ARTHROSCOPY OF THE WRIST

Use and technical possibilities

Christian DUMONTIER
Institut de la Main, Hôpital Saint Antoine, HEGP

With the collaboration of Didier FONTES and Remy BLETON

Clinique Moventis, HEGP, Paris - - Hôpital Foch, Suresnes

The wrist is a frequent source of pain, the clinical and radiographic investigation of which remains
difficult (See Maîtrise Orthopédique n°49). Accordingly, arthroscopic diagnosis is still indicated in 
some cases. However, as in other joints, wrist arthroscopy is, above all, a therapeutic act. Although
its use is not yet widespread in France, probably because of the material cost, wrist arthroscopy is
an ever-growing part of the therapeutic arsenal of hand surgeons. In certain indications, the results
of arthroscopic treatment are now superior to those of open techniques. At present, the number of
patients in published series and follow-up are sufficiently extensive for arthroscopy of the wrist to
warrant more widespread attention. Even if you have few indications in your practice, this short
article is designed to illustrate what one sees in an arthroscope and how it can be used. This is only
an introduction, which is in no way intended to replace regularly organized theoretical and practical
courses, notably those of the Société Française d'Arthroscopie. For didactic reasons, all the inner 
views of the joints are those of a right wrist.

Regional anesthesia is sufficient. The patient is placed in the supine position on a table with an arm
support and an inflatable cuff. The wrist must be placed in traction, using either a system such as
that used for shoulder traction or fingertraps (The arm should be blocked proximal to the elbow under
the inflatable cuff.)

Another possibility is to use a swiveling arm support, entirely sterilizable and placed on the table
facilitating ulnar and radial deviation. Traction should not exceed 3 to 5 kg, depending on the
patients.

In any event, the wrist must be free, especially if one uses an image intensifier.
 The material used must be adapted. An endoscope 2.7 mm in diameter is ideal. A 3-mm endoscope
can also be used, but this may hinder insertion into the mediocarpal joint in certain patients. The 1.9-
mm endoscopes are fragile and their field of view is more limited. They are especially useful in the
scaphoid-trapezium-trapezoid joint and indispensable if one intends to perform arthroscopy of the
trapezium-metacarpal joint.

A small hook, a shaver with a 3-mm resector, and a 3-mm burr are indispensable. The shaver can, in
some cases, be replaced by electrocautery of appropriate size. Needles for suturing or more
sophisticated devices are also useful for intraarticular sutures. If one uses a drill, it should be
waterproof.

Irrigation is best performed using a pump with sensors (but there is a risk of fluid diffusion, notably in
fractures). Otherwise, one can use drip infusion, in some cases even a simple system of irrigation by
an assistant with a syringe.

The surgeon sits at the posterior side of the wrist (practically all portals are posterior), the video
system being placed in front of the surgeon, on the other side of the patient in most cases.

For the radiocarpal joint, the portals bear the names of the compartments of the underlying
extensors. These consist of the 1-2 portal (between the abductor pollicis longus and extensor carpi
radialis), the 3-4 portal (between the extensor pollicis longus and extensor digitorum communis), the
4-5 portal (between the extensor digitorum communis and extensor digiti minimi), the 6R portal (radial
at the extensor carpi ulnaris) and the 6U portal (ulnar at the extensor carpi ulnaris).

There are several portals. One should always use at least two per joint, and they are
interchangeable. The portals should be drawn on the skin before fluid distension using bony landmarks
of the hand: Lister's tubercle, distal radioulnar joint, capitate neck, the second and third
carpometacarpal joint, as well as tendinous landmarks: extensor carpi ulnaris, extensor pollicis longus,
and the common extensor.

The anterior 3-4 portal is the most useful and easiest to draw on the skin. It is situated
approximately 1 cm under the Lister's tubercle, which is always palpable (except in radial fractures).
This portal is situated immediately distal to the angle in the extensor pollicis longus. The anterior 3-4
portal is not dangerous, tendons (8 mm) and nerves (16 mm) being situated at a distance. The
instrument should be inserted straight ahead, with a proximal tilt of roughly 10° to take into account 
 the slight sagittal angle of the radius.

For a triangular approach, an ulnar portal is needed, either 4-5 or 6R. The choice depends on the
surgeon and on the lesion being treated. The 4-5 portal is situated approximately 1 cm distal to the
radioulnar joint line (it is necessary to take into account the ulnar length on preoperative films). The
tendons (7 mm) are at a distance and the risks are low. The 6R portal is immediately radial to the
extensor carpi ulnaris. Tendons (4 mm) and nerves (7 mm) are closer, but the risks are minimal.
Insertion is aimed slightly laterally, toward the center of the wrist.

