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Outcomes of Operative Treatment of Triangular Fibrocartilage Tears in Pediatric and Adolescent Athletes

Fishman, Felicity G., MD*; Barber, Jarrad, MD; Lourie, Gary M., MD; Peljovich, Allan E., MD, MPH§

doi: 10.1097/BPO.0000000000001243
Sports Medicine

Background: Triangular fibrocartilage complex (TFCC) tears have been treated with increasing frequency in pediatric and adolescent patients over the past decade. There is little information on these injuries in young athletes and a scarcity of data regarding their ability to return to preinjury levels of athletic participation. The purpose of this study was to review the outcomes of pediatric and adolescent athletes with operatively treated TFCC tears with or without a concurrent ulnar shortening osteotomy and to determine their ability to return to their preoperative level of activity.

Methods: A retrospective chart review was performed for all patients who underwent operative treatment of TFCC tears between 2006 and 2012 within one Upper Extremity practice. Patients were included if they were high-level athletes, unable to participate in their sport secondary to wrist pain and desired to return to their sport. All operative patients had imaging studies and clinical findings consistent with TFCC injury as the primary source of their activity-limiting pain and had failed nonoperative management prior to surgery. Patients without at least 3 months of documented postoperative follow up were excluded.

Results: In total, 22 patients were included in the chart review with 20 patients willing to participate in a telephone survey and PODCI. Eighty percent of patients returned to their sport following operative treatment of their injury at an average of 4.8 months. Seven of the 22 patients underwent a concurrent ulnar shortening osteotomy for ulnar positive variance. All 20 patients reported satisfaction with the outcomes of their surgery and treatment.

Conclusions: Operative treatment of TFCC injuries in adolescent and pediatric athletes after failure of conservative treatment allowed return to sport at the previous level of participation. Concurrent ulnar shortening osteotomy in the setting of ulnar positive variance did not prohibit return to high-level athletic participation.

Level of Evidence: Level IV.

*Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, IL

Department of Orthopaedic Surgery, Atlanta Medical Center

The Hand and Upper Extremity Center of Georgia

§Pediatric Hand & Upper Extremity Center of Georgia, Atlanta, GA

The authors declare no conflicts of interest.

Reprints: Felicity G. Fishman, MD, Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, 2160 S 1st Avenue, Maguire Center, Building 105, Suite 1700, Maywood, IL 60153. E-mail: felicity.fishman@lumc.edu.

As sports participation has increased in the pediatric and adolescent population, sports injuries have concurrently increased.1,2 The spectrum of reported injuries includes patterns typically seen in adults.3 Previous reports have demonstrated a higher percentage of athletic injuries to the hand and wrist in adolescents than in adults, and while injuries to the triangular fibrocartilage complex (TFCC) and their subsequent treatment have been discussed frequently in recent literature, few have specifically addressed the pediatric and adolescent population.4–13 The purpose of this study was to review the outcomes of pediatric and adolescent athletes with operatively treated TFCC tears and to determine their ability to return to their preoperative level of activity without symptoms.

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METHODS

Institutional review board approval was obtained prior to initiation of this study. Between July 2007 and April 2012, 37 pediatric and adolescent athletes underwent surgical treatment for their TFCC injuries within one Upper Extremity practice as identified by a CPT code search for wrist arthroscopy with further chart review to determine the diagnosis warranting surgical intervention. Inclusion criteria included (1) age of 18 years old or younger at the time of surgery, (2) preoperative participation in high-level athletics (defined as either high-school level and/or travel/club level), (3) arthroscopic treatment of traumatic TFCC injury, and (4) minimum of 3 months follow up in the office after surgery. Patients who underwent concurrent soft tissue procedures at the time of arthroscopy (scapholunate ligament debridement, lunotriquetral ligament stabilization) were not excluded; however, the main impetus for surgical treatment was ulnar-sided wrist pain. Exclusion criteria included: (1) any concern or evidence of insidious onset of pain or any history suggesting a nonacute or nontraumatic injury, (2) patients who decided to discontinue their sport, and (3) all patients successfully treated nonoperatively.

