School

School of Health Sciences and Human Performance

Department

Physical Therapy

ICC Theme

Other

Date

2-4-2019 12:10 PM

Abstract

Background: The triangular fibrocartilage complex (TFCC) is an important structure in the distal radioulnar joint (DRUJ) for stability and axial load transmission.It is role in wrist mechanics that makes identification of TFCC pathology crucial. Unfortunately, there are not thorough protocols for clinical identification. Rather, the gold standard of detection is arthroscopy, as it allows for direct visualization of damaged tissue. A non-invasive option for detection is Magnetic Resonance Imaging (MRI). However, both of these diagnostic tools are costly and may not be readily available. The purpose of this case is to describe the challenge of diagnosis and management of a patient with TFCC pathology. Clinical protocols for conservative care and rehabilitation following surgical intervention will also be discussed to make recommendations for future diagnostic and practice standards.

Methods: A 41-year old female presented to clinic with painful pinching on the ulnar side of her right wrist. The patient had spoken to her primary care physician who suggested she rest her arm, she then visited an urgent care where she had negative x-ray imaging and was diagnosed with a wrist sprain. At this time, she was referred to physical therapy. She reported 5/10-9/10 pain with intermittent mild to severe tingling radiating from her elbow medially through her forearm into her 5th digit. The patient had tenderness with palpation over the TFCC distribution. Active range of motion was limited in all directions except pronation and symptoms were provoked in most directions (Figure 1). Clinical examination completed by the physical therapist was consistent with the diagnosis of an unspecified wrist sprain. Therapeutic intervention included active assisted range of motion (AAROM) for the wrist, tendon glides, stabilization training for the wrist, strengthening for the upper extremity, and use of an upper body ergometer. Instrument assisted soft tissue mobilization and various modalities were used to improve ROM and for pain relief.

Results: After five weeks of physical therapy with little to no respite in symptoms, the patient elected to have further imaging. Significant findings were noted at the insertion of the TFCC to the ulnar styloid and foveal attachment to the ulna (Figure 3). Soft tissue edema was noted as well as dorsal subluxation of the ulnar head. Upon this discovery, she decided to pursue surgery rather than continue with conservative care. The patient returned to therapy 7 weeks following surgical debridement and repair. A variety of modalities, therapeutic exercises, stretches, mobilizations, and functional tasks were used with the patient to help work on returning to baseline from before her injury. Despite being consistent with attending therapy sessions, the patient had difficulty regaining full range of motion (ROM), particularly in supination and wrist extension. Most protocols strive to achieve full ROM by 10 weeks post-operatively.6–10 This struggle to gain ROM may have been due to the long period of pain and immobility prior to accurate diagnosis. She showed a reduction in pain and decreased rating of perceived disability on The Disabilities of the Arm, Shoulder and Hand Score (QuickDASH).

Discussion and Conclusions: The case presented in this report exemplifies the challenges in diagnosis of TFCC pathology as well as the potential consequences a patient faces as a result. The delay in diagnosis and therefore wait for surgery followed by a postponed initiation of ROM post-operatively may have contributed to the patient’s difficulty restoring full ROM. These setbacks not only resulted in an increased amount of time that the patient had pain and limited function, but also increased medical expenses due to diagnostic imaging and the cost of extended physical therapy services. There are a multiple special tests and procedures that can be used in identification of potential TFCC pathology. However, there are no published clinical prediction rules in physical therapy practice concerning the diagnosis of TFCC pathology. Therefore, based on review of the literature on provocative tests available for TFCC, we propose the following diagnosis test cluster: Piano Key Sign, Ulnocarpal Meniscoid Test, Press Test, and Ulna Fovea Sign (Figure 2). Early and accurate clinical diagnosis can help the therapist and the patient work together to develop a plan of care that best suits the needs and impairments the patient is experiencing leading to more timely intervention at a lower cost to the patient

