- Email: [email protected]
Wrist Arthroscopy
Wrist Arthroscopy ELIZABETH RICKS, RN, BSN, CNOR
1.8
A
rthroscopic surgery is a minimally invasive, outpatient procedure that allows direct visualization of the structures of a joint while causing minimal damage to surrounding soft tissue. The ability to see inside the joint and closely examine the bones, cartilage, and ligaments make wrist arthroscopy an excellent diagnostic tool and a primary method of evaluating and treating many disorders.1 Wrist arthroscopy has been performed since 1979, and with advances in technology and surgical expertise, the wrist is now the third most common joint, after the knee and shoulder, for which this surgical approach is used.2 Arthroscopy also is valuable in assessment of intraarticular wrist structures before and during other procedures, such as ulnar shortening and fracture fixation.
ANATOMY The wrist is a complex joint composed of eight carpal bones with many articulating surfaces that are connected by 28 ligaments. These ligaments are both intrinsic (ie, all connections are contained within the wrist) and extrinsic (ie, at least one connection exists outside the wrist). From lateral to medial, the bones of the proximal row are the scaphoid, lunate, triquetrum, and pisiform. The dorsal row consists of, from lateral to medial, the trapezium, trapezoid, capitate, and hamate.
indicates that continuing education contact hours are available for this activity. Earn the contact hours by reading this article and taking the examination on pages 189–190 and then completing the answer sheet and learner evaluation on pages 191–192. You also may access this article online at http://www.aornjournal.org.
© AORN, Inc, 2007
These small bones are the link between the radius and ulna of the forearm and the metacarpals of the hand (Figure 1). There are no muscle attachments to the carpal bones; therefore, movement is generated by extrinsic forces outside the wrist. The bones are lubricated with synovial fluid and are surrounded by the joint capsule. Numerous tendons, nerves, and vessels cross the wrist, providing movement, sensation, and blood to the hand. The most common disorders of the wrist include • arthritis, • carpal instabilities, • cartilage damage, • damage to the triangular fibrocartilage complex, • foreign bodies in the joint, • fractures, • ganglion cysts, • ligament tears, and • unresolved wrist pain.
PREOPERATIVE PHASE During the admission process to the ambulatory care setting, the preoperative nurse identifies the patient, obtains
ABSTRACT ARTHROSCOPIC SURGERY, a minimally invasive, outpatient procedure, is a valuable tool in the diagnosis and treatment of most disorders of the wrist. It offers direct visualization of the structures of the joint anatomy and existing disease processes while causing minimal damage to surrounding soft tissue. OTHER BENEFITS of arthroscopic treatment compared to traditional open procedures include less postoperative pain, shorter recovery times, and fewer surgical complications. AORN J 86 (August 2007) 181-188. © AORN, Inc, 2007.
AUGUST 2007, VOL 86, NO 2 • AORN JOURNAL • 181
Ricks
AUGUST 2007, VOL 86, NO 2
INTRAOPERATIVE PHASE
distal phalanges middle phalanges proximal phalanges metacarpals trapezoid hamate
trapezium
pisiform
capitate
triquetrum
scaphoid
lunate
radius ulna
Figure 1 • Illustration of the wrist and hand bones.
a medical and surgical history, performs a physical assessment, and establishes IV access. The nurse then assesses the patient’s knowledge and understanding of the surgical procedure. The anesthesia care provider arrives in the preoperative area to assess the patient and discuss plans for anesthesia. The anesthesia care provider then obtains the patient’s informed consent and has the patient sign the anesthetic consent form. The surgeon arrives to meet with the patient and family members and to answer any lastminute questions regarding the surgery. After all questions have been answered, the surgeon and patient or designated representative both initial the surgical site and sign the surgical informed consent. The circulating nurse arrives in the preoperative area to assess the patient and review the patient’s medical record. After identifying the patient, the circulating nurse ensures that all documentation is complete and that the patient’s questions have been answered. The circulating nurse and anesthesia care provider confirm with the patient the type of surgery to be performed, the surgeon, surgical site, and type of anesthesia. After the circulating nurse prepares a care plan specific to this patient (Table 1), the patient is ready to be taken to the surgical suite.
182 • AORN JOURNAL
The anesthesia care provider and circulating nurse escort the patient to the surgical suite and assist the patient onto the OR bed. The circulating nurse places a foam headrest to cradle the patient’s head, places a pillow under the patient’s knees for comfort, pads the patient’s heels, and secures a safety belt across the patient’s thighs. The circulating nurse extends the patient’s surgical arm onto a padded extremity table and secures the patient’s nonsurgical arm comfortably on an arm board at no more than a 90-degree angle (Figure 2). During this time, the circulating nurse introduces the patient to all other surgical team members and asks the patient to say his or her name, the surgeon’s name, the type of surgery to be performed, and the surgical site. Although general anesthesia frequently is used for a wrist arthroscopy, regional anesthesia (ie, axillary block, Bier block) with sedation also is an anesthetic option. The patient’s medical history, surgeon’s preference, anesthesia care provider’s recommendation, and the patient’s preference all factor into which type of anesthesia will be used. After anesthesia has been induced, the circulating nurse and anesthesia care provider rotate the OR bed, positioning the patient’s surgical arm in the center of the room to allow the surgical team full access to the surgical field. The circulating nurse or surgeon places a tourniquet high on the patient’s upper arm over cotton padding for cushioning and protection. The tourniquet always is applied preoperatively, although the tourniquet rarely is inflated because bleeding during wrist arthroscopy usually is minimal. The circulating nurse then secures the patient’s arm to the extremity table with padding and a hook-and-loop strap. This provides counter traction when the arm is later positioned in a distraction tower. The circulating nurse preps the patient’s arm with the surgeon’s choice of surgical skin prep solution, taking into consideration any patient allergies. The surgeon and scrub person apply the sterile drapes (eg, a stockinette, extremity sheet, medium drape sheets) to isolate the surgical field. The surgical team moves to the sterile
Ricks
AUGUST 2007, VOL 86, NO 2
TABLE 1
Nursing Care Plan for Patients Undergoing Wrist Arthroscopy Diagnosis Risk for injury related to pre-existing condition and surgery
• • •
• Risk for anxiety related to knowledge deficit and stress of surgery
Interim outcome criteria
Outcome statement
Confirms identity using at least two identifiers, operative procedure, surgical site, and laterality before the surgical procedure. Assesses patient for physical alterations and sensory impairments that may affect procedure-specific positioning. Implements protective measures to prevent injury (eg, electrical, thermal, chemical, or physical), including • verifying allergies; • positioning patient correctly, padding pressure points, and applying safety devices; • placing the electrosurgical unit grounding pad and ensuring prep solution does not pool under it; • using supplies and equipment within safe parameters. Evaluates for signs and symptoms of injury.
