Houston Methodist. Leading Medicine

Wrist FAQ

Question:

Years ago, I tore the triangle ligament in my wrist and had to put my bowling activities on hold. I never did get back to bowling but I'm interested in trying it again. The problem is: my wrist clunks and clicks and I'm worried I might reinjure myself. Do you think it's safe to give it a try anyway?

Answer:

Painful clicking or clunking of the wrist is a sign that the triangular fibrocartilage complex or TFCC has been torn. The triangular fibrocartilage complex (TFCC) suspends the ends of the radius and ulna (forearm) bones over the wrist. It is triangular in shape and made up of several ligaments and cartilage. The TFCC makes it possible for the wrist to move in six different directions (bending, straightening, twisting, side-to-side).Without it, the wrist is not stable at the distal radioulnar joint (DRUJ) -- that's where the two bones of the forearm attach to the first row of wrist bones. With the symptoms you described, an orthopedic evaluation may be a good idea before lifting a heavy bowling ball with that hand. Understanding exactly what's going on in the wrist and providing treatment if necessary is your first step. Your physician will take your history (how, when, and what happened), ask about your symptoms, and perform a physical examination to make the diagnosis. Tests of joint stability can be conducted. Special tests such as stress testing of the wrist radioulnar and ulnocarpal joints help define specific areas of injury. An accurate diagnosis and grading of the injury (degree of severity) is important. Usually, the grade is based on how much disruption of the ligament has occurred (minimal, partial, or complete tear). There are two basic grades of triangular fibrocartilage complex injuries. Class 1 is for traumatic injuries. Class 2 is used to label or describe degenerative conditions. Other tests may be done to provoke the symptoms and test for excess movement. These include hypersupination (overly rotating the forearm in a palm-up position) and loading the wrist in a position of ulnar deviation (moving hand away from the thumb) and wrist extension. A new test called the fovea sign applies external pressure to the area of the fovea. The examiner compares the involved wrist with the wrist on the other side. Tenderness and pain during this test is a sign that there is a split-tear injury (down the middle length-wise). Split tears are more common with lower energy, repetitive torque injuries such as from bowling or golf. This type of ligament injury was first discovered when a surgeon pushed on the area of pain while using an arthroscope to look inside the joint. The surgeon saw the ligament open up like a book. X-rays may show disruption of the triangular fibrocartilage complex when there is a bone fracture present. Ligamentous instability without bone fracture appears normal on standard X-rays. X-rays with a dye injected is called a wrist arthrography. Arthrography is positive for a TFCC tear if the dye leaks into any of the joints. There are three specific joint areas tested, so this test is called a triple injection wrist arthrogram. It's possible you had all these tests done when you were first told you had a torn "triangle ligament" (most likely, a triangular fibrocartilage complex or TFCC) injury. Wrist arthroscopy is really the best way to accurately assess the severity of damage. At the same time, the surgeon looks for other associated injuries of ligaments and cartilage. The surgeon performs the test by inserting a long thin needle into the joint. A tiny TV camera on the end of the instrument allows the surgeon to look directly at the ligaments. Treatment for you with a chronic (older) injury will depend on the results of the testing. Conservative (nonoperative) care with splinting, antiinflammatory drugs, physical therapy, and possibly steroid injections may be advised. If the wrist is unstable (and that clicking/clunking you mentioned is usually a sign of instability), then surgery may be needed. But see your physician before leaping from "can I go bowling?" to "do I need surgery?" 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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