6 wrist arthroscopy rsrinivasan - office of continuing...
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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?
Background: Why Do Wrist Arthroscopy?
• Less invasive/minimize scarring
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Background: Why Do Wrist Arthroscopy?
• 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
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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
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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
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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
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EPL
EDCECU
EPL
EDCECU
3-4
EPL
EDCECU
3-4
4-5
EPL
EDCECU
3-46R
4-5
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EPL
EDCECU
3-46R
MCR
4-5
EPL
EDCECU
3-46R
MCRMCU
4-5
EPL
SRN
EPL
SRN
1-2
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DCUN
ECU
DCUN
ECU
6U
VR
VR
DCUN
ECU
6U
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Sc
RSC
Rad
RSL LRL
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Sc
Rad
RSC
Sc
LRL
Rad
RSL
RSC
Sc
SLIOLRL
RSL
Sc
SLIO
Lu
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TFCC
Ulna
UTL ULL
TrapeziumTrapezoid
Scaphoid
Cap
Scaphoid
Lunate
Cap
Scaphoid
LunateSL
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ScaphoidLunate
Capitate
Triquetrum
Capitate
Triquetrum
Lunate
ScaphoidLunate
Capitate
Triquetrum
Capitate
Triquetrum
Lunate
LT
ScaphoidLunate
Capitate
Triquetrum
Hamate
Triquetrum
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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)
Case Ex #1: Radial Styloidectomy
Sc
Rad
RSC
Case Ex #1: Radial Styloidectomy
Sc
RSC
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Case Ex #1: Radial Styloidectomy
Case Ex #1: Radial Styloidectomy
Case Ex #2: Ganglion
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*
Sc
RadStalk
Sc
Sc
Ext
Sc
Ext
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Sc
Lu
Cap
Ext
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Dry Technique
Dry Technique
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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
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Case Ex. #3: TFCC repair Case Ex. #3: TFCC repair
Case Ex. #3: TFCC repair
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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
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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
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SL
What else can be done?
• CMC arthritis
• Ulnar shortenings
• Wrist contracture releases
• Kienbock’s dz
Dorsal Wrist Syndrome
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Fluids
• Pressure: 30 mm Hg
• Avoid bubbles!!!
Getting Started