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So we are gonna talk about risk, arthroscopy very quickly and very gently. This is a very basic session covering more anatomy rather than anything else. We are gonna concentrate uh this lecture on a couple of uh important points for Fr CS and mainly this is just indication how you set up the theater for an arthroscopy. What instruments are you gonna use? Which are the landmarks? Sometimes uh people can be asking the Fr CS to actually draw the landmarks on the examiner's glove. Yeah. And then we're gonna talk about the anatomy of the most common portal use and the complications associated with it. The complication. I'm going to discuss about the structural ones which are affected by the port placement rather than general ones. OK. So this is an anatomy session. So please jump in all the ST three will have all the anatomy, you know, up to date. Um Not everybody would have done uh a hand placement yet and not everybody would have done arthroscopy in ther yet, but doesn't matter. This lecture is about basics. OK? So this needs to be very interactive. As I said, it's so basic that we cannot uh it is not going to fleur in it. So, let's see, jump in and give me a couple of indication for which you you have seen in the past or you might think that arthroscopy of the wrist might be used anybody. So, arthroscopy of the wrist in their practice TFCC injuries might be excellent. That is probably the most common one. Yes, that's very good. Uh scale for ate injuries. Excellent. Yeah, I've seen it in that way used as well. It can be used as a diagnostic tool in the context of kbox. That's, that's very good. And not only that some people like to diagnose the extent of arthritis in the wrist before going on and fusing that. That's, that's very good. So it's, it's used in different pigment procedures as well. Anything else you can think of? Ok. So can you, can you use it as a, as a way of aiding sort of fusion surgeries? II, I'm, I'm just, this is kind of a guess for you, but I don't know. Well, yeah, II suppose you can because if you can put the bird inside the joint and break the cartilage down the joint surface, II would think people can use it in that way is, is used, basically depends upon the experience from basic stuff to very complex stuff. Um And here are just a couple of indication, as you said, TFC injury probably is the most common. Some people um like to wash septic arthritis of the wrist, arthroscopically, um ligamentous injury. Yes, that's very good. Uh, for ligament injury. I I've seen it used um and also some people are using for this, the radioulnar joint. Um then as, as the same indication as knees or on any other places is to remove loose bodies. You know, to address the chondral lesions. Sometimes you have sinusectomy and some people prefer to clean it this way. You know, there are a lot of things and I suppose in time, this list is gonna go even bigger as the people experience with this um uh procedure increases. Now, in terms of set up, this is, this is actually very important because sometimes you can be put to draw. How are you gonna set up in theater? Where is the bed, where is everything around the patient? So if you look on the first image, this is usually what we how we set up for. So the patient is usually so fine, you have an arm table and then you have um a tourniquet which is uh applied. Now make sure that tourniquet stay away from the elbow because in the context where you, you flex the elbow to 90 degrees, you can have compressions on the nerve at the elbow level. If you put the tourniquet very close and then you bend the elbow and then we use Distraction towers. And if you look at this one that I put a picture of this is the most commonly used. Definitely the one I have seen used. And then if you look at the setup, you can see how the elbow has been 90 degrees. And then how is the elbow protected with swabs to protect compression on the median and ulnar nerve as well? Given the fact that all this to is is metallic and sometimes the procedure can be long and we use the the finger uh straps as well. You have the Arthroscopy Tower like for every other arthroscopy. And so some people use uh you know, laptops, there are apps on the laptops you can use uh which um which gives them a very good um view without huge amount of equipment can be used in theaters, which are not very big. Now, in terms of instruments, what is special about this um arthroscope is 2.7 millimeter, obviously needs to be smaller because the joint is smaller and has a 30 degrees angulation. And then in terms of uh the rest of the instruments are approximately the same you will find in the rest of arthroscopies, you will need some hooks, you will need some probe spons, you know, graspers, ablator depends and because the joints are tight, some people prefer to inflate the joints with fluid. Um if you put a lot of Cine, you can cause lots of swelling into the soft tissue. And then the procedure can be a bit limited in terms of how much time can you take until the swelling is too much? Um I have seen people using um ringer lactate where they say that uh probably that causes less swelling. But yeah, just remember you have 2.7 millimeter scopes and there are also na anoscopes used which um are very, very nicely, you know, packed keys associated with, with the laptop. And basically you can do this procedure very easily and elegantly even in a small setting. Good. Now we talk about the instruments, we talk about the landmarks. This is what you might need to draw in the examination if they ask you to to show where the arthroscopy portals will be. So start with the basics. Yeah, you draw a distal radius, you draw a distal Unna that's very clear where they are and then identify the most prominent point on the radial side, which is the lister tubercle. Once you put