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Arthroscopic Wrist Anatomy and Setup

Authors:
  • Rimini Hand Center
  • PRO-Mano Treviso - Italy

Abstract and Figures

Wrist arthroscopy is a reasonable recently introduced technique but has continued to evolve rapidly. It has equipped the orthopedic surgeon with an excellent tool to assess and treat intra-articular pathologies with dedicated small optics and miniaturized instruments. Meticulous knowledge of the normal wrist anatomy is essential for performing wrist arthroscopy as well as palpation of the surface landmarks in relation to the portals that are to be established. That way important neurovascular structures are not jeopardized. While the classic (wet) wrist arthroscopy bears the disadvantage of cumbersome extra-articular water leakage into the soft tissue and the risk of serious complications as development of compartment syndrome the wrist joint can easily be inspected without the use of water, referred to as “dry arthroscopy”. The standard arthroscopic portals have been developed on the dorsal side of the wrist. With the more recent introduction of volar wrist portals it is now possible to have viewing and working portals that encircle the whole wrist joint. Wrist arthroscopy comprises the radiocarpal-, midcarpal-, and distal radioulnar joint. A standardized, systematic arthroscopic examination with a routine circuit helps in visualizing all structures and should be performed in each intervention. Once normal arthroscopic wrist anatomy is clear, pathologic problems can be identified and treated. This chapter includes video.
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1
W.B. Geissler (ed.), Wrist and Elbow Arthroscopy: A Practical Surgical Guide to Techniques,
DOI 10.1007/978-1-4614-1596-1_1, © Springer Science+Business Media New York 2015
Introduction
Arthroscopy, rst described in 1918 in a cadaver knee joint
and 1962 successfully as an operative procedure [ 1 ], has
equipped the orthopedic surgeon with an excellent tool to
assess and treat intra-articular pathologies. After successful
application on large joints, the technique has been progres-
sively extended onto smaller sized joints as the shoulder, the
hip, the ankle, the elbow and the wrist. Wrist arthroscopy
was reported fi rst in 1979 for diagnostic purposes [ 2 ]. From
the late 1980s through the 1990s arthroscopy has become an
important means in the armory of a hand surgeon and wrist
arthroscopy the so-called golden standard for diagnosing
intra-articular lesions in the wrist. Since then it has contin-
ued to evolve not only as a diagnostic, but also therapeutic
tool and indications have steadily grown. Iatrogenic compli-
cations from open wrist surgery as capsular fi brosis resulting
in stiffness are reduced by arthroscopic surgery [ 3 , 4 ]. Wrist
arthroscopy is now an established procedure for treating
many intra-articular wrist pathologies with chronic wrist
pain and in acute wrist trauma [ 5 ].
The wide list of indications for wrist arthroscopy is
continuously growing and includes basic treatment of soft
tissue pathologies as synovitis, ganglia, fi brosis, stiffness,
management of triangular fi brocartilage complex (TFCC)
tears, scapholunate- and lunotriquetral ligament lesions and
removal of loose bodies. Osseous procedures include partial
bone resections in ulnocarpal- or ulnostyloid impaction syn-
drome and scaphotrapeziotrapezoid (STT) or triquetroham-
ate (TH) arthritis [ 6 ]. The method has also gained wider
acceptance in more sophisticated procedures as assisting
reduction of intra-articular distal radius fractures [ 713 ], or
scaphoid fractures [ 14 , 15 ] and in posttraumatic sequelae.
Arthroscopically assisted osteotomy in intra-articular distal
radius malunions [ 16 , 17 ], treatment of scaphoid nonunions
[ 15 ] and arthroscopic arthrolysis has been described [ 18 ].
Arthroscopic decompression of the lunate for Kienböck’s
disease [ 19 ], arthroscopic proximal row carpectomy [ 20 ] and
arthroscopically assisted partial wrist fusions have been
described [ 21 ].
Dedicated miniaturized instrumentation meeting the needs
of a small joint, a thorough knowledge of wrist anatomy and
the anatomic landmarks [ 22 ] as well as careful and skilled
surgical technique are required to allow a safe and appropri-
ate arthroscopic treatment of disorders in the wrist joint.
Setup and Equipment
Setup
Wrist arthroscopy requires standard arthroscopic equipment.
An arm table, arthroscopy tower system with monitor, video
recorder and printer, a scope with a camera attached, light
source with fi ber-optic cable, motorized shavers, radiofre-
quency ablators, an image intensifi er and a traction system
have become the standard of care. Digital systems allow data
transfer to a USB stick.
The intervention is frequently carried out under regional
anesthesia (axillary block) or general anesthesia under sterile
Arthroscopic Wrist Anatomy
and Setup
Nicole Badur , Riccardo Luchetti , and Andrea Atzei
1
N. Badur , M.D.
Hand Surgery and Surgery of Peripheral Nerves , University
Hospital Bern , Freiburgstrasse , Bern 3010 , Switzerland
e-mail: nicbadur@hotmail.com
R. Luchetti , M.D. (*)
Private Activity , Rimini Hand & Rehabilitation Center ,
Via Pietro da Rimini 4 , Rimini 47924 , Italy
e-mail: rluc@adhoc.net
A. Atzei , M.D.
Fenice HSRT Hand Surgery and Rehabilitation Team , Centro di
Medicina , Via Repubblica, 10/B Villorba , Treviso 31050 , Italy
Policlinico San Giorgio , Via Gemelli 10 , Pordenone 33170 , Italy
e-mail: andreatzei@gmail.com
Electronic supplementary material: Supplementary material is available
in the online version of this chapter at 10.1007/978-1-4614-1596-1_1 .
Videos can also be accessed at http://www.springerimages.com/
videos/978-1-4614-1595-4 .
2
conditions in an aseptic operation theater. Although wrist
arthroscopy has also been described without exsanguination
[ 15 ], the use of a pneumatic tourniquet placed at the upper
arm is generally recommended.
The patient is positioned supine on the operation table
with the affected arm on a hand table. The arm is abducted
90° and the elbow fl exed 90° allowing a vertical position of
the forearm, wrist and hand. In this position the wrist is kept
in neutral prono-supination. Horizontal wrist arthroscopy
has been described [ 23 , 10 ], however, we prefer the vertical
position to maintain a neutral rotation of the wrist and
360-degree access to the wrist. Traction is usually recom-
mended to distend the wrist and improve intra-capsular
vision [
1 ]. Vertical traction across the wrist is preferably
achieved using a traction tower. The arm and forearm need to
be padded with towels, preventing direct skin contact with
the metal of the tower, and are then stabilized to the tower.
Different models of traction towers exist (Fig.
1.1 ).
Vertical traction is then applied by suspending the fi ngers
with sterile fi nger traps and applying counter-traction
through a gearing mechanism at the tower that allows precise
modulation. To visualize the radiocarpal joint, the fi nger
traps are preferably placed on the index- and middle-fi nger
or the index-, middle- and ring fi nger. Other traction devises
allowing traction to all fi ngers are also used (Fig. 1.2 ). The
applied traction varies between 3.5 and 7 kg in patients. For
visualization of the STT joint traction can be applied by sus-
pending only the thumb.
Advantages of traction towers as the Whipple-, Borelli- or
Geissler traction tower are that they provide good stability
that can be crucial for certain interventions as arthroscopic
assisted reduction of distal radius fractures. Further they can
Fig. 1.1 Different traction systems. Vertical traction tower designed by
Whipple (Linvatec
® , Largo, FL, USA). Wrist positions can be adjusted
through a ball-and-socket joint. The central rod position hinders intra-
operative X-ray views ( a ). Traction tower designed by Borelli (Micai
® ,
Genova, Italy), allowing free dorsal and volar approach to the wrist,
rotation of the wrist and easy image intensifi er access with the eccentric
rod position. Vertical and horizontal position of the wrist is possible ( b ).
Wrist tower designed by Geissler (Acumed
® , Hillsboro, Oregon, USA)
that can be modifi ed allowing different angles in wrist position and
vertical or horizontal traction positioning without interference with
intraoperative X-ray ( c )
N. Badur et al.
3
be sterilized. For some interventions, however, we need a
free pronosupination as for arthroscopic stabilization of
TFCC lesions and the stability provided by the tower can
hinder. Also the central bar of some towers can interfere with
the intraoperative use of an image intensifi er. The fact that
traction towers need to be sterilized can be a hassle if there is
only one available and more wrist arthroscopies are per-
formed within the same operating session.
If a traction tower is not available a simple traction method
can be used: a shoulder traction holder can provide overhead
suspension with a counter traction band around the arm
proximal to the elbow. The tension can be adjusted by adding
weights (Fig. 1.3 ). Those systems are easy to set up and
allow undisturbed intra-operative X-ray access as well as
more freedom of motion than a traction tower while provid-
ing less stability (Fig. 1.4 ).
Fig. 1.2 Vertical traction is applied using Chinese fi nger traps at the
index- and middle fi nger ( a ). Traction on all fi ngers, the thumb included
if needed, can be applied by special traction hands (e.g., Arthrex
® ,
Naples, FL, USA) ( b ) and standard suspension systems ( c ) [Modifi ed
from Atzei A, Luchetti R, Sgarbossa A, Carità E, Llusà M. Set-up,
portals and normal exploration in wrist arthroscopy. Chir Main. 2006;25
Suppl 1:S131-44. French. With permission from Elsevier]
Fig. 1.3 Unconventional vertical overhead traction systems allowing rotation of the wrist and 360° access ( a and b ). A counter-traction band is
placed around the arm proximal to the elbow. The tension can be adjusted by adding weights ( c )
1 Arthroscopic Wrist Anatomy and Setup
4
Anesthesia is positioned on the side of the uninvolved
extremity or at the patient’s head, the surgeon on the side that
is awaiting surgery, at the patient’s head. The arthroscopy
tower and video monitor are placed at the patient’s feet, usu-
ally on the opposite side of the patient. An image intensifi er
is positioned in the operating theater so that it is not in the
way of the surgeon and rolled into the operating fi eld as
needed. The assistant and scrub nurse can position them-
selves depending on the intervention and the surgeon’s needs
which may differ in diagnostic and interventional wrist
arthroscopies (Fig. 1.5 ).
Equipment
The most important instrument is the arthroscope (Fig. 1.6 ).
Because of the size of the joint, arthroscopes for wrist arthros-
copy are smaller in diameter than traditional arthroscopes.
Different diameters of the optic are used in wrist arthroscopy,
ranging from 1.9 to 2.7 mm, with either a 30-degree- or less
common a 70-degree-viewing-angle to meet the needs of the
different articulations in the wrist. The light source cable is
also smaller in diameter. The smaller the diameter of the
arthroscope, the higher is the risk of bending and damaging
the fi ber-optic in the cannula. Short cannulas (5–8 cm) and
scopes (lever arm of 100 mm) are long enough and allow
easier handling and control [ 24 ]. The 2.7 or 2.4 mm optic is
ideal for the exploration of the radiocarpal- and midcarpal
joint as the arthroscopic vision fi eld is bigger, but too bulky
for exploration of the distal radioulnar joint (DRUJ), the sca-
photrapeziotrapezoid (STT) joint and in patients with a small
wrist. In those cases the use of an arthroscope with a diameter
of 1.9 mm or smaller is more appropriate.
