How to treat a Triangular Fibrocartilage Wrist Injury
The Triangular Fibrocartilage Complex is susceptible to be injured after falling on the hand, and may require physiotherapy or occupational therapy consultations, so we must be prepared to treat and assess it properly!
It is quite common to see patients who have suffered a fall on their hand, and who suffer discomfort and pain in the long-term as a result of this traumatic event. Among the structures that may be affected, the Triangular Fibrocartilage Complex (TFCC) stands out. Its impairment can cause a situation of carpal instability, where the radioulnar ligaments lose their passive stabilization capacity., and cause limitations in loading, mobility, functional gestures and pain.
In cases where the radioulnar joint is unstable and causes problems for the patient, the pronator quadratus and extensor carpi ulnaris have been identified in the scientific literature as important active stabilisers of the DRUJ. Thus, focusing our exercise programme on re-education and strengthening of these muscles can be key.
Based on this theory, the DRUST (distal radioulnar stability training) home exercise programme has been developed and applied in a pilot study (Bonhof-Jansen et al 2019). You can read the article here:
But before we get into this issue, we must first understand what exactly this Triangular Fibrocartilage is:
Triangular fibrocartilage complex
The triangular fibrocartilage plays an essential role in stabilisation, rotation, translation and load transmission from the upper limb to the wrist, and acts as an essential pivot point (Kirchberger et al., 2015). Moreover, physiologically, the ulna does NOT contact with the carpus, but rather it is the triangular fibrocartilage complex itself that connects the two parts of the upper limb.
Although generally known only by the fibrocartilaginous disc, the Triangular Fibrocartilage Complex is somewhat broader. It is composed of:
– An articular disc or Triangular Fibrocartilage Disc (2).
– A homologous meniscus .
– The dorsal (3) and volar (4) radioulnar ligaments.
– The ulnolunate (between the ulna and lunate) (5) and ulnotriquetral(between the ulna and triquetrum)(6) ligaments.
– The extensor carpi ulnaris and its tendon sheath on the distal ulna (1).
– The pronator quadratus.
The stability of the distal radioulnar joint relies on passive and active components, including the dynamic components (muscles) that perform their work thanks to the proprioceptive control of the compressive and directional forces produced by the musculature itself (Rein et al., 2015). All this gearing allows a fluid movement of the forearm in pronation-supination.
The articular disc is a fibrocartilaginous extension of the most superficial part of the hyaline articular cartilage, which arises from the radius. It is subdivided into two laminae: superior and inferior.
The anterior and posterior interosseous arteries provide vascularisation to the TFCC.
Regarding its innervation, one study analysed the nerve branches accessing the triangular fibrocartilage complex in cadavers. The data were: 100% of the sample had innervation of the TFCC by the dorsal branches of the ulnar nerve, 91% by the medial antebrachial cutaneous nerve or 73% by the volar branch of the ulnar nerve. Less frequently, the anterior interosseous nerve (27%), the posterior interosseous nerve (18%) and the palmar branch of the median nerve (9%). (Laporte et al., 2014).
Beware of arthroscopic fibrocartilage surgeries! Cases of injury to the dorsal branch of the ulnar nerve have been reported after arthroscopic repair of the TFCC, due to the proximity of the sutures usually performed in this technique. This is why this structure should always be located before making the relevant incisions (Tsu-Hsin Chen et al., 2006).
The Sensorimotor System in the Triangular Fibrocartilage Complex
The work of Rein et al 2015 analysed the presence of nerve endings at the level of the TFCC, where they observed 👉 a large number and density of endings, including Ruffini endings (important in joint position sense) in various structures. Among them, the radioulnar ligaments of the TFCC stand out. This means that these ligaments are essential structures not only for passive joint stability, but also for active stability, providing afferent information for motor control of the wrist.
The articular disc and ulnolunate ligaments were rarely innervated, indicating that their action is more purely mechanical (passive stability).
🚩These data suggest the enormous proprioceptive load of the triangular fibrocartilage complex, which should be taken into account in our therapeutic approach! The authors themselves call for the need to include proprioceptive exercises after surgeries such as distal radioulnar ligament anchorages, once the prudential recovery time has elapsed.
Park et al (2018) stated that it is essential to know the proprioceptive role of each structure in order to understand its impact on injuries, and thus propose appropriate therapeutic management. This work assessed the ability of patients with Triangular Fibrocartilage Complex injuries to practice Joint Position Sense.
