Wrist Arthroscopy Info Evidence Consent

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview

• Wrist arthroscopy provides views of and access to the intraarticular spaces of the wrist that are otherwise difficult to achieve without widely open approaches [1].
• Wrist arthroscopy is a useful tool in the diagnosis and treatment of wrist pathology [1].
• Postoperative infection after wrist arthroscopy is uncommon but clinically relevant [2].
• Postoperative infection after wrist arthroscopy is particularly relevant in elderly patients [2].
• Postoperative infection after wrist arthroscopy is particularly relevant in male patients [2].
• Postoperative infection after wrist arthroscopy is particularly relevant in patients with systemic comorbidities [2].
• Postoperative infection after wrist arthroscopy is particularly relevant in patients undergoing synovectomy [2].
• A simple, effective, and cost-efficient solution exists to overcome oversized finger traps for wrist arthroscopy distraction [3].

Anatomy & Pathophysiology

Bony Anatomy

• The wrist includes the distal radioulnar, radiocarpal, and ulnocarpal joints and the eight carpal bones and their proximal and distal articulations and attached ligaments [15].
• The carpus comprises eight ossicles traditionally separated into a proximal row (scaphoid, lunate, triquetrum, pisiform) and a distal row (trapezium, trapezoid, capitate, hamate) [15].
• The distal radius articular surface has two concave facets, the scaphoid and lunate facets, separated by the scapholunate ridge [17].
• The sigmoid notch along the ulnar border of the distal radius is a shallow concavity for the articulating ulnar head at the distal radioulnar joint [17].
• The distal ulna is covered with hyaline cartilage on its dorsal, lateral, palmar, and distal surfaces [17].
• The ulnar styloid projects distally, and at its base, the fovea is the insertion for the triangular fibrocartilaginous complex (TFCC) [17].
• The scaphoid's primary vascular supply is a branch of the radial artery at the dorsal ridge, with smaller vessels entering the palmar tubercle to supply the distal 30% [17].
• The lunate has a dorsal and palmar vascular supply in 80% of wrists, while only a palmar supply is found in 20% of wrists [17].
• The capitate head often relies on a retrograde vascular supply [17].
• The pisiform is a sesamoid bone within the flexor carpi ulnaris tendon and serves as the origin for the abductor digiti minimi [17].
• Viegas emphasized considerable variation in the fourth carpometacarpal articulation and in the scaphotrapeziotrapezoid, capitolunate, and hamatolunate articulations [15].

Ligaments

• The triangular fibrocartilage complex (TFCC) is formed by the central meniscus homolog, the dorsal and volar radioulnar ligaments, the floor of the extensor carpi ulnaris tendon sheath, and the volar ulnocarpal ligaments [17].
• The TFCC arises from the radial border of the distal radius and inserts into the base of the ulnar styloid and distal ulna through the ligamentum subcruentum [17].
• The dorsal and volar radioulnar ligaments are the primary stabilizers of the distal radioulnar joint [17].
• Only the peripheral 10% to 40% of the volar, ulnar, and dorsal TFCC has a vascular supply [17].
• The scapholunate interosseous ligament is C-shaped in the sagittal plane, with the dorsal third being the thickest and strongest portion [17].
• The volar portion of the lunotriquetral ligament is the thickest [17].
• The extrinsic wrist ligaments include the dorsal intercarpal ligament and the dorsal radiocarpal ligament [17].
• The intrinsic wrist ligaments include the scapholunate interosseous ligament and the lunotriquetral interosseous ligament [17].
• The radial collateral ligament originates from the radius 0 mm from the radial styloid and inserts on the scaphoid waist and distal palmar trapezium [17].
• The radioscaphocapitate ligament originates from the radius 4 mm from the radial styloid and inserts on the scaphoid waist and midpalmar capitate [17].
• The radiolunatotriquetral ligament originates from the radius 10 mm from the radial styloid and inserts on the lunate or triquetrum [17].
• The dorsal radiocarpal ligament originates at the dorsal lip of the distal radius adjacent to the Lister tubercle and inserts into the lunate and triquetrum [17].
• The dorsal intercarpal ligament arises from the triquetrum and inserts on the scaphoid, trapezoid, and capitate [17].
• The ulnotriquetral ligament originates from the volar radioulnar ligament and inserts on the triquetrum [17].
• The ulnolunate ligament originates from the volar radioulnar ligament and inserts on the lunate [17].
• The ulnocapitate ligament originates from the volar margin of the ulnar head and inserts on the capitate [17].