A blunt trocar with a trocar sleeve is important to estab-
lish the viewing and working portals of the joints to be
inspected without damaging the articular cartilage.
Numerous instruments, appropriate to meet the criteria of
diagnosing and treating wrist pathologies have been devel-
oped. The probe is probably the simplest but most useful
diagnostic tool in wrist arthroscopy, serving as an extension
of the surgeon’s fi nger [ 1 ]. For some interventions the use of
a stronger probe as used in shoulder arthroscopy that does
not bend is benefi cial [ 16 ]. A variety of differently angled
punches, baskets with or without the option of incorporating
a suction mechanism and grasping forceps in various sizes
are useful in removing loose bodies and excising pieces of
soft tissue. Small arthroscopy knives with differently shaped
and retrograde blades aid in excising unstable chondral por-
tions of the carpal bones. A freer elevator, pins and a variety
of small differently shaped osteotomes are useful tools in
arthroscopically assisted correction of mal-united distal
radius fractures [ 17 ].
Differently aggressive and sized motorized shavers and
differently sized burrs ranging from 2.0 to 4.5 mm with inte-
grated fi nger-controlled suction mechanism are powered
instruments for debriding synovium or resecting bone, e.g.,
when performing a resection of the distal pole of the scaph-
oid for STT arthritis or a radial styloidectomy for beginning
radiocarpal arthritis as in stage 1 of scaphoid nonunion
advanced collapse (SNAC I). Shavers and burrs can be oper-
ated with a foot pedal or by fi nger control and allow continu-
ous or oscillating cutting.
Radiofrequency probes allow effi cient soft tissue debride-
ment and ligament- or capsular shrinkage [ 25 ], but because
of the risk of thermal injury adequate fl uid control must be
carefully managed [
26 ].
Fig. 1.4 Undisturbed intra-operative X-rays access is possible by sim-
ple overhead suspension of the wrist while providing less stability
Fig. 1.5 Positioning of the patient, the surgical and anesthetic staff and
the arthroscopic equipment
N. Badur et al.
5
Traditionally wrist arthroscopy has been carried out with
constant joint irrigation for distension and improvement of
intra-articular vision [ 27 ]. Lactated Ringer’s solution is used
for irrigation because it is rapidly reabsorbed from the soft
tissues [ 8 ]. Electric fl uid pumps that regulate fl uid volume to
avoid extravasation and decrease intraoperative bleeding may
be used but pure gravitational force is generally suffi cient for
the irrigation of the wrist joint. Outfl ow is provided via the
port of the cannula with the camera or a separate needle
placed into the ulnar side of the wrist or the successively
established portals. While the classic (wet) wrist arthroscopy
bears the disadvantage of cumbersome extra- articular water
leakage into the soft tissue and the risk of serious complica-
tions as development of compartment syndrome [ 7 , 8 , 28 ,
29 ], the wrist joint can easily be inspected without the use of
water, referred to as “dry arthroscopy” [ 30 ]. Synovial villi or
ruptured ligament parts do not interfere with the intra-articu-
lar vision as they do not fl oat into the fi eld of vision and
remain at their origins. In the usual joint there is mucous fl uid
that does not impede vision. However, depending on the pro-
cedure to be performed, an initial washout of the joint may be
useful, e.g., evacuation of hematoma in acute intra-articular
distal radius fractures. Debris can be cleared by injecting
10–20 ml of saline through the side valve of the scope fol-
lowed by aspirating with the shaver. The wrist joint can also
be dried with small neurosurgical patties inserted with a
grasper. Other helpful maneuvers to keep a clear vision in dry
arthroscopy are to immerse the tip of the scope into warm
water to prevent condensation (fog effect) due to temperature
differences outside and inside the wrist and to avoid closeness
of the scope and motorized instruments, thus preventing
splashing. The arthroscope can be cleaned by rubbing its tip
carefully at the local soft tissue [ 30 ].
However, dry arthroscopy also has its limits. For example
when radiofrequency ablators are used, water is necessary as
milieu conductor and to prevent temperature peaks and pos-
sible joint damage. Also when using a burr the aspiration
may be blocked by small cartilage and bone fragments and
water facilitates the aspiration.
The equipment is completed by different utensils for
specifi ed arthroscopic procedures as ligament repair, from
simple needles or longer Tuohy needles [ 31 ] to more sophis-
ticated, commercially available ligament repair kits [ 32 ].
Surgical Technique
Certain rules need to be respected in order to obtain a good
intra-articular vision and to avoid complications. It is very
important that all external anatomic landmarks and portals
must be marked after the traction to the wrist is applied but
before starting the arthroscopic procedure so that the rela-
tionship of surface landmarks are not altered [
28 ]. The fol-
lowing landmarks can be palpated if the wrist is not too
swollen (Fig.
1.7 ):
Osseous landmarks:
Dorsal : Lister’s tubercle, distal radial edge, dorsal ulnar
head, index-, middle-, (ring-) and small metacarpals.
Fig. 1.6 Wrist arthroscopy
equipment
1 Arthroscopic Wrist Anatomy and Setup
6
Radial : radial styloid process, trapezium, base of the fi rst
metacarpal.
Ulnar : ulnar styloid, triquetrum, base of the fi fth metacarpal.
Volar : pisiform and distal pole of the scaphoid.
Tendinous landmarks:
Dorsal : extensor carpi radialis longus (ECRL) tendon,
extensor pollicis longus (EPL) tendon, extensor digito-
rum communis (EDC) tendon, extensor carpi ulnaris
(ECU) tendon.
Radial : abductor pollicis longus (APL) tendon.
Ulnar : extensor carpi ulnaris (ECU) tendon.
Volar : exor carpi radialis (FCR) tendon, fl exor carpi
ulnaris (FCU) tendon.
Not all palpable surface landmarks need to be drawn onto
the skin as orientation for establishing the portals, we mark
the key structures as needed for each intervention (Fig. 1.8 ).
Standard wrist arthroscopy includes the assessment of the
radiocarpal- and ulnocarpal joint, the midcarpal- and STT
joint and the distal radioulnar joint (DRUJ). Numerous
arthroscopic dorsal and palmar approaches have been
described and are routinely used. The most commonly used
dorsal radiocarpal portals are named relative to the extensor
compartments between which they are located.
The rst portal to be established in almost every wrist
arthroscopy is the 3-4 radiocarpal portal. It can be identifi ed
by simple palpation of the “soft spot” just distal of the dorsal
rim of the radius in a vertical line with Lister’s tubercle. Two
methods of localizing the entry point for the 3-4 portal are
used. The fi rst method is called the “3 circle method”
(Fig. 1.9 ). A circle is drawn around Lister’s tubercle.
Two other circles of the same dimension are drawn just distal
to the fi rst one in a vertical line with Lister’s tubercle. The
third circle is located directly over the soft spot that is the
entry point of the 3-4 portal [
33 ]. The second method is
called the “rolling thumb method” (Fig.
1.10 ). The thumb
Fig. 1.7 Osseous and tendinous landmarks of the wrist from dorsal ( a ),
volar ( b ) and ulnar ( c ). RS radial styloid, L Lister’s tubercle, UH ulnar
head, US ulnar styloid, P pisiform, DS distal pole of the scaphoid, APL
abductor pollicis longus, ECRL extensor carpi radialis longus, ECRB
extensor carpi radialis brevis, EPL extensor pollicis longus, EDC
extensor digitorum communis, ECU extensor carpi ulnaris, FCU exor
carpi ulnaris, FCR exor carpi radialis. The numbers 1–6 represent the
extensor compartments. Volar incisions for the establishment of the VR
and VM joint ( black line ), for the VU and V-DRUJ ( red line ) and for the
6-U and DF portal ( blue line )
Fig. 1.8 Preoperative marking of the landmarks and dorsal portals for
performing a standard wrist arthroscopy. Abbreviations are according
to the previous fi gure
N. Badur et al.
7
pulp is placed on Lister’s tubercle and is then rolled over the
tubercle distally. The tip of the thumb is now exactly cen-
tered on the soft spot corresponding to the 3-4 portal. An
18- or 22-G needle is inserted at the soft depression into the
radiocarpal joint, minding the normal inclination of the distal
radius. Therefore the needle is pointing 20–30° proximally
to parallel the articular curve of the distal radius to verify
correct intra-articular placement (Fig. 1.11 ).
Injection of a saline solution through this needle to dis-
tend the radiocarpal joint has been described. A normal unin-
jured wrist can contain 2–5 ml of fl uid, but in the case of
TFCC lesions, or lesions of the intracarpal ligaments of the
proximal carpal row, up to 10–15 ml can be injected and the
adjacent joints (distal radioulnar- and midcarpal joint) are
indirectly fi lled. As stated above our preferred method for
wrist arthroscopy is the so-called dry technique. The traction
often is suffi cient for obtaining a quiet good intra-articular
vision. After the needle has been placed correctly the skin is
incised with a number 15 blade instead of using a number 11
blade as common for arthroscopy in other joints. Care must
be taken to incise only the skin to prevent damage to superfi -
cial vessels, tendons, and cutaneous nerves. Depending on
the portal to be established the nerves can be found in very
close proximity to the portals and are at risk [ 3436 ].
Longitudinal incisions are possible and favorable if the inci-
sion needs to be enlarged in a proximal-distal direction, for
Fig. 1.9 Establishment of the
3-4 portal using the “three circles
technique”: a circle is drawn
around the palpable Lister’s
tubercle ( a ). Two circles of the
same size are then drawn distally
to the fi rst circle. The third and
most distal circle lies at the level
of the 3-4 portal ( b )
Fig. 1.10 Establishment of the
3-4 portal using the “rolling
thumb technique”: the thumb is
placed on the palpable Lister’s
tubercle ( a ). The thumb is then
rolled distally over the tubercle
until the pulp of the surgeon’s
thumb feels the soft spot
corresponding to the 3-4 portal ( b )
1 Arthroscopic Wrist Anatomy and Setup
8
example if conversion to an open intervention needs to be
performed. However, we generally prefer horizontal skin
incisions on the dorsal aspect of the wrist, in line with the
skin lines, thus improving the esthetic appearance of the scar.
A blunt hemostat is advanced through the subcutaneous tis-
sue by carefully spreading the branches until there is contact
with the joint capsule. The capsule is then pierced with the
tip of the closed hemostat (Fig.
1.12 ). A blunt trocar is intro-
duced through a cannula into the joint directed volar and
proximal at an approximately 30° angle, aligning the cannula
with the volar inclination of the distal radius. The trocar is
removed and the arthroscope is introduced through the
cannula. The radial midcarpal portal can be established
following the same technique, following the 10° obliquity of
the fi rst carpal row (Fig.