The results showed large differences between controls and patients in pronation and supination of the forearm (related to injuries to the radioulnar ligament and the TFCC itself), which explains the functional limitations that patients will suffer, and the need, once again, to work proprioceptively with these patients.
Active intervention based on sensorimotor control of the wrist early after a TFCC injury is key to optimal rehabilitation.
Wrist Joint Position Sense Assessment
The Joint Position Sense (JPS) test is a simple test for assess the presence of sensorimotor impairment of the wrist. It is a tool that has been used for many years both in research and in musculoskeletal clinical practice.
It consists of the patient’s ability to accurately reproduce a specific joint angle without vision, using a goniometer. The difference obtained on the goniometer between the initial position and the one lately repeated by the patient will give us the final score, being perfect when it is 0 (the patient has been able to reproduce it perfectly).
1) Preparation:
The patient places the ipsilateral elbow in flexion, resting on a table, while the forearm and wrist remain neutral. The fingers remain relaxed.
2) Starting position of the JPS:
The evaluator places the patient’s wrist at 20° of extension. It is important to note that one end of the goniometer should fall between the 3rd and 4th finger.
Why 20 degrees? It is a fundamental biomechanical position, as it is in this position that the wrist flexor and extensor tendons exert the most force, which promotes optimal stability in the grip gesture.
3) Change of position
At this point, the patient holds the previous position for 3 seconds to memorise it. It is important that he/she also looks at the hand during this time. After this, the wrist is brought into full flexion smoothly.
4) Re-Positioning of the wrist:
Now, the patient should close his eyes and try to repeat as accurately as possible the position of 20º of extension. When he/she confirms that this is the position, a measurement is taken with the goniometer and the degree of difference is assessed.
In this case, we see the images of a patient who has recently undergone surgery for Carpal Tunnel Syndrome. We obtained initial values that will help us to objectify her evolution in future revisions.
We must keep in mind that:
a) A greater error in the JPS may lead to greater functional deficits according to the PRWE wrist scale.
b) Higher pain intensity may correspond to greater SPA deficits.
c) Beware of post-exercise fatigue! It has been related that 20% fatigue data can alter the results up to 200% in the first 5 minutes after the activity.
Triangular Fibrocartilage Exercises
The authors of the study entitled “Rehabilitation with a stabilizing exercise program in triangular fibrocartilage complex lesions with distal radioulnar joint instability: A pilot intervention study” proposed in their pilot study a framework and progression for these wrist injuries: Re-education of the stabilising musculature, Strengthening of the stabilising musculature and Functional phase.
We will now describe the sections and attach some proposals for exercises.
Part I | Re-education Exercises for wrist stabilisation muscles in Fibrocartilage Injuries (TFCC)
In this stage, the aim is to achieve fluid and conscious control of the functional position of 20-25 degrees of extension. This position has been described as the most stable and the most mechanically advantageous for the tendons of the hand and fingers. It is interesting to remember how the hand adopts this position for gripping gestures.
Here are some examples of the Re-education Phase, including some static exercises for Proprioception and Wrist Joint Position Sense work.
Sense of joint position at 20 degrees of wrist extension in kinetic chain with the elbow and shoulder. The patient should aim to reproduce the same 20 degrees of extension position as provided by the goniometer.
In this case, the position to be reproduced is initially presented and he/she is asked to memorise it. After a few seconds, the position of the forearm or elbow is changed and he/she is asked to return to the initial position. The angulation of the wrist must be the same.
Sense of Joint Position in 20 degrees of blind wrist extension. The patient should repeat the position blindly, after bringing the wrist fully into flexion. The goniometer will serve as a reference point, and then to evaluate the final position.
It is similar to the Joint Position Sense assessment process, although it is performed as an additional exercise.
EXTRA EXERCISE in neutral wrist position including reaction movements for the fingers, included in the ReHand App. In this case, work is proposed to control the static position of the wrist at 20º of extension, adding finger reaction exercises.
The fact that we work with external focuses of attention, in this case visual, will help us to accelerate the motor learning process of the desired joint position.
Do you have any doubts? Tell us about your patient’s case and we will advise you! In ReHand, we have exercise programs for TFCC injuries. Write us!