Vascular Anatomy

• The terminal branches of the radial, ulnar, and anterior interosseous arteries provide extraosseous blood supply to the carpus through three dorsal and three palmar transverse arterial arches with longitudinal connections [19].
• The dorsal radiocarpal arch is located at the radiocarpal joint and supplies the lunate and triquetrum [19].
• The dorsal intercarpal arch is the largest dorsal arch, located between the proximal and distal carpal rows, supplying the distal carpal row and, through anastomoses, the lunate and triquetrum [19].
• The basal metacarpal arch is the most variable dorsal arch, located at the base of the metacarpals to supply the distal carpal row [19].
• The palmar radiocarpal arch is located at the level of the radiocarpal joint on the palmar surfaces of the lunate and triquetrum [19].
• The intercarpal palmar arch is the most variable palmar arch and does not contribute to nutrient vessels in the carpus [19].
• The deep palmar arch is located at the level of the metacarpal bases, is consistent, and communicates with the dorsal basal metacarpal arch and palmar metacarpal arteries [19].

Kinematics and Biomechanics

• The wrist functions as a two-joint system linking the hand to the forearm around the highly mobile bones of the proximal carpal row [18].
• The two principal articulations are the radiocarpal and midcarpal joints, situated proximal and distal to the mobile proximal carpal row [18].
• The proximal carpal row has no muscular or tendinous attachments and is an intercalary segment [17].
• With ulnar deviation, the proximal row extends relative to the forearm/distal row, while with radial deviation, the proximal row flexes relative to the forearm/distal row [17].
• With axial loading through the neutral wrist, approximately 80% of forces are transmitted through the distal radius (60% scaphoid facet, 40% lunate facet) and 20% through the distal ulna [17].
• With wrist flexion, 60% of the motion is midcarpal and 40% is radiocarpal [17].
• With wrist extension, 33% of the motion is midcarpal and 66% is radiocarpal [17].
• The dart-thrower’s path of radial extension to ulnar flexion defines the transition between flexion and extension of the scaphoid and lunate [18].
• The dart-thrower’s motion occurs almost exclusively through the midcarpal joint and rotation occurs along the mechanical axis of the wrist [18].
• The lunate, capitate, hamate, trapezium, and trapezoid function collectively as the "stable central column," controlled by the scaphoid in a two-gear, four-bar linkage system [18].
• The triquetrum buffers lunate rotation and prevents ulnar translation in the stable central column model [18].

