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    TFCC Syndrome .doc.doc TFCC Syndrome .doc.doc Document Transcript

    • Page |1 TFCC Syndrome Anthony DeRosa Objective: To determine conclusive indication of TFCC syndrome from a side-armed pitcher. Background: A freshman side-armed pitcher was clinically observed due to complaints of wrist pain. The athlete expressed a history of radiating pain around distal ulnar for the past couple days. Pain generated during activity and symptoms slowly diminished with rest. The pitcher had no previous history of injury or can recall of an acute onset to the dominant hand. Grinding sensation and clicking during the follow- thorough stage with pitching was noted. Evaluation of the elbow and shoulder confirmed no relation to the pitcher’s symptoms. Mild swelling was localized near the distal ulnar, but eccymosis or deformity wasn’t present. Pain was elicited with palpation at the palmar surface around the ulnar head. Ulnar deviation with active, passive, and resistive range of motion was limited due to pain. Passive range of motion extinguished slight pain with wrist flexion, and resistive range of motion showed weakness during supination. Compression test at the distal forearm was positive with pain near the injured site. Differential diagnosis: distal radius stress fracture, carpal tunnel syndrome, dislocation of the ulnar head. Treatment: Rehabilitation started before practice with ultrasound being immersed in a bin of water to facilitate around the bony protuberance at the injured site. Resistive exercises were followed to enhance strength of the forearm. Treatment after practice included compression of ice for 15 minutes. Uniqueness: Finding of an Injured TFCC is seen acutely during a fall on hyper extended wrist, a single traumatic force with ulnar deviation, from distal radial fracture, or chronically with repetitive distractive forces. Conclusion: The pitcher’s was diagnosed with mild case of TFCC syndrome. Treatment lasted two weeks and removal from activity wasn’t necessary. It is significant for early recognition and treatment of this injury to avoid further damage, but correcting proper biomechanics is the right approach towards prevention. Key Words: TFCC syndrome, distal ulnar, ulnar deviation, supination, distractive forces
    • Page |2 The Anatomy of the TFCC originates at the distal radial medial border and inserts into the base of the ulnar styloid. It consists of articular disc, meniscus homologue, ulnocarpal ligament, dorsal and volar radioulnar ligament, and ECU sheath.( Wheeless ) The ligamentous attachments prevent dorsal movement of the distal ulna. The volar ulnocarpal ligaments run from the base of the base of the ulnar styloid process across the volar surface of the TFCC, which inserts to the lunate and triquetrum. (Wheeless) The volar side of the TFFC prevents dorsal displacement and the dorsal aspect prevents volar displacement.Tears of the triangular fibrocartilage causes instability of the distal radioulnar joint.The TFCC is flexible and provides rotational movements of the radiocarpal joint around the ulnar axis. One of the main functions provides gliding motions across the distal radius and ulnar for extension, flexion, and transition. Forces through the ulnocarpal axis are cushioned by the TFCC. (Verheyden) During axial loading, the radius carries the majority 82% of load, and the ulna a smaller load of 18%. (Wheeless) Mechanisms that causes damage to the TFCC includes: falling onto a pronated hyperexented wrist, distraction forces applied to the volar forearm or wrist, and distal radial fractures. (Vereyden) Positioning the ulnar towards an increasing load would apply more stress to the TFCC. This type of axial load which puts more force on the TFCC is a common over use mechanism for pitchers, especially side-arm throwers. A freshman side-armed pitcher came to the Athletic Training room with complaints of wrist pain. The athlete was experiencing distal ulnar pain described as radiating which continued for couple days. Pain occurs during activity and symptoms slowly diminished with rest. He was able to continue through the practice and never felt
    • Page |3 the need to stop activity due to pain. The pitcher had no previous history of injury or any recall of acute onset to the right hand. The athlete also experienced grinding sensation and clicking during the follow-thorough stage with pitching. The pitcher wasn’t taking any kind of medication and no other pain near or around the elbow and shoulder. The athlete was evaluated with primary complaints with pain, which was ranked six out of ten pain scale during activity. At rest, pain was measured two from pain scale. Slight swelling was localized near the distal ulnar, but eccymosis or any kind of deformity wasn’t present. Pain was elicited with palpation at the palmar surface around the ulnar head. Pain with limitation of ulnar deviation was positive with active, passive, and resistive range of motion. Passive range of motion extinguished slight pain with wrist flexion, and resistive range of motion confirmed positive weakness with supination. Glide test and Phalen test was concluded a negative outcome, but compression test at the distal forearm was positive with pain near the