Patient maintains adequate tissue perfusion throughout the procedure.
Patient demonstrates wound and tissue perfusion consistent with or improved from preoperative baseline levels.
Determines knowledge level, readiness to learn, and barriers to communication. Explains sequence of events and reinforces teaching about treatment options. Provides verbal instruction and educational materials for surgical procedure and discharge based on identified need. Communicates patient concerns to appropriate surgical team members. Evaluates response to instruction.
Patient verbalizes decreased anxiety and an ability to cope.
Patient demonstrates knowledge of the expected response to the procedure and discharge care.
Assesses patient’s pain preoperatively. Identifies patient’s accepted postoperative pain threshold. Provides pain management instruction and pain scale to assess pain control. Implements pain management guidelines. Evaluates patient’s response to pain management interventions.
Patient verbalizes and demonstrates adequate pain management, and vital signs are equal to or improved from preoperative values.
Patient demonstrates and reports adequate pain control throughout the perioperative period.
Assesses patients’s skin integrity, sensory impairments, and immune status. Validates that preoperative antibiotic was administered according to facility policy. Observes sterile field and perioperative team members to ensure that asepsis is maintained. Allows sufficient time for surgical prep solution to dry before the patient is draped.
Patient’s wound remains dry and not reddened or warm with no excessive drainage, and patient’s temperature is within normal limits at discharge.
Patient is free of signs and symptoms of infection upon discharge from the facility.
Nursing interventions
• • • • •
Risk for acute or chronic pain related to surgical procedure
• •
Risk for infection related to injury or illness and exposure to the perioperative environment.
•
• • •
• • •
AORN JOURNAL •
183
Ricks
AUGUST 2007, VOL 86, NO 2
field and the circulating nurse brings all surgical equipment close to the sterile field. A video tower is used to organize the many pieces of equipment necessary for a wrist arthroscopy (Figure 3). Included on this tower are a camera console, monitor, fiberoptic light source, photo printer, video/DVD recorder, irrigation pump, and radio-frequency unit. An electrosurgical unit (ESU) also is available in the room. The scrub person attaches the fiberoptic light cord and camera head to the wrist scope (Figure 4) and hands the cord to the circulating nurse who plugs them into the camera console to provide a picture on the monitor. The light source and fiberoptic cord provide light directly to the scope. The surgeon uses the photo printer and video/DVD to take still pictures and to record the surgical procedure for the patient’s chart and for use during postoperative education. An irrigation pump is essential for inflow of normal saline into the wrist joint; the saline is used to ensure a clear field of vision and to monitor intra-articular pressure. The amount of fluid in the joint must be regulated to provide an optimal visual field and yet prevent tissue damage from excessive pressure. For hemostasis and debridement, the surgeon uses the radio-frequency unit with disposable probes at relatively low temperatures, which causes minimal damage to surrounding tissue. The ESU also aids in maintaining arthroscopic hemostasis and must be available if it becomes necessary to convert to an open procedure. After an arthroscopic diagnosis, it may be necessary to make a larger incision to treat the disorder, such as repairing a triangular fibrocartilage complex tear or stabilizing a fracture with plates and screws.
THE SURGICAL PROCEDURE The circulating nurse initiates the surgical time-out to confirm with all other surgical team members the patient’s identity, the surgical site initialed by the patient and surgeon, the surgical procedure to be performed, allergies, antibiotics administered, and any special equipment required. As the surgical procedure begins, the surgeon applies traction to the patient’s arm to
184 • AORN JOURNAL
Figure 2 • The patient’s arm is padded and positioned for surgery.
Figure 3 • A video tower contains the electronic equipment necessary to perform wrist arthroscopy.
distract the carpal bones and provide space for surgical instrument insertion. This distraction is achieved by using sterile finger traps and a wrist tower (Figure 5) to hold the patient’s arm in a vertical position. The tower allows for manipulation of the wrist into multiple positions
Ricks
Figure 4 • A trocar, cannula, arthroscope, camera, and fiberoptic cord are used for wrist arthroscopy.
Figure 5 • The patient’s hand and arm are suspended with traction to distract the carpal bones.
while maintaining the arm in traction. If the surgeon prefers that the arm remain horizontal, sterile finger traps, rope, and a pulley attached to a weight may be used to provide the necessary distraction. When the arm is secured in traction, the surgeon marks the areas for portal placement, taking great care to avoid any underlying
AUGUST 2007, VOL 86, NO 2
nerves, tendons, or vessels (Figure 6). Most wrist arthroscopies are performed through portals on the dorsal (ie, posterior) side of the wrist. Although portals can be placed on the volar (ie, palmar) side to better visualize dorsal structures, these areas are much more difficult to access because of underlying anatomy.3 The surgeon injects 5 mL to 10 mL of normal saline into the wrist joint to further distract the carpal bones (Figure 7). The surgeon makes incisions in the skin and uses a small hemostat to bluntly dissect into the joint capsule. Next, the surgeon inserts an arthroscopic cannula with a blunt trocar into the joint, then removes the trocar, and inserts a 2.5 mm, 30-degree or 70-degree wrist scope through the cannula (Figure 8). The surgeon attaches the fluid inflow tubing from the pump to the cannula and inserts an 18-gauge injectable needle connected to extension tubing into the joint capsule; this acts as an outflow port (Figure 9). The surgeon can use the stopcock on this extension tubing to regulate the outflow as necessary. The surgeon also places other portals, depending on the patient’s existing pathology. The surgeon then thoroughly examines the wrist joint, switching the arthroscope to different portals as needed to best visualize all areas and structures. Most wrist abnormalities (eg, triangular fibrocartilage complex injuries, ligament tears, unresolved wrist pain, fractures, foreign or loose bodies, ganglion cysts, arthritis, carpal instability) can be diagnosed and often treated with arthroscopic surgery. TRIANGULAR FIBROCARTILAGE COMPLEX INJURIES. Injury to the triangular fibrocartilage complex is one of the most common reasons for surgery,4 and wrist arthroscopy is useful in the diagnosis and treatment of triangular fibrocartilage complex injuries.5 The triangular fibrocartilage complex is a composite of ligament, cartilage, and tendon tissue and is considered to be the main stabilizer of the distal radioulnar joint. Acute or chronic injury to this area can cause joint destabilization, arthritic changes, chronic ulnar-sided wrist pain, and loss of motion and grip strength. Treatment of injuries to the triangular fibrocartilage complex depends on the type6 and location of the tear. Some injuries can be treated successfully by debriding the area of loose tissue. Debridement AORN JOURNAL •
185
AUGUST 2007, VOL 86, NO 2
Ricks
Figure 6 • The surgeon marks the portal placement sites, ensuring that underlying nerves, tendons, or vessels are avoided.
Figure 7 • The surgeon injects saline into the wrist to further distract the carpal bones.
