6 Wrist Arthroscopy RSrinivasan - Office of Continuing...

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Wrist ArthroscopyRamesh C. Srinivasan

Hand & Upper Extremity Surgeon

Director of Research

The Hand Center of San Antonio

Associate Master Instructor, AANA Wrist and Elbow Arthroscopy Course

Outline• Background

• What pathology can be addressed?

• Set-up

• Portal Anatomy

• Diagnostic Arthroscopy

• Case Examples

• Complications

• Conclusions

Background: Why Do Wrist Arthroscopy?

Background: Why Do Wrist Arthroscopy?

• Less invasive/minimize scarring

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Background: Why Do Wrist Arthroscopy?

• Less invasive/minimize scarring

• You can see better

You can see better

You can see better

L

Sc

You Can See better

Lu

Sc

Lu

Sc

Radiocarpal

Midcarpal

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Arthroscopy vs. MRI

• MRI, decreased sensitivity: TFCC, SL, LT, etc.

• Arthroscopy: Gold Standard

Arthroscopy vs. MRI

• MRI, poor sensitivity: TFCC, SL, LT, etc.

• Arthroscopy: Gold Standard

****Persistent wrist pain without findings on X-ray or MRI, diagnostic wrist arthroscopy can be considered

What pathology can be addressed?

• Ligament tears: SL, LT, etc.

• Arthritis: Radiocarpal, Midcarpal, CMC

• Ganglions

• Chondral defects

• TFCC tears

• Synovitis

• Fractures: Distal Radius, Scaphoid, etc.

Pre-op Evaluation of patient

• Surgeon may identify anatomic abnormalities

• Difficult to differentiate b/w asx degenerative findings and pathologic findings wrist pain

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Pre-op Evaluation of patient

• Surgeon may identify anatomic abnormalities

• Difficult to differentiate b/w asx degenerative findings and pathologic findings wrist pain

***Preoperative H+P are critical!!!

Basic equipment• 15 blade

• 22 gauge needle, 18 gauge needle

• Fine dissecting hemostat

• 2.5mm, 30o small joint scope

• probe (1.5mm tip)

• 2.0 or 3.0 Shaver

• Arthroscopy Tower

Traction / Suspension

Accumed Traction Tower

Traction / Suspension

• 4 finger traps

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Anatomy of Portals• Standard Portals are Dorsal

• 3-4, 4-5, 6R, MCR, MCU

• 1-2, 6U

• Superficial radial and ulnar nerves at risk

EPL

EPL

EDC

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EPL

EDCECU

EPL

EDCECU

3-4

EPL

EDCECU

3-4

4-5

EPL

EDCECU

3-46R

4-5

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EPL

EDCECU

3-46R

MCR

4-5

EPL

EDCECU

3-46R

MCRMCU

4-5

EPL

SRN

EPL

SRN

1-2

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DCUN

ECU

DCUN

ECU

6U

VR

VR

DCUN

ECU

6U

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Sc

RSC

Rad

RSL LRL

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Sc

Rad

RSC

Sc

LRL

Rad

RSL

RSC

Sc

SLIOLRL

RSL

Sc

SLIO

Lu

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TFCC

Ulna

UTL ULL

TrapeziumTrapezoid

Scaphoid

Cap

Scaphoid

Lunate

Cap

Scaphoid

LunateSL

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ScaphoidLunate

Capitate

Triquetrum

Capitate

Triquetrum

Lunate

ScaphoidLunate

Capitate

Triquetrum

Capitate

Triquetrum

Lunate

LT

ScaphoidLunate

Capitate

Triquetrum

Hamate

Triquetrum

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Case Ex #1: Radial Styloidectomy

• 62 yo F

• s/p distal radius fx, tx closed

• Pain w/ wrist extension/radial deviation (picking up her grandchildren)

Case Ex #1: Radial Styloidectomy

Sc

Rad

RSC

Case Ex #1: Radial Styloidectomy

Sc

RSC

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Case Ex #1: Radial Styloidectomy

Case Ex #1: Radial Styloidectomy

Case Ex #2: Ganglion

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*

Sc

RadStalk

Sc

Sc

Ext

Sc

Ext

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Sc

Lu

Cap

Ext

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Dry Technique

Dry Technique

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Dry Technique Case Ex. #3: TFCC repair• 48 yo m, FOOSH

• ulnar-sided wrist pain

• X-rays: Ulnar neutral variance

• MRI: TFCC tear

Case Ex. #3: TFCC repair

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Case Ex. #3: TFCC repair Case Ex. #3: TFCC repair

Case Ex. #3: TFCC repair

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Case Ex. #3: TFCC repair

What else can be done?

• CMC arthritis

• Ulnar shortenings

• Wrist contracture releases

• Kienbock’s dz

• PIP and MPJ (UCL, etc.)

CMC Arthroscopy

CMC Arthroscopy

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CMC Arthroscopy

CMC Arthroscopy

Complications of Wrist Arthroscopy

• Infection

• Tendon rupture

• Chondrolysis

• Arthrofibrosis

• Neuropraxia

• Skin burns

• Ganglion at portal

Conclusions• Important Diagnostic Modality

• Therapeutic Applications are expanding

• Relatively Safe

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SL

What else can be done?

• CMC arthritis

• Ulnar shortenings

• Wrist contracture releases

• Kienbock’s dz

Dorsal Wrist Syndrome

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Fluids

• Pressure: 30 mm Hg

• Avoid bubbles!!!

Getting Started