http://upload.orthobullets.com/topic/6009/images/Wrist portals_moved.jpg
http://upload.orthobullets.com/topic/6009/images/screen shot 2013-08-16 at 9.50.51 pm.jpg
Introduction
  • Plays an important therapeutic and diagnostic role
  • Indications
    • TFCC injuries 
    • interosseous ligament injuries
    • anatomic reduction assistance (distal radius, scaphoid fxs)
    • ulnocarpal impaction
    • debridement of chondral lesions
    • removal of loose bodies
    • synovectomy
    • excision of dorsal wrist ganglia
    • assistance in treatment of SNAC and or SLAC wrist
    • septic wrist irrigation and debridement
    • diagnosis in unexplained mechanical wrist pain
Positioning and Scope Insertion
  • Patient Position
    • supine, elbow flexed to 90°
    • traction tower with 10lb traction to fingers
  • Landmarks
    • Lister's tubercle
    • Scaphoid, Lunate
    • DRUJ
    • ECU
  • Scope insertion
    • 2.7mm, 30° arthroscope is most common
Portals
  • Portals named for relation to extensor wrist compartments 
  • Created with sharp skin incision followed by hemostat dissection 
Radiocarpal Portals
 Portal
Location, Function
Structures at Risk

3-4

Located just distal to Lister tubercle, between EPL and EDC; Established first, primary viewing portal EPL and EDC tendons
4-5 Located in line with ring finger metacarpal, between EDC and EDM; Portal for instrumentation, visualization of TFCC EDC and EDM tendons
6R Located just radial to ECU tendon; Primary adjunct for visualization and instrumentation, ulnar-sided TFCC repairs Dorsal sensory branch of ulnar nerve
6U Located just ulnar to ECU tendon; Primary adjuct for visualization and instrumentation, ulnar-sided TFCC repairs Dorsal sensory branch of ulnar nerve
1-2
Located between APL and ECRB, along dorsal aspect of snuffbox; Not often utilized, provides access to radial styloid and radial aspect of joint, sometimes used for inflow Superficial branch of radial nerve; Radial artery
Midcarpal Portals 
(necessary for complete carpal visualization, evaluating for wrist instability, and advanced techniques)
MCR Located 1 cm distal to 3-4 portal along axis of radial border of middle finger metacarpal, between ECRB and EDC. Allows visualization of scapholunate, scaphocapitate, and scaphotrapezoid joints. ECRB and EDC tendons
MCU Located 1 cm distal to 4-5 portal along axis of ring finger metacarpal, between EDC and EDM. Allows visualization of lunocapitate, lunotriquetral, and triquetrohamate joints. EDC and EDM tendons
STT Located along axis of index finger metacarpal just ulnar to EPL at level of STT joint. Allows visualization of scaphotrapezial and scaphotrapezoid joints. ECRB and ECRL tendons
First CMC Portals
1U Located on ulnar aspect of EPL at level of first CMC joint (basal joint). Allows diagnosis of DJD of first CMC joint and arthroscopic debridement. Superficial sensory branch of radial nerve
1R Located on radial aspect of EPL at level of thumb CMC joint, just volar to APL tendon. Allows diagnosis of DJD of first CMC joint and arthroscopic debridement. Superficial sensory branch of radial nerve
 
Rehabilitation
  • Immediate post-operative period
    • cast, splint or soft dressing depending on specific procedure(s) performed
  • Rehabilitation
    • progression depending on specific procedure(s) performed
  • Return to full activity
    • timing depending on specific procedure(s) performed
 Complications
  • Incidence
    • overall complication rate is 1-2%
  • Dorsal sensory branch of ulnar nerve
    • averages 8mm from 6R portal
    • at risk with establishment of 6U and 6R portals
      • to a lesser extent main ulnar nerve and artery also at risk
    • when performing a TFCC repair, small open incision is typically made prior to knot tying to prevent injury to this nerve.
  • Superficial sensory branch of radial nerve
    • averages 16mm from 3-4 portal
    • at risk during arthroscopy of basal joint, as 1U and 1R portals are on either side of the first branch of this nerve
    • at risk during placement of 1-2 portal 
  • Radial artery Injury
    • associated with establishment 1-2 portal, used for arthroscopic radial styloidectomy.
  • Extensor tendon injury
    • most commonly EPL and EDM due to improper portal placement
  • Chondral injuries
    • iatrogenic from scope or instrument placement
  • Portal site infection
  • Stiffness
  • MCPJ pain
    • typically caused by over-distraction
 

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Questions (1)

(OBQ12.98) A 22-year-old man presents with pain and hyperesthesias in the dorsoradial wrist and thumb 6 months after undergoing wrist arthroscopy for an acute wrist injury. Placement of which of the following portals is likely responsible for his symptoms? Review Topic

QID:4458
1

6U

1%

(46/3298)

2

6R

11%

(376/3298)

3

1-2

82%

(2703/3298)

4

MCU

2%

(54/3298)

5

4-5

3%

(84/3298)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

The 1-2 wrist arthroscopy portal is the only portal listed that places the superficial branch of the radial nerve (SBRN) at risk.

Wrist arthroscopy plays an important diagnostic and therapeutic role in injuries about the wrist, but carries a 2% complication rate. The 1-2 portal is placed between the ECRB and APL. Care must be taken when accessing this portal, due to reported injuries to the superficial branch of the radial nerve, as well as radial artery.

Kilic et al. dissected 6 cadavers to determine the course of the SBRN. They found that it was .9mm from the 1-2 portal at its closest, and that care should be taken when creating this portal given frequent variations in course.

Auerbach et al. dissected 20 cadavers to determine the course of the SBRN. In all specimens, the nerve arose between the brachioradialis and ECRL ~8cm proximal to the radial styloid. On average, 5.8 branches of the SBRN crossed the wrist joint. They found some variability within the course, and urge surgeons to be respectful of the nerve during dissection.

Tryfonidis et al performed a cadaveric study to determine the anatomic relation of dorsal wrist arthroscopy portals and superficial nerves. They found that the 1-2 portal was only 1.82 mm from the SBRN. Compared to the 3-4 portal, 4-5 portal, 6U portal and midcarpal portal, the 1-2 portal was the closest in proximity to any sensory nerve.

Illustration A shows the various portals used in wrist arthroscopy. Illustration B shows the relation of the SBRN to the various arthroscopic portals.

Incorrect Answers:
Answer 1: The 6U portal places the dorsal sensory branch of the ulnar nerve at risk.
Answer 2: The 6R portal places the dorsal sensory branch of the ulnar nerve at risk.
Answer 4: The MCU portal places the EDC and EDM tendons at risk.
Answer 5: The 4-5 portal places the EDC and EDM tendons at risk.

ILLUSTRATIONS:

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