1.11 ). For establishment of the other
portals we recommend to insert the needle arthroscopically
controlled.
Despite the revolutionary advances in wrist arthroscopy
we have to remember that all indications to perform an
arthroscopy should be based on a thorough clinical exami-
nation, aiming at detecting the origin of the intra-articular
pathology and consequently avoiding inappropriate
Fig. 1.11 Schematic lateral view
of the wrist ( a ). External traction
allows widening of the articular
spaces. The arthroscope should
be inserted into the radiocarpal-
and midcarpal joint respectively,
paralleling the dorsal articular
slope of the joints. Horizontal
introduction of the arthroscope
may damage the articular
cartilage of the carpal bones ( b ) .
Fig. 1.12 Standard procedure for establishment of an arthroscopic
wrist portal (3-4 portal), right wrist. Localization of the radiocarpal
joint space with a 22-G needle ( a ). Horizontal skin incision ( b ).
Spreading of the subcutaneous tissues with a blunt hemostat to
the capsule ( c ). Piercing of the capsule with the closed tip of the hemo-
stat ( d )
N. Badur et al.
9
indications that would not address the true nature of the
pathology [ 37 ].
The diagnostic evaluation always starts with the explora-
tion of the radiocarpal joint, but the evaluation of the
midcarpal joint should never be neglected and is considered a
part of wrist arthroscopy. Arthroscopy of the DRUJ has only
recently gained interest [ 38 , 39 ]. It is performed in special
indications and not conducted in every wrist arthroscopy.
A standardized, systematic arthroscopic examination
with a routine circuit helps in visualizing all structures and
not forgetting anything [ 4 ]. A few simple rules that should be
followed are:
Examination of the radial side before the ulnar side.
Examination of the distal part of the articulation before
the proximal part.
Examination of the volar aspect before the dorsal aspect.
Examination of the ligaments before the articular surfaces.
Simple inspection before using a probe.
Rotation of the 30-degree-angle arthroscope allows the
exploration of different regions of the articulation and
switching the arthroscope and the instrument within the dif-
ferent portals can be limited. It is crucial to stabilize the
arthroscope and control the small movements of the optic
within the joint in order to prevent damage to the articular
cartilage. Therefore the arthroscope should be held in a man-
ner that allows constant contact to the skin of the wrist. The
small optic is short enough to be grasped in a way that pro-
vides contact of the surgeon’s index fi nger to the patient’s
wrist while larger arthroscopes need to be stabilized with the
middle- and ring fi nger (Fig. 1.13 ).
Arthroscopic Portals: Approaches
and Anatomy
Meticulous knowledge of the anatomy is essential for per-
forming wrist arthroscopy (Fig. 1.14 ) [ 40 ]. The entry portals
are numerous (Fig. 1.15 ) and need to be adapted to the
pathology and the particular anatomy in this region [ 1 , 28 ,
41 ]. The standard arthroscopic portals have been developed
on the dorsal side of the wrist and their localizations and
names are in direct relation to the six extensor compartments.
In the space between two extensor compartments the
arthroscopic portals can be established and instruments
introduced without the risk of damaging the extensor ten-
dons. On the dorsal side of the wrist there are not many neu-
rovascular structures that could be damaged (Fig. 1.16a–c ).
Volar portals have been previously reported [
42 , 43 ] but
lacked popularity for a long period because they seemed to
jeopardize important neurovascular structures on the volar
side of the wrist (Fig.
1.16d, e ). Only recently the safety of
volar portals to the wrist could be shown [ 4448 ], and it is
possible to have viewing and working portals that encircle
the whole wrist joint. This is called the “box concept”
(Fig. 1.17 ) [ 24 ].
The arthroscopic exploration of the wrist is divided into
three parts: proximal, volar (dorsal when using a volar por-
tal), and distal. Then the arthroscope can be rotated to the
radial and the ulnar side. We generally proceed with the
arthroscopic overview from proximal to distal and from
radial to ulnar (Fig. 1.18 ).
Fig. 1.13 Handling of the
arthroscope. Control of minimal
movements within the joint is
achieved by constant fi nger
contact to the patient’s wrist with
the index fi nger ( a ) or the
middle- to small fi nger ( b )
1 Arthroscopic Wrist Anatomy and Setup
10
Fig. 1.14 Anatomic dissection of the radiocarpal- ( a ) and midcarpal
joint ( b ). The radiocarpal portals are indicated with red circles and the
midcarpal portals with black circles . The proximal articular part of the
radiocarpal joint is comprised by the scaphoid- and lunate fossa of the
radius (R(S) and R(L)), separated by the interfosseal ridge (š) and the
TFCC with its volar- and dorsal distal radioulnar ligaments (DRUL).
The volar radiocarpal ligaments are from radial to ulnar the radioscapho-
capitate (RSC) ligament, the long radiolunate (LRL) ligament and the
short radiolunate (SRL) ligament. The volar ulnocarpal ligaments are the
ulnolunate (UL) and the ulnotriquetral (UT) ligament. Ulnar and distal
to the UT ligament we fi nd the entry to the pisotriquetral joint (˚). The
distal part of the radiocarpal joint is formed by the proximal articular
surfaces of the scaphoid (S), the lunate (L) and the triquetrum (T). The
scapholunate ligament () and the lunotriquetral ligament () separate
the carpal bones of the fi rst carpal row, respectively. The proximal part
of the midcarpal joint is formed by the distal articular surfaces of the
scaphoid, lunate and triquetrum. The distal pole of the scaphoid and the
proximal articular surfaces of the trapezium (Tz) and the trapezoid (Td)
form the scaphotrapeziotrapezoid (STT) joint as a part of the midcarpal
joint. The scaphoid body articulates with the capitate. The lunate, trique-
trum, capitate and hamate form the 4-bone-corner. The lunate may have
two distal articular facets, a major one for the capitate and a smaller one
for the hamate (), which are separated by a longitudinal crest (). The
volar midcarpal ligaments are radially the scaphocapitate (SC) ligament
as the distal portion of the RSC ligament and ulnarly the capitotriquetral
(CT) ligament, that is usually covered by a fi broadipose structure ().
UH ulnar head, US ulnar styloid. [Modifi ed from Atzei A, Luchetti R,
Sgarbossa A, Carità E, Llusà M. Set-up, portals and normal exploration
in wrist arthroscopy. Chir Main. 2006;25 Suppl 1:S131-44. French. With
permission from Elsevier]
Fig. 1.15 Overview of the dorsal ( a ) and volar ( b ) portals used in wrist arthroscopy. Portals to the radiocarpal joint are marked in red , portals to
the midcarpal joint are marked in black and portals to the DRUJ are marked in blue
N. Badur et al.
11
Fig. 1.16 Anatomic dissection of the wrist from dorso-radial ( a ), dorsal
( b ), dorso-ulnar ( c ), ulnar ( d ) and volar ( e ). ( 1 ) First compartment: con-
taining the abductor pollicis longus (APL) tendon and the extensor pollicis
brevis (EPB) tendon. ( 2 ) Second compartment: containing the extensor
carpi radialis longus and -brevis (ECRL and ECRB) tendons. ( 3 ) Third
compartment: containing the extensor pollicis longus (EPL) tendon.
( 4 ) Fourth compartment: containing the extensor digitorum communis
(EDC) tendons and the extensor indicis proprius (EIP) tendon. ( 5 ) Fifth
extensor compartment: containing the extensor digiti quinti (EDQ) tendon.
( 6 ) Sixth extensor compartment: containing the extensor carpi ulnaris
(ECU) tendon. On the radial side of the wrist the sensitive branches of the
superfi cial radial nerve can be visualized and on the ulnar side the terminal
branches of the sensitive dorsal branch of the ulnar nerve. Entry portals to
the radiocarpal joint and the midcarpal joint are marked in red or black ,
respectively. Entry portals to the DRUJ joint are marked in blue [ ac :
Modifi ed from Atzei A, Luchetti R, Sgarbossa A, Carità E, Llusà
M. Set-up, portals and normal exploration in wrist arthroscopy. Chir Main.
2006;25 Suppl 1:S131-44. French. With permission from Elsevier]
1 Arthroscopic Wrist Anatomy and Setup
12
Dorsal Portals of the Radiocarpal Joint
Five standard dorsal portals of the radiocarpal joint are
routinely used [
35 ].
1-2 Portal
The 1-2 portal is situated between the fi rst extensor compart-
ment, containing the abductor pollicis longus (APL) tendon
and the extensor pollicis brevis (EPB) tendon, and the
second extensor compartment, containing the extensor carpi
radialis longus and -brevis (ECRL and ECRB) tendons.
Proximally it is bordered by the distal, radial end of the
radius, the radial styloid, and distally by the scaphoid.
Several important structures can be found in this interval and
may be endangered when establishing the 1-2 portal
(Fig. 1.19 ). Two branches of the sensory branch of the radial
nerve (SBRN) were shown in proximity with a mean of
3 mm radial and 5 mm ulnar to the portal. The radial artery
was located on average 3 mm radial to the portal [ 34 ]. In a
different study the mean distance of the SBRN was only
1.8 mm [ 36 ]. Partial or complete overlap of the lateral ante-
brachial cutaneous nerve (LABCN) with the SBRN is
reported in up to 75 % [ 49 ].
We recommend to carefully entry the joint capsule close
to the tendons of the fi rst extensor compartment and just dis-
tal to the radial styloid to avoid damage to the dorsal branch
of the radial artery. Inserting the optic through this portal
allows exploration of the entire dorsal capsule of the radio-
carpal joint and the major part of the anterior capsule with
Fig. 1.17 “Box concept” of the wrist. The wrist can be thought of as a
box, which can be visualized from almost every perspective. Through a
combination of arthroscopic portals it is possible to have viewing and
working portals that encircle the wrist. This enables the arthroscopic
surgeon to see and instrument from all directions [Modifi ed from Bain
GI, Munt J, Turner PC. New advances in wrist arthroscopy. Arthroscopy.
2008;24:355-67. With permission from Elsevier]
Fig. 1.18 Arthroscopic tour of the radiocarpal and midcarpal joint. For
the radiocarpal joint the primary viewing portal is the 3-4 portal and we
proceed from radial to ulnar, proximal to distal ( a ). For the midcarpal
joint the MCU portal is the main viewing portal and we proceed with
the arthroscopic tour from ulnar to radial ( b ). Abbreviations are accord-
ing to Fig.
1.14
N. Badur et al.
13
the extrinsic ligaments. Further the proximal pole and the
body of the scaphoid, the proximal pole of the lunate, the
articular surface of the radius, and the dorsal rim of the radius
can be visualized. This portal is mainly used as portal for
instrument placement in special surgical procedures as
arthroscopic arthrolysis, resection of volar or dorsal ganglion
cysts, or styloidectomy just to mention a few.