Pathophysiology

• Scapholunate advanced collapse (SLAC) wrist pathophysiology involves scapholunate interosseous ligament injury and extrinsic ligament complex attenuation leading to palmar flexion of the scaphoid and extension of the lunate (DISI) [13].
• In SLAC wrist, the radioscaphoid joint becomes incongruous, altering normal radioscaphoid contact forces and leading to arthrosis [13].
• As the scaphoid flexes and the scapholunate diastasis increases in SLAC wrist, the capitate migrates proximally [13].
• Altered intercarpal contact forces in SLAC wrist result in arthrosis at the capitolunate joint [13].
• The radiolunate joint is typically spared in SLAC wrist because of its spheroid shape [13].
• Ulnocarpal impingement is a degenerative condition resulting from a discrepancy in the relative length of the distal articular surfaces of the radius and ulna (positive ulnar variance) [13].
• Posttraumatic causes of ulnocarpal impingement include distal radius fracture with shortening, Galeazzi or Essex-Lopresti fracture, and childhood epiphyseal plate injuries [13].
• Congenital causes of ulnocarpal impingement include dyschondroplasia (Madelung deformity) and naturally occurring positive ulnar variance [13].
• The classic pattern of rheumatoid arthritis (RA) wrist deformity involves the radiocarpal and radioulnar joints with destabilization of the carpus caused by attenuation of the extrinsic wrist ligaments [22].
• RA wrist deformity results in ulnar-palmar translocation and wrist supination [22].
• Three main pathophysiological factors play the greatest role in RA wrist deformation: cartilage destruction, synovial expansion, and ligamentous laxity [22].
• Bony erosion in RA arises due to synovial expansion, particularly at the site of vascular penetration into the bone such as the radial origin of the Testut ligament [22].
• In RA, the scapholunate interval starts to dissociate and continues to disintegrate the internal carpal architecture [22].
• The force vector across the RA wrist predominately acts in a palmar-ulnar direction [22].
• Flexion of the scaphoid through the weakening of the scapholunate ligament leads to collapse of the radial column in RA [22].
• Stretching of the wrist ulnar collateral ligament attenuates ulnar column support, leading to a typical carpal supination pattern in RA [22].
• Volar flexion of the lunate relative to the scaphoid occurs in early-to-midstage RA wrists due to intrinsic ligament laxity, mainly of the scapholunate ligament [22].
• In later RA stages, the capitate tends to flex dorsally due to midcarpal instability as a result of extrinsic ligament weakening [22].
• The dorsal wrist ganglion is the prototype of all ganglions of the hand and accounts for 60% to 70% of all hand and wrist ganglions [5].
• The main cyst of a dorsal wrist ganglion is usually located directly over the scapholunate ligament [5].
• A small, mucin-filled duct invariably pierces the transverse fibers of the scapholunate ligament, connecting the underlying scapholunate joint with the main cyst [5].

Classification

TFCC Tear Classification

• The Palmer classification categorizes TFCC tears into traumatic (class 1) or degenerative (class 2) [25].
• Subtypes of TFCC tears are based on the specific location within the TFCC [25].
• The class and location of a TFCC tear have important implications for treatment [25].
• Class 1A TFCC injuries are characterized by central perforation or tear [25].
• Class 1B TFCC injuries are characterized by ulnar avulsion with or without ulnar styloid fracture [25].
• Class 1C TFCC injuries are characterized by distal avulsion involving the origins of the ulnolunate and ulnotriquetral ligaments [25].
• Class 1D TFCC injuries are characterized by radial avulsion involving the dorsal and/or volar radioulnar ligaments [25].
• Class 2A TFCC tears are characterized by TFCC wear or thinning [25].
• Class 2B TFCC tears are characterized by TFCC wear plus lunate and/or ulnar chondromalacia [25].
• Class 2C TFCC tears are characterized by TFCC perforation plus lunate and/or ulnar chondromalacia [25].
• Class 2D TFCC tears are characterized by TFCC perforation, lunate and/or ulnar chondromalacia, and lunotriquetral ligament disruption [25].
• Class 2E TFCC tears are characterized by TFCC perforation, lunate and/or ulnar chondromalacia, lunotriquetral ligament disruption, and ulnocarpal and DRUJ arthritis [25].

Diagnostic Evaluation

• Arthroscopy is the gold standard for detection of TFCC tears [25].
• The arthroscopic trampoline test is performed to assess TFCC resiliency by balloting the central portion with a small probe [25].
• The arthroscopic hook test can be used to demonstrate peripheral detachment of the TFCC [25].
• The arthroscopic suction test can show laxity of the TFCC when peripherally scarred in or foveal detachment when the DRUJ is clinically unstable [25].
• MRI is controversial for TFCC pathology, but newer innovations suggest value in detection and localization [25].

Clinical Presentation

Indications for Diagnostic Arthroscopy

• Chronic wrist pain of uncertain etiology is an indication for diagnostic wrist arthroscopy [14].
• Failed conservative treatment for over 3 months is an indication for diagnostic wrist arthroscopy [14].
• Assessment of ligament and chondral lesions in acute wrist fractures is an indication for diagnostic wrist arthroscopy [14].
• Assessment of Kienböck disease and posttraumatic arthritis is an indication for diagnostic wrist arthroscopy [14].

