Non-operative management of TFCC injury; a randomised, control trial investigating hand therapy, wrist splint and cortisone injection for triangular fibrocartilage complex injuries in the wrist

Participants will be randomly assigned to one of four treatment groups: Group A: will receive hand therapy Group B: will receive a thermoplastic, volar wrist splint + hand therapy Group C: will receive a corticosteroid injection to the wrist + hand therapy Group D: will receive a wrist splint + corticosteroid injection + hand therapy All procedures and appointments will be based in Brisbane, Queensland. Hand therapy (all participants) Participants will have a 30 minute therapy session with a qualified hand therapist at baseline and two 15 minute sessions, at 2 and 6 weeks post baseline. The hand therapist will use a therapy protocol designed by study investigators to deliver advice on protecting the wrist using activity modification and instruct the participant on an exercise regime to follow at home. All participants, irrespective of treatment randomisation, will be provided with the same Hand Therapy Protocol booklet to follow at home. Participants will be encouraged to use the support of their unaffected wrist when performing activities that may otherwise aggravate symptoms of the injured wrist. The protocol is divided into three phases, to be provided to participants in installments at each therapy appointment. A 2kg and 0.5kg vinyl dumbbell will be provided to participants at the baseline and 2 week appointment for the completion of exercises at home. Phase one, delivered at baseline, involves daily active range of motion exercises and bicep curls using a 2kg weight. Phase two, initiated at 2 weeks post baseline, incorporates the addition of resistance exercises. All prescribed exercises from the first phase will continue, with the addition of an isometric ECU exercise and resisted pronation with a 0.5kg dumbbell. Phase three, commencing 6 weeks post baseline, includes further strengthening exercises and gentle loading to the wrist. The 0.5kg weight will be used to perform resisted ulnar deviation and controlled wall push-ups will be included in the home exercise regime from 6 weeks, in addition to the exercises prescribed in the first two phases. Compliance to the exercise regime over the 12-week treatment period will be recorded on a patient-reported exercise log provided to all participants. Thermoplastic, volar wrist splint (Treatment arms B and D) At the baseline therapy appointment, the therapist will fit a custom thermoplastic, volar wrist splint. As two therapy clinics will be administering treatment, a standardised design protocol designed by study investigators will be distributed to ensure consistency between therapists and clinics. The splint design will be a short-arm, volar thermoplastic splint. The splint will be approximately two thirds of the length of the patients forearm and cover half of the circumference on the volar/palmer side of the wrist. Care will be taken to ensure that the ulnar styloid is not covered, the thumb is free to allow full opposition and that range of movement of the MCP joints are not restricted. Velcro straps will be used to secure the splint and a tubigrip sleeve will be worn underneath for comfort. Participants will be instructed to wear the splint during the day for 6 weeks, before reducing to symptomatic use only for 2 weeks. Corticosteroid injection (Treatment arms C and D) On the day of the 6 week treatment appointment following hand therapy the participant will be referred to a radiologist who will administer a corticosteroid injection to the wrist. A 1 mL betamethasone sodium phosphate/betamethasone acetate injection with 0.5% bupivacaine hydrochloride will be injected under direct ultrasound guidance to the triangular fibrocartilage complex of the wrist. Symptomatic and functional progress in addition to compliance to treatment protocols will be monitored using patient-reported questionnaires administered in-person at baseline, 6 weeks and 12 weeks. The questionnaire will be administered by a research assistant at individual participant appointments.