Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Triangular Fibrocartilage Complex (TFCC) Tears


Related Terms

  • Radioulnar Disc Injury
  • Ulnar Wrist Pain
  • Wrist Meniscus Injury

Specialists

  • Orthopedic (Orthopaedic) Surgeon
  • Physiatrist (Physical Medicine and Rehabilitation Specialist)
  • Physical Therapist
  • Sports Medicine Physician

Comorbid Conditions

Factors Influencing Duration

Duration depends on severity of injury, whether the dominant or non-dominant wrist is involved, type of treatment, and complications. In individuals who require surgery, surgical complications may influence on the duration.

Medical Codes

ICD-9-CM:
842.09 - Sprains and Strains, Wrist, Other; Sprains and Strains, Radioulnar Joint, Distal

Overview

At the wrist, the triangular fibrocartilage complex (TFCC) is formed by the triangular fibrocartilage (TFC) discus, the radioulnar ligaments (RULs) and the ulnocarpal ligaments (UCLs). The TFCC functions as a shock absorber, stabilizing the bones of the wrist, and enabling smooth movement of the wrist joint.

The TFC is an articular discus that is attached to the end of the distal ulna. It is triangular in shape and is biconcave, which results in it being thicker around the edges than its center. The central portion is thin and is made of chondroid fibrocartilage. The central area is often so thin that it is translucent and in some individuals is even absent. This normal variation of its being absent can be confusing when an MRI is obtained after an injury. Therefore, a "positive" MRI does not necessarily indicate a tear secondary to trauma. The peripheral portion of the TFC is often well vascularized, while the central portion has limited to no blood supply. This arrangement is important regarding healing of a tear.

The distal radioulnar joint is further stabilized by the radioulnar ligaments (RULs). The RULs are the principal stabilizers of the distal radioulnar joint (DRUJ). There are two RULs, the palmar and dorsal radioulnar ligaments. These ligaments attach to the distal radius medial border and insert on the ulna at the ulna styloid and the fovea. The ulnocarpal ligaments (UCLs) consist of the ulnolunate and the ulnotriquetral ligaments. They originate on the ulnar styloid and insert into the carpal bones of the wrist.

Thus, the TFCC has a substantial risk for injury and degeneration because of its anatomic complexity and multiple functions. Application of an extension-pronation force to an axial-load wrist, such as in a fall on an outstretched hand, causes most of the traumatic injuries of the TFCC. Dorsal rotation injury, such as when a drill lock ups and rotates the wrist instead of the bit, can also cause traumatic injuries. Injury can also occur from a distraction force applied to the volar forearm or wrist or with distal radius fractures.

TFCC tears may be traumatic (type 1) or degenerative (type 2). Traumatic TFCC tears usually occur from loading or twisting forces to the wrist, such as when falling onto an outstretched hand with the palm down (pronated) and the wrist extended. A traumatic tear typically involves the cartilaginous disc, but also may involve the support ligaments of the complex. In approximately 50% of cases, type 1 tears are associated with a wrist fracture or dislocation (Bombaci; Hohendorff). Degenerative TFCC tears typically result from chronic overloading of the wrist joint and may also occur in older individuals with thin disc cartilage and in those with a congenitally long ulna that can cause pinching of the TFCC (ulnar impaction syndrome). Not all degenerative tears are symptomatic (Verheyden).

Incidence and Prevalence: In recent studies, 45% to 57% of individuals with distal radius fractures also sustained TFCC tears at the time of the injury (Bombaci; Hohendorff).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Individuals at risk for type 1 traumatic TFCC tears are those who sustain a fall onto an outstretched hand; those who experience repeated, forceful twisting or pulling movements such as when using heavy tools or equipment; and those who participate in sports that involve a racket, a bat, or a club (e.g., tennis, baseball) or that involve direct pressure on the hands (e.g., gymnastics).

