Direct radiographs, computerized tomography (CT), and magnetic resonance imaging (MRI) can be used to identify the underlying cause of wrist pain based on the patient’s history and physical examination findings. However, there are various intra-articular and extra-articular structures in and around the wrist that can be challenging to detect using these imaging techniques. In cases where a definitive diagnosis cannot be made or when there is diagnosed pathology in the wrist but no specific abnormality is found radiologically, wrist arthroscopy has emerged as a highly effective approach. Wrist arthroscopy has been found to yield successful outcomes in the evaluation of undiagnosed wrist pain or in the treatment of wrist conditions with confirmed pathology. The indications for wrist arthroscopy can be summarized as follows:

A. Diagnostic Arthroscopy

  1. Exploring the source of mechanical wrist pain
  2. Assessing the condition of the joint surfaces
  3. Evaluating ligament injuries
  4. Examining and evaluating identified wrist pathologies

B. Surgical Arthroscopy

  1. Elimination of loose bodies within the joint
  2. Evaluation and treatment of synovial tissue through biopsy or synovectomy
  3. Flushing and cleaning the joint, as well as removing debris
  4. Repairing TFCC (Triangular Fibrocartilage Complex) injuries
  5. Addressing complications related to fractures in the area

Arthroscopic surgery is a technique employed by orthopedic surgeons to diagnose and treat conditions within the joint. The wrist, being a complex joint comprised of eight small bones and multiple ligaments, benefits from the use of arthroscopy.

By utilizing arthroscopy, surgeons can visualize the internal structures of the joint without the need for extensive incisions into the surrounding muscles and tissues.

The primary purposes of arthroscopic surgery are twofold: to achieve a more precise diagnosis (diagnostic arthroscopy) and to address and correct the identified issues.

Arthroscopic surgery serves as a valuable tool for both diagnosis and treatment. Its minimally invasive nature, involving smaller incisions, often leads to reduced complications and faster recovery compared to traditional surgical approaches. As a result, many patients can return home within a few hours of the procedure.

Technique

The surgical procedure involves making small incisions in specific locations on the skin.

These incisions are typically shorter than 1 cm. An instrument called an arthroscope, resembling a pen, is inserted into the joint through a tunnel. The arthroscope, equipped with a small lens and a miniature camera, provides three-dimensional images that can be observed on a television screen.

Two entry portals are created on the wrist that will undergo the operation. Through one portal, the arthroscope is inserted, while the other portal allows for the use of probes, forceps, blades, and shaving devices (sheavers) to perform necessary interventions.

Diagnostic Arthroscopy

Diagnostic arthroscopy can be performed when the underlying cause of wrist pain remains unidentified. It may also be utilized in cases where wrist pain persists beyond a few months following open surgery.

Before arthroscopic surgery, the following steps will be taken by your physician:

  • A thorough physical examination of the hand and wrist under consideration for surgery.
  • Further inquiry into the patient’s medical history to gain additional insights.
  • Performance of pain-provoking tests (provocative tests) to ascertain and assess the pathology by exacerbating the patient’s discomfort.
  • Implementation of imaging modalities for the hand and wrist region, encompassing procedures such as X-rays with contrast administration or arthrograms, magnetic resonance imaging (MRI), or other relevant techniques.

Administration of anesthesia can be performed using either regional anesthesia targeting the hand and arm or general anesthesia.

Multiple small incisions (portals) can be created on the wrist to facilitate access to the joint using the arthroscope and hand instruments. Following the procedure, the incisions are meticulously sutured and dressed to ensure optimal wound healing.

Arthroscopic Surgical Treatment:

Arthroscopic wrist surgery is a viable option for a range of treatments. It can address conditions such as chronic wrist pain, wrist fractures, ganglion cysts, as well as ligament and triangular fibrocartilage complex (TFCC) tears. Furthermore, wrist arthroscopy can be utilized to rectify bone fractures.

  • Chronic wrist pain: Wrist arthroscopy serves as a diagnostic modality for identifying the etiology of chronic pain when conventional diagnostic tests have been inconclusive. It frequently reveals areas of inflammation, cartilage lesions, or other pathological findings that may arise following wrist injuries. Subsequently, appropriate therapeutic interventions can be employed arthroscopically to address the identified pathology.
  • Wrist fractures: When small fragments of fractured bone are retained within the joint, wrist arthroscopy can be utilized to restore proper alignment of the fractured bone and excise these fragments. Subsequently, stabilization of the fragments can be accomplished through the implementation of pins, wires, or screws.
  • Ganglion cysts: Ganglion cysts are usually fluid-filled structures originating from the joint capsule. The arthroscopic approach in wrist surgery can be employed for the excision of these cysts.
  • Ligament/TFCC tears: Ligament and TFCC (Triangular Fibrocartilage Complex) tears are common injuries that affect the stability and function of the wrist joint. Ligaments, which are fibrous connective tissues, play a crucial role in maintaining joint integrity, while the TFCC provides cushioning and support within the wrist. These tears can occur due to traumatic events such as falls, resulting in pain, limited range of motion, and a clicking sensation. Arthroscopic surgery offers a minimally invasive approach to repairing ligament and TFCC tears, allowing the surgeon to restore the structural integrity of the wrist joint and alleviate symptoms.
  • Carpal tunnel syndrome: Carpal tunnel syndrome manifests as paresthesia or tingling sensation accompanied by pain in the hand and upper extremity. The region harbors the median nerve, which traverses the carpal tunnel—a constrained conduit formed by carpal bones and a robust fibrous roof. Multiple etiological factors can contribute to intratunnel pressure. In instances where conservative modalities fail to yield satisfactory outcomes, surgical intervention represents the solitary recourse. The surgeon undertakes a procedure to release the constriction on the nerve by severing the flexor retinaculum, thus effectuating tunnel decompression. By mitigating nerve compression, this maneuver assuages symptoms. Notably, arthroscopic implementation may be contemplated in select cases.

(wrist picture)

This procedure entails the insertion of a commonly used arthroscope to provide visualization. In the event of a torn TFCC ligament, the surgeon undertakes the process of debridement within the surgical field and employs an anchor to facilitate the suturing of the disrupted ligament.

After Surgery

In the initial two to three days following the surgical procedure, it is crucial to maintain elevation of the wrist. The bandage should be meticulously kept clean and dry to promote proper wound healing. The prudent application of ice packs can effectively mitigate the development of edema. Controlled and supervised movements are gradually introduced to optimize wrist rehabilitation and enhance its functional capacity. While postoperative pain is generally of a mild nature, the administration of appropriate analgesic medications is instrumental in ameliorating discomfort and facilitating patient comfort.

Complications

Postoperative complications following arthroscopic wrist surgery are infrequently encountered. These may encompass phenomena such as swelling, hemorrhage, scar tissue formation, tendon ruptures, infections, and nerve injuries. However, the involvement of a proficient surgeon, particularly one with specialization in arthroscopic hand surgery, can significantly mitigate the probability of complications.