Document Type

Poster

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Apr 2nd, 12:10 PM

Limitations of Current Diagnostic Processes of Triangular Fibrocartilage Complex Tears and Protocols for Conservative vs Surgical Care

Background: The triangular fibrocartilage complex (TFCC) is an important structure in the distal radioulnar joint (DRUJ) for stability and axial load transmission.It is role in wrist mechanics that makes identification of TFCC pathology crucial. Unfortunately, there are not thorough protocols for clinical identification. Rather, the gold standard of detection is arthroscopy, as it allows for direct visualization of damaged tissue. A non-invasive option for detection is Magnetic Resonance Imaging (MRI). However, both of these diagnostic tools are costly and may not be readily available. The purpose of this case is to describe the challenge of diagnosis and management of a patient with TFCC pathology. Clinical protocols for conservative care and rehabilitation following surgical intervention will also be discussed to make recommendations for future diagnostic and practice standards.

Methods: A 41-year old female presented to clinic with painful pinching on the ulnar side of her right wrist. The patient had spoken to her primary care physician who suggested she rest her arm, she then visited an urgent care where she had negative x-ray imaging and was diagnosed with a wrist sprain. At this time, she was referred to physical therapy. She reported 5/10-9/10 pain with intermittent mild to severe tingling radiating from her elbow medially through her forearm into her 5th digit. The patient had tenderness with palpation over the TFCC distribution. Active range of motion was limited in all directions except pronation and symptoms were provoked in most directions (Figure 1). Clinical examination completed by the physical therapist was consistent with the diagnosis of an unspecified wrist sprain. Therapeutic intervention included active assisted range of motion (AAROM) for the wrist, tendon glides, stabilization training for the wrist, strengthening for the upper extremity, and use of an upper body ergometer. Instrument assisted soft tissue mobilization and various modalities were used to improve ROM and for pain relief.

Results: After five weeks of physical therapy with little to no respite in symptoms, the patient elected to have further imaging. Significant findings were noted at the insertion of the TFCC to the ulnar styloid and foveal attachment to the ulna (Figure 3). Soft tissue edema was noted as well as dorsal subluxation of the ulnar head. Upon this discovery, she decided to pursue surgery rather than continue with conservative care. The patient returned to therapy 7 weeks following surgical debridement and repair. A variety of modalities, therapeutic exercises, stretches, mobilizations, and functional tasks were used with the patient to help work on returning to baseline from before her injury. Despite being consistent with attending therapy sessions, the patient had difficulty regaining full range of motion (ROM), particularly in supination and wrist extension. Most protocols strive to achieve full ROM by 10 weeks post-operatively.6–10 This struggle to gain ROM may have been due to the long period of pain and immobility prior to accurate diagnosis. She showed a reduction in pain and decreased rating of perceived disability on The Disabilities of the Arm, Shoulder and Hand Score (QuickDASH).

Discussion and Conclusions: The case presented in this report exemplifies the challenges in diagnosis of TFCC pathology as well as the potential consequences a patient faces as a result. The delay in diagnosis and therefore wait for surgery followed by a postponed initiation of ROM post-operatively may have contributed to the patient’s difficulty restoring full ROM. These setbacks not only resulted in an increased amount of time that the patient had pain and limited function, but also increased medical expenses due to diagnostic imaging and the cost of extended physical therapy services. There are a multiple special tests and procedures that can be used in identification of potential TFCC pathology. However, there are no published clinical prediction rules in physical therapy practice concerning the diagnosis of TFCC pathology. Therefore, based on review of the literature on provocative tests available for TFCC, we propose the following diagnosis test cluster: Piano Key Sign, Ulnocarpal Meniscoid Test, Press Test, and Ulna Fovea Sign (Figure 2). Early and accurate clinical diagnosis can help the therapist and the patient work together to develop a plan of care that best suits the needs and impairments the patient is experiencing leading to more timely intervention at a lower cost to the patient

 

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