History and Physical Examination Principles

• A thorough history and physical examination should precede the review of radiographs or special imaging studies to avoid cognitive bias [23].
• The patient's medical history should include details about the mechanism of injury, acuity, location, duration, and characteristics of pain [23].
• History should include aggravating and relieving factors and previous treatments [23].
• For chronic problems, history should include the patient's jobs, hobbies, and exposure to repetitive stress, vibrating tools, or potentially dangerous instruments [23].
• A history of ligamentous laxity or multiple joint instabilities should be elucidated, especially in younger patients with chronic wrist pain [23].
• Assessment of the patient's stress coping skills should be included in the evaluation [23].
• Palpation for areas of maximal tenderness is one of the most useful tools in the diagnosis of wrist pathology, especially in patients with chronic dysfunctions [23].
• In acute dislocations, tenderness is seldom elicited at specific points but rather in a diffuse manner due to extensive soft tissue damage [23].
• Palpation should be performed methodically, starting from the basal joint of the thumb and proceeding across the proximal carpal row from the scaphoid to the triquetrum [23].
• Palpation continues from the hamate and its hook back across the distal row and CMC joints, ending with provocative clinical maneuvers [23].
• A careful assessment of neural and vascular status is imperative, with particular attention to the median and ulnar nerves [23].
• The median and ulnar nerves may be injured by direct contusion, compression from displaced bones, or swelling within the carpal canal [23].
• A thorough set of provocative maneuvers should be performed to rule out alternative or concurrent diagnoses [23].
• The examination should begin in a nontender area and proceed rotationally around the carpus, ending at the most symptomatic area [23].
• Bilateral grip and pinch strength are useful to uncover underlying pathology in chronic cases [23].
• Strength may be diminished due to muscle atrophy, pain inhibition, or learned behaviors [23].
• Rapid alternating grip assessment may be helpful in determining voluntary effort [23].
• A local injection of anesthetic to a painful joint or selected tendon sheath may help normalize dynamometer readings and narrow the diagnostic spectrum [23].
• Sensory testing should accompany an examination of suspected nerve compression using threshold or density testing [23].

Specific Provocative Maneuvers and Tests

• Watson’s scaphoid shift test involves pressure directed over the palmar scaphoid tuberosity while the wrist is moved from ulnar to radial deviation [13].
• A positive Watson shift test results when the scaphoid subluxates dorsally out of the scaphoid fossa and relocates when pressure is released [13].
• The midcarpal joint "pivot shift" test consists of supinating and volar subluxing the distal row of the carpus [27].
• The pivot shift test is performed by placing the patient elbow upon a firm surface, holding the elbow at 90 degrees, putting the hand into a fully supine position, and holding the distal forearm firmly [27].
• In the pivot shift test, the hand is moved into full radial deviation and then the ulnar side of the carpus is forced into further supination and a volar subluxed position [27].
• The wrist must not be flexed during the pivot shift test [27].
• The hand is gently moved from radial to full ulnar deviation while the displacing force is applied during the pivot shift test [27].
• In a normal wrist, the capitate engages the lunate as the hand moves from radial to ulnar deviation, notching into a less supinated position [27].
• Rupture, attenuation, or excess laxity allow the capitate to drift out of the lunate during the pivot shift test [27].
• Watson’s test is designed to show scaphoid instability [27].
• In Watson’s test, the examiner places one hand on the radial border of the distal forearm with the thumb on the palmar aspect of the scaphoid [27].
• The examiner moves the patient’s hand to bring about ulnar then radial deviation of the wrist while maintaining thumb pressure on the scaphoid [27].
• Watson’s test causes a dorsal subluxation of the scaphoid accompanied by a painful click [27].
• Ballotment tests or shear tests demonstrate abnormal movements between adjacent bones by exerting pressure in opposite directions [27].
• Ballotment tests can show instability of the scapholunate joint, lunotriquetral joint, capitolunate joint, or at the distal radioulnar joint [27].
• Triquetral hamate instability is demonstrated with the wrist straight with ulnar deviation [27].
• Triquetral hamate instability produces a firm block after a range of about 20 degrees of ulnar deviation [27].
• Forcing a sharp click accompanied by discrete posterior movement of the wrist indicates the proximal row has moved from the VISI position to the DISI position [27].
• The ligamentous habitus of a given individual must be assessed using information from the normal wrist due to wide variation in mobility and laxity [27].
• Special maneuvers are performed first on the normal side and then on the symptomatic wrist [27].
• Areas of tenderness, clicks, or clunks associated with the production of pain are noted during the examination [27].

