Chronic/Acute Triangular Fibrocartilage Complex (TFCC) Injury

Conservative Management

General rule: Acute refers to 1 – 9 weeks from injury. Chronic refers to more than 9 weeks from injury.

0 – 4 (chonic) / 0 – 6 (acute) weeks

A muenster splint is fabricated for total immobilization.
Initiate AROM of unaffected joints 3 times a day, 10 repetitions.

Patient education on joint protection to optimize healing of TFCC. Avoid loading over the affected hand (e.g. pulling, pushing, weight bearing and carrying heavy things). Avoid forceful grasp and grip. Avoid usage of affected hand in repetitive forearm rotation movement or in pronated and ulnar deviation manner.

4 (chronic) / 6 (acute) weeks from splinting

Intermittent muenster splinting.
Initiate AROM of wrist and forearm, 3 times a day, 10 repetitions.

Initiate isometric strengthening exercises for ECU and PQ in forearm neutral position, 3 times a day, 3 sets of 10 repetitions, hold 5 seconds for each repetition, 2 minutes rest break in between sets.

6 (chronic) / 8 (acute) weeks from splinting

Protective muenster splinting at night and outdoors as necessary.

Initiate PROM to wrist and forearm if functional AROM not achieved at this point, 3 times a day, 10 repetitions.

Progress to isometric strengthening of ECU in supination and PQ in forearm mid pronation (= / > 45 degrees).

Initiate grip strengthening exercise with stress ball in forearm supinated or neutral position.

Initiate isometric strengthening of general wrist flexors and extensors.
Recommend to also strengthen proximal joints and core muscles using cuff weights.

All strengthening exercise to be perform 3 times a day, 3 sets of 10 repetitions, hold 5 seconds for each repetition, 2 minutes rest break in between sets.

10 (chronic) / 12 (acute) weeks from splinting

Discontinue muenster splint.

Progress to isotonic strengthening of PQ and ECU with theraband (level 2 resistance).

Progress to isotonic strengthening of general wrist flexors and extensors.

Initiate torque strengthening exercise.

All strengthening exercise to be perform 3 times a day, 3 sets of 10 repetitions, hold 5 seconds for each repetition, 2 minutes rest break in between sets.

Initiate reactive muscle training with throw and catch object round from unaffected hand to affected hand. Grade up from affected hand catching in supination, to catching in neutral, then to catching in pronation. Lastly, challenge patient with juggling object from affected to unaffected hand. Heavier objects are easier compared to lighter objects. 3 times a day, 30 repetitions each.

14 (chronic) / 16 (acute) weeks from splinting

Gradual return to normal activities that involve weight bearing or loading with forearm in pronation.

Initiate push ups, starting in incline position such as wrist is not in extreme extension then slowly reduce the inclination (e.g. making use of table top or stairs) and increase the number of push ups done.

Progress to reactive muscle training with unconscious co-contraction of wrist muscles using the PowerBall. Get patient to start by maintaining at 3000 – 5000 rpm for 3 sets of 2 minutes, with 2 minutes rest breaks in between. Can progress to as high an rpm they can maintain for 5 minutes continuously. Encourage patient to purchase powerball to practice 3 times a day.

18 (chronic) / 20 (acute) weeks from splinting

Discharge if nil issue and patient satisfied with function.