Proximal : we can observe the radial styloid and the scaph-
oid fossa of the radius.
Volar : we identify the radioscaphocapitate (RSC) liga-
ment and the long radiolunate (LRL) ligament that origi-
nate from the anterior margin of the radius.
Distal : the most proximal 2/3 of the scaphoid and the
proximal surface of the lunate can be visualized.
Radial : rotating the arthroscope to the radial side one is
very close to the radial part of the radiolunate articulation
and the vision is limited.
Ulnar : pivoting to the ulnar side the anterior margin of the
radius and the radioscapholunate (RSL) ligament (liga-
ment of Testut) can be appreciated.
Dorsal : rotating to the dorsal side we can see the entire
dorsal part of the radiocarpal capsule with an oblique
view of the dorsal radiocarpal ligament (DRCL).
3-4 Portal
The 3-4 portal is situated between the third extensor com-
partment, containing the extensor pollicis longus (EPL) ten-
don and the fourth extensor compartment with the common
nger extensor (EDC) tendons and the extensor indicis pro-
prius (EIP) tendon (Fig. 1.20 , Video 1.1 ). Proximally it is
boarded by the distal radius and distally by the scapholunate
ligament. The entry is 1 cm proximal to Lister’s tubercle.
The portal is considered safe with a low risk of damaging
neurovascular structures. The mean distance of the SBRN is
reported between 4.85 mm [ 36 ] and 16 mm radial to the
portal [ 34 ]. The main risk is damaging the EPL tendon itself.
We recommend to routinely establish this portal as the fi rst
portal for placement of the arthroscope. It is the main radio-
carpal viewing portal as almost the complete radiocarpal
articulation can be visualized through this portal:
Proximal : we can observe the distal radial epiphysis with
the interfosseal ridge that separates the scaphoid fossa
and the lunate fossa in a sagittal direction.
Volar : in the center of the fi eld of vision we see the RSL
ligament that has the aspect of a fi bro-fatty villus. It is con-
sidered to be more of a neurovascular connective tissue
than a true ligament [
50 ]. De facto it is the reference point
Fig. 1.19 Particular anatomy of the radial ( a ) and ulnar ( b ) aspect of
the wrist. Branches of the sensitive branch of the radial nerve (SBRN)
are moved radially by a retractor and the close relation of the dorsal
branch of the radial artery to the 1-2 portal becomes evident. On the
ulnar side the close relation of the two dorsal branches of the ulnar
nerve (UN) to the 6-U portal and the direct foveal (DF) portal is
demonstrated. The terminal branching of the dorsal branch of the ulnar
nerve (DBUN) is variable and a transverse branch of the DBUN
(TBDBUN) can be found in some cases [ a : Modifi ed from Atzei A,
Luchetti R, Sgarbossa A, Carità E, Llusà M. Set-up, portals and normal
exploration in wrist arthroscopy. Chir Main. 2006;25 Suppl 1:S131-44.
French. With permission from Elsevier]
1 Arthroscopic Wrist Anatomy and Setup
14
for the exploration of the radiocarpal articulation. The
volar radiocarpal ligaments are examined next. From
radial to ulnar we fi nd the stout radioscaphocapitate (RSC)
ligament, arising from the radial styloid, then inserting on
the waist of the scaphoid and reaching the palmar part of
the capitate. Ulnar to the RSC ligament we fi nd the long
radiolunate (LRL) ligament that is wider and its fi bers are
orientated more obliquely. Its insertion is mainly at the
lunate while some fi bers proceed to the triquetrum. The
short radiolunate (SRL) ligament is the most ulnar liga-
ment. The RSC and the LRL ligaments are separated by an
interligamentous gap where volar wrist ganglions usually
originate. The LRL ligament forms together with the SRL
ligament a reversed V that comprises the radioscapholu-
nate ligament. At the apex of the V one will fi nd the ante-
rior part of the scapholunate ligament.
Distal : The articular surfaces of the scaphoid and the
lunate and the scapholunate interosseous ligament (SLIL)
between the two bones are visualized. It appears as an
“indentation” and has a cartilage-like look [ 22 ]. The SLIL
can be divided into a weak anterior part, a thin membra-
nous proximal part and a strong dorsal part [ 51 ]. By
slightly fl exing and extending the wrist, the articular sur-
faces of the scaphoid and the lunate can be inspected
more volarly and dorsally.
Radial : rotating the arthroscope radially one can explore
the radial compartment of the radiocarpal articulation. We
can visualize the proximal pole and the body of the scaph-
oid, the radiocarpal ligament, the radial styloid, and the
scaphoid fossa of the radius very nicely.
Ulnar : rotating the optic to the ulnar side we can appreciate
the lunate fossa of the radius and the triangular brocartilage
complex (TFCC). Sometimes it can be diffi cult to see the
separation between the radial margin of the TFCC and the
articular surface of the lunate fossa of the radius. A probe
will help in distinguishing between articular surface and
TFCC. The TFCC is arranged in a three- dimensional man-
ner into three components: the proximal triangular liga-
ment, the distal hammock structure, and the ulnar collateral
ligament (UCL) [ 52 ]. The volar and dorsal distal radioulnar
ligaments (v-DRUL and d-DRUL) are thickenings of the
periphery of the TFCC. They originate from the ulnar mar-
gin of the radius and insert as the proximal component of
the TFCC at the ulna fovea (pc- TFCC) while the distal
hammock structure and the UCL represent the distal com-
ponent of the TFCC (dc-TFCC), attaching at the ulnar sty-
loid and the ulnocarpal capsule. If the TFCC is intact only
the superfi cial part of the ulnar attachment of the radioulnar
ligaments can be seen. In traumatic or degenerative central
TFCC lesions we can see onto the exposed ulnar head and
the pc-TFCC at the fovea can be visualized. The ulnocarpal
ligaments consist of the ulnolunate ligament (UL), the
ulnocapitate (UC) and the ulnotriquetral ligament (UT) and
originate at the anterior edge of the TFCC, the v-DRUL
and the ulnar styloid and insert on the lunate and the trique-
trum, respectively. It is also possible to visualize the presty-
loid recess, a synovial pouch that is located volar to the
ulnar styloid. The meniscus homologue, a synovial tissue
distal to the prestyloid recess that physiologically covers
the tip of the ulnar styloid, can sometimes present as an
indurated structure that can lead to impingement between
the ulnar styloid and the triquetrum [ 53 ]. Next we analyze
the complete articular surface of the lunate and the trique-
trum as well as the lunotriquetral ligament.
Fig. 1.20 Complete arthroscopic view of the radiocarpal joint through
the 3-4 portal, from the radial styloid to the ulnar insertion of the TFCC in
a right wrist. S scaphoid, R(S) scaphoid fossa of the radius, L lunate, R(L)
lunate fossa of the radius, T triquetrum, SL ( -line) scapholunate liga-
ment, RSC radioscaphocapitate ligament, LRL long radiolunate ligament,
TS Testut (radioscapholunate) ligament, SRL short radiolunate ligament,
LT ( -line) lunotriquetral ligament, UL ulnolunate ligament, UT ulnotri-
quetral ligament, V-DRUL volar distal radioulnar ligament, D-DRUL dor-
sal distal radioulnar ligament, @ gap between RSC and LRL ligament
[Modifi ed from Atzei A, Luchetti R, Sgarbossa A, Carità E, Llusà
M. Set-up, portals and normal exploration in wrist arthroscopy. Chir Main.
2006;25 Suppl 1:S131-44. French. With permission from Elsevier]
N. Badur et al.
15
4-5 Portal
This portal is situated between the fourth extensor compart-
ment containing the above-mentioned tendons and the fi fth
extensor compartment with the extensor digiti quinti (EDQ)
tendon. It is in line with the fourth metacarpal and slightly
proximal to the 3-4 portal. Proximally it is bordered by the
radius and distally by the lunate. Establishing the 4-5 portal
does not put any particularly relevant structures at risk except
from the EDC and EDQ tendons itself, dorsal sensory nerve
branches are at a mean distance of 16.13 mm (range: 9.48–
26.82 mm) [ 36 ]. The 4-5 portal has been the most frequently
used portal for placement of the instruments, however, nowa-
days it is less frequently used than the 6-R portal. The 4-5
portal allows observation of the same structures as the 3-4
portal but with a more direct view onto the ulnar compart-
ment of the wrist joint (Fig. 1.21 ). The possibility of exchang-
ing the position of the arthroscope and the instruments with
the 3-4 portal allows to accomplish surgical interventions in
all parts of the radiocarpal articulation:
Proximal : in the center of the fi eld of vision we see the
radial insertion of the TFCC that merges with the lunate
fossa on the radial side.
Volar : focusing on the ulnar side we encounter the LRL
ligament and the SRL ligament, the UL ligament and the
UT ligament.
Distal : we recognize the proximal lunate and triquetrum,
separated by the lunotriquetral interosseous ligament (LTIL).
Radial : swinging the arthroscope to the radial side we can
visualize the volar rim of the radius and the ulnar part of
the scaphoid fossa, the RSC and the LRL ligaments as
well as the dorsal capsule of the radiocarpal articulation.
We can observe the dorsal surface of the lunate and the
central, membranous part as well as the dorsal part of the
scapholunate ligament and its distal attachment to the
dorsal capsule.
Ulnar : rotating the arthroscope to the ulnar side we can
observe the most ulnar part of the TFCC up to the presty-
loid recess and the pisotriquetral articulation. The pisotri-
quetral joint is part of the wrist joint. It is a diarthrosis and
is enclosed in a small capsule. The pisotriquetral joint
often communicates with the radiocarpal joint through a
fenestration in the capsule [
54 ] .
6-R Portal
The 6-R portal is localized radial to the sixth extensor com-
partment that contains the extensor carpi ulnaris (ECU) ten-
don. Its radial border is the EDQ tendon. The portal is
approximately 5 mm distal to the dorsal part of the TFCC,
representing the proximal border. Distally the portal is
bounded by the lunotriquetral interosseous ligament. The
structure most at danger in establishing this portal is the
TFCC. To avoid damage of the TFCC this portal is estab-
lished by the use of a needle under direct vision of the arthro-
scope (Videos 1.2 and 1.3 ). The structure second most at risk
is the dorsal sensory branch of the ulnar nerve (DBUN)
(Fig. 1.19b ). The mean distance of the DBUN to the 6-R
portal has been found to be 8.2 mm [ 34 ]. A transverse branch
of the DBUN (TBDBUN) has been found in 27 % of dis-
sected cadavers [ 55 ] with a very variable course. If present it
is encountered a mean of 2 mm proximal to the 6-R portal
[ 34 ] (Fig. 1.22 ). Together with the 3-4 portal the 6-R portal
is one of the two essential portals in wrist arthroscopy as they
allow to examine and access the whole radiocarpal joint.