Distal Radioulnar Joint (DRUJ) and Ulnar-Sided Pathology

• An exaggeration of the normal ulna head prominence is seen in dorsal subluxation or articular effusion [27].
• The ulnar head prominence may be temporarily reduced by direct pressure over the ulna head [27].
• In the rheumatoid wrist, the ulnar head prominence is further exaggerated by a supination deformity of the carpus [27].
• If the hand is held in full ulnar deviation and the ulna head is held forward by the examiner’s thumb, significant pain may be precipitated by this movement alone [27].
• Pain precipitated by pronosupination while the ulna head is pressed volarward and the pisiform pressed dorsally is usually indicative of some form of ulnar impingement or abutment syndrome [27].
• Pain on the dorsal side of the DRUJ and an intermittent clicking sensation are symptoms of ulnocarpal impingement [13].
• Pain exacerbated by forearm rotation and ulnar deviation is a symptom of ulnocarpal impingement [13].
• Pain with axial loading of the ulnar side of the wrist is a symptom of ulnocarpal impingement [13].
• Pain with dorsal and palmar displacement of the distal ulna, with the wrist in ulnar deviation (positive ballottement test), is a symptom of ulnocarpal impingement [13].
• Pain on the dorsum of the wrist with limitation of forearm pronation and supination is a symptom of DRUJ arthrosis [13].
• Snapping and crepitus at the DRUJ are symptoms of DRUJ arthrosis [13].
• Clinical findings for DRUJ arthrosis include pain that increases with proximal rotation of the forearm and compression of the ulna against the radius [13].
• The diagnosis of DRUJ arthrosis is confirmed by improvement in rotation and grip strength with injection of a local anesthetic into the DRUJ [13].

Scapholunate Advanced Collapse (SLAC) Wrist

• Reduced grip and pinch strength are symptoms of SLAC wrist [13].
• Stiffness with extension and radial deviation is a symptom of SLAC wrist [13].
• Localized tenderness at the radioscaphoid articulation is a symptom of SLAC wrist [13].
• Decreased wrist motion on extension and radial deviation is a symptom of SLAC wrist [13].

Arthroscopic Diagnostic Correlation and Preoperative Considerations

• Patients without positive provocative sign on examination seldom yield positive findings at wrist arthroscopy [14].
• Arthroscopic findings need to correlate with clinical examination [14].
• For chronic ulnar wrist pain, a portal should not be created on the ulnar wrist before the ulnocarpal joint is inspected from the 3-4 portal [14].
• Postoperative infection after wrist arthroscopy is uncommon but clinically relevant, particularly in elderly, male patients with systemic comorbidities or undergoing synovectomy [2].

Investigations

Diagnostic Utility and Indications

• Wrist arthroscopy provides views of and access to intraarticular spaces of the wrist that are otherwise difficult to achieve without widely open approaches [1].
• Wrist arthroscopy has developed from a mostly diagnostic tool into an effective therapeutic tool for the treatment of wrist disorders ranging from arthritis to acute fractures [10].
• Arthroscopic assessment of intercarpal ligament injuries and instability is considered by many the “gold standard” for evaluation of these conditions [10].
• Arthroscopic assessment is also considered the gold standard for examination of patients who have wrist pain of unknown origin [10].
• Indications for wrist arthroscopy include the evaluation of ligamentous injuries, examination of joint articular surfaces, removal of loose bodies, biopsy of synovium, irrigation and debridement of joints, and confirmation and supplementation of wrist arthrography [10].
• Wrist arthroscopy has produced new arthroscopic classifications for disorders such as Kienböck disease, TFCC injuries, and interosseous ligament tears that can help guide treatment [10].

Comparison with Arthrography

• Arthroscopy has been found to be more accurate than arthrography in identifying the location and size of triangular fibrocartilage and interosseous ligament injuries [10].
• Arthroscopy is more accurate than triple-injection cinearthrography in detecting tears of the dorsal sensory branch of the ulnar nerve during arthroscopic repair of the triangular fibrocartilage [10].