For the mediocarpal joint, three portals are useful, but only two are commonly used: the radial
midcarpal (RMC) and ulnar midcarpal (UMC) portals. The STT portal is used only for the procedures
involving this joint.

The STT portal leads directly to the STT joint. This portal is found directly by palpating the joint line,
but it is dangerous, because of the proximity of the radial artery. This risk is reduced by insertion
medial to the extensor pollicis longus tendon.

Normal Radiocarpal arthroscopy

Before penetrating the radiocarpal joint, it must be distended. Fluid is injected into the 3-4 joint in
most cases, given the straightforwardness there. One should see the return of fluid to be certain of
the intraarticular placement. Very often the capsule swells and the wrist moves slightly.
 The first elements seen upon penetration through the 3-4 portal are the capillaries of the anterior
capsule. By pulling the arthroscope slightly back, a vascularized "ball" sparsely covered with filaments
comes into view. It is a fatty structure, which accompanies the Testut and Kuentz radial
scapholunate ligament. In the 3-4 portal, this is the primary landmark, which permits orientation in
the radiocarpal joint.

By turning the arthroscope toward the lateral side of the wrist, a curtain of two oblique ligaments
appears. The medialmost ligament is the radiolunate ligament, the lateralmost ligament is the radial
scaphocapitate ligament, and between the two begins Poirier's space, where anterior synovial cysts
develop. More laterally, one may begin to see the lateral edge of the scaphoid, which can be followed
to its distal third.

Turning toward the medial side, one is blocked by the projection of the convex proximal aspect of the
lunate. The anterior ulnocarpal ligaments are often poorly visible through this portal, as is the
lunotriquetral joint line.

Far on the medial side coursing in a deep direction, one sees a cavity, which is often sparsely lined
with filaments. This cavity is the prestyloid recess, where the greatest amount of synovial
proliferation is situated in rheumatoid arthritis. This cavity constitutes the medial limit of the
triangular fibrocartilage complex (TFCC), a set of anatomic structures including the triangular
ligament.

Turning the arthroscope 180°, one brings into view the proximal portion of the joint with, laterally to 
medially, first the radial styloid, 4 mm to 5 mm of which is intraarticular.
 Then the scaphoid fossa of the radius, separated from the lunate fossa by a marked crest.

More medially, the junction between the articular surfaces of the radius and the TFCC is difficult to
see, but palpation permits clear distinction of the limits. Radial surfaces are hard, while the ligament
can be depressed, but preserves a physiological tension, which has been referred to as the
“trampoline” effect. There is often a certain degree of synovitis, which partially hides the ulnar
insertion of the TFCC, and which one has to resect for a clear view.

This portal permits complete exploration of the radiocarpal joint, the medial portal providing a
pathway for instruments. However, it is important to change arthroscopes and instruments to get a
complete view from two different angles.

Medial portals show the same structures from a different angle. Insertion is still oriented toward the
center of the wrist. Consequently, the same landmarks are used: laterally, the convex aspect of the
lunate above, the scapholunate “buttocks” with the scapholunate ligament between the two, and
further back, the radius and the radial styloid.

From the medial portals are best seen the posterior capsule and the scapholunate ligament, the latter
on the posterior aspect, which has greater physiological significance.

Medially, there is a better view of the TFCC, the synovial recess and, in some cases, the
pisotriquetral joint. The lunotriquetral joint line, very oblique, is always difficult to see, but one can
probe the lunotriquetral ligament with a hook palpator.
 The arthroscope is directed upward. Moving it medially, one brings into view the capitate-hamate
junction, then the superior aspect of the hamate.

Especially in subjects with pronounced laxity, it is possible to see the triquetrocapitate ligament, the
internal branch of 5th ligament. Laterally, the head of the capitate can be bypassed to penetrate into
the scaphocapitate joint space.

If one turns the arthroscope 180°, one has a better view of the inferior aspect of the proximal row of 
carpal bones. Laterally, the scaphoid is separated from the lunate by a space of approximately 1 mm
into which it is not usually possible to introduce the hook palpator. Both articular surfaces are at the
same level.

In 45% to 63% of cases, the inferior articular surface of the lunate displays two facets.

In this configuration, the lunotriquetral joint line articulating with its counterpart capitate hamate has
a crenellated aspect, and the hook of the hamate bears two articular facets (type 2 configuration).
 This complex resembles the pelvis and thighs of a woman seen from the front, while the first row is
similar to her intimate region, i.e., another way of distinguishing between the two joint lines.

More medially, the lunotriquetral joint space is also flush, and it is not possible to slip a hook into it.

