Arthroscopic surgery can be used for the following conditions of the Wrist:

1. Loose bodies
2. Synovial irritation or swelling - resulting in local pain or pinching
3. Torn ligaments to remove flaps and assess the extent of damage This may then suggest that repair or reconstruction is necessary later.
4. Fractured bones (eg. scaphoid can sometimes be screwed and radius joint line reconstructed (lifted) in a fractured wrist when treated early.
5. Wrist instability to assess the state of other joint surfaces to allow for accurate planning of the best treatment.
6. Meniscus (cartilage) tear can be trimmed so that it doesn't get caught and irritate the joint or if torn from the surrounding capsule it can be sutured back to the periphery (needs to be immobilised in a cast afterwards for 6 weeks.
7. Arthritis in the joint can be cleaned out (debrided) to reduce the ongoing irritation of the synovium and instillation of cortisone to help control the inflammation.

Lasers may be used in the following Arthroscopic Surgery in the Wrist:

1. synovectomy
2. loose bodies
3. chondroplasty
4. osteoplasty
5. meniscectomy (T.F.C.) or Excision of the torn cartilage

Key Benefits

• Small instruments therefore minimal damage to surrounding tissues
• No bleeding therefore tourniquet is not needed and less pain
• Precise surgery as good visibility is maintained at all times (no blood in the fluid used to wash out and distend the joint)

Colles fractures - New alternative treatments?

Fractures about the wrist have traditionally been treated with plaster of Paris caste immobilisation. Today's Orthopaedic surgeon has the ability to treat these fractures with numerous techniques and the benefit or difficulty of each method should be discussed with the patient so that the patient is involved in making the final decision.

Factors which must be considered in this decision making process are:

Methods Available:

• reduction under Image Intensifier control
• reduction under Arthroscopic control
• caste immobilisation
• external fixation
• internal fixation

Reduction under Image Intensifier control

If the fracture pieces are not satisfactorily aligned, that is if there is deformity, a step in the joint surface or angulation, then the patient will usually need an anaesthetic and the bone pieces manipulated to close any gaps and regain the normal shape of the bone. If not corrected the joint is more likely to go onto arthritis at an earlier age. This process of rearranging (reducing) the fracture is often performed while watching a monitor screen showing the bones under X-ray (Image Intensifier). When the bones are in the best position they can then be held (in a caste) or fixed with pins inserted through the skin revolving at high speed to penetrate the bone fragments easily.

Reduction under Arthroscopy

In a younger person it is very important that the joint surface is aligned perfectly, that is there is no gaps or steps which will wear down adjacent bone surfaces over time and become arthritic. So with the patient asleep or their arm anaesthetised, the hand is gently pulled from the arm distracting the wrist joint, an arthroscope is introduced into the joint through a small stab wound (about 3mm long) and the joint surfaces watched while the bone pieces are manipulated until perfectly aligned

and then fixed in that best position - under direct vision. To manipulate the bone fragments we often use pins inserted in the bones as handles or joysticks.

Caste immobilisation

If there is no deformity, the fracture is stable or once the fracture is reduced then it may be held in the corrected position by encasing the hand, wrist and lower arm in plaster or fibreglass caste. We try to apply some forces to the bone fragments while the plaster is setting to resist the fracture deforming again which is always a possibility in the first week as the swelling subsides. If there is increasing swelling, circulation problems or pain not controlled with simple analgesic tablets (e.g. Paradex, Digesic) then your doctor must be notified as the plaster may be too tight!

Fibreglass castes have been used recently not because they come in a lovely variety of colours but because they are harder, they set quicker, they are lighter and cooler and do not crumble in bed or soften if accidentally get wet.

When Gortex is used as the soft underwrap (instead of wool) then the fibreglass caste can be fully wet as in showering or swimming without any protection at all. After the shower or swim just shake or pat most of the water out and let dry. A little more expensive but much more comfortable and user friendly - and because they harden quickly may allow earlier return to work if possible within the caste.

External Fixation

When the bone fragments have been aligned and if the surgeon feels that he cannot adequately control the position with a caste or external shell, then he can insert strong pins into the bones above and below the fracture. When the best position is obtained, the pins are connected by rigid bars to form a frame much like a scaffold on a building. This form of treatment is particularly useful when the joint surface has been reconstructed with pins inserted under arthroscopic control and then the external frame gives rigidity to the overall structure, taking forces off the joint alignment.

• Usually the stout pins are inserted : 2 into the major arm bone (Radius) & 2 into the bone at the base of the index finger
• Occasionally when the fracture of the lower end of the radius does not actually enter the wrist joint, all 4 pins may be in the radius, 2 above and 2 below the fracture line.
• The pin sites have to be kept meticulously clean, wiping away any accumulations of blood or serum, and painted regularly with Betadine antiseptic. If any irritation or infection notify your surgeon immediately.
• The frame remains in position until some union and stability develops in the fracture which is usually about 6 weeks for the wrist.

Internal Fixation

With metal plates and screws applied directly onto the bone, a fracture may be made solid immediately and then movement will aid in recovery of the joint surface. Of course there is a scar over the wrist but often these heal nicely and may not be that obvious.

The newer metal plates are low profile with the screw heads fitting into depressions in the plate so that the screws cannot be felt through the skin and do not irritate the tendons which must glide over the plate.

The major advantage with this method is that the bone fragments may be manipulated under direct vision into the best possible position and the stability tested directly. If there is any defect in the bone because it has been crushed in, then a bone graft can be inserted into the hole to make the bone stable, increasing the chance to heal and allow early movement to the joint. Stiffness comes to joints immobilised for long periods especially in older people.

Metal plates are often removed in younger patients especially if there is danger of further trauma to the area, whereas in older patients the plates may never be removed.

The aim with this form of treatment is to make the fracture completely stable on the operating table so that movement can be allowed at the wrist joint immediately without the need for casting. Often a removable splint may be applied for protection but this can be removed for exercises to keep the joint moving.