Comparison with MRI

• MRI should be added for evaluation of the triangular fibrocartilage, the distal radioulnar joint (DRUJ), and vascularity of the various carpal bones, extrinsic ligaments, joint surfaces, and surrounding soft tissues to confirm clinical suspicion and correlate with physical examination findings [11].
• A high rate of false-positive findings on MR images of normal subjects has been reported [11].
• A dedicated wrist coil provides enhanced resolution of wrist structures [11].
• With proper technique, injuries to the triangular fibrocartilage complex (TFCC) can be demonstrated with MRI [21].
• The TFCC is composed of signal-poor fibrocartilage, and perforations in the TFCC appear as linear defects or gaps filled with hyperintense fluid on coronal gradient-echo or T2-weighted pulse sequences [21].
• Evaluation of the scapholunate and lunotriquetral ligaments is more challenging than TFCC evaluation, but with optimal technique and equipment the integrity of these structures can be consistently assessed [21].
• The addition of arthrographic contrast improves the visualization of scapholunate and lunotriquetral ligaments on MR images [21].
• Extrinsic carpal ligaments can be identified with three-dimensional volumetric scanning and subsequent reconstruction [21].
• MRI assessment of extrinsic carpal ligaments has less impact on treatment at present [21].
• MRI is useful in detecting additional marrow abnormalities in osteonecrosis, as seen in the lunate in Kienböck disease or in the scaphoid after fracture [21].
• Asymmetry of marrow signal in proximal and distal fragments of a fractured scaphoid is suggestive of proximal pole ischemia [21].
• MRI currently has a limited role in the evaluation of carpal tunnel syndrome, which remains a clinical diagnosis [21].
• Axial imaging with T2 weighting can clearly display masses within the confines of the carpal tunnel, as well as edema and swelling of the median nerve [21].
• Tenosynovitis and tendon injuries in the wrist and hand can be assessed with MRI [21].
• MRI provides earlier detection of synovitis and erosive bone changes associated with rheumatoid arthritis than do radiographs [21].

Radiographic Techniques

• After the history and physical examination, radiographic evaluation is helpful in determining the diagnosis, prognosis, and management of wrist problems [11].
• Routine radiographic series for wrist evaluation consists of four views: posteroanterior, lateral, oblique, and ulnar-deviated posteroanterior scaphoid view [11].
• Spot views of the carpal bones for detail (carpal tunnel view) are a useful radiographic technique [11].
• Fluoroscopic spot views of the wrist are a useful radiographic technique [11].
• A series of views for instability includes anteroposterior clenched fist, posteroanterior in neutral, radial, and ulnar deviation, lateral in neutral and full flexion and extension, semipronated oblique 30 degrees from the posteroanterior, and semisupinated oblique 30 degrees from the lateral [11].
• Diagnostic ultrasound is a useful radiographic technique for evaluating a painful wrist [11].
• Cine or video fluoroscopy is a useful radiographic technique for evaluating a painful wrist [11].
• Bone scanning is a useful radiographic technique for evaluating a painful wrist [11].
• Arthrography of the wrist (triple injection when indicated) is a useful radiographic technique [11].
• CT is a useful radiographic technique for evaluating a painful wrist [11].

Preoperative Assessment for Specific Pathologies

• Careful preoperative palpation of a dorsal wrist ganglion cyst with digital compression often reveals its extent and the direction of the pedicle [5].
• Transillumination or aspiration confirms the diagnosis of a dorsal wrist ganglion preoperatively [5].
• Review of the patient's preoperative radiographs to rule out an interosseous component is wise when evaluating a dorsal wrist ganglion [5].

