What is the Natural History of the Triangular Fibrocartilage Complex Tear Without Distal Radioulnar Joint Instability?

Abstract

Background The triangular fibrocartilage complex (TFCC) tear is a common cause of ulnar-side wrist pain; however, its natural course is not well understood. Questions/purposes We sought (1) to determine the natural course of TFCC tears without distal radioulnar joint (DRUJ) instability, and (2) to identify the factors associated with poor prognosis after nonsurgical treatment of TFCC tears. Methods Over a 3-year period, we treated 117 patients with TFCC tears who did not have DRUJ instability. The diagnosis was made on the basis of ulnar-sided wrist pain, a positive ulnocarpal stress test or ulnar grinding test, and identification of a tear on MRI or CT arthrography. Of those, 25 were excluded during the initial evaluation period because they met the previously defined indications of surgery on the basis of clinical history. Another 19 patients (20%) were lost to followup before 6 months, and one patient was excluded because of prior wrist surgery, leaving 72 wrists in 72 patients for analysis in this retrospective study, which drew data from a review of electronic medical records of one institution. The group consisted of 42 men and 30 women, with a mean age of 40 years (range, 18-70 years). The study group was followed for a mean of 16 months (range, 6 to 36 months). We evaluated the pain VAS and patient-rated wrist evaluation (PRWE) at the initial visit, at 4, 8, and 12 weeks, and at more than 6 months after the initial visit. A PRWE score ≤ 20 points indicated complete recovery, and a PRWE score more than 20 points was considered an incomplete recovery. We used Kaplan-Meier survival analysis and Cox regression modelling to estimate the time to complete recovery and to identify factors associated with incomplete recovery among the seven possible factors of older age (≥ 45 years), male, obesity (body mass index ≥ 30 kg/m2), dominant-hand involvement, chronic symptoms (≥ 6 months), traumatic tear, and ulnar-plus variance. Results The Kaplan-Meier survival analysis showed that estimated cumulative incidence of complete recovery was 30% (95% confidence interval [CI], 20–40) at 6 months and 50% (95% CI, 39–61) at 1 year. We could not find any risk factors among the seven candidate factors, including older age (hazard ratio [HR], 0.608; 95% CI, 0.34–1.087; p = 0.093), male (HR, 1.152; 95% CI, 0.667–1.991; p = 0.612), obesity (HR, 1.433; 95% CI, 0.603–3.402; p = 0.415), dominant hand involvement (HR, 1.808; 95% CI, 0.927–3.527; p = 0.082), chronic symptoms (HR, 0.763; 95% CI, 0.443–1.922; p = 0.133), traumatic tear (HR, 0.756; 95% CI, 0.432–1.32; p = 0.325), and ulnar plus variance (HR, 0.804; 95% CI, 0.461–1.404; p = 0.443). Conclusions This study demonstrates that nonsurgical treatment is moderately successful for treating patients with TFCC tears without DRUJ instability. We recommend a minimum of 6 months nonsurgical treatment as the first-line treatment for this injury. Future studies are necessary to clarify predictors of persistent pain with nonsurgical treatment to avoid an unnecessary surgical delay. Level of Evidence Level III, prognostic study.

CORR Insights®: What is the Natural History of the Triangular Fibrocartilage Complex Tear Without Distal Radioulnar Joint Instability?

“…However, there is little evidence to support this recommendation. The current study by Lee and colleagues [4] suggests that many of these patients may not need surgery at all.…”

“…I note that ulnar impaction syndrome is not limited to ulnar-plus wrists; this also occurs in the ulnar-negative and ulnarneutral wrist [7]. Choosing a specific treatment is made still-more challenging because there may be no difference in the prognosis between a degenerative and a traumatic associated tear [4], and no studies to my knowledge have assessed the accuracy and reproducibility of our clinical tests. It is important that we come to a consensus on this because the causal connection between an MRI-detected tear and the cause of ulnar-sided wrist pain is not certain.…”

Surgical Repair of Triangular Fibrocartilage Complex Tears: A Systematic Review

“…The relative scarcity of studies on open repair techniques and comparative studies between the two techniques is also noted in recent publications. 3,11,17 DRUJ instability, both as a preoperative finding and postoperative outcome, was assessed with only clinical maneuvers such as the ballottement test. 55 Determination of the severity of DRUJ instability or subluxation continues to be difficult to standardize, due to the lack of an objective and validated measure.…”

“…[8][9][10] Pain caused by TFCC tears may be treated by nonoperative means including rest, splinting, cortisone injections, and activity modification. 11 However, surgery is considered when nonoperative measures fail and this includes arthroscopic debridement, arthroscopic/arthroscopic-assisted repair (outside-in, inside-out, all-inside), or open repair. 8 Ulnar shortening osteotomy (USO) can also be performed to unload the ulnocarpal joint; in the event there is associated ulna abutment from ulna positive variance.…”

The triangular fibrocartilage complex on high-resolution 3 T MRI in healthy adolescents: the thin line between asymptomatic findings and pathology

“…Magnetic resonance imaging (MRI) can be performed when a clinical suspicion of TFCC injury remains. Arthroscopy, the diagnostic reference standard, is performed only when prompted by physical examination combined with MRI abnormalities [7].…”