Boston Children’s Hospital Suggests Safety and Efficacy with Surgical Treatment of TFCC Tears in Kids

A recent study out of the renowned Boston Children’s Hospital found surgical repair of triangular fibrocartilage complex (FTCC) tears in kids to safely and effectively reduce pain, improve range-of-motion, and increase activity over one year later. Surgery for this painful and debilitating injury has not been well studied in children, making these results very important to understanding best treatment practices for this vulnerable population.

TFCC Anatomy

The TFCC is a crucial, if relatively unknown, structure on the pinky side of the wrist. It provides cushioning and support between the two forearm bones (radius and ulna), as well as between the wrist bones (carpals) and the forearm bones, allowing all of these structures to glide across each other when the hand grasps or the forearm rotates.

Tears: Causes, Symptoms, and Diagnosis

In general, there are two types of TFCC tears: those caused by trauma, and those caused by aging or degeneration. The former – which were the focus of this study – typically stem from over-rotation of the joint or trying to brace a fall and bending the wrist too far backward. Those who play wrist-heavy sports – e.g., baseball, tennis, gymnastics – are at an especially high risk.

Patients with a TFCC tear typically present with pain along the pinky side of the wrist that increases with movement. Swelling, stiffness, instability, and loss of mobility or strength are all hallmarks of a TFCC tear. Notably, the injury often coincides with a bone fracture, which can add a clicking in the joint on top of the aforementioned symptoms.

To diagnose a TFCC tear, a doctor will begin with a review of your medical history, your symptoms, and any relevant incident. The physical exam usually includes applying pressure to the outside of the wrist, rotating it, and/or gently shifting the outer forearm bone up and down against the wrist. Any pain during the last of these tests is a particularly good indicator of TFCC damage, as the structure normally facilitates this isolated movement. In certain cases, a doctor may use x-ray, MRI, or even arthroscopy – a small camera inserted into the wrist cavity through an incision – to finalize the diagnosis.

Treatment Options.

Treatment can be operative or non-operative, depending on the extent of the tear. The TFCC can heal on its own with proper immobilization, over the counter anti-inflammatory medicines, and physical therapy. Moderate cases could also respond well to a cortisone injection, which reduces inflammation in the affected tissue. However, more severe tears or those that don’t respond to non-operative treatments will require arthroscopic surgery. In this procedure, the same small camera that is sometimes used for diagnosis will be inserted into the wrist cavity along with several other tiny instruments to remove damaged tissue (also known as debridement) and repair tears. Debridement is usually used in cases where blood supply is relatively intact (so that any tears can heal naturally), while surgical repair is used if blood supply is restricted. In certain cases, the ulna (the pinky-side forearm bone) can be shortened to reduce pressure on the torn TFCC.

Patients will leave the operation with several, small scars (~1 cm long), and a splint to immobilize the wrist for several weeks.

Background and Study Methods

A TFCC tear can be a significantly painful and debilitating injury. As such, if it occurs in a child or adolescent, knowing the best treatment to ensure long-term recovery is key. TFCC injuries are not as well studied in younger populations, (they are much more common in older patients), making this study particularly noteworthy.

Surgical repair of a TFCC injury was used in 149 patients with an age range of 7-19 years old (mean = 15.5). All diagnoses were confirmed with arthroscopy. Then, patients were seen regularly for an average of over a year after surgery to follow up on pain, range-of motion, and quality-of-life measures.

Data Deep Dive

All in all, the researchers concluded their use of surgery to be efficacious and safe. The number of patients experiencing moderate or severe pain decreased from 91% before surgery to 18% at their final follow-up – a statistically significant finding (e.g., a finding that was unlikely to be due to chance).

Investigators also used the Mayo Modified Wrist Score (MMWS) – a validated, composite measure of pain, range-of-motion, and ability to do activity that is completed by patients – finding that these scores also significantly improved after surgery. That said, 6% of patients did record poor scores on the MMWS after surgery, driven by high pain and limited range-of-motion. However, researchers did note that activity improved after surgery even for these patients.

Notably, those with concomitant injuries (e.g., a broken bone on top of a TFCC tear), achieved “good to excellent” outcomes 81% of the time – a significant finding considering that just over 50% of the patients fell into this category. In this population, patients also saw a significant jump in their MMWS score, indicating a better quality-of-life after the procedure.

Intriguingly, patients who also had a bone-related procedure (shortening of the ulna or fracture repair) achieved better post-operative quality-of-life measures than those who had only a TFCC repair. Authors posited this to be due to better wholistic management of the injury – both soft tissue and bone issues were resolved to maximize benefit from surgery.

Data Limitations

There were several limitations to this study, principal among them the relatively small size of the cohort, which precluded comparisons between subgroups. For example, authors could not detect differences in recovery between patients receiving an FTCC repair vs. a debridement.

The high rate of concomitant injuries – more than half of study participants had more than just a TFCC tear – also reduced the authors ability to determine whether benefit from the surgery was primarily due to TFCC treatment or other repairs, especially considering that those with concomitant injuries also achieved better outcomes.

Implications for You

Most importantly, this study demonstrates safety and efficacy with surgical treatment of TFCC tears in pediatric patients. Whether or not to have surgery is always a difficult decision to make, especially for a child, but study results like these give confidence that surgery can provide the desired outcome in the long-term. Of course, the researchers did acknowledge that selecting the right patients for surgery is key to maximizing benefit, meaning you should seek out a trusted hand and wrist surgeon for any procedure you are considering.

Citations

1. Wu, M., et al. (September 2019). Early Results of Surgical Treatment of Triangular Fibrocartilage Complex Tears in Children and Adolescents. Retrieved from https://www.jhandsurg.org/article/S0363-5023(18)30007-8/fulltext
2. Triangular Fibrocartilage Complex (TFCC) Tear (n.d.). Retrieved from https://www.rushortho.com/body-part/wrist/triangular-fibrocartilage-complex-tear
3. Verheyden, J.R. (November 2018). Triangular Fibrocartilage Complex Injuries Treatment & Management. Retrieved from https://emedicine.medscape.com/article/1240789-overview

Dr. John Knight

Dr. Knight is a renowned hand, wrist and upper extremity surgeon with over 25 years of experience. Dr. Knight is a Board Certified Orthopedic Surgeon and Fellowship trained. Dr Knight has appeared on CNN, The Doctors TV, Good Morning America, The Wall Street Journal, The Washington Post, Forbes, The Huffington Post, Entrepreneur, Oxygen network and more.