Treatment

Indications and Diagnostic Role

• Wrist arthroscopy provides views of and access to intraarticular wrist spaces that are difficult to achieve without widely open approaches [1].
• Diagnostic arthroscopy is indicated for the evaluation of chronic wrist pain of uncertain etiology with more than 3 months interval that is unresponsive to conservative treatment [9].
• Diagnostic arthroscopy is indicated for the assessment of acute ligamentous injuries, including scapholunate, lunotriquetral, and triangular fibrocartilage complex (TFCC) injuries [9].
• Diagnostic arthroscopy is indicated for the evaluation of carpal instability [9].
• Diagnostic arthroscopy is indicated for the assessment of chondral lesions [9].
• Diagnostic arthroscopy is indicated for the evaluation of associated soft tissue injury in fracture conditions, including distal radius, scaphoid, ulnar styloid, and other carpal bone fractures [9].
• Diagnostic arthroscopy is indicated for the assessment of scaphoid healing in delayed union and nonunion [9].
• Diagnostic arthroscopy is indicated for the staging of posttraumatic arthritis, including scapholunate advanced collapse (SLAC), scaphoid nonunion advanced collapse (SNAC), and distal radius fractures [9].
• Diagnostic arthroscopy is indicated for the evaluation of monoarticular arthritis and synovial biopsy [9].
• Diagnostic arthroscopy is indicated for the evaluation of Kienböck disease [9].

Operative Setup and Technique

• The patient is positioned supine on the operating table for wrist arthroscopy [9].
• A traction device is applied to distract the wrist joint, using either an overhead traction boom or a dedicated sterilizable wrist traction device [9].
• Traction force of 10 to 12 lb is applied through plastic finger traps over the index and middle fingers, or preferably the middle three fingers [9].
• Overdistraction or the use of wire finger traps may cause postoperative finger joint pain or localized contusion to soft tissue or digital nerves [9].
• Nylon finger traps are more comfortable and atraumatic to the patient, especially in awake cases [9].
• An additional trap and traction can be applied to the thumb for arthroscopy over the scaphotrapeziotrapezoid joint [9].
• When an overhead traction boom is employed, countertraction is provided by securing the arm to the hand table, and the operated limb is draped free up to the elbow level [9].
• When a dedicated wrist traction device is used, the limb is draped up to the axilla level and the lower arm is wrapped to the basal plate of the device close to the elbow level [9].
• A traction device should be sterilizable and allow flexible positioning of the wrist intraoperatively in varying degrees of extension, flexion, and radial and ulnar deviation [9].
• Tourniquet use is optional and is often unnecessary for diagnostic and uncomplicated therapeutic procedures performed under local anesthesia without sedation [9].
• Joint visibility is maintained by saline inflow, as the small volume of the wrist makes fluid distention impractical compared to the knee or shoulder [9].
• The main maneuver in creating working space is controlled traction, while saline maintains a clear view by removing intraarticular debris through the outflow portal [9].
• The hydrostatic pressure generated by saline serves a hemostatic role when arthroscopy is performed without a tourniquet [9].
• Continuous irrigation is achieved with a 3 L bag of normal saline suspended 1.5 m above the patient and instilled under gravity [9].
• Gentle manual pumping is used occasionally, such as in acute fracture treatment, for the removal of blood clots [9].
• Caution should be used to avoid extravasation of fluid that may lead to compartment syndrome [9].
• A pressure control device is not essential for wrist arthroscopy irrigation [9].

Therapeutic Procedures

• Ablative soft tissue procedures include TFCC debridement, debridement of ligament tears, synovectomy, wrist ganglionectomy, removal of loose body, capsulotomy/capsulectomy, lavage, and arthrolysis [9].
• Synovectomy is indicated for inflammatory arthritis, septic arthritis, gouty arthritis, and posttraumatic synovitis [9].
• Ablative bone procedures include scaphoidectomy, radial styloidectomy, wafer procedure, proximal row carpectomy, and proximal hamate excision [9].
• Ablative cartilage procedures include debridement of chondral and osteochondral lesions [9].
• Reparative soft tissue procedures include repair of peripheral TFCC tears, TFCC foveal avulsions, scapholunate ligament injuries, and lunotriquetral ligament injuries [9].
• Reparative bony tissue procedures include arthroscopic-assisted reduction and internal fixation (ARIF) for distal radius and scaphoid fractures [9].
• Reparative cartilage procedures include drill/abrasion chondroplasty [9].
• Reconstructive soft tissue procedures include arthroscopic TFCC reconstruction with tendon graft and arthroscopic-assisted scapholunate ligament reconstruction with tendon graft [9].
• Reconstructive bone procedures include arthroscopic bone grafting for scaphoid nonunion, limited carpal fusion, intraosseous bone cyst, and intraosseous ganglion [9].
• Reconstructive cartilage tissue procedures include osteochondral grafting [9].