Figure 8 • The surgeon places the arthroscope into the joint through the arthroscopic cannula.
Figure 9 • The surgeon inserts an 18-gauge needle for the outflow port.
can be accomplished by using a grasper, shaver, various knife blades, and more recently with lasers and radio-frequency devices.7 Depending on location or size, some triangular fibrocartilage complex tears must be repaired for satisfactory outcomes. Numerous techniques have been de-
veloped using nonabsorbable suture for the repair if no bone is involved.8 If the trauma involves bone, Kirschner wires or cannulated bone screws may be used to stabilize the bone fragments. WRIST BONE FRACTURES. The scaphoid bone is the most common of the wrist bones to sustain a
186 • AORN JOURNAL
Ricks
AUGUST 2007, VOL 86, NO 2
fracture. This injury often is sports-related and weaken, the carpal bones become misaligned, not unusual after a fall onto the hands. Wrist often resulting in weakness, stiffness, and pain. arthroscopy, along with fluoroscopy, allows the Arthroscopic treatment of these damaged ligasurgeon to reduce and stabilize the fracture ments may include while minimizing further tissue damage as • debridement; compared to in a conventional open procedure.9 • ligament repair (ie, reattaching the ligaThe arthroscopic approach also allows the surments with suture); geon to visualize accompanying ligament and • plication (ie, shortening the length of the ligacartilage damage, which are common with ments and stabilizing excess motion); and scaphoid fractures10 and often are undetected • electrothermal shrinkage (ie, applying heat by other diagnostic methods. Arthroscopy also that results in shrinkage of the ligament to is useful in assisting in the fixation of intraimprove stability).12,13 articular distal radial fractures and other lessAt the conclusion of the surgical procedure, common fractures of the carpal bones. the surgeon removes all instruments from the GANGLIONS. Ganglions are subcutaneous cysts as- patient, releases traction, and sutures the small sociated with joints. They often are asymptomatic skin incisions. The scrub person helps the surbut also can cause discomfort and nerve dysfuncgeon apply a bulky dressing (Figure 10), which tion. The most common ganglion in the wrist is includes a plaster splint to immobilize and rest the dorsal ganglion, but ganglions can occur in a the wrist. variety of locations throughout the wrist and hand. After failure of conservative treatment, surPOSTOPERATIVE PHASE gical excision of the ganglion cyst and stalk may The anesthesia care provider and circulating be necessary. Arthroscopic excision of the gannurse transport the patient to the postanestheglion cyst and stalk most commonly is accomsia care unit (PACU) where a PACU nurse plished by morsilating and removing the tissue closely monitors the patient during recovery with an arthroscopic shaver. This method profrom anesthesia. The PACU nurse ensures that vides a closer look at the tissue and decreases the patient’s surgical wrist is elevated and apscarring, pain, recovery time, risk of postoperaplies ice packs to reduce swelling and pain. tive complications, and risk of reoccurrence comWhen the patient meets discharge criteria, the pared to the conventional open procedure.11 nurse helps him or her change into clothes and TRAUMA OR DEGENERATIVE PROCESSES. Trauma or deencourages the patient to eat and drink a small generative processes such as rheumatoid arthritis amount. The duration of this phase can vary may leave pieces of loose bone or cartilage in the wrist joint, causing pain and limiting range of motion. These loose bodies can be removed easily via the arthroscopic approach, using a grasper or shaver to morsilate the tissue as it is removed. Debridement of the injured cartilage areas also can aid in relieving symptoms. A synovectomy will remove much of the diseased tissue that has resulted from the arthritic process. Carpal instability is the result of traumatic or degeneraFigure 10 • After the surgeon sutures the small skin incisions, the surgeon and scrub tive injury to the ligaments of person apply a forearm splint and bulky dressing. the wrist. As the ligaments AORN JOURNAL •
187
AUGUST 2007, VOL 86, NO 2
and is dependent on the patient, the surgical procedure, and the type of anesthesia. Before leaving the ambulatory care center, the PACU nurse discusses discharge instructions and postoperative care with the patient and his or her family members. This includes instructions to • keep the surgical hand elevated and dry until the postoperative office visit, usually in four to seven days; • use ice intermittently on the surgical site to reduce swelling and lessen discomfort; • treat normal postoperative discomfort with over-the-counter or prescription medications; and • control normal bleeding and fluid leakage by reinforcing the dressing. The patient begins postoperative therapy on the day of surgery, which initially involves moving the shoulder and elbow and gently flexing and extending the fingers. When the splint is removed, the surgeon prescribes simple wrist exercises and instructs the patients not to grip tightly or lift anything until the wrist is healed and the surgeon has cleared the patient for activity. Further physical therapy may be necessary depending on the extent of the patient’s pathology and type of surgery performed.
AN IMPROVED SURGICAL OPTION Arthroscopy is a valuable tool in the diagnosis and treatment of most wrist disorders. It offers a closer view of the anatomy and disease processes and often provides a more accurate diagnosis. Other benefits of arthroscopic treatment compared to traditional open procedures include less surgical tissue trauma, less postoperative pain, shorter recovery times, and fewer surgical complications.
REFERENCES 1. Lee JH, Taylor NL, Beckman RA, Rosenwasser MP. Arthroscopic wrist anatomy. In: Geissler WB, ed Wrist Arthroscopy. New York, NY: SpringerScience & Business Media, Inc; 2005:7-14.
188 • AORN JOURNAL
Ricks
2. Wrist arthroscopy. American Society for Surgery of the Hand. http://www.assh.org/AM/Template .cfm?Section=Wrist_Arthroscopy. Accessed May 29, 2007. 3. Slutsky DJ. Clinical applications of volar portals in wrist arthroscopy. Tech Hand Up Extrem Surg. 2004;8(4):229-238. 4. Tracy MR, Wiesler ER, Poehling GG. Arthroscopic management of triangular fibrocartilage tears in the athlete. Oper Tech Sports Med. 2006;14(2): 95-100. 5. Kuzma GR, Ruch DS. Debridement of central TFCC tears. In: Geissler WB, ed. Wrist Arthroscopy. New York, NY: SpringerScience & Business Media, Inc; 2005:55-62. 6. Palmer AK. Triangular fibrocartilage complex lesions: a classification. J Hand Surg [Am]. 1989;14(4): 594-606. 7. Nagle DJ. Lasers and electrothermal devices. In: Geissler WB, ed. Wrist Arthroscopy. New York, NY: SpringerScience & Business Media Inc; 2005: 22-30. 8. Geissler WB, Short WH. Repair of peripheral radial TFCC tears. In: Geissler WB, ed. Wrist Arthroscopy. New York, NY: SpringerScience & Business Media, Inc; 2005:42-49. 9. Ask the experts. PhysioRoom. http://www .physioroom.com/experts/asktheexperts/index .php. Accessed June 26, 2007. 10. Wong TC, Yip TH, Wu WC. Carpal ligament injuries with acute scaphoid fractures—a combined wrist injury. J Hand Surg [Br]. 2005;30(4):415-418. 11. Geissler WB. Excision of dorsal wrist ganglia. In: Geissler WB, ed. Wrist Arthroscopy. New York, NY: SpringerScience & Business Media, Inc; 2005: 139-144. 12. Moskal MJ, Savoic FH III. Management of lunotriquetral instability. In: Geissler WB, ed. Wrist Arthroscopy. New York, NY: SpringerScience & Business Media, Inc; 2005:94-101. 13. Geissler WB. Management if scapholunate instability. In: Geissler WB, ed. Wrist Arthroscopy. New York, NY: SpringerScience & Business Media, Inc; 2005:86-93.