Thirty-seven patients were identified as having undergone arthroscopic treatment of a TFCC tear between July 2007 and April 2012 by one of the senior authors. Fifteen patients were excluded secondary to inadequate length of follow up, the TFCC pathology being an incidental finding at the time of arthroscopy or lack of participation in high-level athletics. Twenty-two patients met inclusion criteria and were included in this study. The diagnosis of a TFCC tear was determined by physical examination and confirmed by a wrist MRI (with or without an arthrogram). Data were gathered by retrospective chart review, physical examination, radiographic studies, and a standardized outcome metric. The information gained from patients’ medical charts included: date of injury, athletic participation, date of presentation to the hand surgeon, date of surgery, preoperative treatment modalities and imaging, surgical pathology and procedures, date of most recent postoperative evaluation, and any postoperative complications. Imaging illuminated patients’ ulnar variance and time until healing of ulnar shortening osteotomy, when performed. All 22 charts and corresponding imaging were reviewed.

Twenty-one of the 22 patients were contacted by telephone. One patient did not desire to participate in the telephone survey and one patient was unable to be reached after multiple failed attempts. After obtaining appropriate consent from a parent for patients under the age of 18, each of the 20 patients were asked the following questions pertinent to their surgery and their ability to return to their sport: (1) Are you satisfied with the outcomes of your surgery and treatment? (2) Were you able to return to your sport at the same level at which you played prior to surgery? If yes, when did you return to your sport? (3) Is your range of motion in your operative arm now the same as your nonoperative arm? A verbal description of “normal motion” (including wrist extension/flexion and forearm pronation/supination was provided during the telephone conversation. In addition, they patient was asked to compare their operative wrist to their nonoperative wrist. Each family was asked to return to clinic for an additional follow up visit, but if they declined, the Adolescent (self-reported) Pediatric Outcomes Data Collection Instrument (PODCI)14 was then administered over the telephone. Twenty patients completed the PODCI and the additional questions.

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Treatment Algorithm

Patients were assessed for evidence of distal radioulnar (DRUJ) instability based on physical examination. In the absence of instability, a trial of nonoperative management was initiated as many TFCC injuries can be successfully treated in this setting in a nonoperative manner. Casting, bracing, therapy, and corticosteroid injections were all incorporated in varying degrees in the management of patients. Corticosteroid injections were utilized when other modalities failed to provide relief. Assessment included plain films (neutral rotation PA, lateral and pronated grip PA) of the affected and contralateral side15 to assess carpal alignment and DRUJ variance. Magnetic resonance imagining (MRI) was obtained in all patients before surgical consideration, with 20 of the 22 having an MRI-arthrogram using intra-articular gadolinium. The 2 patients who did not have an arthrogram presented to the senior authors having already undergone their MRI.

Failure of nonoperative treatment was defined by a patient’s inability to participate in sport with or without bracing, pain with activities of daily living, and a strong desire on the part of the patient to return to sport. The decision to proceed with surgical intervention was primarily driven by the patients’ aspiration to return to sport as they were unable to participate secondary to their level of pain despite nonoperative treatment.

The authors’ operative approach was designed to treat the TFCC and address ulnar variance. Ulnar-sided tears were typically repaired arthroscopically using the Linvatec TFCC repair kit (Conmed-Linvatec Corp, Largo, FL), whereas radial or central tears were debrided. Tears were typically repaired with 1-2 simple sutures using an outside-in technique with 2-0 PDS suture. Patients who had static ulnar positive variance or those with dynamic positive variance, defined as ulnar variance evident with pronated grip views, in addition to traumatic TFCC pathology underwent an ulnar shortening osteotomy before arthroscopic evaluation of the wrist. The RAYHACK Ulnar Shortening Generation II Low Profile Locking System (Wright Medical Technology, Arlington, TN) was used to perform the ulnar osteotomy with the resection amount based upon preoperative evaluation of the patient’s ulnar variance. Within this system, even utilizing the smallest settings for resection can sometimes result in less than neutral variance, therefore the goal was to achieve neutral to 1 to 2 mm of ulnar negative variance.

