- Author: John J Walsh, IV, MD; Chief Editor: Harris Gellman, MD more...
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. 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. 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.
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), 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.
The TFCC is a homogeneous structure comprising the following components :
Dorsal and volar radioulnar ligaments
Ulnar collateral ligament
Sheath of the extensor carpi ulnaris
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.
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.) For more information, also see Wrist Joint Anatomy.
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.
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.
Adolfsson used arthroscopy to examine 144 patients who had posttraumatic wrist pain but normal findings on standard radiographs. 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.
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|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|