- 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 Huracek and Troeger (2000), the authors describe a technique for arthroscopy of wrist which is carried out without traction and with the arm lying horizontally on the operating table;
- wrist is not immobilised, which makes it possible to assess the extent of instability after a ligamentous tear;
- 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.
- 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 EPL and the ECRL, in order to avoid artery
Techniques of wrist arthroscopy.