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Wrist Arthroscopy

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Topic updated on 05/10/13 4:40pm
Introduction
  • Plays an important therapeutic and diagnostic role
  • Indications
    • diagnosis in unexplained mechanical wrist pain
    • TFCC injuries
    • interosseous ligament injuries, including SL ligament rupture (must view from radiocarpal and midcarpal portals to make diagnosis)
    • assistance in anatomic reduction and fixation of distal radius or carpal fractures
    • debridement of chondral lesions
    • removal of loose bodies
    • synovectomy
    • excision of dorsal wrist ganglia
    • septic wrist irrigation and debridement
Technique
  • Wrist placed in traction aparatus
  • 2.5 or 3.0 mm scope used
  • Portals named in relation to wrist compartments
Radiocarpal Portals
 Portal
Function
Structures at Risk
3-4 Established first, primary viewing. Tracks between EPL and EDC EPL and EDC tendons
4-5 portal for instrumentation EDC and EDM tendons
6R Primary adjuct for visulaization and instrumentation, ulnar-sided TFCC repairs Dorsal sensory branch of ulnar nerve
6U Primary adjuct for visulaization and instrumentation, ulnar-sided TFCC repairs Dorsal sensory branch of ulnar nerve
Midcarpal Portals 
(necessary for complete carpal visualization, evaluating for wrist instability, and advanced arthroscopic techniques)
MCR Located 1 cm distal to 3-4 portal along axis of radial border of middle finger metacarpal. Located between ECRB and EDC. Allows visulaization 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. Located between EDC and EDM. Allows visualization of lunocapitate, lunotriquetral, and triquetrohamate joints. EDC and EDM tendons
STT Located between ECRB and ECRL. Allows visualization of scaphotrapezial and scaphotrapezoid joints. ECRB and ECRL tendons
First CMC Portals
1U Located on the 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 the radial 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
 
 Complications
  • Overall complication rate of 2%
  • Dorsal sensory branch of the ulnar nerve injury
    • at risk with establishment of 6U and 6R portals, and to a lesser extent main ulnar nerve and artery.  
    • when performing a TFCC repair, small open incision typically made prior to knot tying to prevent injury to this nerve.
  • Superficial sensory branch of the radial nerve injury
    • at risk during arthroscopy of basal joint, as the 1U and 1R portals are on either side of the first branch of this nerve.
    • at risk during placement of 1-2 portal
  • Extensor tendon injury
    • most commonly EPL and EDM.
  • Radial artery Injury
    • associated with establishment 1-2 portal, used for arthroscopic radial styloidectomy.
  • Portal site infection.

 

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