Wrist Arthroscopy - Hand

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 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.
- 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