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Wrist Arthroscopy

  • Author: John J Walsh, IV, MD; Chief Editor: Harris Gellman, MD  more...
 
Updated: Oct 22, 2015
 

Background

Surgical visualization by means of arthroscopy has revolutionized orthopedics by allowing direct treatment of intra-articular pathology. Wrist arthroscopy evolved from the successful application of arthroscopy in larger joints.

The wrist is a complex joint that continues to challenge clinicians. This joint consists of eight carpal bones, multiple articular surfaces with extrinsic and intrinsic ligaments, and a triangular fibrocartilage complex (TFCC)—all within a 5-cm interval. Surgeons who use wrist arthroscopy are able to directly visualize cartilage, synovial tissue, and ligaments under bright illumination and magnification.

Most acute wrist sprains in which radiographic findings are normal resolve after conservative measures. However, the evaluation of the patient who does not improve after such treatment is controversial.[1] Historically, tricompartmental wrist arthrography has been the criterion standard for the detection of intra-articular pathology.[2, 3, 4] Wrist arthroscopy, which can be used simultaneously to detect and treat wrist injuries, and magnetic resonance imaging (MRI) have changed the way in which wrist pathology is treated.[5, 6, 7, 8, 9, 10, 11, 12, 13]

Wrist arthroscopy continues to grow in popularity as a feasible adjunct in the management of disorders of the wrist.[14] The procedure enables evaluation and detection of carpal structures under bright magnifying conditions with minimal morbidity as compared with arthrotomy. Improved wrist arthroscopic techniques continue to emerge as more surgeons are exposed to wrist arthroscopy and new instrumentation is developed. Despite short-term follow-up, the results of one study add another technique, arthroscopic resection arthroplasty, to the treatment algorithm of the very common pantrapezial arthritis.[15]

For patient education resources, see Wrist Injury and Carpal Tunnel Syndrome.

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Indications

The indications and applications for wrist arthroscopy continue to expand as new techniques and instrumentation evolve. Operative intervention is indicated for treatment of intra-articular fractures of the distal radius and scaphoid, wrist lavage, synovectomy (ie, rheumatoid arthritis), ganglionectomy, distal ulnar shortening, detection and removal of loose bodies, debridement of degenerative arthritis, debridement and repair of the TFCC, resection arthroplasty (proximal row carpectomy), management of septic arthritis (arthroscopic incision and drainage),[16] and stabilization of interosseous ligaments, as well as other conditions.

Diagnostically, wrist arthroscopy can allow for assessing interosseous ligament tears and determining whether the tears are partial or complete, evaluating the TFCC, inspecting for chondral defects in the carpal and midcarpal space, and evaluating chronic wrist pain of unknown etiology.

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Technical Considerations

Anatomic considerations

The TFCC is a homogeneous structure comprising the following components[17] :

  • Articular disc
  • Dorsal and volar radioulnar ligaments
  • Ulnar collateral ligament
  • Sheath of the extensor carpi ulnaris
  • Meniscal homologue

The TFCC acts as an extension of the articular surface of the radius to support the proximal carpal row, and it also provides stability to the distal radioulnar joint. The volar carpal ligaments assist in limiting wrist extension and radial deviation, as well as assist in stabilizing the volar-ulnar aspect of the carpus. Approximately 20% of the load of the forearm is transferred through the ulnar side of the wrist and the TFCC.[17]

The articular disc has thickening of the volar and dorsal margins, which are known as the volar and dorsal radioulnar ligaments. These ligaments assist in providing stability to the distal radioulnar joint. Palmer proposed a classification system for TFCC tears, which divided the injuries into two categories: traumatic (class I) and degenerative (class II). (See Technique.)[17] For more information, also see Wrist Joint Anatomy.

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Outcomes

Sammer and Shin, in their study of 36 patients with septic arthritis of the wrist, found arthroscopic irrigation and debridement (19 patients) to be effective in patients with isolated disease; arthroscopy was associated with fewer operations and a shorter hospital than open treatment (17 patients). However, these benefits were not seen in patients who had multiple sites of infection.[16]

In a study of 55 patients who underwent arthroscopic resection for dorsal wrist ganglion cysts, Edwards and Johansen found that patients had a significant increase in function and a significant decrease in pain within 6 weeks after the procedure. At 2 years after surgery, all patients had wrist motion that was within 5 º of preoperative motion; there were no recurrences. The authors noted that recurrent ganglion cysts originating from the midcarpal joint are not contraindications for arthroscopic resection, that assessment of the midcarpal joint is necessary for complete resection of most ganglion cysts, and that identification of a discrete stalk is an uncommon finding and is not necessary for successful resection.[18]

Adolfsson used arthroscopy to examine 144 patients who had posttraumatic wrist pain but normal findings on standard radiographs.[19] During the procedure, ligamentous changes were observed in 75 patients, TFCC lesions (including lunotriquetral instability) in 61 patients, and degrees of scapholunate instability in 14 patients.

The results of one small study found that arthroscopic proximal row carpectomy can be a safe and reliable alternative to the open procedure. Range of motion and grip strength compared favorably, and mobilization of the wrist was improved over the open technique.[20]

 

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Contributor Information and Disclosures
Author

John J Walsh, IV, MD Professor and Chairman, Department of Orthopedic Surgery, University of South Carolina School of Medicine

John J Walsh, IV, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Christian Medical and Dental Associations, American Society for Surgery of the Hand

Disclosure: Nothing to disclose.