Elizabeth Ricks, RN, BSN, CNOR, is a staff nurse at the Moses Cone Surgery Center, Greensboro, NC. Ms Ricks has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article.
Examination
1.8
Wrist Arthroscopy PURPOSE/GOAL To educate perioperative nurses about wrist arthroscopy.
BEHAVIORAL OBJECTIVES After reading and studying the article on wrist arthroscopy, nurses will be able to
1. describe the anatomy of the wrist, 2. identify the conditions that can be diagnosed or treated by wrist arthroscopy, and 3. describe wrist arthroscopy procedures. QUESTIONS 1.
2.
3.
The muscle attachments to the carpal bones generate movement inside the wrist. a. true b. false The most common disorders of the wrist include 1. arthritis. 2. cartilage damage. 3. triangular fibrocartilage complex damage. 4. ganglion cysts. 5. meniscus tears. 6. rotator cuff tears. a. 1, 3, and 5 b. 1, 2, 3, and 4 c. 2, 4, 5, and 6 d. 1, 2, 3, 4, 5, and 6 The factors that determine which type of anesthesia will be used during a wrist arthroscopy procedure include the 1. anesthesia care provider’s recommendation. 2. patient’s preference. 3. patient’s medical history. 4. surgeon’s preference. a. 1 and 3 b. 2 and 4
© AORN, Inc, 2007
c. 1, 2, and 3 d. 1, 2, 3, and 4 4.
To achieve distraction of the carpal bones, the surgeon uses a. a wrist tower with finger traps and injection of normal saline. b. injection of normal saline and the lead hand. c. a Senns retractor and a wrist tower with finger traps. d. the lead hand and a Senns retractor.
5.
Most wrist arthroscopies are performed through portals on the dorsal side of the wrist. a. true b. false
6.
The main stabilizer of the distal radioulnar joint is the a. biceps tendon. b. brachial plexus. c. scaphoid bone. d. triangular fibrocartilage complex.
7.
The _____________ bone is the most common of the wrist bones to sustain a fracture. a. capitate b. hamate AUGUST 2007, VOL 86, NO 2 • AORN JOURNAL • 189
Examination
AUGUST 2007, VOL 86, NO 2
c. scaphoid d. trapezium 8.
9.
Using an arthroscopic approach, loose bodies in the wrist joint can be removed with a grasper or a. laser. b. radio-frequency device. c. shaver. d. scissors. Arthroscopic treatment of the damaged ligaments of the wrist may include 1. debridement. 2. ligament repair. 3. plication.
The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, BC, director, Center for Perioperative Education.
190 • AORN JOURNAL
4. electrothermal shrinkage. a. 1 and 3 b. 2 and 4 c. 1, 2, and 4 d. 1, 2, 3, and 4 10. Benefits of wrist arthroscopy over open surgical procedures include 1. less surgical tissue trauma. 2. less postoperative pain. 3. shorter recovery times. 4. fewer surgical complications. a. 1 and 3 b. 2 and 4 c. 1, 2, and 3 d. 1, 2, 3, and 4
This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements. AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Answer Sheet
1.8
Wrist Arthroscopy
Event #07039 Session #8395
lease fill out the application and answer form on this page and the evaluation form on the back of this page. Tear the page out of the Journal or make photocopies and mail with appropriate fee to:
P
AORN Customer Service c/o AORN Journal Continuing Education 2170 S Parker Rd, Suite 300 Denver, CO 80231-5711 or fax with credit card information to (303) 750-3212. Additionally, please verify by signature that you have reviewed the objectives and read the article, or you will not receive credit.
Signature ______________________________________ 1. Record your AORN member identification number in the appropriate section below. (See your member card.) 2. Completely darken the spaces that indicate your answers to examination questions 1 through 10. Use blue or black ink only. 3. Our accrediting body requires that we verify the time you needed to complete this 1.8 continuing education contact hour (108-minute) program. ______ 4. Enclose fee if information is mailed. AORN (ID) #____________________________________________ Name__________________________________________________ Address ________________________________________________ City ___________________________________________________
State __________ Zip __________
Phone number __________________________________________ RN license #____________________________________________
State __________
Fee enclosed ___________________________________________ or bill the credit card indicated
■ MC
■ Visa
Card #____________________________________
■ American Express
Expiration date _____________________
Signature _________________________________________________ Fee: Members $9 Nonmembers $18 Program offered August 2007 The deadline for this program is Aug 31, 2010 © AORN, Inc, 2007
■ Discover
(for credit card authorization)
A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program will receive a certificate of completion. AUGUST 2007, VOL 86, NO 2 • AORN JOURNAL • 191
1.8
Learner Evaluation Wrist Arthroscopy
his evaluation is used to determine the extent to which this continuing education program met your learning needs. Rate these items on a scale of 1 to 5.
T
PURPOSE/GOAL To educate perioperative nurses about wrist arthroscopy.
OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Describe the anatomy of the wrist. 2. Identify the conditions that can be diagnosed or treated by wrist arthroscopy. 3. Describe wrist arthroscopy procedures. To what extent 4. did this article increase your knowledge of the subject matter? 5. was the content clear and organized? 6. did this article facilitate learning? 7. were your individual objectives met? 8. did the objectives relate to the overall purpose/goal?
TEST QUESTIONS/ANSWERS To what extent 9. were they reflective of the content? 10. were they easy to understand? 11. did they address important points?
