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Wrist arthroscopy


Indications

Diagnostic

The diagnostic indications include the following:

  • To identify or confirm pathology that is suggested by physical examination or noninvasive radiographic imaging, such as x-ray or magnetic resonance imaging (MRI).

  • To investigate the source of chronic pain that is thought to originate in the wrist and has persisted despite conservative measures, such as corticosteroid injections or occupational therapy (including splinting).

  • To characterize partial and complete ligamentous and cartilaginous injury, and to determine whether the patient will benefit from either arthroscopic or open operative intervention.

Therapeutic

A therapeutic indication is to aid in the treatment of (1) distal radius and scaphoid fractures, (2) debridement and shrinkage or repair of the scapholunate (SL) or lunotriquetral (LT) interosseous (IO) ligaments and dorsal wrist capsule, (3) triangular fibrocartilage complex (TFCC) repairs, (4) removal of foreign bodies, or (5) wrist irrigation in the case of infection or debridement of synovitis in inflammatory conditions such as rheumatoid arthritis ( Table 19.1 ).

TABLE 19.1
Therapeutic Indications for Wrist Arthroscopy
Common Arthroscopic Procedures
Loose body removal
Synovectomy
Intraarticular adhesion release
Lavage of septic wrist joint
Debridement of chondral lesion; hypertrophic or torn ligament
Ganglion excision; volar and dorsal
Assisted reduction of distal radius and scaphoid fractures
Bone resection (radial styloidectomy; distal ulnar; proximal hamate)
Carpal bone excision (scaphoid; lunate; proximal row) and arthrodesis
TFCC repair
Treatment of carpal instability
TFCC , Triangular fibrocartilage complex.

Contraindications

  • Contraindications include any cause of visible swelling that distorts the normal anatomy and/or significant capsular tears that might lead to extravasation of irrigation fluid, neurovascular compromise, coagulopathy, or severe infection.

  • Being unfamiliar with regional anatomy is a relative contraindication.

Clinical examination

  • History and physical examination should cue the surgeon to the specific anatomic structures that may have been injured.

  • Anatomic snuff box tenderness suggests a scaphoid fracture.

  • Pain distal to the Lister tubercle, between the third and fourth extensor compartments, prompts suspicion of an SL ligament injury. LT ligamentous injury may be suspected with pain over the 4-5 interval or with radial-ulnar compression of the wrist.

  • Ulnar-sided wrist pain and tenderness over the ulnar head or prestyloid recess suggests a possible TFCC injury.

  • Diffuse wrist swelling and tenderness over the distal radius suggests a distal radius fracture.

Imaging

  • Noninvasive imaging may be enough to identify an injury that would benefit from either nonoperative or operative intervention.

  • Plain x-rays can help identify dynamic or static wrist ligamentous injury, displaced carpal bone fractures, fractures of the distal radius and ulna, and ulnar variance.

  • MRI or magnetic resonance arthrography can be used to locate ligamentous pathology with reasonable sensitivity and may demonstrate changes within the lunate or triquetrum associated with an ulnar abutment.

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