Coauthor(s)

William Geissler, MD Professor of Orthopedic Surgery, Chief, Division of Hand/Upper Extremity Surgery, Chief, Sports Medicine, Arthroscopic Surgery, Department of Orthopedic Surgery and Rehabilitation, University of Mississippi Medical Center

William Geissler, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Southern Orthopaedic Association, Mississippi Orthopaedic Society, Society of Tennis Medicine and Science, American Association for Hand Surgery, American Medical Association, American Society for Surgery of the Hand, Arthroscopy Association of North America, Mississippi State Medical Association

Disclosure: Received royalty from Acumed for consulting.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Robert J Nowinski, DO Clinical Assistant Professor of Orthopaedic Surgery, Ohio State University College of Medicine and Public Health, Ohio University College of Osteopathic Medicine; Private Practice, Orthopedic and Neurological Consultants, Inc, Columbus, Ohio

Robert J Nowinski, DO is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, Ohio State Medical Association, Ohio Osteopathic Association, American College of Osteopathic Surgeons, American Osteopathic Association

Disclosure: Received grant/research funds from Tornier for other; Received honoraria from Tornier for speaking and teaching.

Chief Editor

Harris Gellman, MD Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine, Clinical Professor, Surgery, Nova Southeastern School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, Arkansas Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

A Lee Osterman, MD Director of Hand Surgery Fellowship, Director, Philadelphia Hand Center; Director, Professor, Department of Orthopedic Surgery, Division of Hand Surgery, University Hospital, Thomas Jefferson University

Disclosure: Nothing to disclose.

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Traction tower after draping.
The wrist is suspended in the traction tower, and the portals are drawn with the associated landmarks on the extensor surface of the wrist.
The wrist is suspended in the traction tower, and the portals are drawn with the associated landmarks on the extensor surface of the wrist.
Arthroscopic image of the radial radiocarpal joint. The radioscaphocapitate ligament is the most volar radial extrinsic wrist ligament. Adjacent and ulnar to the radioscaphocapitate ligament, the long radiolunate ligament is depicted. Note that the long radiolunate ligament is larger. The scaphoid is depicted above.
The short radiolunate ligament appears as a vascularized tuft. It is ulnar to the long radiolunate ligament.
Trampoline test. Similar to a trampoline, the disc of the triangular fibrocartilage complex should be taut when probed.
Lunotriquetral ligament, as depicted from the 4-5 portal in the radiocarpal space.
Grade III scapholunate tear, as depicted from the midcarpal space. Note that the gap allows passage of a 1-mm probe.
Grade IV scapholunate tear, as depicted from the midcarpal space. A 2.7-mm arthroscope may be freely passed through the tear.
Posteroanterior radiograph of a wrist. Abnormal widening between the scaphoid and lunate is present, indicating a complete scapholunate tear.
Electrothermal shrinkage performed in a patient with dynamic carpal instability. Careful use of the probe is required to avoid damage to critical structures.
Class IA tear of the triangular fibrocartilage complex. The probe points at the tear.
Arthroscopic debridement in a class IA tear. The flap has been debrided, and the arthroscope is used to smooth the remaining disc.
Class 1B tear, as depicted from the 3-4 portal. Reactive synovitis may cover the tear.
Repair of a class IB tear with the outside-in technique. A small, longitudinal incision incorporates the 6-R portal.
Arthroscopic image of a cannulated needle piercing the articular disc in a class IB repair.
Arthroscopic view reveals retrieval of the suture with a small joint grasper.
Sutures placed before being tied in a class IB tear.
Class ID tear. Avulsion of the disc from the sigmoid notch is depicted.
Arthroscopic image of the rim of the sigmoid notch, which is debrided to a bleeding bone bed before reattachment of the disc.
Class IIC tear of the triangular fibrocartilage complex. Note the chondromalacia of the ulna.
Radiocarpal view after arthroscopic removal of the ganglion stalk.
Arthroscopic view demonstrating the articular step-off in a distal radius fracture. Hematoma and debris are removed for optimal visualization.
Radiograph of a wrist after arthroscopic-assisted pinning of an intra-articular distal radius fracture
Before the scaphoid is pinned, the wrist is flexed at 45 degrees, which places the scaphoid in 90 degrees flexion.
Fluoroscopic image demonstrates reaming of the scaphoid in a proximal-to-distal fashion after arthroscopic reduction and percutaneous pinning.
Anteroposterior radiograph after reduction and fixation with a headless screw.
Lateral radiograph after reduction and fixation with a headless screw.
Table 1. Arthroscopic classification of carpal interosseous ligament tears (Adapted from Geissler et al. [33] )
Grade Description Management
I Attenuation and/or hemorrhage of the interosseous ligament as observed from the radiocarpal joint. No incongruence of carpal alignment in midcarpal space. Immobilization
II Attenuation and/or hemorrhage of the interosseous ligament, as observed from the radiocarpal joint. Incongruence and/or stepoff, as observed from the midcarpal space. A slight gap (less than the width of a probe) between the carpals may be present. Arthroscopic reduction and pinning
III Incongruence and/or stepoff of the carpal alignment are observed in both the radiocarpal and midcarpal space. The probe may be passed through a gap between the carpals. Arthroscopic reduction and/or open reduction and pinning
IV Incongruence and/or stepoff of the carpal alignment are observed in both the radiocarpal and midcarpal space. Gross instability with manipulation is noted. A 2.7-mm arthroscope may be passed through the gap between the carpals. Open reduction and repair
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