LEARNER INPUT 12. Will you be able to use the information from this article in your work setting? a. yes b. no 13. I learned of this article via a. the Journal I receive as an AORN member. b. a Journal I obtained elsewhere. c. the AORN Journal web site. 14. What factor most affects whether you take
192 • AORN JOURNAL • AUGUST 2007, VOL 86, NO 2
an AORN Journal continuing education examination? a. need for continuing education contact hours b. price c. subject matter relevant to current position d. number of continuing education contact hours offered What other topics would you like to see addressed in a future continuing education article? Would you be interested or do you know someone who would be interested in writing an article on this topic? Topic(s): __________________________________ __________________________________________ Author names and addresses: _______________ __________________________________________ __________________________________________ __________________________________________ © AORN, Inc, 2007
1.8
A
rthroscopic surgery is a minimally invasive, outpatient procedure that allows direct visualization of the structures of a joint while causing minimal damage to surrounding soft tissue. The ability to see inside the joint and closely examine the bones, cartilage, and ligaments make wrist arthroscopy an excellent diagnostic tool and a primary method of evaluating and treating many disorders.1 Wrist arthroscopy has been performed since 1979, and with advances in technology and surgical expertise, the wrist is now the third most common joint, after the knee and shoulder, for which this surgical approach is used.2 Arthroscopy also is valuable in assessment of intraarticular wrist structures before and during other procedures, such as ulnar shortening and fracture fixation.
ANATOMY The wrist is a complex joint composed of eight carpal bones with many articulating surfaces that are connected by 28 ligaments. These ligaments are both intrinsic (ie, all connections are contained within the wrist) and extrinsic (ie, at least one connection exists outside the wrist). From lateral to medial, the bones of the proximal row are the scaphoid, lunate, triquetrum, and pisiform. The dorsal row consists of, from lateral to medial, the trapezium, trapezoid, capitate, and hamate.
indicates that continuing education contact hours are available for this activity. Earn the contact hours by reading this article and taking the examination on pages 189–190 and then completing the answer sheet and learner evaluation on pages 191–192. You also may access this article online at http://www.aornjournal.org.
© AORN, Inc, 2007
These small bones are the link between the radius and ulna of the forearm and the metacarpals of the hand (Figure 1). There are no muscle attachments to the carpal bones; therefore, movement is generated by extrinsic forces outside the wrist. The bones are lubricated with synovial fluid and are surrounded by the joint capsule. Numerous tendons, nerves, and vessels cross the wrist, providing movement, sensation, and blood to the hand. The most common disorders of the wrist include • arthritis, • carpal instabilities, • cartilage damage, • damage to the triangular fibrocartilage complex, • foreign bodies in the joint, • fractures, • ganglion cysts, • ligament tears, and • unresolved wrist pain.
PREOPERATIVE PHASE During the admission process to the ambulatory care setting, the preoperative nurse identifies the patient, obtains
ABSTRACT ARTHROSCOPIC SURGERY, a minimally invasive, outpatient procedure, is a valuable tool in the diagnosis and treatment of most disorders of the wrist. It offers direct visualization of the structures of the joint anatomy and existing disease processes while causing minimal damage to surrounding soft tissue. OTHER BENEFITS of arthroscopic treatment compared to traditional open procedures include less postoperative pain, shorter recovery times, and fewer surgical complications. AORN J 86 (August 2007) 181-188. © AORN, Inc, 2007.
AUGUST 2007, VOL 86, NO 2 • AORN JOURNAL • 181
Ricks
AUGUST 2007, VOL 86, NO 2
INTRAOPERATIVE PHASE
distal phalanges middle phalanges proximal phalanges metacarpals trapezoid hamate
trapezium
pisiform
capitate
triquetrum
scaphoid
lunate
radius ulna
Figure 1 • Illustration of the wrist and hand bones.
a medical and surgical history, performs a physical assessment, and establishes IV access. The nurse then assesses the patient’s knowledge and understanding of the surgical procedure. The anesthesia care provider arrives in the preoperative area to assess the patient and discuss plans for anesthesia. The anesthesia care provider then obtains the patient’s informed consent and has the patient sign the anesthetic consent form. The surgeon arrives to meet with the patient and family members and to answer any lastminute questions regarding the surgery. After all questions have been answered, the surgeon and patient or designated representative both initial the surgical site and sign the surgical informed consent. The circulating nurse arrives in the preoperative area to assess the patient and review the patient’s medical record. After identifying the patient, the circulating nurse ensures that all documentation is complete and that the patient’s questions have been answered. The circulating nurse and anesthesia care provider confirm with the patient the type of surgery to be performed, the surgeon, surgical site, and type of anesthesia. After the circulating nurse prepares a care plan specific to this patient (Table 1), the patient is ready to be taken to the surgical suite.
182 • AORN JOURNAL
The anesthesia care provider and circulating nurse escort the patient to the surgical suite and assist the patient onto the OR bed. The circulating nurse places a foam headrest to cradle the patient’s head, places a pillow under the patient’s knees for comfort, pads the patient’s heels, and secures a safety belt across the patient’s thighs. The circulating nurse extends the patient’s surgical arm onto a padded extremity table and secures the patient’s nonsurgical arm comfortably on an arm board at no more than a 90-degree angle (Figure 2). During this time, the circulating nurse introduces the patient to all other surgical team members and asks the patient to say his or her name, the surgeon’s name, the type of surgery to be performed, and the surgical site. Although general anesthesia frequently is used for a wrist arthroscopy, regional anesthesia (ie, axillary block, Bier block) with sedation also is an anesthetic option. The patient’s medical history, surgeon’s preference, anesthesia care provider’s recommendation, and the patient’s preference all factor into which type of anesthesia will be used. After anesthesia has been induced, the circulating nurse and anesthesia care provider rotate the OR bed, positioning the patient’s surgical arm in the center of the room to allow the surgical team full access to the surgical field. The circulating nurse or surgeon places a tourniquet high on the patient’s upper arm over cotton padding for cushioning and protection. The tourniquet always is applied preoperatively, although the tourniquet rarely is inflated because bleeding during wrist arthroscopy usually is minimal. The circulating nurse then secures the patient’s arm to the extremity table with padding and a hook-and-loop strap. This provides counter traction when the arm is later positioned in a distraction tower. The circulating nurse preps the patient’s arm with the surgeon’s choice of surgical skin prep solution, taking into consideration any patient allergies. The surgeon and scrub person apply the sterile drapes (eg, a stockinette, extremity sheet, medium drape sheets) to isolate the surgical field. The surgical team moves to the sterile
Ricks
AUGUST 2007, VOL 86, NO 2
TABLE 1
Nursing Care Plan for Patients Undergoing Wrist Arthroscopy Diagnosis Risk for injury related to pre-existing condition and surgery
• • •
• Risk for anxiety related to knowledge deficit and stress of surgery
Interim outcome criteria
Outcome statement
Confirms identity using at least two identifiers, operative procedure, surgical site, and laterality before the surgical procedure. Assesses patient for physical alterations and sensory impairments that may affect procedure-specific positioning. Implements protective measures to prevent injury (eg, electrical, thermal, chemical, or physical), including • verifying allergies; • positioning patient correctly, padding pressure points, and applying safety devices; • placing the electrosurgical unit grounding pad and ensuring prep solution does not pool under it; • using supplies and equipment within safe parameters. Evaluates for signs and symptoms of injury.
Patient maintains adequate tissue perfusion throughout the procedure.