Although the 6-R portal is the main working portal, instru-
ments and the arthroscope can easily be switched between
those two portals. The 6-R portal shows the ulnocarpal com-
partment and is particularly useful in repairing lesions of the
TFCC, the lunotriquetral ligament or lesions of the lunate
and the triquetrum (Video 1.4 ):
Proximal : we can perfectly visualize the complete periph-
eral component of the TFCC up to the prestyloid recess
and the opening into the pisotriquetral bursa.
Volar : the ulnolunate and ulnotriquetral ligaments (ULL
and UTL), supporting the TFCC volarly, and the depres-
sion corresponding to the pisotriquetral articulation are
examined.
Distal : The entire articular surface of the triquetrum and
the central volar part of the LTIL can be analysed.
Fig. 1.21 Arthroscopic exploration of the ulnar compartment of the
wrist from the 4-5 radiocarpal portal. Abbreviations and symbols are
used according to the previous fi gure. ˚: entry to the pisotriquetral joint.
The opening is covered by a synovial membrane (right wrist) [Modifi ed
from Atzei A, Luchetti R, Sgarbossa A, Carità E, Llusà M. Set-up, por-
tals and normal exploration in wrist arthroscopy. Chir Main. 2006;25
Suppl 1:S131-44. French. With permission from Elsevier]
1 Arthroscopic Wrist Anatomy and Setup
16
Radial : sweeping the arthroscope radially we will fi nd
the TFCC, the lunate fossa of the radius and the short
radiolunate ligament. We also can explore parts of the
dorsal aspect of the radiocarpal articulation (Fig. 1.23 ,
Video 1.5 ).
Ulnar : rotating the arthroscope to the ulnar side it is pos-
sible to glide into the prestyloid recess and the pisotriqu-
etral space if the opening is not covered by a thick synovial
membrane as reported in 27 % [ 54 ] .
6-U Portal
The 6-U portal is situated ulnar to the ECU tendon. Ulnarly
it is bounded by the DBUN, proximally by the TFCC and
distally by the triquetrum. Damaging the terminal branches
of the DBUN that divides itself inconsistently about 1.5 cm
distal to this portal is the highest risk when establishing the
6-U portal. The frequent anatomical variations of the ter-
minal branching of the DBUN are an additional risk. The
mean distance of the DBUN from the 6-U portal is 8.3 mm
if there is only one terminal branch and 1.9 mm if two ter-
minal branches are present. In cases where a TBDBUN is
found the mean distance is 2.5 mm proximal to the portal.
In some cases the branch is crossing directly over the por-
tal [ 36 ]. Therefore the 6-U portal has been used for a long
time predominantly as an outfl ow portal. Some authors
however have shown that respecting certain rules and
keeping the possible anatomic variations of the dorsal
branch of the ulnar nerve in mind, the 6-U portal can be
used advantageously in diagnostic wrist arthroscopy and
in treating certain pathologies [ 56 ], especially those
around the ulnocarpal complex as the visualization of the
ulnocarpal compartment is excellent.
Proximal : we can see the ulnar and dorsal border of the
TFCC and the prestyloid recess.
Volar : the ULL and the UTL can be inspected.
Dorsal : the dorsal ulnotriquetral ligament on the dorsal
aspect of the TCFF may be visualized if not covered with
synovial tissue. The ECU subsheath is a further stabilizer
on the dorsal aspect of the TFCC but not visible with an
intact capsule.
Distal : the triquetrum can be perfectly displayed, most
notably the ulnar part as well as the depression between
the triquetrum and the lunate corresponding to the lunotri-
quetral ligament. The lunotriquetral ligament is more dif-
cult to detect than the scapholunate interosseous
ligament and probing the ligament is the best way to
localize it [ 57 ] .
Volar Portals of the Radiocarpal Joint
Two volar portals to the radiocarpal joint are used. Especially
the dorsal capsular structures, dorsal radiocarpal ligaments
and volar subregions of the scapholunate interosseous liga-
ment as well as the lunotriquetral interosseous ligament are
better visualized from a volar perspective [ 44 , 45 ].
Fig. 1.23 Arthroscopic view onto the dorsal aspect of the radiocarpal
joint from the 6-R portal. The dorsal, distal aspect of the lunate (L) and
the scapholunate ligament (-line) can be inspected up to the attach-
ment of the SL ligament to the dorsal capsule (§), that separates the
radiocarpal joint from the midcarpal joint (right wrist) [Modifi ed from
Atzei A, Luchetti R, Sgarbossa A, Carità E, Llusà M. Set-up, portals
and normal exploration in wrist arthroscopy. Chir Main. 2006;25 Suppl
1:S131-44. French. With permission from Elsevier]
Fig. 1.22 Open approach to the DRUJ after wrist arthroscopy. Note
the transverse branch of the dorsal branch of the ulnar nerve (TBDBUN)
crossing 3 mm proximal to the 6-R portal
N. Badur et al.
17
Volar Radial Portal (VR)
Two ways of establishing this portal have been described and
are considered safe. The fi rst method is the so-called in-out
technique, fi rst described in cadavers (Fig. 1.24 ) [ 43 ]: the
optic is placed in an ulnar portal (4-5 or 6-R), a blunt trocar
is inserted into the 3-4 portal and pushed towards the anterior
radiocarpal joint capsule. It is then pushed through the cap-
sule between the RSC and LRL ligaments, exiting next to the
exor carpi radialis tendon where a small skin incision is
made. A cannula can then be placed safely over the trocar
and the arthroscope inserted from the volar side into the
radiocarpal joint. The second method of establishing the
volar radial portal has also been shown to be safe [
44 , 45 ]: a
1–2 cm longitudinal skin incision is made at the proximal
wrist crease over the fl exor carpi radialis (FCR) tendon, the
tendon sheath is divided and the tendon retracted ulnarly.
After identifi cation of the radiocarpal joint space with an
18-G needle the volar capsule is penetrated with the tip of a
blunt artery forceps between the RSC ligament and the LRL
ligament. A blunt trocar is inserted with a cannula, the trocar
removed and the arthroscope is introduced over the cannula.
Structures at risk are the radial artery on the radial side and
the volar cutaneous branch of the median nerve (VBMN)
ulnarly (Fig. 1.16d ). There is a safe zone of 3 mm in all
directions with respect to the mentioned structures [ 47 ].
This portal allows visualization of the complete radiocar-
pal articulation, particularly the dorsal capsule, the dorsal
radiocarpal ligament (DRCL), the volar aspect of the bones
of the fi rst carpal row and the volar subregions of the
intercarpal ligaments. The TFCC can also be visualized
(Fig.
1.25 ). A good surgical indication where the volar radial
portal is benefi cial is arthroscopic arthrolysis in cases in
which complete dorsal capsulotomy for the treatment of fl ex-
ion stiffness is needed:
Proximal : the scaphoid and lunate fossae of the distal
radius as well as the dorsal rim of the radius can be
visualized.
Dorsal : the dorsal capsule is inspected, the established
dorsal 3-4 portal can be localized and the radiolunotriqu-
etral ligament is seen.
Distal : we can visualize the proximal pole of the scaphoid
and the volar part of the SLIL.
Radial : rotating the optic to the radial side it is possible to
visualize the radial styloid and the external part of the
articular capsule.
Ulnar : swinging the optic to the ulnar side one can visual-
ize the entire surface of the distal radius up to the TFCC
and the prestyloid recess. It is also possible to visualize
the anterior part of the lunate but the vision may be lim-
ited in cases where the radioscapholunate ligament is very
voluminous.
Volar Ulnar Portal (VU)
The volar ulnar portal of the radiocarpal joint has been
described by Slutsky [ 46 ]. Like the volar radial portal its
clinical experience is still limited. The VU portal is bounded
Fig. 1.24 Establishment of the volar radial radiocarpal portal with the
“in-out” technique (right wrist). The optic is introduced via a dorsal
ulnar portal (4-5 or 6-R): above the proximal pole of the scaphoid (S) is
visualized and below we see the scaphoid fossa of the radius (R(S)); the
trocar is introduced via the 3-4 portal and advanced through the gap (@)
between the radioscaphocapitate (RSC) and the long radiolunate (LRL)
ligaments and advanced volarly ( a ). On the volar radial side of the wrist
the skin incision is made at the level of the proximal wrist crease
( blue line ), radial to the fl exor carpi radialis (FCR) tendon, close to the
radial artery ( b ). After the blunt tip of the trocar has been advanced
volarly through the joint capsule, a trocar sleeve can be placed over the
trocar from the volar side, the trocar removed from the dorsal side and
the arthroscope is place into the trocar sleeve from volar ( c ) [Modifi ed
from Atzei A, Luchetti R, Sgarbossa A, Carità E, Llusà M. Set-up, por-
tals and normal exploration in wrist arthroscopy. Chir Main. 2006;25
Suppl 1:S131-44. French. With permission from Elsevier]
1 Arthroscopic Wrist Anatomy and Setup
18
proximally by the ulnar styloid, distally by the triquetrum,
ulnarly by the FCU tendon and radially by the fi nger fl exor
tendons. A 2 cm longitudinal skin incision is centered over
the proximal wrist crease along the ulnar edge of the com-
mon fi nger fl exor tendons (Fig. 1.7b ). The tendons are
retracted radially and the volar radiocarpal joint capsule is
pierced with an 18-G needle. The capsule is then pierced
with the tip of a blunt hemostat, followed by the insertion of
a cannula and a blunt trocar. The trocar is removed and the
arthroscope is inserted. The portal penetrates the ulnolunate
ligament adjacent to the radial insertion of the TFCC. As for
the establishment of the volar radial portal the volar ulnar
portal can also be created with the “in-out” technique with
the arthroscope in the 3-4 portal. A blunt trocar is inserted
into the 6-U portal and pushed towards the anterior ulnocar-
pal joint capsule. It is then pushed through the capsule
between the UL and UT ligaments, exiting ulnar to the fl exor
tendons where a small skin incision is made.
Structures at risk are the fl exor tendons, the ulnar artery
and ulnar nerve; however, they have been generally found
more than 5 mm ulnar to the trocar (Fig. 1.16d ). The median
nerve is protected by the fl exor tendons. The volar cutaneous
branch of the ulnar nerve is highly variable and its distal
branch is at risk with a volar ulnar approach if present.
Like the VR portal the VU portal provides a view of the
dorsal articular surface of the radius and the dorsal extrinsic
ligaments. Ulnar-sided structures that are more easily seen
from the ulnar volar side of the wrist include the volar subre-
gion of the LTIL, the dorsal distal radioulnar ligament, and
the dorsal ulnar wrist capsule, containing the ECU subsheath
(ECUS) [ 46 ]. Like the scapholunate interosseous ligament
(SLIL) the LTIL can be divided into three parts: the volar
part, the central part and the dorsal part [ 58 ]. While the cen-
tral part has more the structure of a thin membrane, the dor-
sal part of the SLIL and the volar part of the LTIL are the
most important subregions contributing to stability. The VU
portal is especially useful for the viewing and debridement
of palmar tears of the lunotriquetral ligament [ 46 ] and in
assisting in reduction of distal radius fractures [ 24 ].
