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 (1cm) 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 adjunct 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) Portal Location, Function Structures at Risk 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 Portal Location, Function Structures at Risk 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. dorsal branch at risk with CMC portals 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