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Wrist Arthroscopy
Chapter 233 Wrist Arthroscopy
The complex anatomy of the wrist joint in addition to its multiplanar capabilities has provided diagnosticians with numerous challenges in assessing the structure and function of the wrist in an acute and chronic pathologic setting. There are many noninvasive modalities available to evaluate wrist pain; however, when the diagnosis remains unclear or conservative measures fail in the presence of significant wrist pain, more invasive procedures need to be considered. Diagnostic tools such as magnetic resonance imaging, although useful for soft tissue injuries, have been shown to have weaknesses in the accurate evaluation of certain wrist injuries. Alternatively, wrist arthroscopy allows greater three-dimensional visualization of wrist structures, decreasing the rate of false-negative results encountered in obscure causes of wrist pain. The greatest degree of sensitivity and specificity for evaluating wrist pain is achieved when the various analytic assessments are used in conjunction with one another. The decision to perform arthroscopy is comprised of intertwined factors involving cost and the activity level of the patient. These various elements should be evaluated on a case-by-case circumstance, and a clinical decision made after the full picture is taken into account. For example, the decision to perform such a procedure on an athlete would encompass whether or not the patient’s sport was in season and their competitive level within the sport. Indications: 1. Evaluation and treatment of ligamentous injury 2. Triangular fibrocartilage complex lesions 3. Examination of joint articular surfaces 4. Removal of loose bodies 5. Biopsy of synovium 6. Irrigation and debridement of carpal joints 7. Confirmation and supplementation of wrist arthrography 8. Intra-articular fractures of the distal radius, ulna, and carpal bones Complications: Wrist traction performed during arthroscopic evaluation of the wrist is the source of many complications that may include joint edema, stiffness, ligamental strain, and stretching of peripheral nerves. In addition, the portal placement may cause damage to peripheral arteries, veins, or nerves, and increase the risk of articular cartilage, ligament, and tendon laceration. The majority of these problems result in an inability to restore proper functioning of the joint or inadequate relief of symptoms. A less commonly encountered complication is joint effusion resulting in forearm compartment syndrome, which can be avoided by compression of the forearm during the procedure. Positioning and Setup: Wrist arthroscopy can be performed under general or regional block anesthesia, and a tourniquet around the mid arm provides a blood-free surgical field during the operation. The wrist to be scoped is placed in sterile finger-traps and suspended from a vertical
Portal 2–3
Portal 3–4
Portal 4–5 Portal 6R
Portal 1–2
Portal 6U
Radius
Ulna
Fig. 233-1 Cross-section of wrist at level of distal radius showing compartments and portals used for examination of radiocarpal and ulnocarpal joints. (Redrawn from Botte MJ, Cooney WP, Linscheid RL: Arthroscopy of the wrist: anatomy and technique. J Hand Surg 14A:313, 1989.)
486
• Between 2nd (extensor carpi radialis
2nd Portal
6-R Portal
4-5 Radiocarpal portals
3-4 Radiocarpal portals
•
•
•
extensor carpi ulnaris tendon The proximal border of the triquetrum should be used as a landmark rather than the distal ulna to avoid injuring the triangular fibrocartilage complex
• Located on the dorsoradial aspect of the
digitorum communis tendon) and 5th (extensor digiti minimi tendon) extensor compartments
• Located between the 4th (extensor
pollicis longus tendon) and 4th (extensor digitorum communis tendon) extensor compartments
• 1 cm distal to Lister’s tubercle • Palpated between the 3rd (extensor
longus and brevis) and 3rd (extensor pollicis longus) extensor compartments
• Lunate bone • Lunotriquetral joint • Volar ulnocarpal ligaments • Ulnar-sided wrist disease • Extensor carpi ulnaris tendon • Frequently used for irrigation
fibrocartilage complex
• Scaphoid and lunate facets • Midportion of the triangular
ligaments
• Intercarpal and volar radiocarpal
viewing portals
• Main radiocarpal arthroscopic
ligaments
• Evaluation of the radial palmar
Evaluation of articular surface of distal radius
Visualization/Use
1st Portal
Between 1st (abductor pollicis longus and extensor pollicis brevis) and 2nd (extensor carpi radialis longus and brevis) extensor compartments
Location
Name
Table 233-1.
•
fibrocartilage complex Dorsal sensory branch of the ulnar nerve
• Triangular
Danger
Wrist Arthroscopy • 487
Ulnar midcarpal portal
Radial midcarpal portal
6-U Portal
axis of the 4th metacarpal and proximal to the capitohamate joint (1 cm distal from 4-5 portal).