the lister down, you know that around the lister you're gonna have the E PL. Yeah. So you've already done a lot of work only by knowing this, you draw two bones, you draw lister, you draw that. And then on the ulnar side, you need to draw the EC U as well. And if you have these, these points already drawn, that is very simple. And if you look on this drawing, then the portals will be two at two, the main ones at the wrist and two, the main ones at mid carpal Yeah, there are more portals to be used like in every other joint. You can use accessory portals everywhere. But you just need to remember four portals, two at the wrist level and two in between the carpal bones that mid carpal joint. So remember this drawing, try to draw it yourself before the exam because then it is gonna be such an easy station for you to pass. And now if you look at the extensor compartments, yeah. So everybody knows about the extensor compartments, everybody could do them before the ST three interview and MRC S exams and stuff. But it's something you need to recap because for obvious reasons, you know, the memory works like that. Now there are a lot of spots on this picture. However, you concentrate on the four main ones which are in the middle of the drawing. Yeah, I'm talking about 34, I'm talking about six R. I'm talking about MC and I'm talking about M CL. Yeah. So four spots. Those are the main points and then you have two more auxiliary ones which is 12 and then um six U and obviously more. But concentrate on this. You need to know that you have dorsal portals and have volar portals. We keep it basic. Today, we talk about dorsal portals and those portals are in two categories. Once you are gonna look into the wrist joint, which is the radiocarpal joint and with two portals, you are gonna look in the midcarpal joint, which is basically in between the first and the second row. OK. So four ports, two in the wrist to midcarpal. Now, it's very interesting how these ones are named. And I'm gonna tell you why. So before I go there, I'm gonna tell you like this R means radius and U means ulnaria. So if you have an R must be on the radial side, if you have au must be on the ulnar side of the structure and then the numbers are associated with the extensor compartment. Yeah. So if we say 34 portal means that portal is in between the third compartment and the fourth compartment. Yeah. If we say six R compartment means this is on the radial side of the sixth compartment. If we say six U compartment, that means it's on the ulnar side of the sixth compartment. Yeah, simple, very simple is extensor compartment is RN U and then you look one row up and you see MCR and M CM cr basically means mid carpal, radial, mid carpal ulnar. So nothing complicated. It's extensor compartments, radius and ulnar. Now we're gonna talk about the 34 compartment. Now let's now having this knowledge. Somebody shout uh 3rd and 4th compartment components. So where is gonna be this port in between 3rd and 4th compartment? Is extensor strongest. Yes. And the extensor and extensor in dishes. Yes. So which one or is gonna be on the on the radial side in between the two. So it's gonna be MCR. No, I was gonna be 34 in the in the fourth compartment. Yeah, you are gonna have the extensor uh in and digitorum. Yeah. So the digitorum. Yeah, because in this is on the side. OK. So here is the first part. Now if you are there. Yeah. Which structure do you think is gonna be at risk in that part of the of the wrist? Mm Anything for nerve, obviously, tendons are all the time at risk when you put a sharp instrument in between them or sometimes through them. Yeah. So the tendons are gonna be all the time at risk. But what nerve do you think is gonna be on on the dorsal aspect of the wrist, innervating the wrist? Somebody else if OK, posterior and trass nerve. Exactly good. Now that being said this is the 34 portal you can see the dot the dot there is the lister tubercle. This is the this is the radius one centimeter on top of the Lister is where the portal should be, as we said is in between the third compartment which is E TL and the fourth compartment which is EDC. OK. Now, sometimes you want to introduce the arthroscope there and just doesn't go and doesn't go and you don't know why the reason is because probably you went into dorsal radiocapitellar ligament which is with the blue in the third image Yeah, in which case, you need to undulate it um further and put more traction and then the space opens up. And then in the fourth picture, you can see the posterior interosseous nerve and also you can see that it's in that area actually can be pretty thick giving like a trunk type structure. So it is at risk there. Excellent. So this is the first portal. Now if we move on, we are gonna talk about the six our portal. Yeah. Now look at this image again, six our portal and somebody knowing now what we know so far can tell me where that portal should be. So six compartment which makes sixth compartment ec excellent good. And if it is R it should be where, so it's going to be to the radial side of that. Yes and six U is gonna be on the ulnar side of that ulnar side of that. So which nerve do you think is gonna be at risk with both of these ports? The dorsal, the 10 branch of the ulnar nerve? Exactly. Exactly. So you are on the ulnar side, you know that the the the sensory branch is is there OK? And its cross is just um just uh distal to the um to the ulnar styloid and it's gonna be at risk at that point. Excellent, good. So we have another portal and that is the six R portal. You can see the yellow dot there ECU is there, this is on the radial side of the ec and this one needs to be, you know, placed under the direct vision. Usually you put arthroscopy in 34 and then um you put the the second portal under direct vision, you use this to, to instrument the joints, you put