RICE & MICE: Wrist cartilage tears (aka TFCC tears)

Flyers players Mike Richards and Andrej Meszaros both had wrist surgery on Wednesday morning. 

Both had cartilage tears. It’s reported that Meszaros had some ligament involvement with his surgery. It seems that there’s a lot of uncalled for speculation going on about Richards’ wrist procedure.  When did he hurt it? How did it happen? Why didn’t he have surgery during the season? Even a sighting of Flyers (including Richards) at the Wednesday evening Philadelphia Union match, left the doors open for comments about his quick recovery from surgery. Seems to be everything just shy of questioning whether the injury is real.

Questions about how the wrist injuries affected the shots of each Meszaros and Richards are a bit simpler to answer. Richards suffered the tear in his left wrist, his bottom hand on the stick. Meszaros injured his right wrist, his top hand. There are different mechanics involved, thus different degrees of effect on the shots of the two players.

It might surprise people to find out that playing through this type of injury is not uncommon.  Vinny Lecavalier had similar surgery on both his wrists. His left wrist was operated on during the summer of 2007. He postponed similar surgery on his right wrist because he needed surgery to repair his right shoulder and he didn’t want to be rehabbing 2 different injuries on the same arm. So he played 77 games in the ’08-09 season with a wrist injury, only to miss the final five games of the season in favor of getting the surgery done.

Oddly enough Lecavalier’s point total for that season was 67 – that’s only one more than the 66 points that Richards posted this past season playing with what I am guessing is a very similar injury.

Chris Pronger has also had similar surgery on each of his wrists, though the issue with the left wrist was more complex. In May 2002, he had ligament and cartilage damage repaired in his right wrist. Pronger had played all season for the St. Louis Blues with the sore wrist and it couldn’t be determined at the time exactly when the injury started. Sound familiar? It should.

The wrist is composed of the 2 forearm bones, the radius is the bone on the thumb side of the arm and the ulna is the bone on the pinky side of the wrist and 8 bones (carpal bones) arranged in 2 rows. Ten bones involved in the wrist and countless ligaments.

The triangular fibrocartilage complex (TFCC) is composed of a group of ligaments and a cartilage disc that stabilizes the wrist between the carpal bones and the radius and ulna. The cartilage disc acts similarly to the meniscus of the knee as a shock absorber in the wrist as well as enabling smooth movement at the wrist joint.

The TFCC can be damaged in a number of ways. Trauma to the TFCC is commonly and generically called a wrist sprain, though there may or may not be one distinct trauma in a contact sport such as hockey where any number of falls or hits can cause damage. The cartilage and ligaments of the TFCC have poor blood supply, thus injuries from trauma or degeneration do not heal well.

The TFCC can be torn as the result of a wrist injury, most commonly a fall onto an outstretched hand or any similar force. Forceful twisting and pulling movements can injure the wrist. This may occur in sports, such as when swinging a bat, club, or racquet. These movements may also take place at work when using tools and equipment – believe it or not, a household drill can produce enough torque to cause damage to the TFCC. Gymnasts and cheerleaders are also at risk for TFCC injury.

Repetitive movements may also hasten degeneration and everyone experiences some degree of TFCC degeneration through their life.

Athletes that play through wrist cartilage injuries may use taping methods to reinforce the stability of the wrist. A torn wrist cartilage may be noticed as a new and uncomfortable click in the wrist. Painless clicking is generally not as concerning. More significant TFCC tears will hurt during play, and persist after play is finished. Sometimes it hurts just to grip the racquet or stick. Pain may progress to interfere with everyday activities, such as turning doorknobs. There is usually ulnar sided wrist pain with popping, catching and clicking with movement. Tenderness or pain is present when pushing on the area over the TFCC on the wrist. The pain is reproduced when pushing off to lift out of a chair bearing weight on the wrists. This “test” is almost 100% in detecting tears.

The wrist sprain can be treated more conservatively, by utilizing RICE (rest-ice-compression-elevation) for acute injuries in which swelling and bruising may be a problem. The wrist can also be immobilized for a period of time with a splint or cast. The sure way to assess the severity of damage to the TFCC is through arthroscopy.

Arthroscopy is a surgical procedure done in an operating room where small incisions are made and a camera is used to see the structures inside the joint. The surgery can be done using general anesthesia in which the patient is asleep, or it can be done with a nerve block to the arm that is operated on. During an arthroscopy, the surgeon will use a probe to identify and explore tears as well as to assess the tension of the fibrocartilage disk. A disk that is too loose can be treated at that time. The outside perimeter of the triangular fibrocartilage complex has a good blood supply. Tears in this area can be repaired or reattached with sutures. The central area of the disc has very poor blood supply, so smoothing or shaving of the damaged tissue is required to allow smooth motion at the joint.

If ligaments are ruptured, or completely torn, they can be reattached with a series of wires or screws to help reinforce the repair and encourage healing. If identification and repair of ruptured ligaments is delayed, a tendon graft may be the best option to strengthen the repair.

After surgery, the wrist is splinted or casted to immobilize it according to the type of surgery. Many surgeons have different rehab protocols that they prefer their patients to follow. Most rehab can start between 2 and 6 weeks, again depending on the type of surgery.

Pain relief, improved motion, and increased function are the main goals of surgery for most patients. Restoring wrist stability and ability to bear loads on the wrist is also important. Complications may occur such as persistent pain and stiffness and further surgery may be needed to revise the first operation. Let’s hope that’s not the case for Mike or Andrej.

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