- Positioning and Preparation:
- joint is distended w/ finger traps (to index and long fingers) w/ about 10 lbs, using a pulley system;
- counter traction is applied to the arm w/ use of a second 10 lb pulley;
- this allows the elbow to be flexed 90 deg;
- gravity assistant inflow;
- initially inject about 6 cm of lidocaine w/ epinephrine to distend the capsule;
- 2.7 mm or 3 mm wrist scope;
- wrap out the forearm with carefully applied sterile Coband which will help prevent extravasation
of fluid from the frx site into the forearm;
-
pitfalls:
- don't forget to mark out the dorsal wrist veins before wraping out and elevating the tourniquet;
- if the veins are transected, a larger portal skin incision will be needed to achieve hemostasis;
- Wrist Portals:
-
distraction:
- distraction is not always required for routine wrist arthroscopy;
- in the report by J. Huracek and H. Troeger (JBJS 2000), the authors describe a technique for arthroscopy of
the wrist which is carried out without traction and with the arm lying horizontally on the operating table;
- the wrist is not immobilised, which makes it possible to assess the extent of instability after a ligamentous tear;
- in a prospective study of 30 patients, the authors compared this technique with conventional wrist arthroscopy,
performing the new method first followed by conventional arthroscopy;
- advantages were that the horizontal position of the arm allows the surgeon to proceed directly from arthroscopic
diagnosis to treatment, and that no change of position is required for fluoroscopy;
- Wrist arthroscopy without distraction. A Technique to visualize instability of the wrist after a ligamentous tear.
J. Huracek, H. Troeger.
J Bone Joint Surg [Br] 2000;82-B:1011-12.
-
outflow cannula:
- use 14 gauge angiocath;
- placed just ulnar to
ECU (6U portal);
- note the proximity of the dorsal ulnar cutaneous branch;
- some surgeons will use this as an outflow portal;
-
arthroscopic portal:
- 3-4 portal: (between
ECRL and
EPL)
- lies 1 cm distal to the Lister's tubercle;
- insert the scope in line with the dorsal radial slope;
-
instrumentation portal:
- 4-5 portal: (between
EDC and
EDQ)
- the arthroscope may be inserted thru this portal inorder to visualize a
TFCC tear;
-
mid-carpal portal:
- lies in the scaphocapitate interval;
- inserted radial to the third ray, distal to the proximal row, just radial
to the EDC to the index finger;
-
1-2 wrist portal:
- may serve as the the inflow cannula;
- lies in the 1-2 wrist portal (between the
ECRB and the APL;
- note that the
radial artery courses along the volar aspect of this interval;
- the portal should be inserted near the proximal and dorsal portion of the snuff box adjacent to
the EPL and the ECRL, inorder to avoid the artery;
Techniques of wrist arthroscopy.
T. Whipple, J Marotta, J Powell.
Arthroscopy. vol 2. 1986. p 244.
Precautions for arthroscopy of the wrist. T. Whipple.
Arthroscopy. vol 6. 1990. p 3.
Complete avulsion of the distal posterior interosseous nerve during wrist arthroscopy: a possible cause of persistent pain after arthroscopy.
F. del Pinal et al.
J. Hand Surg. Vol 24-A. No 2. March 1999 p 240.
Arthroscopic portals of the wrist: An anatomic study.
Abrams R, Petersen M, Botte M: J Hand Surg Am 19:940-944, 1994