Individuals at risk for type 2 degenerative TFCC tears are those with a previous history of fracture (distal radius fracture, distal ulnar fracture, or childhood wrist fracture), and those with congenital abnormalities in which the bone of the ulna is anatomically longer than the radius. In individuals with an ulna of normal length, the TFCC accepts 20% of the loading forces across the wrist, whereas in those with a longer ulna, force transmission can reach up to 40% (Topper). The incidence of type 2 tears also increases with age. In one study of cadaveric wrists, degenerative TFCC tears were present in 7.6% of wrists by age 30; 18.1% of wrists by age 40; 40% of wrists by age 50; 42.8% of wrists by age 60; and 53.1% of wrists in individuals older than 60 (Zlatkin).

Source: Medical Disability Advisor



Diagnosis

History: The individual may report diffuse pain at the ulnar side of the wrist, with painful clicking or snapping when moving the wrist. The pain is increased with supination and pronation (palm up and then palm down). The individual may note weakness and pain when gripping objects or when performing rotational movements such as turning a doorknob or key. With type 1 TFCC tears, there may be a history of recent wrist trauma or a fall onto an outstretched hand. With type 2 TFCC tears, the individual may report a history of previous wrist injury.

Physical exam: There may be evidence of swelling, bruising, or abrasions if a recent trauma is reported. The individual may have tenderness in response to gentle probing (palpation) of the wrist at the ulnar surfaces. The best place to palpate the TFCC is between the extensor carpi ulnaris (ECU) and the flexor carpi ulnaris (FCU), distal to the ulnar styloid and proximal to the pisiform bone. Tenderness in this area may be consistent with a TFCC lesion.

Range of motion may or may not be restricted, but testing might reveal a clicking noise at the wrist with passive or active movement of the joint. Gentle compression of the TFCC by moving the hand toward the little finger (ulnar deviation) on a stable forearm may cause pinching pain. Stress tests, in which the examiner compresses the wrist into extension with ulnar deviation while twisting the forearm into pronation (ulnocarpal stress test), or when pressing the tip of the dorsal ulna down while pushing up on the pisiform carpal bone (ulnar carpal shift test), may reveal pain indicative of a TFCC tear. The piano key sign suggests dorsal DRUJ instability that can cause a protruding ulna head, which can be pressed down. When you release the pressure, the ulna head will spring back in position again, similar to a piano key. Grip strength may be diminished as compared to the uninjured side.

Tests: Tests may include plain x-rays to rule out associated fractures or dislocations;. However; magnetic resonance imaging (MRI) is considered the most definitive test to identify TFCC tears, with a 90% accuracy rate for most tears (Topper). Wrist arthrography, in which contrast dye is injected into the wrist joint and viewed on x-ray to assess for fluid flow and leakage between the compartments of the wrist, is now rarely used as a result of a high rate of false-positive findings (Topper; Wheeless). Rarely, the diagnosis is made only by performing arthroscopic surgery to view the wrist structures and rule out alternate pathology. However, arthroscopic surgery can help to confirm the diagnosis.

Source: Medical Disability Advisor



Treatment

After an acute injury, many individuals with type 1 TFCC tear respond to conservative treatment that involves using a long arm cast or splint on the wrist and forearm to immobilize the wrist for 4 to 6 weeks, followed by progression to a removable splint that allows progressive range of motion and strengthening exercises for another 4 to 6 weeks (Verheyden). Treatment also may include over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDS) for pain relief and in some cases, corticosteroid injection into the wrist joint. After the period of immobilization, physical therapy may be necessary to restore full wrist range of motion, strength, and coordination of the hand.

Unfortunately, outcomes do not always match the clinical examination or the diagnostic tests. Because the central portion of the TFCC has no direct blood supply (avascular), large central disc tears do not heal well and may require arthroscopic surgery to trim or remove torn cartilage while leaving the support ligaments in place ("TFCC Tear"). Wrist arthroscopy may be performed under general or regional anesthesia to smooth (débride) or remove (excise) unstable fragments of cartilage. Peripheral tears of the cartilage disc may be repaired with stitches (sutures).

After surgery, the wrist is immobilized in a splint for 2 weeks, reassessed for healing, and then re-immobilized in a removable splint for an additional 4 weeks to allow range of motion exercises to begin (Topper). Strengthening exercises may be initiated once the individual has regained 80% of normal wrist range of motion (Topper). The individual may return to sports and lifting activities at 5 to 6 weeks post injury as symptoms allow and guided by the treating physician (Topper).