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Postoperative Rehabilitation

Patients who underwent TFCC repair were maintained in a long arm cast postoperatively for 4 to 6 weeks. They were then transitioned to a long, short-arm, ulnar gutter brace, and hand therapy was initiated. Patients who underwent TFCC debridement were maintained in a long arm cast for 3 to 4 weeks postoperatively at which time therapy was initiated and they were transitioned to a long, short arm, ulnar gutter splint. Ulnar shortening osteotomies did not influence the duration of casting, but these patients were restricted from lifting >1 pound with the operative arm until radiographic healing was confirmed. Once strength goals were achieved, patients were transitioned to sport-specific simulation using external supports as needed. Patients were officially cleared for return to sport if they completed their sport-specific simulations with minimal activity and postactivity pain.

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RESULTS

The 22 study patients consisted of 16 females and 6 males who sustained 11 right and 11 left wrist injuries. Their average age at initial presentation was 14.2 years old (range, 11 to 17); and their average time from injury to surgical intervention was 7.4 months (range, 3 to 19 mo). Eight patients presented within 2 months of injury, whereas 14 patients presented 3 months or longer from the time of their injury. The overall average time between injury and initial presentation to a hand surgeon was 4.5 months (range, 1 wk to 18 mo), with an average of 6.3 months for the 14 patients who presented at least 3 months after their injury (range, 3 mo to 18 mo). Average postoperative office follow-up was 5.9 months (range, 3 mo to 22 mo). The average total follow-up was 18.6 months, including the contact with the patients to complete the PODCI survey. Four patients had discomfort with stress of the DRUJ on preoperative examination but there was no gross instability noted.

With the exception of 3 patients who presented subsequent to a distal radius fracture, 19 patients presented with isolated TFCC tears. The distal radius fractures occurred remotely with patients describing the ulnar-sided wrist pain as developing after return to sport following their original distal radius fracture. Nine patients reported insidious onset of ulnar-sided wrist pain, whereas 8 patients reported a discrete injury that occurred during participation in their respective sport. Two patients had discrete injuries that occurred outside of athletic participation and were not associated with a fracture. All of the patients associated the onset of their pain with either their sport or a discrete traumatic episode. Two patients presented with ligamentous injuries in addition to the TFCC injury (1 partial scapholunate and lunotriquetral tear, 1 partial lunotriquetral tear). The main complaints and physical examination findings for these patients were related to their TFCC pathology.

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Sports Participation

All 22 patients were involved in at least one sport at a high level. The study group consisted of: 5 gymnasts, 5 volleyball players, 5 cheerleaders, 4 tennis players, 2 baseball players, 2 football players, 2 bowlers, and 1 patient who rowed crew. All participated at the high school and club/travel level with aspirations to continue their level of activity

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Initial Treatment

As majority of patients were referred for specialist evaluation after an initial period of time had elapsed, conservative treatment had often already been attempted (bracing, casting, anti-inflammatory medications). Fifteen of the 22 patients underwent ulnocarpal corticosteroid injections either before evaluation by the specialist or by the hand specialist. The remainder of the patients were offered a corticosteroid injection as part of the initial discussion of treatment and either refused an injection or opted not to undergo a second injection. Two patients had a trial of hand therapy before proceeding with surgical intervention. Two of the 22 patients were noted to have DRUJ instability on physical examination. Seven patients (32%) were found to have either static or dynamic ulnar positive variance on preoperative radiographic evaluation, with an average of 1.3 mm ulnar positive variance. Three of the 5 gymnasts as well as 3 of the 5 volleyball players were found to have ulnar positive variance.

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Operative Treatment

All 22 patients underwent diagnostic wrist arthroscopy with evaluation of the TFCC and subsequent debridement or repair. Arthroscopic pathology demonstrated 3 patients with 1A tears, 10 patients with 1B tears, 5 patients with 1D tears and 4 patients with both 1A and 1B tears. There were no foveal tears seen in this series of patients. The 7 patients with ulnar positive variance underwent a concurrent ulnar shortening osteotomy performed before arthroscopic repair or debridement. Arthroscopic pathology for these patients included 4 patients with 1B tears, 2 patients with 1D tears, and 1 patient with both 1A and 1B tears. All of the osteotomies healed (by clinical and radiographic evaluation) at an average of 2.4 months postoperatively (range, 1.5 mo to 3.5 mo). All patients demonstrated DRUJ stability on postoperative physical examination. Complications included 4 patients with minor wound or suture problems which resolved with nonoperative treatment, 1 patient who complained of paresthesias in the distribution of the dorsal ulnar sensory nerve, which subsequently resolved, 2 patients who underwent ulnar shortening osteotomies demonstrated ulnar positive variance at final follow up (0.8 mm and 1.2 mm), and 1 patient who underwent hardware removal of the ulnar osteotomy plate 28 months postoperatively. Although the ulnar variance increased for these specific patients, they remained asymptomatic postoperatively.