Complications and Risk Factors

• Postoperative infection risk is particularly elevated in elderly, male patients with systemic comorbidities or those undergoing synovectomy [2].

Complications

• Overdistraction during wrist arthroscopy distraction may cause postoperative finger joint pain [9].
• Use of wire finger traps for wrist arthroscopy distraction may cause postoperative finger joint pain [9].
• Use of wire finger traps for wrist arthroscopy distraction may cause localized contusion to soft tissue [9].
• Use of wire finger traps for wrist arthroscopy distraction may cause localized contusion to digital nerves [9].
• Extravasation of fluid during wrist arthroscopy may lead to compartment syndrome [9].

Key Evidence

• [L5] Wrist arthroscopy can be a useful tool in one’s armamentarium in the diagnosis and treatment of wrist pathology, providing views of and access to the intraarticular spaces of the wrist that are otherwise difficult to achieve without widely open approaches. [1] (10.1016/j.eats.2024.103223)
• [L3] Postoperative infection after wrist arthroscopy is uncommon but clinically relevant, particularly in elderly, male patients with systemic comorbidities or undergoing synovectomy. [2] (10.1016/j.otsr.2026.104771)
• [L5] We present a simple, effective, and cost-efficient solution to overcome oversized finger traps for wrist arthroscopy distraction. [3] (10.1016/j.eats.2025.103662)

References

[1] Wrist Arthroscopy: Positioning, Portal Placement, and Diagnostic Evaluation. Arthroscopy Techniques. 2024. DOI: 10.1016/j.eats.2024.103223

[2] Incidence and risk factors of postoperative infection after wrist arthroscopy: an 11-year nationwide population-based cohort study in South Korea. Orthopaedics & Traumatology: Surgery & Research. 2026. DOI: 10.1016/j.otsr.2026.104771

[3] Tip to Overcome Oversized Finger Traps in Wrist Arthroscopy Distraction. Arthroscopy Techniques. 2025. DOI: 10.1016/j.eats.2025.103662

[5] Green S Operative Hand Surgery. BOX 59.1 Ganglions of the Hand and Wrist > Operative Treatment > Dorsal Wrist Ganglion.

[9] Green S Operative Hand Surgery. AUTHOR'S PREFERRED METHOD OF TREATMENT: ARTHROSCOPIC PARTIAL WRIST FUSION > SURGICAL TECHNIQUE FOR DIAGNOSTIC ARTHROSCOPY > Setup.

[10] Campbell S Operative Orthopaedics 4 Volume Set. NERVE INJURIES AT THE LEVEL OF THE HAND AND WRIST > ARTHROSCOPY OF THE WRIST.

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[13] Aaos Comprehensive Orthopaedic Review 3. Arthritides of the Hand and Wrist* > IV. Posttraumatic Arthritis.

[14] Green S Operative Hand Surgery. AUTHOR'S PREFERRED METHOD OF TREATMENT: ARTHROSCOPIC PARTIAL WRIST FUSION > Diagnostic Wrist Arthroscopy.

[15] Campbell S Operative Orthopaedics 4 Volume Set. NERVE INJURIES AT THE LEVEL OF THE HAND AND WRIST > ANATOMY.

[17] Aaos Comprehensive Orthopaedic Review 3. Anatomy of the Hand and Wrist > VII. The Wrist.

[18] Green S Operative Hand Surgery. WRIST BIOMECHANICS > Carpal Kinematics.

[19] Campbell S Operative Orthopaedics 4 Volume Set. NERVE INJURIES AT THE LEVEL OF THE HAND AND WRIST > CIRCULATION.

[21] Campbell S Operative Orthopaedics 4 Volume Set. WRIST AND ELBOW.

[22] Green S Operative Hand Surgery. WRIST INVOLVEMENT IN RA.

[23] Green S Operative Hand Surgery. Diagnosis and Treatment > Assessment of the Symptomatic Wrist.

[25] Miller S Review Of Orthopaedics. DISTAL RADIOULNAR JOINT, TRIANGULAR FIBROCARTILAGE COMPLEX, AND WRIST ARTHROSCOPY > 2. TFCC tears.

[27] Exam Of The Hand Wrist 2Ed. Examination.