Because outcomes of surgery do not always match the clinical examination or the diagnostic tests, with symptomatic type 2 degenerative TFCC tears, the individual may need surgery to shorten an abnormally long ulna and tighten the support ligaments in an effort to decompress and stabilize the TFCC (Topper). Arthroscopic or open surgery to resect the distal 2 to 4 mm of the tip of the ulna ("wafer procedure") and débride the edges of a hole in the central disc may be necessary (Topper; Wheeless). The wrist is immobilized in a splint for 2 weeks, checked for healing, and progressed to using a removable splint for a further 2 weeks as range of motion and strengthening exercises begin (Topper).

Source: Medical Disability Advisor



Prognosis

In mild cases, conservative treatment improves symptoms. Wrist arthroscopy to remove the central part of a torn disc (disc resection) results in good to excellent outcomes in 85% of cases (Topper). Following arthroscopic débridement of a large central cartilage tear, 73% of individuals will be pain free ("TFCC Tear"). Arthroscopic surgical repair of a TFCC tear achieves good to excellent results in 63% of cases (Reiter).

Source: Medical Disability Advisor



Rehabilitation

The goal of rehabilitation is to decrease pain and return the individual to full function with a mobile, painless wrist. Rehabilitation will emphasize restoring range of motion, strength, and dexterity of the affected extremity. Resumption of pre-injury status is the goal, with consideration of any residual deficit.

Initially, local cold application may be beneficial for controlling pain and swelling (edema). As indicated, the therapist begins range of motion activities of the involved wrist, and progresses to strengthening exercises. Restoring full range of motion is a goal, and careful attention must be paid to regaining full wrist and forearm movement, particularly pronation and supination, which may be especially difficult after joint immobilization.

If the injury required surgery, the treating physician will dictate the rehabilitation protocol. The treating physician should guide the resumption of heavy work and sports.

FREQUENCY OF REHABILITATION VISITS
Nonsurgical
SpecialistTriangular Fibrocartilage Complex (TFCC) Tears
Occupational / Hand / Physical TherapistUp to 4 visits within 6 weeks
Surgical
SpecialistTriangular Fibrocartilage Complex (TFCC) Tears
Occupational / Hand / Physical TherapistUp to 12 visits within 8 weeks

Source: Medical Disability Advisor



Complications

Traumatic TFCC tears may be associated with fractures, dislocations, and tendon injuries that may require additional surgical intervention and delay return of full use of the wrist. An untreated TFCC tear may result in instability of the distal radioulnar joint. Because the TFCC's fibrocartilaginous disc is mostly avascular, with only 15% to 20% of the peripheral disc having a blood supply, attempts to repair a central disc tear will be unsuccessful (Wheeless). Individuals having surgery may have adverse reactions to anesthesia, delayed or poor wound healing, infection, continued pain, and chronically decreased strength.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Ability to work is dependent on the injury and the job tasks. After an acute traumatic TFCC tear, ice packs may be required. The wrist will be immobilized for some time as indicated by the treating physician, and the individual may need temporary reassignment to alternate tasks if the dominant wrist was involved. There may be decreased range of motion in the wrist, and lifting or carrying assignments may need to be reduced or temporarily eliminated. The individual may need additional time off to attend rehabilitation sessions during recovery.

Individuals with TFCC tears requiring surgery and those involving the dominant wrist will require longer periods of work restrictions, depending on the individual's situation. If pain medication is needed, company policy on medication use should be reviewed to determine if medication usage is compatible with job safety and function.

Source: Medical Disability Advisor



Maximum Medical Improvement

8 to 12 weeks post surgery

Continued improvement is possible over 18 months, but the amount of improvement is limited.

