Background
Nonspecific wrist pain is a difficult problem to treat. When a patient presents with wrist pain and/or other symptoms, the treating clinician will typically consider their history and perform a physical examination. If the diagnosis remains in question—either at that time or after a period of watchful waiting and/or conservative treatment—the clinician may subsequently order a radiological test. In cases that still elude a specific diagnosis, diagnostic wrist arthroscopy may be suggested as the next step to identify the pathology. Diagnostic wrist arthroscopy is considered the gold standard for patients presenting with nonspecific wrist pain that does not improve, and it is a useful adjunct to patient history and physical examination that can accurately diagnose many wrist conditions.The rationale for diagnostic wrist arthroscopy is that a discrete, treatable pathophysiology is not always detectable on examination or radiological studies.1,2
Historical Overview
In the timeline of medical interventions, wrist arthroscopy has only earned its place in the last three decades. It followed the developments of laparoscopic techniques, as the instruments initially developed for cystoscopy and laparoscopy were subsequently used to inspect joints. Takagi is believed to be the first to use arthroscopy in 1919 for diagnosing tuberculosis of the knee, and arthroscopic examination of the wrist was first attempted on cadavers in 1932. Improvements in the technique included the use of traction instead of distension with fluid to create space—which avoided the complication of fluid extravasation—and the eventual development of specific instruments for the wrist. The description of the entry portals to the wrist in 1986 by Whipple enabled a safe entry to the wrist, and the first wrist arthroscopy workshop was also organized in that same year. Wrist arthroscopy continues to evolve and advance as a valuable clinical technique that facilitates effective diagnoses.3,4
Description
Before initiating the delivery of anesthesia, the correct instrumentation and arthroscopy setup must be confirmed, and either general or regional anesthesia and sedation may be used. The proper positioning involves placing the patient in the supine position with the shoulder abducted and elbow flexed at 90°. A tourniquet is then placed above the elbow and the arm is padded in preparation for traction. The arm is then secured to the hand table using a soft, gauze wrap, and traction is applied through appropriately sized finger traps to gently distract the wrist. The surgeon is seated on the side of the hand table toward the feet of the patient, and the arthroscopy viewing tower should be placed across from the surgeon. The standard equipment includes a 2.7 mm, 30°-angled arthroscope, a 3-mm hook probe, and overhead traction. Instruments that are used in the treatment of intra-articular pathology include a radiofrequency ablation probe and a mechanical shaver, which may be necessary to clear the wrist of synovitis or degenerative soft tissue changes.Traditionally, the workhorse arthroscopic portals are positioned over the dorsal wrist to avoid the risk of injury to the neurovascular structures of the volar wrist, but authors have more recently described volar arthroscopic portals that can be used to examine and repair dorsal soft-tissue structures.2