Patient demonstrates wound and tissue perfusion consistent with or improved from preoperative baseline levels.
Determines knowledge level, readiness to learn, and barriers to communication. Explains sequence of events and reinforces teaching about treatment options. Provides verbal instruction and educational materials for surgical procedure and discharge based on identified need. Communicates patient concerns to appropriate surgical team members. Evaluates response to instruction.
Patient verbalizes decreased anxiety and an ability to cope.
Patient demonstrates knowledge of the expected response to the procedure and discharge care.
Assesses patient’s pain preoperatively. Identifies patient’s accepted postoperative pain threshold. Provides pain management instruction and pain scale to assess pain control. Implements pain management guidelines. Evaluates patient’s response to pain management interventions.
Patient verbalizes and demonstrates adequate pain management, and vital signs are equal to or improved from preoperative values.
Patient demonstrates and reports adequate pain control throughout the perioperative period.
Assesses patients’s skin integrity, sensory impairments, and immune status. Validates that preoperative antibiotic was administered according to facility policy. Observes sterile field and perioperative team members to ensure that asepsis is maintained. Allows sufficient time for surgical prep solution to dry before the patient is draped.
Patient’s wound remains dry and not reddened or warm with no excessive drainage, and patient’s temperature is within normal limits at discharge.
Patient is free of signs and symptoms of infection upon discharge from the facility.
Nursing interventions
• • • • •
Risk for acute or chronic pain related to surgical procedure
• •
Risk for infection related to injury or illness and exposure to the perioperative environment.
•
• • •
• • •
AORN JOURNAL •
183
Ricks
AUGUST 2007, VOL 86, NO 2
field and the circulating nurse brings all surgical equipment close to the sterile field. A video tower is used to organize the many pieces of equipment necessary for a wrist arthroscopy (Figure 3). Included on this tower are a camera console, monitor, fiberoptic light source, photo printer, video/DVD recorder, irrigation pump, and radio-frequency unit. An electrosurgical unit (ESU) also is available in the room. The scrub person attaches the fiberoptic light cord and camera head to the wrist scope (Figure 4) and hands the cord to the circulating nurse who plugs them into the camera console to provide a picture on the monitor. The light source and fiberoptic cord provide light directly to the scope. The surgeon uses the photo printer and video/DVD to take still pictures and to record the surgical procedure for the patient’s chart and for use during postoperative education. An irrigation pump is essential for inflow of normal saline into the wrist joint; the saline is used to ensure a clear field of vision and to monitor intra-articular pressure. The amount of fluid in the joint must be regulated to provide an optimal visual field and yet prevent tissue damage from excessive pressure. For hemostasis and debridement, the surgeon uses the radio-frequency unit with disposable probes at relatively low temperatures, which causes minimal damage to surrounding tissue. The ESU also aids in maintaining arthroscopic hemostasis and must be available if it becomes necessary to convert to an open procedure. After an arthroscopic diagnosis, it may be necessary to make a larger incision to treat the disorder, such as repairing a triangular fibrocartilage complex tear or stabilizing a fracture with plates and screws.
THE SURGICAL PROCEDURE The circulating nurse initiates the surgical time-out to confirm with all other surgical team members the patient’s identity, the surgical site initialed by the patient and surgeon, the surgical procedure to be performed, allergies, antibiotics administered, and any special equipment required. As the surgical procedure begins, the surgeon applies traction to the patient’s arm to
184 • AORN JOURNAL
Figure 2 • The patient’s arm is padded and positioned for surgery.
Figure 3 • A video tower contains the electronic equipment necessary to perform wrist arthroscopy.
distract the carpal bones and provide space for surgical instrument insertion. This distraction is achieved by using sterile finger traps and a wrist tower (Figure 5) to hold the patient’s arm in a vertical position. The tower allows for manipulation of the wrist into multiple positions
Ricks
Figure 4 • A trocar, cannula, arthroscope, camera, and fiberoptic cord are used for wrist arthroscopy.
Figure 5 • The patient’s hand and arm are suspended with traction to distract the carpal bones.
while maintaining the arm in traction. If the surgeon prefers that the arm remain horizontal, sterile finger traps, rope, and a pulley attached to a weight may be used to provide the necessary distraction. When the arm is secured in traction, the surgeon marks the areas for portal placement, taking great care to avoid any underlying
AUGUST 2007, VOL 86, NO 2
nerves, tendons, or vessels (Figure 6). Most wrist arthroscopies are performed through portals on the dorsal (ie, posterior) side of the wrist. Although portals can be placed on the volar (ie, palmar) side to better visualize dorsal structures, these areas are much more difficult to access because of underlying anatomy.3 The surgeon injects 5 mL to 10 mL of normal saline into the wrist joint to further distract the carpal bones (Figure 7). The surgeon makes incisions in the skin and uses a small hemostat to bluntly dissect into the joint capsule. Next, the surgeon inserts an arthroscopic cannula with a blunt trocar into the joint, then removes the trocar, and inserts a 2.5 mm, 30-degree or 70-degree wrist scope through the cannula (Figure 8). The surgeon attaches the fluid inflow tubing from the pump to the cannula and inserts an 18-gauge injectable needle connected to extension tubing into the joint capsule; this acts as an outflow port (Figure 9). The surgeon can use the stopcock on this extension tubing to regulate the outflow as necessary. The surgeon also places other portals, depending on the patient’s existing pathology. The surgeon then thoroughly examines the wrist joint, switching the arthroscope to different portals as needed to best visualize all areas and structures. Most wrist abnormalities (eg, triangular fibrocartilage complex injuries, ligament tears, unresolved wrist pain, fractures, foreign or loose bodies, ganglion cysts, arthritis, carpal instability) can be diagnosed and often treated with arthroscopic surgery. TRIANGULAR FIBROCARTILAGE COMPLEX INJURIES. Injury to the triangular fibrocartilage complex is one of the most common reasons for surgery,4 and wrist arthroscopy is useful in the diagnosis and treatment of triangular fibrocartilage complex injuries.5 The triangular fibrocartilage complex is a composite of ligament, cartilage, and tendon tissue and is considered to be the main stabilizer of the distal radioulnar joint. Acute or chronic injury to this area can cause joint destabilization, arthritic changes, chronic ulnar-sided wrist pain, and loss of motion and grip strength. Treatment of injuries to the triangular fibrocartilage complex depends on the type6 and location of the tear. Some injuries can be treated successfully by debriding the area of loose tissue. Debridement AORN JOURNAL •
185
AUGUST 2007, VOL 86, NO 2
Ricks
Figure 6 • The surgeon marks the portal placement sites, ensuring that underlying nerves, tendons, or vessels are avoided.
Figure 7 • The surgeon injects saline into the wrist to further distract the carpal bones.
Figure 8 • The surgeon places the arthroscope into the joint through the arthroscopic cannula.
