Wednesday, October 17, 2018

Triangular Fibrocartilage complex (TFCC)

What is TFCC?

Figure 1. Collection of ligaments, TFCC
It is an abbreviation for Triangular FibroCartilage Complex. It is named "triangular" due to the triangular shape of the central articular disc (see the red border in Figure 2). TFCC is a collection of ligaments originating from styloid process of ulna. TFCC is surrounded by synovial fluids.
Figure 2. Triangular shape of central articular disc

TFCC includes:
  • Posterior and volar (relating to the palm, anterior side) radioulnar ligaments
  • Central articular disc
  • Meniscus homologue
  • ECU (Extensor carpi ulnaris) tendon sheath
  • Ulnolunate ligament
  • Ulnotriquetral ligament
Figure 3. Features of TFCC
Origin:
  • All the ligaments originates from ulna including central articular disc.
Insertion:
  • Radius (radioulnar ligaments, posterior ["Dorsal" in figure 3] and anterior ["Palmar" in Figure 3] and central articular disc)
  • Lunate (ulnolunate ligament)
  • Triquetrum (ulnotriquetral ligament)
What is the tissue type of TFCC?

The TFCC is ligaments that are made out of fibrocartilage which is also what the invertebral discs are made out of. However, it is different from intervertebral discs since the peripheral parts (ligaments) of TFCC are vascular, but the central articular disc is avascular (no direct blood supply). This makes the central articular disc heal slower than the ligaments around.

Why is it important?

Figure 4. Roll, Yaw and Pitch motion of the hand
The TFCC works as a shock absorber, distributing the applied force evenly across the carpal region. It is a major stabilizer of the distal radioulnar joint (abbreviated as DRUJ) and ulnar carpus (ulna side of the wrist). This ligaments are responsible for roll (supination and pronation), yaw and pitch motion of the hands.

Case Study

"An Unusual Case of Triangular Fibrocartilage Complex Tear after a Wrist-Lock Restraint" by Philippa A Rust and S-A Philips
Department of Plastic Surgery, St John's Hospital, UK

What happened?

This case study is about a 51-years old Police Training Officer who injured his wrist during the training. He reported pain in the right wrist after one of his colleagues wrist-locked him as a part of the training. His wrist was hyperflexed when the wrist-lock was performed.
Figure 5. Wrist-Lock
The report says it is a rare cause of TFCC tear.

Where was the injury?

The injury was located at central articular disc. This is classified as class IA TFCC tear. This TFCC tear is common mostly in children. This injury is usually caused by hyperextention of the wrist, wrist bending backwards, but the cause of this case was rare in that he got this injury by hyperflexion.
Figure 6. Classification of TFCC injury
The patient reported that he felt pain when he tried to roll his hand. (supination and pronation)

What was the treatment?

Figure 7. Surgical procedure of debridement of TFCC
Treatment for the class IA TFCC tear was a debridement surgery (removal of the damaged tissue or foreign object from the wound). This is so that any undamaged healthy tissue can heal properly.
Arthroscope is a small camera used for the surgery to minimize the incision as shown above.

What happened after the treatment?

2 weeks after his surgery, his incision on the wrist healed and stopped taking analgesia, the painkiller medication. After 3 months, his distal radioulnar joint pain has relieved, started to regain the strength through rehabilitation. 
Figure 8. Rehabilitation for TFCC
After 2 years of the surgery, he was symptom free and got back to normal activities, no restriction in his wrist movement at all. This is typical result for class IA TFCC tears since the tear is not severe.

Citations:
  1. What is TFCC? section:
    • Informations:
      • Abbasi, David Vitale, Mark. “TFCC Injury.” Orthobullets. July 29th, 2011. Web. Accessed Oct. 16th, 2018. https://www.orthobullets.com/hand/6047/tfcc-injury
    • Pictures:
      • Figure 1 - MD. Masem, Mathias. "Triangular Fibrocartilage Complex (TFCC) Injuries" Bay Area Hand Associates. web. Accessed Oct. 16th, 2018. http://www.bayareahand.com/tfcc-tear.shtml
      • Figure 2 - Osterman, Lee. "Arthroscopic and Open Triangular Fibrocartilage Complex Repair" Doctorlib. Web. Accessed Oct. 15th, 2018. https://doctorlib.info/surgery/operative-techniques-orthopaedic-surgery/292.html
      • Figure 3 - Durrant, Adam. "TFCC Tears" Durrant Orthopaedics. Web. Accessed Oct. 14th, 2018. http://www.durrantortho.co.nz/injuries/hand-and-wrist-injuries/tfcc-tears/
  2. What is the tissue type? section:
    • Information:
      • Dr. Goel, Ayush and Dr. Knipe, Henry et al. "Triangular fibrocatilage complex" Radiopaedia. Web. Accessed Oct. 13th, 2018.  https://radiopaedia.org/articles/triangular-fibrocartilage-complex
  3. Why is it important? section:
    • Informations:
      • Wheeless, R. Clifford. "Anatomy and Function of the Triangular Fibrocartilage Complex" Wheeless' Textbook of Orthopaedics, Dec. 12th, 2018. Web. Accessed Oct. 15th, 2018. http://www.wheelessonline.com/ortho/anatomy_and_function_of_the_triangular_fibrocartilage_complex 
    • Pictures:
      • Figure 4 - Suarez Fernandez, A. Ramon et al. "Natural user interfaces for human-drone multi-modal interaction" International Conference on Unmanned Aricraft Systems. 2016. Web. Accessed Oct. 13th, 2018. https://www.semanticscholar.org/paper/Natural-user-interfaces-for-human-drone-multi-modal-Fernandez-S%C3%A1nchez-L%C3%B3pez/9b97967b3b8f6868d71abbcb7c10b084f8fbf101 
  4. Case Study Section:
    • Informations:
      • Rust, A. Phillippa and Philips, S-A. "An Unusual Case of Triangular Fibrocartilage Complex Tear after a Wrist-Lock Restraint" SciMedCentral.  Dec. 12th, 2018. Web. Accessed Oct. 16th, 2018.  https://www.jscimedcentral.com/Orthopedics/orthopedics-3-1059.pdf 
      • Bayoumy, A. Maysara et al. "Arthroscopic grading of common wrist disorders and its role in management" National Institutes of Health. Nov. 1st, 2015. Web. Accessed Oct. 14th, 2018. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4796527/
    • Pictures:
      • Figure 5 - Schlosser, Michael. "The Rear Wrist Lock" Police The Law Enforcement Magazine. Nov. 26, 2014. Web. Accessed Oct. 16th, 2018. http://www.policemag.com/channel/careers-training/articles/2014/11/the-rear-wrist-lock.aspx
      • Figure 6 - MD. Kim, Byungsung et al. "Traumatic Triangular Fibrocatilage Complex Injuries and Instability of the Distal Radioulnar Joint" Journal of The Korean Orthopaedic Association. Apr. 19th, 2017. https://jkoa.org/DOIx.php?id=10.4055/jkoa.2017.52.2.112
      • Figure 7 - No author specified. "Arthroscopic Debridement of Right Wrist" Certified Medical Illustrations. Web. Accessed Oct. 16, 2018. http://certifiedmedicalillustrations.com/arthroscopic-debridement-right-wrist/
      • Figure 8 - Bond, Thomas. "Wrist Injuries Part 2" Blogspot. Apr. 15th, 2013. Web. Accessed Oct. 16th, 2018. http://thomasbondphysio.blogspot.com/2013/04/wrist-injuries-part-2.html 
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