Arthroscopic diagnosis remains useful in the work-up of ligamentous lesions (determination of severity
and search for associated degenerative osteoarthritis) and in certain chronic painful wrists (to look
for chondral lesions difficult to see on imaging studies). However, arthroscopy is above all a technique
of therapeutic interest, providing numerous possibilities, some of which remain anecdotal.

l Arthroscopic treatment of scapholunate ligamentous lesions

l Arthroscopic treatment of TFCC lesions
l Arthroscopic treatment of fractures of the radius
l Arthroscopic treatment fractures of the scaphoid
l Arthroscopic treatment of degenerative lesions of the medial edge of the carpal bones, notably in
hyperpressure syndrome.
l Arthroscopic debridement of chondral lesions of the radial styloid, the STT, the mediocarpal joint, …
l Arthroscopic treatment of dorsal and volar synovial cysts,
l Arthroscopic synovectomy, notably in rheumatoid arthritis
l Partial osseous resection of the carpal bones

Arthroscopy has several advantages: primarily diagnostic. Most of the ligamentous tears seen in
arthrography are bilateral; rupture is not synonymous with instability.

The degree of instability may be better evaluated through mediocarpal portals. These signs of
instability include joint dislocation and abnormal mobility between bones during passive wrist
movements.

Normally, it is impossible to slip a hook or other instruments between the bones.

The existence of a spontaneous abnormally wide joint space and the possibility of introducing a hook
are also signs of instability.

In certain cases, the radiocarpal joint is visible through the mediocarpal portal, reflecting severe
lesions.

On the contrary, the joint space may contain post-traumatic fibrous scarring, which is necessary to
excise to expose the lesions. Whipple suggested arthroscopic treatment of scapholunate injuries by
creating fibrous nonunion. This involves freshening of the scapholunate joint with a shaver through a
mediocarpal portal, then inserting 4 to 6 fine scapholunate pins attempting to obtain an osteofibrous
syndesmosis.

Ligamentous lesions of the TFCC are frequent and one of the best therapeutic indications. These
lesions are either traumatic (Palmer type 1) or degenerative (Palmer type 2) and, in this case, involve
a long ulna.

The surgeon should pronate the forearm to be certain to have harmoniously resected 1 to 2 mm of
the distal portion of the ulna. This is sufficient to relieve internal hyperpressure.

Treatment assisted by arthroscopy of radial fractures

As in the knee, arthroscopic verification of radial surfaces has been proposed in the management of
fractures of the radius, involvement of the articular surface being suggestive of poor prognosis.
Arthroscopy permits assessment of associated ligamentous lesions, and contributes to the quality of
articular reduction. In a series of 105 fractures, Doi showed that the quality of outcome was better in
 the group managed with arthroscopic verification.

From a practical standpoint, the surgeon should wrap the forearm with elastic banding to avoid fluid
diffusion, a theoretical source of compartment syndrome, even though this complication has yet to be
reported with this technique. After washing, which should be abundant, the articular surfaces are
“tacked” with pins of 0.12 mm used for manipulating the fragments.

One begins by restoring the length of the lateral column, onto which the fragments are returned.
Once the reduction is obtained, the pins are pushed under fluoroscopic guidance. This procedure is
long and demanding. The indications are still limited, but in young subjects, the initial published
results are promising.

Chondral lesions

These lesions are frequent in the wrist, and difficult to delineate with conventional imaging studies. In
a series of 54 cases of chondral lesions, Koman reported 34 that had failed to be detected
preoperatively. In most cases these lesions were situated on the hook of the hamate, perhaps
favored by an anatomic predisposition (lunate of type 2), on the posterior aspect of the triquetrum,
or on the radial styloid.

The treatment of synovial cysts

A capsulectomy centered on the insertion of the capsule across from the scapholunate joint can be
used to empty the cyst arthroscopically. We often inject the cyst with methylene blue preoperatively
to facilitate localization of the cyst and its neck during the intervention. There is a risk involving the
extensor tendons, which one always sees at the end of the procedure.
 When proximal, cysts near the radial artery arise from the radiocarpal joint between the radiolunate
ligament and the radial scaphocapitate ligament. They are also accessible to rather simple
arthroscopic treatment, because a shaver inserted through the 3-4 portal arrives directly on the
capsule. The radial artery, in danger in conventional surgery, is in this technique at a distance,
because the artery is separated from the capsule by the thickness of the cyst.

Resection of the distal end has been proposed and can, in some cases, be achieved arthroscopically
if the joint space is not too tight.

Conclusion

In our opinion, wrist arthroscopy warrants more widespread use. Although its development is less
rapid than that of shoulder or elbow arthroscopy, wrist arthroscopy is a promising technique. With
quite limited morbidity, it permits a substantial number of technical procedures in a large range of
domains, from traumatology to the treatment of cysts. The indications still need to be clarified, but
orthopedic hand specialists should master the technique wrist arthroscopy. For those who wish to
learn more, numerous books and articles are now available and several courses are organized every
year in France.

Maîtrise Orthopédique n°119 - 2002, December

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