Part II | Strengthening phase of the wrist stabilising musculature in TFCC injuries
🚨IMPORTANT🚨 It is essential that the patient masters the exercises proposed in the re-education phase before starting strengthening. In other words, the patient must be able to consciously and fluently control the 20-25° wrist extension position.
In the strengthening phase, we aim to improve the neuromuscular control and resistance of this stabilising musculature. Among the proposed exercises, the active work of the pronator quadratus and extensor carpi ulnaris is highlighted, as they favour the stability of the distal radioulnar joint.
Some ideas:
1. Isometric strengthening of wrist stabilisers
Strengthening the wrist while maintaining a stable position, and changing the forearm in pronation, neutral position and supination. We also work on the kinetic chain with the shoulder, making the exercise more difficult.
2. Strengthening of the pronator quadratus of the forearm
Pronator quadratus strengthening, performing pronations with the elbow extended from supinated to neutral position.
Strengthening of pronator quadratus , performing pronations with the elbow at 90º of flexion from supination to neutral position.
This exercise can be performed more easily with a hammer. The fact of having a wide handle and the weight at one side, allows a great way of load dosification and a simple progression.
3. Extensor carpi ulnaris (ECU) and pronator quadratus strengthening
Bilateral strengthening of the extensor carpi ulnaris with elastic. The aim is to move the wrists into extension and ulnar deviation (NOTE: if it is uncomfortable, it can be performed in neutral forearm).
Strengthening of the pronator quadratus with elastic band throughout the AROM from supination to pronation, in concentric-eccentric contraction.
Part III | Functional Training Phase for TFCC
Once the patient has mastered the re-education and strengthening exercises of the distal radioulnar muscle stabilisers, it is time to increase the complexity and include functional and reactive tasks.
Here are some examples of exercises to work on with your patients!
Exercise of conscious stabilisation of the wrist. With only a folder or a tennis racket or paddle racket, we can propose this exercise.
Exercises with gradual exposure to weight bearing on stable or unstable surfaces to gradually expose the wrist.
In this case, we use a soft ball to dilute the direct impact on the wrist and decrease the degree of extension.
Plyometric exercises performing push-ups on a wall. This can be performed uni or bilaterally, depending on the patient’s capacities. We can progress in difficulty towards a horizontal surface such as the floor itself.
Reaction exercises throwing a ball in the air, changing the position of the forearm in pronation or supination, depending on the muscles to be activated.
Any other ideas, please share your suggestions with us!
References
Hagert, E. (2010). Proprioception of the Wrist Joint: A Review of Current Concepts and Possible Implications on the Rehabilitation of the Wrist. Journal of Hand Therapy, 23(1), 2-17. https://doi.org/10.1016/j.jht.2009.09.008.
Karagiannopoulos, C., Watson, J., Kahan, S., & Lawler, D. (2019). The effect of muscle fatigue on wrist joint position sense in healthy adults. Journal of Hand Therapy, 1-9. https://doi.org/10.1016/j.jht.2019.03.004
Karagiannopoulos, C., Sitler, M., Michlovitz, S., & Tierney, R. (2013). A descriptive study on wrist and hand sensori-motor impairment and function following distal radius fracture intervention. Journal of Hand Therapy, 26(3), 204-215. https://doi.org/10.1016/j.jht.2013.03.004
Bonhof-Jansen E, Kroon G, Brink S, van Uchelen J. Rehabilitation with a stabilizing exercise program in triangular fibrocartilage complex lesions with distal radioulnar joint instability: A pilot intervention study. Hand Therapy. 2019;24(4):116-122. doi:10.1177/1758998319861661
Rein S, Semisch M, Garcia-Elias M, Lluch A, Zwipp H, Hagert E. Immunohistochemical Mapping of Sensory Nerve Endings in the Human Triangular Fibrocartilage Complex. Clin Orthop Relat Res. 2015;473(10):3245–53
Laporte DM, Hashemi SS, Dellon AL. Sensory innervation of the triangular fibrocartilage complex: A cadaveric study. J Hand Surg Am [Internet]. 2014;39(6):1122–4. Available from: http://dx.doi.org/10.1016/j.jhsa.2014.03.007
Semisch M, Hagert E, Garcia-Elias M, Lluch A, Rein S. Histological assessment of the triangular fibrocartilage complex. J Hand Surg Eur Vol. 2014;41(5):527–33
Pablo Rodríguez Sánchez-Laulhé
PhD Candidate | PT and eHealth Researcher
