Houston Methodist. Leading Medicine

Wrist FAQ

Question:

I'm looking for any information I can find on the latest in surgical treatment of a torn triangular complex ligament for the wrist. I would like to be fully informed before I go back to the doctor for the results of the tests I had. I've already been told I'm likely going to need surgery.

Answer:

There are several repair techniques for triangular fibrocartilage complex (TFCC) tears of the wrist. Too much damage to the surrounding tissues and/or severe wrist instability may mean repair isn't possible. In such cases, full reconstruction is required. But let's take a look at repair procedures first. The outside edges of the triangular fibrocartilage complex have a good blood supply. Tears in this area can be repaired. But there is no potential for healing when tears occur in the central area where there is no blood supply. Arthroscopic debridement (smoothing or shaving) of the damaged tissue is then required. The surgeon debrides any tears of the nearby soft tissue structures that might catch against other joint surfaces. Then the surgeon looks for any problems with the ligaments. A probe is used to detect tension or laxity (looseness) of the ligaments. Laxity is a sign of injury. Arthroscopic debridement works well for simple tears. Much of the damaged tissue can be removed while still keeping a stable wrist joint. The torn structures can be reattached with repair sutures. Some ligamentous ruptures with fracture can also be repaired arthroscopically with reattachment and instrumentation. Instrumentation refers to the use of hardware such as wires and screws to help hold the repaired tissue in place until healing occurs. There are new surgical techniques being tried for triangular fibrocartilage complex (TFCC) tears. For example, in Japan surgeons have reported arthroscopical treatment for TFCC tears that were torn at the foveal insertion point. The fovea is a groove that separates the ulnar styloid from the ulnar head. The styloid is a small bump on the edge of the wrist (on the side away from the thumb) where the ulna meets the wrist joint. The foveal groove is at the junction of the ulnar bone and wrist. The deep portion of the TFCC attaches at the fovea. Rupture or avulsion of the TFCC at this place of insertion or attachment leaves the distal radioulnar joint unstable. Their arthroscopic technique called transosseous outside-in was used to reattach (repair) the torn TFCC. They tunneled through the bone to get to the fovea. This creates bleeding from inside the bone. The bleeding helps form adhesions to hold the triangular fibrocartilage complex (TFCC) to the ulnar insertion point. K-wires were used to reattach the ligament to the bone. Some complex tears require open repair. Open repair means the surgeon makes an incision and opens the tissues to perform the operation. This gives the surgeon a better view and better access of the area. The specific procedure depends on the tissues injured and the extent of the injury. For example, detachment of the radioulnar ligaments usually requires open repair. Instability of the distal radioulnar joint may require the use of wires to hold the area together until healing occurs. In other cases, surgery has been delayed long enough that the torn ligament has retracted (pulled back) so far that direct repair can't be done. In these cases, a tendon graft may be needed to help strengthen the repair. Chronic and degenerative TFCC may require a different surgical approach. Debridement is not as successful with this group as it is with acute TFCC injuries. Sometimes it is necessary to shorten the ulnar bone at the wrist to obtain pain relief. There are different ways to accomplish shortening of the ulna to unload the ulnocarpal joint. It's good to have in mind different ways your injury might be treated. Your surgeon will also explain what is recommended for you and why. You may not need details of how the repair or reconstruction is actually done but if you ask, the surgeon will likely be glad to give you more information. Takaaki Shinohara, MD, PhD, et al. Arthroscopically Assisted Repair of Triangular Fibrocartilage Complex Foveal Tears. In The Journal of Hand Surgery. February 2013. Vol. 38A. No. 2. Pp. 271-277.

*Disclaimer:* The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic.
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