surgical intervention. Ice and heat applications may be beneficial, particularly for more acute symptoms, offering symptomatic relief.
Cryotherapy / Heat
Recommended for self-application of ice in the treatment of acute, subacute, or chronic TFCC tears.
Self-Application of Heat
Recommended for treating acute, subacute, or chronic TFCC tears.
Immobilization
Recommended for splinting in the treatment of moderate or severe, acute or subacute TFCC tears, especially to minimize forearm rotation. Wrist splints may assist in avoiding activities or movements that provoke symptoms, making them particularly suitable for acute or moderately severe injuries.
Surgery
Surgical Repair (Arthroscopic or Open Surgical Repair)
Recommended for specific patients exhibiting instability, concurrent fractures, or persistent symptoms with no improvement following nonoperative treatment for approximately 3 to 6 weeks. The rationale for this recommendation is based on the preference for arthroscopic repair, although open repairs are also a viable option.
Ulna Shortening and Wafer Procedures for Chronic Triangular Fibrocartilage Complex (TFCC) Tears
Recommended for specific cases involving chronic tears where non-surgical interventions have been ineffective, and there is evident ulna positive variance. The recommendation for this procedure is justified in instances with ulna positive variance, persistent or debilitating symptoms, or a lack of improvement trends.
