Disclaimer: The following case is for education purposes only and does not depict any actual person or patient.
A 20-year-old male collegiate cheerleader reports gradual pain in his left wrist over the past three months during basketball cheer. He specifically, reports pain when holding his partner with a single-arm base. Additionally, he has pain with back handsprings as well as push-ups. He states otherwise he does not have any difficulties with activities of daily living. He is able to drive his car, type on his laptop, and use his phone with no pain. He does not report any numbness or tingling in the hand.
On physical exam, he has full flexion and extension of the wrist as well as full radial and ulnar deviation. There is no noted swelling of the wrist. He has normal neurologic function. He has no tenderness over the distal radius or ulna including the ulna styloid. However, he reports pain on the ulnar side of the wrist just distal to the ulna styloid, with deep pressure. An ulnar grind test is positive. Additionally, the pain can be reproduced with the patient performing a few pushups in the exam room.
X-rays obtained in clinic show no fracture. However slight positive ulnar variance is noted.
An MRI of the wrist is obtained and reveals the diagnosis
Clinical Approach
What are the key exam features of this injury?
I generally use three specific exam findings that I find to be reliably efficient at confirming the diagnosis of a TFCC injury. Keep in mind, it is important that the patient has a relaxed wrist during the exam as tension can limit the ability for deep palpation to key areas. First, I will apply deep and firm pressure to the soft tissue just distal to the ulna styloid. Secondly, I will shake the patient's hand while deviating it toward the ulna trying to compress the tissue in that area. Lastly, I will either have the patient perform classical push-ups or wall push-ups as an easier option. (If the patient is a gymnast I will have them perform a handstand to reproduce the pain)
What is your general treatment approach to a TFCC tear?
It definitely depends on the level of the athlete, however, in a high school athlete I will typically treat as a presumptive TFCC tear if the clinical history and physical exam findings above are very consistent. My approach, which is similar to the literature, includes modification from weight-bearing activities of the wrist and bracing for 4-6 weeks. If no improvement I will proceed with an MRI to confirm the diagnosis. When the diagnosis is confirmed, I will provide option of either further rest or opinion from the hand surgeon on corticosteroid injection verus surgical intervention. If the patient opts for further rest, I have had some success with a cast for complete immobilization for 3-4 weeks.
What is positive ulnar variance?
Positive ulnar variance is a variant in anatomic positioning of the ulna bone compared to the radius bone. It occurs when the joint surface of the ulna is more distal than the joint surface of the distal radius. In many individuals, this can be an asymptomatic finding, but it can be associated with a predisposition to a TFCC tear.
Clinical Pearls
Ulnar-sided wrist pain with or without trauma is commonly associated with TFCC injuries in athletes.
TFCC injuries tend to occur more often in gymnastics, cheer, volleyball and strength training.
3T MRI is highly sensitive and specific for TFCC tear, therefore an arthrogram is not typically needed when obtaining advanced imaging.
Especially when traumatic, when concern is for a TFCC injury one should verify the stability of the distal radial ulnar joint.
Annotated Image
Reference:
Nagle DJ. Triangular fibrocartilage complex tears in the athlete. Clin Sports Med. 2001;20(1):155-166. doi:10.1016/s0278-5919(05)70253-2
Fishman FG, Barber J, Lourie GM, Peljovich AE. Outcomes of Operative Treatment of Triangular Fibrocartilage Tears in Pediatric and Adolescent Athletes. J Pediatr Orthop. 2018;38(10):e618-e622. doi:10.1097/BPO.0000000000001243