Figure 9 • The surgeon inserts an 18-gauge needle for the outflow port.
can be accomplished by using a grasper, shaver, various knife blades, and more recently with lasers and radio-frequency devices.7 Depending on location or size, some triangular fibrocartilage complex tears must be repaired for satisfactory outcomes. Numerous techniques have been de-
veloped using nonabsorbable suture for the repair if no bone is involved.8 If the trauma involves bone, Kirschner wires or cannulated bone screws may be used to stabilize the bone fragments. WRIST BONE FRACTURES. The scaphoid bone is the most common of the wrist bones to sustain a
186 • AORN JOURNAL
Ricks
AUGUST 2007, VOL 86, NO 2
fracture. This injury often is sports-related and weaken, the carpal bones become misaligned, not unusual after a fall onto the hands. Wrist often resulting in weakness, stiffness, and pain. arthroscopy, along with fluoroscopy, allows the Arthroscopic treatment of these damaged ligasurgeon to reduce and stabilize the fracture ments may include while minimizing further tissue damage as • debridement; compared to in a conventional open procedure.9 • ligament repair (ie, reattaching the ligaThe arthroscopic approach also allows the surments with suture); geon to visualize accompanying ligament and • plication (ie, shortening the length of the ligacartilage damage, which are common with ments and stabilizing excess motion); and scaphoid fractures10 and often are undetected • electrothermal shrinkage (ie, applying heat by other diagnostic methods. Arthroscopy also that results in shrinkage of the ligament to is useful in assisting in the fixation of intraimprove stability).12,13 articular distal radial fractures and other lessAt the conclusion of the surgical procedure, common fractures of the carpal bones. the surgeon removes all instruments from the GANGLIONS. Ganglions are subcutaneous cysts as- patient, releases traction, and sutures the small sociated with joints. They often are asymptomatic skin incisions. The scrub person helps the surbut also can cause discomfort and nerve dysfuncgeon apply a bulky dressing (Figure 10), which tion. The most common ganglion in the wrist is includes a plaster splint to immobilize and rest the dorsal ganglion, but ganglions can occur in a the wrist. variety of locations throughout the wrist and hand. After failure of conservative treatment, surPOSTOPERATIVE PHASE gical excision of the ganglion cyst and stalk may The anesthesia care provider and circulating be necessary. Arthroscopic excision of the gannurse transport the patient to the postanestheglion cyst and stalk most commonly is accomsia care unit (PACU) where a PACU nurse plished by morsilating and removing the tissue closely monitors the patient during recovery with an arthroscopic shaver. This method profrom anesthesia. The PACU nurse ensures that vides a closer look at the tissue and decreases the patient’s surgical wrist is elevated and apscarring, pain, recovery time, risk of postoperaplies ice packs to reduce swelling and pain. tive complications, and risk of reoccurrence comWhen the patient meets discharge criteria, the pared to the conventional open procedure.11 nurse helps him or her change into clothes and TRAUMA OR DEGENERATIVE PROCESSES. Trauma or deencourages the patient to eat and drink a small generative processes such as rheumatoid arthritis amount. The duration of this phase can vary may leave pieces of loose bone or cartilage in the wrist joint, causing pain and limiting range of motion. These loose bodies can be removed easily via the arthroscopic approach, using a grasper or shaver to morsilate the tissue as it is removed. Debridement of the injured cartilage areas also can aid in relieving symptoms. A synovectomy will remove much of the diseased tissue that has resulted from the arthritic process. Carpal instability is the result of traumatic or degeneraFigure 10 • After the surgeon sutures the small skin incisions, the surgeon and scrub tive injury to the ligaments of person apply a forearm splint and bulky dressing. the wrist. As the ligaments AORN JOURNAL •
187
AUGUST 2007, VOL 86, NO 2
and is dependent on the patient, the surgical procedure, and the type of anesthesia. Before leaving the ambulatory care center, the PACU nurse discusses discharge instructions and postoperative care with the patient and his or her family members. This includes instructions to • keep the surgical hand elevated and dry until the postoperative office visit, usually in four to seven days; • use ice intermittently on the surgical site to reduce swelling and lessen discomfort; • treat normal postoperative discomfort with over-the-counter or prescription medications; and • control normal bleeding and fluid leakage by reinforcing the dressing. The patient begins postoperative therapy on the day of surgery, which initially involves moving the shoulder and elbow and gently flexing and extending the fingers. When the splint is removed, the surgeon prescribes simple wrist exercises and instructs the patients not to grip tightly or lift anything until the wrist is healed and the surgeon has cleared the patient for activity. Further physical therapy may be necessary depending on the extent of the patient’s pathology and type of surgery performed.
AN IMPROVED SURGICAL OPTION Arthroscopy is a valuable tool in the diagnosis and treatment of most wrist disorders. It offers a closer view of the anatomy and disease processes and often provides a more accurate diagnosis. Other benefits of arthroscopic treatment compared to traditional open procedures include less surgical tissue trauma, less postoperative pain, shorter recovery times, and fewer surgical complications.
REFERENCES 1. Lee JH, Taylor NL, Beckman RA, Rosenwasser MP. Arthroscopic wrist anatomy. In: Geissler WB, ed Wrist Arthroscopy. New York, NY: SpringerScience & Business Media, Inc; 2005:7-14.
188 • AORN JOURNAL
Ricks
2. Wrist arthroscopy. American Society for Surgery of the Hand. http://www.assh.org/AM/Template .cfm?Section=Wrist_Arthroscopy. Accessed May 29, 2007. 3. Slutsky DJ. Clinical applications of volar portals in wrist arthroscopy. Tech Hand Up Extrem Surg. 2004;8(4):229-238. 4. Tracy MR, Wiesler ER, Poehling GG. Arthroscopic management of triangular fibrocartilage tears in the athlete. Oper Tech Sports Med. 2006;14(2): 95-100. 5. Kuzma GR, Ruch DS. Debridement of central TFCC tears. In: Geissler WB, ed. Wrist Arthroscopy. New York, NY: SpringerScience & Business Media, Inc; 2005:55-62. 6. Palmer AK. Triangular fibrocartilage complex lesions: a classification. J Hand Surg [Am]. 1989;14(4): 594-606. 7. Nagle DJ. Lasers and electrothermal devices. In: Geissler WB, ed. Wrist Arthroscopy. New York, NY: SpringerScience & Business Media Inc; 2005: 22-30. 8. Geissler WB, Short WH. Repair of peripheral radial TFCC tears. In: Geissler WB, ed. Wrist Arthroscopy. New York, NY: SpringerScience & Business Media, Inc; 2005:42-49. 9. Ask the experts. PhysioRoom. http://www .physioroom.com/experts/asktheexperts/index .php. Accessed June 26, 2007. 10. Wong TC, Yip TH, Wu WC. Carpal ligament injuries with acute scaphoid fractures—a combined wrist injury. J Hand Surg [Br]. 2005;30(4):415-418. 11. Geissler WB. Excision of dorsal wrist ganglia. In: Geissler WB, ed. Wrist Arthroscopy. New York, NY: SpringerScience & Business Media, Inc; 2005: 139-144. 12. Moskal MJ, Savoic FH III. Management of lunotriquetral instability. In: Geissler WB, ed. Wrist Arthroscopy. New York, NY: SpringerScience & Business Media, Inc; 2005:94-101. 13. Geissler WB. Management if scapholunate instability. In: Geissler WB, ed. Wrist Arthroscopy. New York, NY: SpringerScience & Business Media, Inc; 2005:86-93.
