Getting High-Level Athletes with Triangular Fibrocartilage Tears Back Into ActionWrist pain can be very disabling for the athlete. This is especially true for gymnasts; tennis, soccer, or volleyball players; and even competitive divers. Pain can occur along either side of the wrist, but when it affects the ulnar wrist (side away from the other hand), surgeons must rule out triangular fibrocartilage (TFC) tears.
The triangular fibrocartilage (TFC) is a thin, oval plate of fibrous cartilage. It is sometimes referred to as the articular disc or radioulnar disc because of its location between the distal radius and ulna (bones of the forearm). Distal refers to the bottom ends of these two bones where they meet the wrist.
This triangular-shaped soft tissue structure binds the distal radius and ulna together while also providing a buffer between the ends of these bones and the wrist bones. The articular disc also creates an even spread of forces between the connecting surfaces of bones.
Besides increasing the stability of the joint, the TFC also helps move synovial fluid to areas of the articular cartilage that have the most friction. Several wrist ligaments interconnect with the TFC to form a stable, but pliable, wrist.
If it turns out that a TFC injury is causing the athlete's painful symptoms, then the next step is to determine a plan of care that will get the athlete back into competition as soon as possible. The first approach is a combination of antiinflammatories and immobilization in a cast or splint. Physical therapy is often helpful. Steroid injections may be tried if these other methods don't work.
But if conservative (nonoperative) care fails to change symptoms or improve function, then surgery may be needed. There are two main types of surgical procedures. The first is dÃ©bridement. The surgeon cleans up any frayed edges and removes any fragments in the area. If this is not enough to improve symptoms and function and the wrist is unstable, then repair of the TFC is done. Most patients requiring a TFC repair need debridement first, then the repair can be done.
In this study, the goal was to see how well athletes with traumatic TFC injury that failed conservative care did after surgery. How soon did they get back to play (return-to-sports)? Could they return at their previous (high-level or full) participation? The hope was to perform arthroscopic debridement or repair and get them back to full function as quickly as possible.
The athletes were all ages from 16 to 42. There were an equal number of right versus left TFCs involved. Athletes involved in all kinds of different sports (e.g., soccer, gymnastics, football, basketball, baseball, golf) were included.
The authors described two surgical techniques for TFC repair: the ulnar-sided repair and the radial-sided repair. Just like it sounds, these two techniques are based on which side of the TFC is torn. Type and location of the incision and drill holes, size of needle to use, and description of the sutures are provided. Drawings are included to show the inside-out arthroscopic TFC repair. The surgeons suggest ways to avoid injuring the nerves when moving the needle in and out of the wrist.
Two-thirds of the group needed a repair done; one-third of the group just had a dÃ©bridement. Three-fourths of the athletes had an ulnar-sided TFC tear. The remaining patients either had a radial-sided TFC or combination of both radial and ulnar-sided tears.
Results were very positive with most of the athletes returning to their sport within three months' time. Pain was reduced. Full wrist motion and improved function were achieved. They were able to fully participate at a high-level. Ulnar-sided repairs had slightly better results. The authors suggest this may be because there is more blood supply on that side.
There aren't very many studies of high-level athletes with this type of injury and treatment. Most athletes at this level are able to rehab without surgery. For those who have surgery, guidelines for post-operative recovery and return-to-play are few and far between. Most of the rehab protocols are based on surgeon preference, not necessarily evidence. A conservative approach suits the surgeon but may not sit well with the athlete who is eager to get back into action.
Until a more aggressive timeline can be studied, surgeons try to err on the conservative side of things. This means giving patients plenty of time to heal in order to avoid problems and complications. The results of this study at least show that arthroscopic treatment of TFC tears (either dÃ©bridement or repair) is successful for competitive athletes. More studies are needed to compare aggressive versus conservative rehab programs.
Timothy R. McAdams, MD, et al. Arthroscopic Treatment of Triangular Fibrocartilage Wrist Injuries in the Athlete. In The American Journal of Sports Medicine. February 2009. Vol. 37. No. 2. Pp. 291-297.
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