Arthroscopy of the wrist joint

A wrist joint is a complex of joints connecting the wrist with the forearm. The carpal joint includes the wrist, distal radial-fiber, carpal, intervascular, carpal-metacarpal and intercostal joints. The carpal joint is small in size and at the same time it is formed by 8 bones of the wrist, radial and ulnar bones, a three-faceted fibrous-cartilaginous complex (cartilaginous articular disc).

Damage to the wrist joint is various and can arise on the basis of traumatic, infectious-inflammatory, degenerative and congenital causes. Among all injuries of the musculoskeletal system, injuries and diseases of the wrist joint range from 4 to 6%.

The complexity of the anatomical structure, the variety of movements and the high functional requirements imposed on the wrist joint necessitate the most accurate and careful execution of surgical manipulations on the wrist joint with its damage. In connection with this, arthroscopic surgery becomes more important.

Arthroscopy allows for direct visualization of all intra-articular structures of the wrist joint: articular surfaces, synovial membrane, carpal bones, etc.

In case of acute damage to the capsular-ligament apparatus, arthroscopy is recommended in cases where, after the fixation period necessary for the normalization of the joint state, and subsequent recovery treatment, the condition does not improve. Earlier, in such situations, doctors had to use ultrasound, MRI, contrast arthrography to clarify the nature of the intra-articular lesions received. However, the effectiveness of arthroscopy of the radiocarpal joint markedly changed this situation: arthroscopy along with these diagnostic methods allowed not only to detect, but also to perform simultaneous correction of intraarticular deviations. In some cases (according to different authors, up to 75%), arthroscopy can detect lesions of the triangular fibrotic cartilaginous complex, semilunar triangular and semilunar-navicular instability, chondromalation of articular surfaces and joint fibrosis, while in most cases when carrying out special radiation examinations (ultrasound, MRI) do not reveal any pathological changes.

[1], [2], [3], [4]

Indications for arthroscopy of the wrist joint

At present, it is difficult to formulate clear criteria for the need for surgical treatment. This is due to the fact that the indications for arthroscopy of the wrist joint are constantly expanding. They are determined on the basis of an evaluation of the integrity of the ligamentous apparatus: in the presence of ligament injuries, the degree of rupture is assessed, as well as the presence of instability associated with this damage. Also of great importance are the presence and extent of damage to the three-faceted fibro-cartilaginous complex, the revealed cartilage defects in the wrist and wrist joints and chronic wrist pain of unknown etiology.

Thanks to arthroscopy, minimally invasive and low-traumatic performance of the following treatment and diagnostic measures became possible.

• Control of reposition of fragments with extra-focal or minimally invasive osteosynthesis of intraarticular fractures of the wrist bones.
• Instability of interosseous joints (suturing, vaporization, radiofrequency ablation of ligaments).
• Damage of a three-faceted fibrous-cartilaginous complex (stitching, resection or debridement).
• Arthroscopic synovectomy.
• Detection and removal of intraarticular bodies.
• Ganglionectomy.
• Sanitation and lavage of the wrist joint.
• Carpal tunnel syndrome.

Technique of operation of arthroscopy of the wrist joint

The space available for carrying out arthroscopic manipulations is much less in the wrist than in larger joints. For arthroscopy of the wrist joint, a tool of smaller diameter (2.7-2.9 mm with a viewing angle of 30 and 70 °) is needed. Accurate placement and proper selection of tools makes it possible to ensure normal visualization of all structures and perform manipulations on all parts of the wrist joint.

For artificial increase of the joint cavity during arthroscopy it is necessary to stretch the brush. The degree of traction is different and depends on the tasks performed. There are several methods of stretching.

• They impose a specially developed universal traction system.
• Preliminary application of the external fixation apparatus is carried out, by means of which the distraction is performed.
• The assistant performs manual traction for a brush or for a finger.

The most important for the successful implementation of arthroscopy of the wrist joint is the knowledge of the normal anatomy of the joint and the precise placement of arthroscopic portals. Inappropriate placement of portals can not only interfere with the operation, but also lead to additional damage to intraarticular or periarticular structures.

Portal 3 - 4 is standardly used for visualization; 4-5 and 6 - R - the main working portals for performing various manipulations. The outflow is established through the 6-U portal.

Complications of arthroscopy of the wrist joint

With proper observance of the technique of surgery, complications of arthroscopy of the wrist are extremely rare. They can be prevented by following the following rules.

• The surgeon must absolutely accurately navigate the anatomical structure of the joint, should be familiar with the anatomical landmarks and the location of the arthroscopic portals.
• It is necessary to observe the correct location and direction of the portals. Toolkit should always be directed along the portal lines, so that the tool instead of the joint cavity does not get into the soft tissues outside the joint.
• In order to avoid damage to intraarticular structures, it is important to use blunt trocars and perform manipulations only when the visualization of the working surface of instruments inside the joint is clearly visible.
• A well-established drainage system avoids liquid entry into soft tissues.
• The use of physiological solution promotes the fastest absorption of fluid in soft tissues, thus reducing the risk of contraction syndrome.

[5], [6]