injured site. A neurological screening was tested within normal limits and a radiological review wasn’t necessary due to the conclusion of the clinical evaluation. Due to the clinical injury report and observation of rehabilitation of the athlete’s injury, I do believe the impression of this pathology is accurate. The pitcher is a side-arm thrower with complaints of pain during activity that slowly diminishes with rest. This indicates a chronic injury due to possible improper biomechanics. A negative Phalen test concludes the pathology has no neurological relations. Negative glide test proved normal ligament stability of the wrist. Since the athlete’s symptoms are wrist pain near the distal ulna side and frequent clicking or popping is a clear indicative sign of a TFCC injury. Injury to the TFCC is commonly diagnosed from a fall on hyper extended wrist, and
    • Page |4 distraction forces from a traumatic force or repetitive motion.( Wheeless) From observing a side-armed pitcher go through the pitching phases, I do understand how the force is distributed near the ulnar side of the wrist. From close observation of athlete’s biomechanics, it is difficult to uncover distinctive abnormalities during his pitching phases. However, I do recall the freshman pitcher being stretched for the first time during mid-season and showed signs of tightness in all areas of the lower extremity. He showed poor flexibility while being stretched. This is significant because the lower body is included in the pitching phases, especially during the follow –through stage whereas pain is elicited. Assuming that the patient has poor flexibility of the upper extremity as well, I came to a conclusion the athlete wasn’t properly conditioned to start the season. This could be the cause of the athlete’s improper biomechanics during the pitching phases. Although the primary mechanism that caused this pathology is repetitive distraction forces to the ulnar side of the wrist, I believe the athlete’s lack of conditioning before the season started makes my theory quite relevant. Treatment began with 30 minutes before practice. Rehabilitation with ultrasound was started by being submerged in a bin of water because of the bony protuberance at the site of injury. Ultrasound was used for 15 minutes to increase blood flow to the TFCC. Resistive range of motion was followed with a “foamed cylinder” shaped tool whereas the patient grips both hands. It resists moveable motions that maximize strength during wrists mobility. Radial deviation, ulnar deviation, elbow supination and pronation were being performed with this modality. “Putty” was given next to the patient whom he sculpted and molded in the palm with the injured wrist. The patient played with the “putty” for ten minutes. This helped strengthened the muscles of the forearm. Treatment
    • Page |5 after practice included compression of ice for 15 minutes. The athlete didn’t feel the need to head back to ESBY team house, so the pitcher was given ice after every practice. The freshman pitcher rehabilitation lasted for two weeks since the injury was a mild severity. After the first three days of treatment, pain was quickly reduced after pitching but still had some pain during activity. The athlete’s symptoms slowly diminished during the motions of pitching. Pain mostly elicited with ulnar deviation during the follow-through stage, but gradually diminished with rehabilitation. Since the athlete came to the student Athletic Trainers as soon the symptoms occurred, he was able to continue with pitching with rehabilitation. The pitcher wasn’t eliminated from baseball practice, but was strictly informed to stop activity if symptoms started to reoccur. The TFFC is an active site of injury commonly seen with the wrist. Mechanisms usually seen that causes injury to the articular disk is falling on hyper extended wrist, and distraction forces from a traumatic force or repetitive motion. The freshman pitcher experienced clicking sensation located near the head of the ulnar, elicited pain during the follow-through stage of pitching, and experienced signs and symptoms diminished with rest indicates TFCC syndrome. The anatomy of the TFFC is vulnerable to degeneration if abnormal biomechanics forces are prolonged at the site of the TFCC. Early recognition of TFCC syndrome will overcome a faster recovery with proper rehabilitation. Discovering early signs of improper biomechanics of athletes prevents this chronic pathology.
    • Page |6 References Nagle, D.J. “ Evaluation of Chronic Wrist Pain” Journal of the American Academy of Orthopedic Surgeons (2000). www.jassos.org/cgi/content. 01 May 2008 Verheyden, James “Trinagular Fibocartilage Complex” eMedicine Specialities (2007). www.emedicine.com/orthoped/topic. 25 Apr 2008 Wheeless, Clifford “Ligaments of the Wrist” Duke of Orthopaedics presents Wheeless’ Textbook of Orthopedics (2008) www.wheelessonline.com/ortho/ligmaments_of_the_wrist . 25 Apr 2008 Wheeless, Clifford “Triangular Fibrocartilage Complex” Duke of Orthopaedics presents Wheeless’ Textbook of Orthopedics. www.wheelessonline.com/ortho/traingular_fibrocartilage_complex 25 Apr 2008 Hunter/ john “extensor carpi ulnaris tendon tears” BORG Collective (2003) www.uwmsk.org/borg/stories/storyReader 24 Apr 2008