• Another location is in the center of the
•
•
•
and capitohamate joint and associated ligaments Distal ends of the lunate and triquetrum and the proximal portions of the capitate and hamate Midcarpal disease
• • Evaluation of the scaphocapitate
•
and capitohamate joint and associated ligaments Distal scaphoid, the lunate, and proximal pole of the capitate Midcarpal disease
axis proximal to the capitate in a soft depression between the capitate and scaphoid (1 cm distal from 3-4 portal). In line with Lister’s tubercle
• Lies to radial side of the 3rd metacarpal
recess next to the ulnar styloid
• Triangular fibrocartilage complex • Ulnocarpal ligaments • Can be used as outflow • Evaluation of the scaphocapitate
• Ulnar to the extensor carpi radialis tendon • Enters the joint through the prestyloid branch of the ulnar nerve
• Dorsal sensory
488 • Wrist Arthroscopy
Wrist Arthroscopy
• 489
MCU Radial A. MCR 3-4 Radial N.
6-U 6-R Ulnar N. Extensor carpi ulnaris
Fig. 233-2 The 3-4, 6-U, and 6-R portals provide the access and visibility needed for basic diagnostic wrist arthroscopy. The midcarpal (MC) portals provide a view of the midcarpal joint. R, radial; U, ulnar. (From Wrist Arthroscopy: Portals to Progress, as described by Gary Poehling. Andover, Mass, Dyonics Inc., 1989.)
traction apparatus above the operating table. Seven to 10 pounds of traction may be used to provide adequate distraction force needed for the procedure. A forearm clamp stabilizes the forearm and maintains the elbow in 80 to 90 degrees of flexion. Alternatively, traction may be placed longitudinally with the elbow in extension on the operating table. Anatomic Landmarks: Osseous Structures: Lister’s tubercle, radial styloid, dorsal lip of radius, ulnar styloid, and the distal radioulnar joint. Soft Tissue Structures: Extensor tendons. Soft Tissue Structures at Risk of Injury during the Procedure: Radial artery, sensory branch of the radial nerve, and the dorsal sensory branch of ulnar nerve. Portal Placement: Portal placement is determined by the goals of the operation and the suspicion of the attending physician. They are numbered according to the extensor tendon compartments immediately lateral to them and the surrounding osseous structures (Table 233-1). Aftertreatment: The exact procedure and extent of injury will ultimately determine the treatment outcome; however, in general the splint is normally removed and mobilization reassumed 7 to 10 days after arthroscopy. The more extensive the injury, the more prolonged the immobilization and rehabilitation required.
The complex anatomy of the wrist joint in addition to its multiplanar capabilities has provided diagnosticians with numerous challenges in assessing the structure and function of the wrist in an acute and chronic pathologic setting. There are many noninvasive modalities available to evaluate wrist pain; however, when the diagnosis remains unclear or conservative measures fail in the presence of significant wrist pain, more invasive procedures need to be considered. Diagnostic tools such as magnetic resonance imaging, although useful for soft tissue injuries, have been shown to have weaknesses in the accurate evaluation of certain wrist injuries. Alternatively, wrist arthroscopy allows greater three-dimensional visualization of wrist structures, decreasing the rate of false-negative results encountered in obscure causes of wrist pain. The greatest degree of sensitivity and specificity for evaluating wrist pain is achieved when the various analytic assessments are used in conjunction with one another. The decision to perform arthroscopy is comprised of intertwined factors involving cost and the activity level of the patient. These various elements should be evaluated on a case-by-case circumstance, and a clinical decision made after the full picture is taken into account. For example, the decision to perform such a procedure on an athlete would encompass whether or not the patient’s sport was in season and their competitive level within the sport. Indications: 1. Evaluation and treatment of ligamentous injury 2. Triangular fibrocartilage complex lesions 3. Examination of joint articular surfaces 4. Removal of loose bodies 5. Biopsy of synovium 6. Irrigation and debridement of carpal joints 7. Confirmation and supplementation of wrist arthrography 8. Intra-articular fractures of the distal radius, ulna, and carpal bones Complications: Wrist traction performed during arthroscopic evaluation of the wrist is the source of many complications that may include joint edema, stiffness, ligamental strain, and stretching of peripheral nerves. In addition, the portal placement may cause damage to peripheral arteries, veins, or nerves, and increase the risk of articular cartilage, ligament, and tendon laceration. The majority of these problems result in an inability to restore proper functioning of the joint or inadequate relief of symptoms. A less commonly encountered complication is joint effusion resulting in forearm compartment syndrome, which can be avoided by compression of the forearm during the procedure. Positioning and Setup: Wrist arthroscopy can be performed under general or regional block anesthesia, and a tourniquet around the mid arm provides a blood-free surgical field during the operation. The wrist to be scoped is placed in sterile finger-traps and suspended from a vertical
Portal 2–3
Portal 3–4
Portal 4–5 Portal 6R
Portal 1–2
Portal 6U
Radius
Ulna
Fig. 233-1 Cross-section of wrist at level of distal radius showing compartments and portals used for examination of radiocarpal and ulnocarpal joints. (Redrawn from Botte MJ, Cooney WP, Linscheid RL: Arthroscopy of the wrist: anatomy and technique. J Hand Surg 14A:313, 1989.)
