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Surgical

approaches and
anatomy
Landmarks
Dorsal veins
Osseous structures:
Ulnar head
Styloïds
Lister ++
Crucifixion fossa
Metacarpals
Landmarks

Compartments of tendons
Approaches

Between tendinous
compartments
Take care of subcutaneous
nerves
Radio-carpal approaches - 3/4 approach

Most important approach for
the optic
Between EPL and EDC
1-1,5 cm under Lister’s
tubercle
Radio-carpal approaches - 4/5 approach

Between EDC and EDM, in line
with the DRUJ.
Most important instrumental
approach
Optic use for TFCC.
Radio-carpal approaches - 6R approach

Radial to the ECU.
Instrumental approach for the
TFCC.
Visualization of lunotriquetral
ligament.
Radio-carpal approaches - 1/2 approach

Between APL/EPB and ECRL/
ECRB.
Instrumental approach for
anterior wrist ganglia, radial
styloïd.
Take care to the radial artery and sensory
branches of the radial nerve.
Radio-carpal approaches - 6U approach

Ulnar side of the ECU
Use for irrigation.
ATTENTION DANGER: sensory branches of
the ulnar nerve.
Midcarpal approaches - UMC approach

1,5 cm under the 4/5 approach
in line with M4
Easy. mainly used for the optic
Midcarpal approaches - RMC approach

Line Lister-M2,
1 cm under the 3/4, radial
side of EDC
In line with the UMC
Other arthroscopic approaches

Anterior approaches are less used
How to do an arthroscopic
approach ?

Draw before injecting water
(Use a needle if necessary)
Only skin incision
Dissection with the Halstedt
Enter the joint with a blunt trocar
How to do an arthroscopic
approach ?

Oblique introduction
Other approaches are made with transillumination and
guidance with a needle
What are the dangers ?
DANGERS Tendons Nerves Arteries

Voie 1/2 10 mm 3 mm 3 mm

Voie 3/4 8 mm 16 mm 26 mm

Voie 4/5 6,7 mm non non

Voie 6R 4,5 mm 8,2 mm non

Voie 6U 8,3 mm 1,9 mm non

Voie STT contact EPL radial radiale

Voie RMC 7,2 mm 15,8 mm non

Voie UMC 8,1 mm 15,1 mm non
Arthroscopic anatomy
Arthroscopic anatomy of
the radio-carpal joint

RL RS
RS

In front of you: anterior ligaments: Radiolunate,
radioscapholunate, radioscaphocapital, ulno-carpal.
Pre-styloid recess: not to mistake with a TFCC tear
dicl
S
sll

L ltl
T

P
R tfc

U
Arthroscopic
anatomy of
the radio-
carpal joint

Floor: Articular surface of the radius, two fosse
separated by a ridge, cartilage on all the surface with a
harmonious continuity with the TFCC.
No visual interruption between radius and TFCC. Limits
are found with palpation.
Depressible TFCC: « trampoline effect ».
Radially: scaphoid fossa
of the radius and radial
styloid
downward: Ridge and
lunate fossa
Medially: Triangular
ligament and pre-styloid
recess

TFCC
Medially: Triangular
ligament and pre-styloid
recess
Arthroscopic anatomy of
the radio-carpal joint

Roof: 1st row, scapholunate and luno-triquetral
ligaments. Ligaments present as a small depressed
« valley between two hills ».
LLT Lunatum

TFCC
Radiocarpal vision through 4/5 approach
Arthroscopic anatomy of
the radio-carpal joint

Tz
T
C
Posterior: Dorsal T
capsule, (extensor * S
L
*
tendons)
R

ECRB Ul
ECRL
Arthroscopic anatomy of
the mid carpal joint

Anterior: Ligaments (deltoïd ligament)
Above: STT, capitate head, capito-hamate and hamato-
triquetral joint
Down: 1st row, SL and LT joint spaces
Posterior: Capsule
trapezoïde

Trapèze

scaphoïde
Dynamic Exploration of instability
(SL & LT) :
Midcarpal evaluation
3 stages of instability -Dautel (J
Hand Surg (B) 93)
or 4 stages - Geissler (Clin
Orthop 96)
Arthroscopic “Watson” test

Grade 0 Grade 3

Grade 1 Grade 2
Complications
Complications: A long list ! but their real frequency is
low

Exact frequency is not well known (1,2 to 5,2 %
according to series)
Less than 1% are major complications
No chapter on complications in textbooks on wrist
arthroscopy

Remerber: Elbow 11%, Shoulder 6-10%, Ankle 9%
General complications
Cartilage abrasion
Bony lesions with introduction
Infection
CRPS type I
Wrist stiffness
Vicious scarring
Compartment syndrome (in DRF)
Complications due to the
technique or the devices

Problems with devices are
the most frequent
Migration of anchors,
thermal burns, tendinous
ruptures,...
Take care !

«...We located a total of 426 studies about wrist
arthroscopic, published in 89 journals over the study
period. Of all the publications retrieved (426), original
articles were 387 (90.84%), but only two (0.47%) were
randomised controlled trials, level 1 of evidence. This
study showed there are a large number of studies on
wrist arthroscopy, but the level of methodological
evidence is low...»

Fernandes CH, Meirelles LM, Raduan Neto J, dos Santos JB, Faloppa F, Albertoni WM.
Characteristics of global publications about wrist arthroscopy: a bibliometric analysis .
Hand Surg. 2012;17(3):311-5.