Twenty patients (91%) completed the telephone survey and PODCI questionnaire. All 20 patients reported that they were satisfied with the outcomes of their surgery and treatment and that they had regained full range of wrist motion postoperatively. Patients also reported favorable subjective outcomes, as demonstrated in Table 1. Seventeen of 20 patients (85%) returned to their preoperative sport at the same level in which they had previously competed. Patients were cleared to return to their respective sport by their surgeon at an average of 4.8 months (range, 2.1 to 7.8 mo). Patients reported return to their preoperative level of athletic participation at an average of 5.9 months after surgery (range, 2 to 16 mo). Six of the 7 (86%) patients who underwent ulnar shortening osteotomies were cleared to return to athletics at an average of 5.8 months postoperatively (range, 2.6 to 14 mo). Patients who underwent a TFCC repair without an ulnar shortening osteotomy were cleared to return to sport at an average of 3.7 months and those that underwent debridement alone were cleared at an average of 5.4 months postoperatively. One patient did not return to their previous sports (bowling/tennis) but did begin horseback riding at an equally competitive level. One graduated high school soon after her surgery and chose not to pursue athletics at the same level in college as she had in high school. One patient had not returned to preoperative competition levels as she had recently undergone wrist arthroscopy and ulnar shortening osteotomy on their contralateral extremity.

TABLE 1

TABLE 1

Seven of the 20 patients (35%) underwent an ulnar shortening osteotomy at the time of wrist arthroscopy for an average preoperative static or dynamic ulnar positive variance of 1.3 mm (range, 0.3 mm to 2.0 mm). The average change in variance immediately postoperatively compared with the preoperative value was 3.6 mm (range, 1.8 mm to 5.0 mm). However, at the time of final radiographic evaluation (at an average of 21 mo from the time of surgery), the average change in variance had diminished to 0.32 mm (range 0.5 mm negative ulnar variance −4.1 mm positive ulnar variance) compared with the immediate postoperative value with 2 patients demonstrating ulnar positive variance (0.8 mm and 1.2 mm).

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DISCUSSION

Diagnosis and treatment of TFCC pathology have been frequently discussed topics in recent literature.4,6–9 Recognition of the occurrence of TFCC injuries in pediatric and adolescent athletes has also become more prevalent as participation in athletics has increased in this patient population.1 Hand and wrist injuries seem to be more common in adolescent than in adult athletes, comprising up to 14.8% of athletic injuries.11 There is often a delay in evaluation of these patients by a specialist. In our study, these patients were initially evaluated by a hand and upper extremity surgeon at an average of 4.5 months after the onset of ulnar-sided wrist pain. Despite this delay, previous studies reported a much longer interval before surgical intervention, including an average of 2.4 years, as reported by Terry and Waters.13

Both McAdams et al7 and Papapetropoulos and Ruch9 demonstrated that arthroscopic treatment of TFCC injuries in adult athletes allows them to predictably return to competition. Wrist arthroscopy in children is a safe modality in which to diagnose and treat pediatric wrist pathology.16 In our case series, 17 of 20 (85%) patients returned to their preoperative sport at the same level of participation. Eighteen of 20 patients (90%) were able to return to athletic competition at their preoperative level, with one patient electing to change sports but not because of limitations secondary to injury. All of the pediatric and adolescent athletes reviewed in this study reported satisfaction with the outcomes of their treatment and had excellent Upper Extremity PODCI scores (97 SM, 46 NS). Their Sports and Physical Functioning PODCI scores were 91 SM and 46 NS, indicating their ability to return to athletic activities. We did note lower scores in the categories of Pain/Comfort on the PODCI (73 SM, 41 NS). However, many of these athletes noted current injuries to their lower extremities and/or contralateral upper extremities that affected their reporting on the PODCI.