Elizabeth Ricks, RN, BSN, CNOR, is a staff nurse at the Moses Cone Surgery Center, Greensboro, NC. Ms Ricks has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article.
Examination
1.8
Wrist Arthroscopy PURPOSE/GOAL To educate perioperative nurses about wrist arthroscopy.
BEHAVIORAL OBJECTIVES After reading and studying the article on wrist arthroscopy, nurses will be able to
1. describe the anatomy of the wrist, 2. identify the conditions that can be diagnosed or treated by wrist arthroscopy, and 3. describe wrist arthroscopy procedures. QUESTIONS 1.
2.
3.
The muscle attachments to the carpal bones generate movement inside the wrist. a. true b. false The most common disorders of the wrist include 1. arthritis. 2. cartilage damage. 3. triangular fibrocartilage complex damage. 4. ganglion cysts. 5. meniscus tears. 6. rotator cuff tears. a. 1, 3, and 5 b. 1, 2, 3, and 4 c. 2, 4, 5, and 6 d. 1, 2, 3, 4, 5, and 6 The factors that determine which type of anesthesia will be used during a wrist arthroscopy procedure include the 1. anesthesia care provider’s recommendation. 2. patient’s preference. 3. patient’s medical history. 4. surgeon’s preference. a. 1 and 3 b. 2 and 4
© AORN, Inc, 2007
c. 1, 2, and 3 d. 1, 2, 3, and 4 4.
To achieve distraction of the carpal bones, the surgeon uses a. a wrist tower with finger traps and injection of normal saline. b. injection of normal saline and the lead hand. c. a Senns retractor and a wrist tower with finger traps. d. the lead hand and a Senns retractor.
5.
Most wrist arthroscopies are performed through portals on the dorsal side of the wrist. a. true b. false
6.
The main stabilizer of the distal radioulnar joint is the a. biceps tendon. b. brachial plexus. c. scaphoid bone. d. triangular fibrocartilage complex.
7.
The _____________ bone is the most common of the wrist bones to sustain a fracture. a. capitate b. hamate AUGUST 2007, VOL 86, NO 2 • AORN JOURNAL • 189
Examination
AUGUST 2007, VOL 86, NO 2
c. scaphoid d. trapezium 8.
9.
Using an arthroscopic approach, loose bodies in the wrist joint can be removed with a grasper or a. laser. b. radio-frequency device. c. shaver. d. scissors. Arthroscopic treatment of the damaged ligaments of the wrist may include 1. debridement. 2. ligament repair. 3. plication.
The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, BC, director, Center for Perioperative Education.
190 • AORN JOURNAL
4. electrothermal shrinkage. a. 1 and 3 b. 2 and 4 c. 1, 2, and 4 d. 1, 2, 3, and 4 10. Benefits of wrist arthroscopy over open surgical procedures include 1. less surgical tissue trauma. 2. less postoperative pain. 3. shorter recovery times. 4. fewer surgical complications. a. 1 and 3 b. 2 and 4 c. 1, 2, and 3 d. 1, 2, 3, and 4
This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements. AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Answer Sheet
1.8
Wrist Arthroscopy
Event #07039 Session #8395
lease fill out the application and answer form on this page and the evaluation form on the back of this page. Tear the page out of the Journal or make photocopies and mail with appropriate fee to:
P
AORN Customer Service c/o AORN Journal Continuing Education 2170 S Parker Rd, Suite 300 Denver, CO 80231-5711 or fax with credit card information to (303) 750-3212. Additionally, please verify by signature that you have reviewed the objectives and read the article, or you will not receive credit.
Signature ______________________________________ 1. Record your AORN member identification number in the appropriate section below. (See your member card.) 2. Completely darken the spaces that indicate your answers to examination questions 1 through 10. Use blue or black ink only. 3. Our accrediting body requires that we verify the time you needed to complete this 1.8 continuing education contact hour (108-minute) program. ______ 4. Enclose fee if information is mailed. AORN (ID) #____________________________________________ Name__________________________________________________ Address ________________________________________________ City ___________________________________________________
State __________ Zip __________
Phone number __________________________________________ RN license #____________________________________________
State __________
Fee enclosed ___________________________________________ or bill the credit card indicated
■ MC
■ Visa
Card #____________________________________
■ American Express
Expiration date _____________________
Signature _________________________________________________ Fee: Members $9 Nonmembers $18 Program offered August 2007 The deadline for this program is Aug 31, 2010 © AORN, Inc, 2007
■ Discover
(for credit card authorization)
A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program will receive a certificate of completion. AUGUST 2007, VOL 86, NO 2 • AORN JOURNAL • 191
1.8
Learner Evaluation Wrist Arthroscopy
his evaluation is used to determine the extent to which this continuing education program met your learning needs. Rate these items on a scale of 1 to 5.
T
PURPOSE/GOAL To educate perioperative nurses about wrist arthroscopy.
OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Describe the anatomy of the wrist. 2. Identify the conditions that can be diagnosed or treated by wrist arthroscopy. 3. Describe wrist arthroscopy procedures. To what extent 4. did this article increase your knowledge of the subject matter? 5. was the content clear and organized? 6. did this article facilitate learning? 7. were your individual objectives met? 8. did the objectives relate to the overall purpose/goal?
TEST QUESTIONS/ANSWERS To what extent 9. were they reflective of the content? 10. were they easy to understand? 11. did they address important points?
LEARNER INPUT 12. Will you be able to use the information from this article in your work setting? a. yes b. no 13. I learned of this article via a. the Journal I receive as an AORN member. b. a Journal I obtained elsewhere. c. the AORN Journal web site. 14. What factor most affects whether you take
192 • AORN JOURNAL • AUGUST 2007, VOL 86, NO 2
an AORN Journal continuing education examination? a. need for continuing education contact hours b. price c. subject matter relevant to current position d. number of continuing education contact hours offered What other topics would you like to see addressed in a future continuing education article? Would you be interested or do you know someone who would be interested in writing an article on this topic? Topic(s): __________________________________ __________________________________________ Author names and addresses: _______________ __________________________________________ __________________________________________ __________________________________________ © AORN, Inc, 2007