486
• Between 2nd (extensor carpi radialis
2nd Portal
6-R Portal
4-5 Radiocarpal portals
3-4 Radiocarpal portals
•
•
•
extensor carpi ulnaris tendon The proximal border of the triquetrum should be used as a landmark rather than the distal ulna to avoid injuring the triangular fibrocartilage complex
• Located on the dorsoradial aspect of the
digitorum communis tendon) and 5th (extensor digiti minimi tendon) extensor compartments
• Located between the 4th (extensor
pollicis longus tendon) and 4th (extensor digitorum communis tendon) extensor compartments
• 1 cm distal to Lister’s tubercle • Palpated between the 3rd (extensor
longus and brevis) and 3rd (extensor pollicis longus) extensor compartments
• Lunate bone • Lunotriquetral joint • Volar ulnocarpal ligaments • Ulnar-sided wrist disease • Extensor carpi ulnaris tendon • Frequently used for irrigation
fibrocartilage complex
• Scaphoid and lunate facets • Midportion of the triangular
ligaments
• Intercarpal and volar radiocarpal
viewing portals
• Main radiocarpal arthroscopic
ligaments
• Evaluation of the radial palmar
Evaluation of articular surface of distal radius
Visualization/Use
1st Portal
Between 1st (abductor pollicis longus and extensor pollicis brevis) and 2nd (extensor carpi radialis longus and brevis) extensor compartments
Location
Name
Table 233-1.
•
fibrocartilage complex Dorsal sensory branch of the ulnar nerve
• Triangular
Danger
Wrist Arthroscopy • 487
Ulnar midcarpal portal
Radial midcarpal portal
6-U Portal
axis of the 4th metacarpal and proximal to the capitohamate joint (1 cm distal from 4-5 portal).
• Another location is in the center of the
•
•
•
and capitohamate joint and associated ligaments Distal ends of the lunate and triquetrum and the proximal portions of the capitate and hamate Midcarpal disease
• • Evaluation of the scaphocapitate
•
and capitohamate joint and associated ligaments Distal scaphoid, the lunate, and proximal pole of the capitate Midcarpal disease
axis proximal to the capitate in a soft depression between the capitate and scaphoid (1 cm distal from 3-4 portal). In line with Lister’s tubercle
• Lies to radial side of the 3rd metacarpal
recess next to the ulnar styloid
• Triangular fibrocartilage complex • Ulnocarpal ligaments • Can be used as outflow • Evaluation of the scaphocapitate
• Ulnar to the extensor carpi radialis tendon • Enters the joint through the prestyloid branch of the ulnar nerve
• Dorsal sensory
488 • Wrist Arthroscopy
Wrist Arthroscopy
• 489
MCU Radial A. MCR 3-4 Radial N.
6-U 6-R Ulnar N. Extensor carpi ulnaris
Fig. 233-2 The 3-4, 6-U, and 6-R portals provide the access and visibility needed for basic diagnostic wrist arthroscopy. The midcarpal (MC) portals provide a view of the midcarpal joint. R, radial; U, ulnar. (From Wrist Arthroscopy: Portals to Progress, as described by Gary Poehling. Andover, Mass, Dyonics Inc., 1989.)
traction apparatus above the operating table. Seven to 10 pounds of traction may be used to provide adequate distraction force needed for the procedure. A forearm clamp stabilizes the forearm and maintains the elbow in 80 to 90 degrees of flexion. Alternatively, traction may be placed longitudinally with the elbow in extension on the operating table. Anatomic Landmarks: Osseous Structures: Lister’s tubercle, radial styloid, dorsal lip of radius, ulnar styloid, and the distal radioulnar joint. Soft Tissue Structures: Extensor tendons. Soft Tissue Structures at Risk of Injury during the Procedure: Radial artery, sensory branch of the radial nerve, and the dorsal sensory branch of ulnar nerve. Portal Placement: Portal placement is determined by the goals of the operation and the suspicion of the attending physician. They are numbered according to the extensor tendon compartments immediately lateral to them and the surrounding osseous structures (Table 233-1). Aftertreatment: The exact procedure and extent of injury will ultimately determine the treatment outcome; however, in general the splint is normally removed and mobilization reassumed 7 to 10 days after arthroscopy. The more extensive the injury, the more prolonged the immobilization and rehabilitation required.