There are multiple studies evaluating the approach to treatment of TFCC tears in elite, physeally mature, and athletes.7,9,17 Our study sought to address the paucity of literature evaluating operatively treated TFCC tears in adolescent athletes. Mariscalco briefly mentions TFCC tears as a consequence of ulnar positive variance in adolescent gymnasts in a review of upper extremity injuries in adolescent athletes.2 Previous reports specifically noting TFCC tears in a pediatric population describe injuries occurring in the setting of a distal radius fracture.12,13

A common treatment dilemma associated with traumatic TFCC injuries is coexistent ulnar positive variance. Previous studies have reported successful improvement of persistent ulnar-sided wrist pain following arthroscopic treatment of TFCC tears with a second stage ulnar shortening procedure.5,18 Minami et al8,19 reported satisfactory short term results following arthroscopic TFCC debridement and concurrent ulnar shortening for patients with ulnar positive variance and found that ulnar positive variance was associated with moderate to severe pain following arthroscopic treatment of TFCC pathology alone. Trumble et al10 demonstrated improved function and decreased pain in patients treated with combined open TFCC repair and ulnar shortening osteotomy in the delayed management of this pathology.

In our study, all patients with ulnar positive variance were treated with ulnar shortening osteotomy before concurrent arthroscopic treatment of their TFCC injury and 6 of the 7 patients (86%) who underwent ulnar shortening osteotomy were cleared to return to their preoperative levels of athletic participation. Epiphysiodesis is an alternative treatment option to address ulnar positive variance which relies on the continued growth of the radius to correct the discrepancy in length. As these patients desired to return to sport as soon as possible, the patients were treated with ulnar shortening osteotomies and not epiphysiodeses. All patients had clinical and radiographic union of their osteotomy sites, although 2 patients were noted to have asymptomatic subsequent ulnar overgrowth with resultant ulnar positive variance. The etiology of the overgrowth may be related to the creation of the osteotomy, but the topic of overgrowth in the pediatric upper extremity following fracture or osteotomy is not well understood at this time. The average Upper Extremity and Sports and Physical functioning PODCI standardized means for this subset of patients were 95 and 87, respectively. Although the results of ulnar shortening osteotomy in our review are positive, without a control group, and with the development of asymptomatic postoperative ulnar positive variance, it is unclear if ulnar shortening is truly necessary.

Majority of the TFCC pathology noted on arthroscopic evaluation in our study were Palmer 1B tears, which is consistent with previous reports of TFCC injuries in athletes.7 The second most common TFCC injury we noted were radial-sided tears (Palmer 1D). There were no foveal tears. Prior studies have arthroscopically identified patients with a “double lesion” of the TFCC.20,21 Unlike previous reports, we also noted a relatively high proportion of patients (4 patients, approximately 18%) with 2 discrete simultaneous tears—Palmer 1A and 1B. These patients were treated with debridement of the central perforation and repair of the peripheral ulnar tear.

We recognize that there are several limitations to this study. First, this is a level 4 retrospective case series with a relatively small collection of patients and a short follow up for some of the patients. The senior authors of this study performed arthroscopic treatment of TFCC injuries on a much larger cohort of patients over the period of time included in this study. However, based on the specificity of the inclusion criteria (high level athlete, traumatic injury) the case series was narrowed to 22 patients. Second, our study does not include any preoperative subjective data to which we can compare our postoperative PODCI scores. Third, majority of the data collected was by phone survey and not by the patient filling out the survey in isolation. It is possible that bias was introduced by having a member of the study team administer the survey. Finally, the actual follow-up period for these patients was quite short (3 mo). However, the PODCI and telephone survey were administered beyond 3 months, confirming at a date further from the time of surgical intervention that they were still involved in their respective sports.

In conclusion, in the pediatric and adolescent high level athlete, operative treatment of TFCC injuries allowed majority of these patients to return to their preoperative levels of athletic participation. In the setting of ulnar positive variance with concurrent TFCC injury, ulnar shortening osteotomy does not seem to prohibit return to high level athletics. Future studies evaluating the incidence and natural history of TFCC injuries in younger athletes, the effect of specific nonoperative modalities as well as further evaluation regarding the necessity of ulnar shortening osteotomies would help to advance our understanding of how to best treat this patient population.

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Keywords:

adolescent athletes; triangular fibrocartilage tears; ulnar shortening osteotomy; wrist arthroscopy

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