Arthroscopy of the Midcarpal Joint
The midcarpal joint contributes together with the radiocarpal
joint to fl exion-extension and radio-ulnar deviation of the
wrist (Fig. 1.14 ) and arthroscopy of the midcarpal joint
should be routinely performed in every wrist arthroscopy.
Six portals to the midcarpal joint are used in wrist
arthroscopy (Figs. 1.15 and 1.16 ). Next to the two standard
dorsal midcarpal portals, one volar midcarpal portal [ 47 ],
the standard ulnar STT portal, the radial STT portal [ 59 ]
and the accessory triquetro-hamate (TH) portal [ 60 ] have
been described. The midcarpal joint is comprised of three
proximal bones: the scaphoid, lunate and triquetrum, and
four distal bones: the trapezium, trapezoid, capitate and
hamate. The depth of the midcarpal joint is less than half of
that of the radiocarpal joint and the joint is tighter than the
radiocarpal joint. The joint space of the scapholunate and
lunotriquetral articulation can be inspected directly as there
are no interosseous ligaments distally. The portal most
Fig. 1.25 Arthroscopic exploration of the radiocarpal joint from the
volar radial portal (right wrist). Abbreviations and symbols are used
according to the previous fi gures. Exploration of the ulnar part of the
radiocarpal joint and the ulnocarpal joint: the articular surface of the
lunate fossa of the radius can be examined and the corresponding proxi-
mal and volar aspect of the lunate. Further the radial insertion of the
TFCC, the TFCC and the volar- and especially the dorsal distal radioul-
nar ligaments are visualized. On the volar aspect the UL and UT liga-
ments can also be seen ( a ). With the probe in the 3-4 portal the Testut
ligament can be palpated. Especially the volar aspect of the scaphoid
and the scapholunate ligament is visualized ( b ). The dorsal extrinsic
radiolunotriquetral (RLT) ligament can be tested with a probe. The
proximal aspect of the scaphoid, lunate and the scapholunate ligament
are inspected ( c ) [Modifi ed from Atzei A, Luchetti R, Sgarbossa A,
Carità E, Llusà M. Set-up, portals and normal exploration in wrist
arthroscopy. Chir Main. 2006;25 Suppl 1:S131-44. French. With per-
mission from Elsevier]
N. Badur et al.
19
commonly used in midcarpal arthroscopy is the ulnar
midcarpal (MCU) portal.
Radial Midcarpal Portal (MCR)
The MCR portal is situated 1 cm distal to the 3-4 portal and
in line with the radial margin of the third metacarpal. It is
bounded radially by the ECRB tendon, ulnarly by the fourth
extensor compartment, proximally by the concave surface of
the scaphoid and distally by the proximal pole of the capi-
tate. The radial midcarpal portal is the principle midcarpal
portal as it allows visualization of the complete midcarpal
joint including the STT joint. Structures at risk while estab-
lishing this portal are the extensor tendons (Fig. 1.16a–c ).
The SBRN is found at a mean distance of 6.65 mm [ 36 ] to
15.8 mm radial to the portal and was found in one occasion
2 mm ulnar to the portal [ 34 ]. A small transverse skin inci-
sion is made over the palpable soft spot 1 cm distal to the 3-4
portal after the entry to the joint has been triangulated with
an 18-G needle. The joint capsule is pierced with a blunt
hemostat, then a trocar sleeve with a blunt trocar is inserted,
orientated approximately 10° proximally to parallel the dor-
sal midcarpal joint axis, followed by a 1.9 mm 30-degree-
angle arthroscope.
The complete midcarpal articulation can be visualized
(Video 1.6 ), the distal surface of the lunate, the triquetrum
and the scaphoid (Fig. 1.26a ) and the proximal surface of the
hamate and the capitate. Sweeping the arthroscope over the
distal pole of the scaphoid, even the proximal surface of the
trapezium and trapezoid can be evaluated (Fig. 1.26b ) and
resection of the distal pole of the scaphoid in STT arthritis is
possible. As the joint is usually tight it is however not always
possible to advance the arthroscope suffi ciently volar to see
the volar capsule and midcarpal ligaments [ 60 ]:
Proximal : we see the concave surface of the lunate and
the scaphoid, separated by a physiologic cleft correspond-
ing to the scapholunate articulation. A brocartilaginous
meniscus can be present in the joint, mainly at the volar
aspect.
Volar : when the joint is lax we can pass the arthroscope
volarly enough to visualize the distal part of the RSC liga-
ment that forms the radial limb of the arcuate ligament
anterior to the capitate.
Distal : the fi eld of vision is completely fi lled by the con-
vex head of the capitate.
Radial : sweeping the arthroscope radially along the
scaphoid, we can follow the complete scaphocapitate
articulation area up to the STT joint distally. The trape-
zoid is found more dorsally than the trapezium, the two
carpal bones are separated by a narrow groove corre-
sponding to the trapeziotrapezoidal articulation.
Sometimes the volar radial scaphotrapezial ligament can
be seen, a strong structure that is reinforced by the FCR
tendon sheath [ 60 , 61 ].
Ulnar : rotating the scope to the ulnar side we fi nd the
articulating corner of four carpal bones, forming a cross
by the hamate, capitate, lunate and triquetrum. We inspect
carefully the lunotriquetral joint and we can assess the
distal alignment of the articulating surfaces of the two
bones. A fi brocartilaginous meniscus can be present in the
joint. The lunate can present with one concave, articulating
Fig. 1.26 Arthroscopic exploration of the midcarpal joint through the
MCR portal (right wrist): below we see the concave surface of the
scaphoid (S) and the lunate (L), separated by a narrow gap correspond-
ing to the scapholunate articulation. Above the articular surface of the
round head of the capitate (C) can be inspected ( a ). Exploration of the
STT joint from the MCR portal (right wrist): the distal pole of the
scaphoid (S), articulating with the trapezium (Tz) and the trapezoid
(Td) can be assessed. Note that the trapezoid is encountered more dor-
sally than the trapezium and only the dorsal aspect of the trapezium can
be visualized through this portal ( b ) [Modifi ed from Atzei A, Luchetti
R, Sgarbossa A, Carità E, Llusà M. Set-up, portals and normal explora-
tion in wrist arthroscopy. Chir Main. 2006;25 Suppl 1:S131-44. French.
With permission from Elsevier]
1 Arthroscopic Wrist Anatomy and Setup
20
only with the capitate, or two concave facets for a
common articulation with the capitate and hamate. In this
case we fi nd a longitudinal ridge at the lunate, separating
the two articulation fossae to the hamate and the capitate,
respectively. Viegas has classifi ed the different types of
the lunate into type I, if articulating only with the capitate,
and type II, if an additional facet for the hamate is present
[ 62 ] (Fig. 1.27 ).
Ulnar Midcarpal Portal (MCU)
The MCU portal is situated symmetrically to the above-
mentioned portal in the soft depression of the four-corner
intersection of the hamate, capitate, lunate and triquetrum,
on the midaxial line of the fourth metacarpal where the soft
sport is easily palpable making it to the preferred portal to
be established fi rst for arthroscopy of the midcarpal joint
(Fig. 1.18b ). The portal is situated approximately 1–1.5 cm
distal to the 4-5 portal. It is bounded radially by the EDC
tendons and ulnarly by the EDQ tendon. In type I lunates the
proximal border is the lunotriquetral joint and the distal bor-
der is the capitohamate articulation. In type II lunates the
proximal border remains the same but the distal border is
the proximal pole of the hamate. The structure most at risk
is the EDQ tendon. The SBRN is remote to this portal and
the branches of the DBUN are found a mean of 15.1 mm
ulnar to this portal (Fig. 1.16a–c ). However, aberrant
branches can run closer or directly over the portal [
34 ]. In
type II lunates the exploration of the ulnar component of the
midcarpal joint is easier via the MCU portal (Fig.
1.28 ),
however, the visualization of the radial aspect of the midcar-
pal joint is not as good as through the MCR portal, espe-
cially the exploration of the STT joint is not convenient
from the MCU portal.
Proximal : the distal lunate with the lunotriquetral
articulation in the center and the scapholunate articulation
can be visualized (Videos 1.7 and 1.8 ).
Volar : one can identify the ulnar limb of the arcuate liga-
ment, the continuation of the capitotriquetral ligament
and the distal fi bers of the ulnocapitate ligament.
Distal : this portal allows visualization of the proximal
aspect of the capitate, the apex of the hamate, and the
capitohamate interosseous ligament (CHIL).
Radial : sweeping the arthroscope radially we have a bet-
ter view of the scapholunate articulation and the align-
ment of those two bones of the proximal carpal row can
be assessed. It is also possible to visualize and test the
scaphocapitate articulation with a probe inserted into the
MCR portal (Video 1.9 ), but not the STT joint.
Ulnar : looking ulnarly we see the distal surface of the
triquetrum and it is possible to analyze the articulation
between the hook-shaped tip of the hamate and the trique-
trum. The saddle-shaped triquetrohamate (TH) joint is
held tightly by the volar triquetrohamate and triquetro-
capitate ligaments [ 60 ] and it is diffi cult to enter the TH
articulation directly except in the setting of midcarpal
instability.
Fig. 1.27 Exploration of the corner of the four midcarpal bones
(lunate, triquetrum, capitate and hamate) via the MCR portal. Lunate
type I according to Viegas with one distal articular facet, articulating
with the capitate. Note the step of the triquetrum to the lunate that is a
physiological fi nding and not a sign for lunotriquetral instability. ()
Fibroadipose tissue, covering the capitatotriquetral ligament ( a ). Lunate
type II according to Viegas with a separate distal articular facet (L(H)),
articulating with the hamate (H). The facet articulating with the capitate
(L(C)) is bigger. The two facets of the lunate are separated by a longi-
tudinal crest () ( b ) [Modifi ed from Atzei A, Luchetti R, Sgarbossa A,
Carità E, Llusà M. Set-up, portals and normal exploration in wrist
arthroscopy. Chir Main. 2006;25 Suppl 1:S131-44. French. With per-
mission from Elsevier]
N. Badur et al.
21
Volar Midcarpal Portal (VM)
The volar midcarpal portal has been mentioned as an accessory
midcarpal portal [ 47 ], however, it lacks widespread use and we
do not have any clinical experience with this portal. The topo-
graphic landmarks and skin incision are the same as for the VR
portal (Figs. 1.15b and 1.16d ). The volar aspect of the midcar-
pal joint is identifi ed with a 22-G needle on average 11 mm
(range 7–12 mm) distal to the entry to the VR portal, and the
joint entered with a cannula and a blunt trocar after piercing the
joint capsule with a blunt artery forceps. The portal may be
useful in assessing the palmar aspects of the capitate and the
hamate in cases of avascular necrosis or osteochondral frac-
tures and the capitohamate interosseous ligament that provides
stability to the transverse carpal arch [ 63 ].
