6 Wrist Arthroscopy RSrinivasan - Office of Continuing ...cme.uthscsa.edu/Courses/TSHT/2017/032417/6_Wrist Arthroscopy... · findings and pathologic findings wrist pain ... 30o small

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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?


• Less invasive/minimize scarring



• 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


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


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


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


EPL

EDCECU

EPL

EDCECU

3-4

EPL

EDCECU

3-4

4-5

EPL

EDCECU

3-46R

4-5


EPL

EDCECU

3-46R

MCR

4-5

EPL

EDCECU

3-46R

MCRMCU

4-5

EPL

SRN

EPL

SRN

1-2


DCUN

ECU

DCUN

ECU

6U

VR

VR

DCUN

ECU

6U


Sc

RSC

Rad

RSL LRL


Sc

Rad

RSC

Sc

LRL

Rad

RSL

RSC

Sc

SLIOLRL

RSL

Sc

SLIO

Lu


TFCC

Ulna

UTL ULL

TrapeziumTrapezoid

Scaphoid

Cap

Scaphoid

Lunate

Cap

Scaphoid

LunateSL


ScaphoidLunate

Capitate

Triquetrum

Capitate

Triquetrum

Lunate

ScaphoidLunate

Capitate

Triquetrum

Capitate

Triquetrum

Lunate

LT

ScaphoidLunate

Capitate

Triquetrum

Hamate

Triquetrum


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)


Sc

Rad

RSC


Sc

RSC




Case Ex #2: Ganglion


*

Sc

RadStalk

Sc

Sc

Ext

Sc

Ext


Sc

Lu

Cap

Ext


Dry Technique

Dry Technique


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


Case Ex. #3: TFCC repair 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


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


SL

What else can be done?

• CMC arthritis

• Ulnar shortenings

• Wrist contracture releases

• Kienbock’s dz

Dorsal Wrist Syndrome


Fluids

• Pressure: 30 mm Hg

• Avoid bubbles!!!

Getting Started

Documents

6 Wrist Arthroscopy RSrinivasan - Office of Continuing ...cme.uthscsa.edu/Courses/TSHT/2017/032417/6_Wrist Arthroscopy... · findings and pathologic findings wrist pain ... 30o small