Source: Medical Disability Advisor



Regarding diagnosis

Regarding diagnosis:
  • Did individual report a recent fall onto an outstretched arm with the wrist extended and the palm down?
  • Is there a history of wrist injury or fracture?
  • Were there complaints of pain and swelling at the ulnar side of the wrist?
  • Does individual report decreased ability to move the wrist? Painful clicking or snapping with wrist movement?
  • Does individual report weakness and pain when gripping objects or when performing rotational movements such as turning a doorknob or key?
  • Was there evidence of swelling, bruising, or abrasions of the wrist? Tenderness in response to palpation of the wrist at the ulnar surface?
  • Was wrist range of motion restricted? Is clicking present with wrist movement?
  • Does compressing the wrist by moving the hand toward the little finger on a stable forearm may cause pinching pain?
  • Does compressing the wrist into extension with ulnar deviation while twisting the forearm into pronation cause pain?
  • Does pressing the tip of the dorsal ulna down while pushing up on the pisiform carpal bone cause pain?
  • Is grip strength diminished?
  • Were X-rays obtained? Was MRI necessary? Wrist arthrography?

Regarding treatment:

  • Was wrist immobilized in a long arm cast or splint?
  • Were analgesics required to relieve pain?
  • Was cortisone injection necessary?
  • Was arthroscopic surgery necessary to trim or remove torn central disc cartilage while leaving the support ligaments in place?
  • Was TFCC tear located peripherally on the disc, allowing surgical repair?
  • Did individual need surgery to shorten an abnormally long ulna and tighten the support ligaments in an effort to decompress and stabilize the TFCC? Ulnar tip resection?
  • Was physical therapy recommended for this individual?

Regarding prognosis:

  • Has physical therapy been completed as recommended? Would additional therapy benefit individual?
  • Did adequate time elapse for full recovery?
  • If surgery was necessary, did individual experience any complications?
  • Has the injury affected the daily activities of individual?
  • Were modifications made to the individual's work environment during recovery?

Source: Medical Disability Advisor



References

Cited

"TFCC Tear." eORIF. 2008. 6 Jun. 2013 <http://eorif.com/WristHand/TFCC.html>.

Bombaci, H. A. "The Value of Plain X-Rays in Predicting TFCC Injury after Distal Radial Fractures (Abstract)." Journal of Hand Surgery - British and European Volume 33 3 (2009): 322-326. PubMed. <PMID: 18562365>.

Hohendorff, B. M., et al. "Palmar Wrist Arthroscopy for Evaluation of Concomitant Carpal Lesions in Operative Treatment of Distal Intraarticular Radius Fractures (Abstract)." Handchir Mikrochir Plast Chir 41 5 (2009): 295-299. PubMed. <PMID: 19790024>.

Reiter, A., et al. "Arthroscopic Repair of Palmer 1B Triangular Fibrocartilage Complex Tears (Abstract)." Arthroscopy 24 11 (2008): 1244-1250. PubMed. <PMID: 18971054>.

Topper, Steven M. "Section C: Wrist Arthroscopy." DeLee and Drez’s Orthopaedic Sports Medicine. Eds. Jesse C. DeLee, David Drez, and Mark D. Miller. 3rd ed. Saunders Elsevier, 2009. MD Consult. 2009. Elsevier, Inc. 6 Jun. 2013 <http://www.mdconsult.com/das/book/body/171061535-4/916740509/2079/42.html#4-u1.0-B978-1-4160-3143-7.. 00020-8--s1615_3120>.

Verheyden, James R., and Andrew K. Palmer. "Triangular Fibrocartilage Complex Injuries." eMedicine. Eds. Joseph Sheppard, et al. 17 Feb. 2012. Medscape. 6 Jun. 2013 <http://emedicine.medscape.com/article/1240789-overview>.

Wheeless, Clifford R. , et al. "Triangular Fibrocartilage Complex." Wheeless' Textbook of Orthopaedics. Duke University, Wheeless' Textbook of Orthopaedics. 12 Dec. 2012. Duke Orthopaedics. 6 Jun. 2013 <http://www.wheelessonline.com/ortho/triangular_fibrocartilage_complex>.

Zlatkin, Michael B., and Joel Rosner. "MRI Imaging of Ligaments and Triangular Fibrocartilage Complex of the Wrist." Radiologic Clinics of North America 44 4 (2006): 595-623. PubMed. 6 Jun. 2013 <PMID: 16829252>.

Source: Medical Disability Advisor






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