Scaphotrapeziotrapezoid Portal (STT)
The STT portal is found at the level of the STT joint in line
with the radial margin of the index metacarpal just ulnar to
the EPL tendon. The portal is bordered ulnarly by the ECRL
tendon, proximally by the distal pole of the scaphoid and
distally by the trapezium and the trapezoid and is localized
approximately 1 cm distally to the 1-2 portal. Structures that
can be jeopardized are the radial artery, the EPL tendon and
small terminal branches of the SBRN (Figs. 1.16a, b and
1.19a ). Establishing the portal on the ulnar side of the EPL
tendon usually keeps the radial artery safe.
The joint is triangulated with an 18-G needle, and con-
rming correct placement of the needle in the STT joint
under fl uoroscopy can be convenient. Then a skin incision is
made and the joint capsule pierced with a blunt artery for-
ceps. A 1.9 mm 30-degree-angled arthroscope is inserted
over a trocar sleeve after a blunt trocar has been introduced
to the joint.
The STT joint can be inspected, however, the concavity of
the distal pole of the scaphoid makes it diffi cult to explore
the anterior part of this articulation. The portal is primarily
utilized for instrumentation, particularly for arthroscopic
resection of the distal pole of the scaphoid in STT arthritis.
Radial STT Portal (STT-R)
The radial STT portal is situated at the same level of the STT
joint as the standard STT portal but radial to the APL tendon
[ 59 ]. The radial artery is found at a mean distance of 8.8 mm
radial to the portal. The terminal branches of the SBRN with
individual arborization are in close vicinity of the portal and
care must be taken when establishing the portal. The portal is
created as described for the standard STT portal above.
Together the two portals for the STT joint allow a working
angle of 130° and the radial STT portal (sometimes also
called volar STT portal) serves as a better working portal for
removal of the distal pole of the scaphoid in STT arthritis.
Triquetrohamate Portal (TH)
For completeness we mention the TH portal that is an acces-
sory portal on the ulnar aspect of the midcarpal joint. It is
located between the ECU and FCU tendon and is bordered
proximally by the triquetrum and distally by the base of the
fth metacarpal and the hamate. The portal has been
described for an infl ow or outfl ow cannula and can be used
as an instrument portal in assessing the triquetrohamate joint
and the proximal pole of the hamate [
60 ]. However, we do
not have any experience with this portal.
Fig. 1.28 Arthroscopic view of the midcarpal joint through the MCU
portal. The scapholunate articulation is tested with a probe ( a ) and is
intact as the probe cannot be protruded into the articulation. The articu-
lation of the lunate, triquetrum, capitate and hamate is inspected,
showing a lunate type Viegas II ( b ) [Modifi ed from Atzei A, Luchetti R,
Sgarbossa A, Carità E, Llusà M. Setup, portals and normal exploration
in wrist arthroscopy. Chir Main. 2006;25 Suppl 1:S131-44. French.
With permission from Elsevier]
1 Arthroscopic Wrist Anatomy and Setup
22
Arthroscopy of the DRUJ
The DRUJ is the main articulation of the wrist allowing
pronosupination. Arthroscopy of the DRUJ is the most
recently introduced part in wrist arthroscopy and pre-
served for special indications. The anatomy of the DRUJ
is complex. It is mostly described as a diarthrodial tro-
choid articulation composed of the medial articular facet
of the distal radius, the radial notch and the distal end of
the ulna. As the distal ulna not only articulates with the
distal radius but also with the carpus by the ulnocarpal
joint, arthroscopy of the DRUJ addresses the evaluation of
pathologies of the DRUJ and the ulnocarpal articulation.
In a normal wrist joint the TFCC with its volar and dorsal
distal radioulnar ligaments, merging at the insertion at the
fovea, supports the DRUJ. The volar branch of the DRUL
merges also with the ulnocarpal (UC) ligaments, which
also contribute stability to the ulnar side of the carpus
(Fig. 1.29 ).
In a normal wrist the DRUJ is very narrow and hard to
enter and explore, therefore the 1.9 mm arthroscope should
be used. Traction should be reduced to 3–5 kg for DRUJ
arthroscopy [ 5 ] to reduce the tension. As for the radiocarpal
joint arthroscopy fl uid distension is generally not necessary
for DRUJ arthroscopy. If needed we use saline to fl ush out
the synovial liquid in intense DRUJ synovitis, then the joint
is dried with suction. DRUJ arthroscopy is useful in the
assessment of soft tissue disorders and the articular cartilage
of the sigmoid notch or ulnar head [ 64 ].
Four portals for the DRUJ have been described, two dor-
sal portals [ 65 ], one volar portal (V-DRUJ) [ 39 ] and the
direct foveal portal (DF) [ 66 ] (Figs. 1.15 and 1.16 ).
The two dorsal portals, the proximal DRUJ portal
(P-DRUJ) and the distal DRUJ portal (D-DRUJ) are the stan-
dard portals for exploration of the DRUJ and normally uti-
lized for the assessment of the foveal insertion of the deep
component of the distal RUL as the main stabilizer of the
DRUJ or for arthrolysis of the DRUJ. However, we prefer to
start the DRUJ exploration through a dorsal portal located at
a midpoint between the traditional P-DRUJ and D-DRUJ
portals, below the radial insertion of the TFCC, at the point
where the distal profi le of the ulnar head curves to parallel
the sigmoid notch (Figs. 1.30 and 1.31 ). Through this portal
we assess the surface of the ulnar head, the TFCC with its
volar and dorsal distal RUL and its foveal insertion, and the
sigmoid notch. As in the radiocarpal joint the dorsal und
volar portals allow an omnidirectional evaluation of the
DRUJ (Fig. 1.32 ).
Distal DRUJ Portal (D-DRUJ)
This portal is located in line with and about 5–8 mm proxi-
mal to the 6-R portal just under TFCC (Fig. 1.16 ). With the
forearm in neutral rotation the TFCC has the least tension,
however, because of the shape of the ulnar head wrist supina-
tion facilitates the establishment of the dorsal DRUJ portals
(Fig. 1.33 ). The DRUJ is bordered radially by the EDQ and
EDC tendons and ulnarly by the ECU tendon. Proximally it
is bounded by the ulnar head and distally by the TFCC
(Fig. 1.16e ). The structure that can be jeopardized is the
TFCC, while the only sensory nerve in proximity to the por-
tal is the TBDBUN that has been found at a mean distance of
17.5 mm distally to the portal (Figs.
1.18b and 1.22 ) [ 34 ]. In
the presence of a positive ulnar variance this portal should
not be used [
64 ]. After localizing the portal with a 22-G
needle, a small longitudinal skin incision is made and the
Fig. 1.29 Drawing of the DRUJ. LT lunotriquetral ligament, ECU
extensor carpi ulnaris, 1, 2, 3: volar ulnocarpal ligaments (1: ulnotriqu-
etral, 2: ulnocapitate, 3: ulnolunate); A : volar distal radioulnar ligament,
B : dorsal distal radioulnar ligament, C : dorsal articular capsule
Fig. 1.30 Dorsal DRUJ portals: drawing of the dorsal portals. D : distal
DRUJ portal, P : proximal DRUJ portal, M : mid–DRUJ portal (pre-
ferred dorsal portal)
N. Badur et al.
23
dorsal capsule is pierced with a blunt artery forceps. Then a
cannula with trocar is inserted, followed by a 1.9 mm
30-degree- angle arthroscope. We recommend starting the
joint exploration by rotating the scope (Fig. 1.34 ), rather than
moving its tip inside the joint.
Proximal : the whole surface of the ulnar head can be
visualized.
Distal : the undersurface of the TFCC is visible.
Radial : rotating the scope radialwards the TFCC is visual-
ized and its radial insertion at the sigmoid notch of the
radius is shown (Fig. 1.35 ). The DRUJ capsule attaches to
the volar and dorsal distal radioulnar ligaments, and the
volar capsule of the DRUJ can be seen obliquely.
Ulnar : turning the arthroscope to the ulnar side, the prox-
imal insertion of the deep component of the distal radio-
ulnar ligaments, merging at the ulnar fovea, can be seen.
A 22-G needle, introduced from the area of the DF por-
tal, may elevate the ligament to obtain a better vision of
the ulnar part of the TFCC, inserting at the fovea
(Fig.
1.36 ).
Fig. 1.31 Establishment of our preferred dorsal DRUJ portal. The red
arrow is pointing at the entry portal and its relation to the classic proxi-
mal DRUJ portal (P-DRUJ) and distal DRUJ portal (D-DRUJ) ( a ).
Verifi cation of the correct entry point with introduction of a needle ( b )
and introduction of a blunt trocar over a trocar sleeve ( c )
Fig. 1.32 Drawing of the “box concept” of the arthroscopic portals to the DRUJ: dorsal view ( a ) and volar view ( b ). There are three dorsal and
two volar portals: (): preferred dorsal portal; (*): preferred volar portal
1 Arthroscopic Wrist Anatomy and Setup
24
Proximal DRUJ Portal (P-DRUJ)
The P-DRUJ portal is situated 1 cm proximal to the distal
DRUJ portal. It is located at the level of the proximal soft
spot of the DRUJ, corresponding to the axilla of the joint,
just proximal to the sigmoid notch of the radius and the fl are
of the ulnar metaphysis [ 64 ]. The portal is bordered radially
by the EDQ tendon and the radial sigmoid notch, ulnarly by
the ECU tendon and the neck of the ulna and distally by the
TFCC. The structure most at risk is the EDQ tendon. The
P-DRUJ portal is a very narrow portal. If preferred the joint
can then be fi lled with saline but the capacity of distension of
this articulation is limited. A small skin incision is made and
the dorsal joint capsule is pierced with a blunt hemostat. A
cannula with a blunt trocar is inserted, aiming slightly dis-
tally, then a 1.9 mm 30-degree wide-angle scope. On entry
into the P-DRUJ we can fi rst see the sigmoid notch of the
radius and the articular surface of the neck of the ulna
(Fig. 1.37 ). Systematically the following structures are
inspected:
Proximal : the palmar aspect of the capsule of the DRUJ
can be visualized.
Distal : the articular surface of the ulnar head can be seen
on the ulnar side and the junction of the TFCC to the sig-
moid notch of the radius is visible.
Fig. 1.33 Transverse drawing of the DRUJ in neutral rotation ( a ) and supination ( b ). Due to the osseous morphology of the ulnar head it becomes
evident that introduction of the scope through a dorsal portal into the DRUJ ( red arrow ) is easier when the wrist is fully supinated ( b )
Fig. 1.34 Rotation of the scope for a better vision of the DRUJ ( red arrows ). The rst position allows a better vision of the TFCC insertion (a );
the second allows a better vision of the radial insertion of the TFCC and the sigmoid notch ( b )
N. Badur et al.
25
Volar : the volar capsule of the DRUJ can be seen and the
course of the volar radioulnar ligament. The origin of the
volar ulnocarpal ligaments more distally is diffi cult to see.
