Wrist Arthroscopy

Indications & Contraindications - Scope Signals

• Indications (Diagnostic & Therapeutic):
  • Persistent unexplained wrist pain, mechanical symptoms (clicking, locking).
  • Triangular Fibrocartilage Complex (TFCC) tears: debridement or repair.
  • Dorsal or volar ganglion cyst excision.
  • Loose body removal, synovectomy (e.g., inflammatory arthritis).
  • Intra-articular fracture management (reduction/fixation).
  • Carpal instability (SL/LT tears): evaluation/treatment.
• Contraindications:
  • Absolute: Active local infection (cellulitis, septic arthritis), compromised overlying skin.
  • Relative: Severe joint contracture/arthrofibrosis, uncorrected coagulopathy, inability to achieve adequate joint distraction.

⭐ Arthroscopy is considered the gold standard for diagnosing and treating TFCC tears.

Portals & Perils - Wrist Roadmap

Safe wrist arthroscopy demands precise portal use & thorough anatomical respect.

• Radiocarpal (RC) Portals:
  • 3-4: Main viewing. Btwn EPL & EDC. 📌 "EPL at 3-4's door". Peril: SRN, EPL.
  • 4-5: Main working. Btwn EDC & EDM. Peril: SRN, PIN.
  • 6R: Radial to ECU. Peril: DSBUN, ECU.
  • 6U: Ulnar to ECU. Peril: DSBUN, ECU.
• Midcarpal (MC) Portals:
  • MCR: Radial midcarpal. Peril: SRN.
  • MCU: Ulnar midcarpal. Peril: DSBUN.
• Other Key Portals:
  • STT: For STT joint. Peril: SRN, Radial Artery.
  • DRUJ: For TFCC pathology.
• ⚠️ Safety Essentials:
  • Vertical skin incisions.
  • Blunt dissection to capsule.
  • Cannula use to protect nerves/tendons.
  • Adequate joint distraction.

⭐ Superficial Radial Nerve (SRN) is the most commonly injured structure, particularly with the 3-4 & 4-5 portals during wrist arthroscopy.

Procedure & Pathologies - Peek & Patch

• General Arthroscopic Steps:
  • Supine, arm on hand table.
  • Regional/General Anesthesia.
  • Finger traps (~10 lbs), tourniquet, fluid pump.
  • Radiocarpal (e.g., 3-4, 6R) & midcarpal portals.
  • "Dry" vs. Saline distension for visualization.
  • Systematic "Peek" (e.g., Geissler’s 7-point exam).
• Common Pathologies & "Patch" Interventions:
  • TFCC Tears: Central debridement; Peripheral suture repair.

    ⭐ TFCC Class 1B tears (ulnar avulsion with or without styloid #) are ideal for arthroscopic repair.

  • Ganglion Cysts (Dorsal/Volar): Stalk ID & excision.
  • Loose Bodies: Removal via grasper.
  • Synovitis (RA, Gout): Synovectomy.
  • Articular Cartilage Lesions: Debridement, chondroplasty.
  • Ligament Injuries (SL, LT): Assess, debride, repair aid.
  • Intra-articular Fractures (DRF): Visual reduction, fragment removal.

Complications & Care - Scope Setbacks

• Common Complications:
  • Neuropraxia: Most frequent.
    • Superficial Radial N. (SRN): Vulnerable at 3-4, 4-5 portals.
    • Dorsal Sensory Ulnar N. (DSUN): At 6R, 6U portals.
  • Tendon Injury: Extensor Pollicis Longus (EPL) common with 3-4 portal.
  • Stiffness/CRPS: Risk; manage with early motion.
• Less Common:
  • Infection: <1%.
  • Instrument breakage.
  • Vascular injury (radial artery).
  • Compartment syndrome (rare).
• Post-operative Care:
  • Bulky dressing, elevation.
  • Analgesia.
  • Early mobilization (protocol-dependent).
  • Suture removal: 10-14 days.
  • Physiotherapy essential.

⭐ Neurological injuries, particularly to the superficial radial nerve, are the most common complications of wrist arthroscopy.

📌 Nerves Suffer Trauma: Neuropraxia (SRN/DSUN), Stiffness, Tendon (EPL).

High‑Yield Points - ⚡ Biggest Takeaways

• Primary indication: Diagnosing and treating TFCC tears; also chronic wrist pain, loose bodies.
• Key portals: 3-4 portal (workhorse), 6R portal (ulnar pathology, TFCC).
• TFCC tears: Central debrided; peripheral tears repaired (better vascularity).
• Nerve injury risk: Superficial radial nerve (3-4 portal), dorsal sensory ulnar nerve (6R portal).
• Contraindications: Active infection, severe soft tissue compromise.
• Advantages: Minimally invasive, superior visualization, faster rehabilitation.
• DRUJ assessment: Crucial with TFCC injuries, often managed arthroscopically.