Chapter 2 Surgical Approaches

10.1055/b-0035-121112

Chapter 2 Surgical Approaches

Arthroscopic surgery avoids the joint exposure that results from extensive surgical approaches. Conventional wrist surgery incisions are known to cause fibrosis and stiffness. Arthroscopic approaches are thus as small as possible. This chapter describes the main arthroscopic approaches, although other possibilities exist, depending on the surgeon, the amount of exposure required, and variations in anatomical configuration.

General Principles of Approaches

The incisions are horizontal, following the skin creases, and ar e left to granulate to achieve an aesthetically pleasing scar. A no. 15 blade is used; no. 11 blades are used for other joints, such as the shoulder or the hip, but not for the wrist, where noble structures such as tendons, vessels, and nerves lie just beneath the skin and are at risk of being damaged ( Fig. 2.1 ).

The following steps are used to establish an approach or portal:

Finger palpation of the zone
Placement of a needle in the exact location of the portal, taking into account the bony anatomy and the required angle
Short incisions of 1 to 2 mm using a no. 15 blade
Breaching of the skin and the capsule using a blunt mosquito clip to push away any noble structures without injuring them ( Fig. 2.2a–d )

The dorsal radiocarpal portals are named for the dorsal extensor compartments they lie between, so that 3–4 portal lies between the third and fourth compartments, and 6R portal is radial to the sixth compartment, and so on.

Radiocarpal Portals

The radiocarpal portals are named according to their positions in relation to the dorsal extensor compartments ( Fig. 2.3 ).

**Fig. 2.1** Operative view of a 3–4 portal. The approach is a small horizontal skin incision allowing introduction of instruments and the scope.

3–4 Radiocarpal Portal

This portal is the real key to wrist exploration and is the easiest portal to locate. The first location method uses the three circles technique: a circle is drawn over the tubercle of Lister, two identical circles of the same size are marked distally, and the portal is located at the center of the third circle ( Fig. 2.4 ). In the second technique, referred to as the flexed-thumb technique, the thumb is held vertically against the wrist so that the pulp feels the tubercle of Lister and the tip is at the distal end of the tubercle, the thumb is flexed and rolled forward, toward the distal end of the wrist, second phalanx of the thumb (P2) passing from the vertical to the horizontal position, and the tip falls into the dip of the radial radiocarpal joint. The 3–4 portal is located just over the nail ( Fig. 2.5 ).

**Fig. 2.2 a–d** Operative view of the sequence to establish an ulnar midcarpal portal. **a–d**: finger palpation, needle insertion, introduction of the blunt clip followed by the arthroscope.

Once the position is marked, the needle is inserted, respecting the radial slope from dorsal to palmar and from lateral to medial. Once the needle is correctly placed and is freely felt inside the joint, the portal is established as usual, using a blunt mosquito forceps ( Fig. 2.6 ).

6R Radiocarpal Portal

This portal is easy to find once the 3–4 radiocarpal portal is established. The scope in 3–4 portal is directed ulnarward, and, when the scope is facing the triangular fibrocartilage complex (TFCC), the spot for the 6R portal is seen by transillumination. The correct position is verified using the needle in the joint ( Fig. 2.7 ).

**Fig. 2.3** The classic radiocarpal portals are named according to their position relative to the dorsal extensor compartments.

**Fig. 2.4** Operative view showing the sequence for a 3–4 portal using the three circles technique.

4–5 Radiocarpal Portal

This portal is less frequently used because the two portals discussed earlier are sufficient for wrist exploration. However, it may be useful for certain techniques.

With the scope in the 3–4 portal, a needle is used to locate this portal, which is situated between the fourth and fifth compartments, 1 cm lateral to the 6R portal.

6U Radiocarpal Portal

This portal was classically used for outflow. It is often associated with a direct foveal distal radioulnar portal for foveal reinsertion of the TFCC.

The 6U radiocarpal portal is ulnar to the extensor carpi ulnaris (ECU) tendon on the medial aspect of the wrist.

**Fig. 2.5** Operative view showing the sequence for a 3–4 portal using the flexed-thumb technique.

**Fig. 2.6** Operative view showing the introduction of a clip through the capsule, respecting the curve of the clip and the curve of the posterior rim of the radius: the clip rolls over the radial slope.

**Fig. 2.7** Operative view showing the localization of the 6R portal: the scope is positioned in the 3–4 portal ulnarward, and the needle is placed in the center of a circle of transillumination. The position of the needle is checked on the screen. The scope is held as a trigger, with the index applied against the skin to control the length of the scope introduced into the joint.

**Fig. 2.8** Operative view showing the sequence for the 1–2 radiocarpal portal. The scope is in the 3–4 portal, the camera points toward the radial styloid, and the needle is positioned at the center of a circle of transillumination with respect to the radial slope.

The scope in position 3–4 is pushed ulnarward and placed at the TFCC facing the styloid recess. The intramuscular needle must emerge in the middle of the styloid recess.

This approach is risky due to the association with the dorsal sensory branch of the ulnar nerve. Extra care is needed to avoid injury to this sensory nerve.

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