Radial : the sigmoid notch of the radius can be inspected
by rotating the arthroscope radially.
Ulnar : the articular surface of the neck of the ulna can be
visualized by turning the scope to the ulnar side.
Volar Distal Radioulnar Portal (V-DRUJ)
Two ways of establishing the V-DRUJ exist. The initial
description of establishing the V-DRUJ portal uses the same
landmarks as those of the VU portal (Figs. 1.7b and 1.15b, e )
[ 39 ]. After the skin incision is made, the common fl exor ten-
dons retracted radially and the FCU tendon with the ulnar
neurovascular bundle retracted ulnarly, the joint capsule is
entered approximately 5–10 mm proximal to the entry to the
VU radiocarpal portal. The DRUJ joint is located with a
22-G needle and the joint capsule pierced with a blunt artery
forceps followed by insertion of a cannula and a blunt trocar,
then the arthroscope. Our preferred method for creating the
V-DRUJ portal uses a similar technique as described above
for the establishment of the volar radial radiocarpal joint
(Fig. 1.38 ). In our experience the ulnar neurovascular bundle
has never been damaged performing this technique. For the
introduction of the arthroscope through the V-DRUJ portal a
switching rod can be used.
From a volar approach the course of the dorsal radioulnar
ligament can be followed, which is not possible from the
dorsal DRUJ portals, until it merges with the volar radioulnar
ligament and inserts at the fovea. With the instruments placed
through one of the dorsal DRUJ portals, arthroscopic proce-
dures as the wafer partial ulnar head resection can be per-
formed directly under the TFCC instead of through its lesion
from above.
Direct Foveal Portal (DF)
The direct foveal (DF) portal as described by Atzei et al.
[ 66 ], is located approximately 1 cm proximal to the 6-U por-
tal (Figs.
1.15b , 1.16e , 1.39 ). For establishment of the DF
portal the forearm is held in full supination. That way the
portal is bounded by the ulnar styloid and the ECU tendon
dorsally, the fl exor carpi ulnaris (FCU) tendon volarly, the
ulnar head proximally and the TFCC distally. The DBUN is
at risk and is usually displaced dorsally to the portal if the
Fig. 1.35 Arthroscopic exploration of the DRUJ through the D-DRUJ
portal. SN sigmoid notch, UH ulnar head, (): central insertion of the
TFCC, (): radial insertion of the volar and dorsal branches of the TFCC
Fig. 1.36 Arthroscopic view of the undersurface of the TFCC with its
volar and dorsal DRUL, merging at the insertion at the fovea ( blue
arrows )
Fig. 1.37 Arthroscopic exploration of the DRUJ from the P-DRUJ
portal. UH ulna head, SN sigmoid notch
1 Arthroscopic Wrist Anatomy and Setup
Fig. 1.38 Technical procedure to establish the volar DRUJ portal: A
blunt trocar perforates the volar capsule and is pushed through the volar
skin after a small skin incision is made ( red circle ) ( a and b ). The trocar
is then used as a guide for the introduction of the shaver into the DRUJ,
the trocar is pulled backwards and the shaver advanced into the DRUJ
through the volar DRUJ portal ( c and d ). Handling of the arthroscope
and shaver. The Surgeon should stay at the ulnar side of the wrist ( e )
Fig. 1.39 Anatomic location of
the DF portal ( a ). The DF portal
is located 1 cm proximal to the
6-U portal and a skin incision can
connect those two portals while
leaving the retinaculum and
capsule intact ( b )
27
forearm is held in supination (Fig. 1.16e ). A 22-G needle is
inserted percutaneously just underneath the TFCC to verify
the correct position. Then a small longitudinal skin incision
is made between the ECU and FCU tendon. Next the exten-
sor retinaculum is exposed and split along its fi bers. The
DRUJ capsule is incised longitudinally to reach the distal
articular surface of the ulnar head under the TFCC.
When the surgeon is more experienced with establishing
this portal and familiar with the anatomy, the DF portal can
be created using the standard portal establishing technique
without any clinically relevant disturbance to the DBUN.
The DF portal is used as a dedicated working portal for
xation of the TFCC to the ulnar fovea in proximal TFCC
lesions. Small shavers or curettes are used to debride the torn
or avulsed ligament back to healthy tissue, debride the fovea
and prepare it for suture screw or anchor insertion while the
arthroscope is in the distal DRUJ portal.
Conclusion
Wrist arthroscopy is a reasonable recently introduced tech-
nique but has continued to evolve rapidly. In its beginnings
wrist arthroscopy was primarily used for diagnostic pur-
poses. The introduction of smaller optics and miniaturized
instruments however has allowed the development of more
arthroscopically sophisticated surgical interventions.
Nowadays it is impossible to ignore the impact of therapeu-
tic wrist arthroscopy that limits the iatrogenic effect of open
wrist procedures, e.g., as creating intra-articular fi brosis. It
has been proved more reliable in assessing many wrist
pathologies than even sophisticated MRI images. Step by
step and adapting to the surgical needs, the portals for wrist
arthroscopy have been developed. Starting with the four
classic standard portals (3-4 radiocarpal, 4-5 radiocarpal,
radial midcarpal and ulnar midcarpal), an increasingly
number of new portals as well as volar portals have been
established and proved to be safe. However, the learning
curve takes its time and precise knowledge of the anatomy
and the pathologies of the wrist is crucial in order to limit
the risk of complications or true diagnostic or therapeutic
failures. Earlier teaching of wrist arthroscopy has been per-
formed under simple observing conditions. Nowadays the
teaching is much more structured and numerous instruc-
tional courses are offered, allowing to study wrist arthros-
copy and the handling of the arthroscope and instruments in
cadavers. The European Wrist Arthroscopy Society (EWAS,
www.wristarthroscopy.eu ) has developed specifi c courses
on fresh cadavers for a couple of years. Practicing on cadav-
ers and examining the wrist joint from different portals and
viewing angles helps in understanding the three-dimen-
sional anatomy of the wrist. Once normal arthroscopic wrist
anatomy is clear, pathologic problems can be more readily
identifi ed and treated. It is without doubt that the creativity
of the surgeon and the introduction of adapted miniaturized
instruments will allow for realization of precise perfor-
mance and continuous development of more and more
sophisticated arthroscopic techniques.
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N. Badur et al.
... [8] Nevertheless, the benefits of arthroscopic wrist surgery were huge in comparison to open surgery, where arthrofibrosis can be a massive drawback. [9] The use of wrist arthroscopy has allowed us to understand the complexity of the anatomy of the TFCC. By 1996, an arthroscopic classification system of scapholunate (SL) ligament injuries emerged [10] and the complex anatomy of radial-sided ligamentous stabilizers was appreciated. ...
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Triangular fibrocartilage complex (TFCC) tears are a frequent cause of ulnar-sided wrist pain, and our understanding of these injuries has evolved significantly over the past few decades. As we have come to better understand these complex injuries, the indications for surgery have been refined and classifications have been created to delineate what specific types of pathology are clinically relevant to the surgeon. Similarly, surgical treatment methods have evolved as well. TFCC repairs were initially performed open, but there has been a shift toward performing these repairs arthroscopically. Moreover, there is a plethora of literature describing different techniques for arthroscopic repair. In this chapter, we describe an arthroscopic technique for transosseous repair of peripheral TFCC repairs to the ulnar foveal through an ulnar bone tunnel. It is our belief that this technique is a relatively straightforward and reproducible way to anatomically reduce the TFCC to its footprint on the ulnar fovea and thus restore stability to the distal radioulnar joint (DRUJ). In addition to background information about the diagnosis of and clinical treatment guidelines for TFCC tears, this chapter describes in detail our technique for performing an arthroscopic peripheral TFCC repair through an ulnar bone tunnel.
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Secondary wrist stiffness usually occurs following trauma or surgery and is classified as intra-articular, capsular, or extra-articular. Arthrofibrosis affects the radiocarpal, midcarpal, ulnocarpal, and/or distal radioulnar joints. Conservative treatment is the mainstay of management. Once conservative modalities fail, surgical arthrolysis, either open or arthroscopic, helps to relieve pain and restore motion. Arthroscopic arthrolysis involves resection of intra-articular adhesions, chondral debridement, capsulotomy, and release of radiocarpal ligaments. Arthroscopy will often reveal other occult pathologies which can be treated during the same procedure if appropriate. Rehabilitation should be started immediately after surgery and individualized to the pathologies and requirements of the patient. Arthroscopic arthrolysis is the surgical treatment of choice as it is less invasive, allows immediate postoperative mobilization with minimal scarring.
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We 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 we compared this technique with conventional wrist arthroscopy, performing the new method first followed by conventional arthroscopy. The advantages are 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. In terms of diagnostic sensitivity, we found our technique matched that of conventional arthroscopy. We had no difficulty in carrying out minor surgical procedures such as debridement and suturing.
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Since its introduction more than three decades ago, wrist arthroscopy has continually evolved. The procedure has a wide list of indications, including diagnostic and management applications. The scope of practice for the wrist arthroscopic surgeon includes management of triangulofibrocartilage complex pathology, evaluation and management of carpal instability, assistance in fracture reduction of the radius and scaphoid, treatment of trapeziometacarpal synovitis and arthritis, distal ulnar and carpal bone excisions, and salvage procedures. In addition, innovations such as new portals and smaller arthroscopes have expanded the applications of wrist arthroscopy.
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A retrospective analysis was performed based on the medical records and imaging studies of 16 wrists (14 patients) with isolated partial intercarpal ligament tears (scapholunate ligament: 6 wrists, lunotriquetral ligament, 10 wrists) treated with arthroscopic debridement and thermal shrinkage. Three wrists had Geissler grade 1 tears and 13 wrists had grade 2 tears. Mean follow-up was 52.8 months. Overall pain visual analog scale scores improved significantly (P<.05) at rest and during activities of daily living and heavy manual work. Mean flexion-extension arc was 136.5°. Mean postoperative grip strength was 106 lb, which was significantly better than preoperative grip strength. Mean modified Mayo wrist score was 70 preoperatively and 94.7 postoperatively, a significant improvement. Overall functional outcomes according to the modified Mayo wrist score were rated as excellent in 13 wrists and good in 3. No patient had radiographic evidence of instability or arthritic changes. The scapholunate and lunotriquetral intervals in all patients were less than 3 mm on neutral and pronation grip radiographs. On lateral radiographs, no signs of intercalated segmental instability were seen, with a mean scapholunate angle of 55.3°. The results of this study suggest that arthroscopic debridement and thermal shrinkage provide symptomatic pain relief and prevention of intercarpal instability for a significant period of time in patients with partial intercarpal ligament tear.