instruments through this one. And as we said, you can see in the third picture is the dorsal branch of the ulnar nerve. Yeah, which crosses the area. And also if you remember now, this is the sixth compartment, not far away from the sixth compartment is the fifth compartment and the fifth compartment has the EDM which is extensor D um digiti minimi. Now this is a very firm c tendon. OK? And very easily can be damaged by the arthroscope. And in order to avoid that from happening, you shouldn't ever put traction on the little finger. Yeah. So as as you could see in my first image, you put finger traps on the rest of the fingers, but leave this alone because otherwise you are gonna stretch even more the EDM and the risk of injury increases. Yeah. So this is the way to avoid EDM injury. In terms of the uh dorsal branch injury, every single nerve which is very superficial in the fat. The way to avoid injuring is just doing a very fine cut with a 15 blade only in the skin and then do the rest blunt dissection until we identify the nerve are protected. So we have another portal done. Now, if we talk about this one, it's very easy. On the the other side of the EC is the six U portal you can use sometimes if the position in the six R is not good enough for you to instrument the joint. Now you can see it here. Six U Yeah. EC U is on the extensor side. FC U is on the other side. And if you look inside the joint, you can see the EC U tendon and then one side and the other and you can see the way you access the joint. Yeah, so you can see the angles, the instruments can enter the joint. So now you understand, you know why in some situation it is more useful to use this one or that one. OK. Obviously it's the same nerve at injury because it's in the same area. And the way to avoid this if you go with the portal in the six U is to pro um to, to do supination of the forearm, wrist and hand and also flexion can help to take the the the branch away as you can see in the last picture good. So we have 34, we have six R, we have six U and then there is one more portal that can be used sometimes even that is less and less used just because it's in a very dangerous area. And this is 12. And if I say 12, what compartments are gonna be there, what tendons are gonna be in those compartments? Any ST threes? Ok. Anybody else? So it'll be AP and PB and then uh E cl E CLL E CLB. Ok. So it's in the first compartment. Yeah, I II in the second compartment you are bang in anatomical snuffbox. Therefore, which structures are gonna be at at in, at the risk of injury. Uh radio artery well done. But before radial artery, radial artery is a bit deeper, let's say uh uh the um sensory branch of radial nerve. Excellent. How are you going to avoid damaging those structures? Careful dissection, good. It's it's simple stuff. It's just simple stuff, just basic stuff. You just need to take it very simple in the examining everything state the obvious. OK. So one to portal, as you can see there, you have APL tendon, you have RL tendon. OK? And then you can see how useful it is if you look in the second image, how beautiful you can place instruments from those angles. Yeah. So you can see why people use it. And then in the third picture, you can see the superficial branches of the radial nerve. And then in the fourth picture, you can see the radial artery which is a risk and those are the main reasons people are trying to avoid this portal um as much as possible if they can unless they absolutely need that access. OK. Good. So now we have finished with, with this part which is the radio um carpal joints and then we're gonna talk about two more portals which are placed in the midcarpal. Yeah. OK. Now going back to the first image which is this one. So you can see MCR and you can see MC. OK. So start with the MC who's gonna have a girl? Where is that placed? OK. So look at the yellow dot here, OK? Is in line with the fourth metacarpal axis is in between EC and M, OK? And gives a very beautiful access to the four corner joint space. Yeah. And I'm gonna show you in the next picture here. Can you see where the instrument is going? That is the four corner. Yeah, the four bones there enters there. Now what I'm gonna tell you about, can you see the second image on this slide? You can see that the the instruments needs to be put in a different angle. OK. If you look at the wrist joint, you can put the portal in at around 40 five degrees because remember you have a molar tilt of the distal radio surface. Now, if you look in this, if you are trying to do that, you are gonna damage the articular surface. So here this joint is parallel to the floor in the position the hand is in. So make sure when you instrument this joint, your portals are going parallel to the floor, otherwise you're gonna damage the cartilage. Ok. So that being said, looking here um is it, you know, obviously used to access that particular joint space? Yeah. And structures at risk apart from the tendons, which are all the time at risk. Yeah. Um there is this very big um vein network and sometimes that could cause actually lots of bleeding and if you are not careful and went to AAA vein like that can cause lots of bleeding and issues with the wound and stuff. So you you need to be careful to avoid them if possible. All right, the most important thing about this one. Yeah, is the position of the instruments in order to avoid damaging the joint surface. OK? And then you have the other one on the opposite side. Yeah, which is MCR the yellow dot is now there, OK? And this goes to the radial margin of the EDC. Yeah. And this is in line with the third metacarpal axis, OK? And those are the tendons and obviously given that the position is here is gonna give you access to all the joints in between the scid and the rest of the bones. Yeah. And then that is a scale scale capitate sca trapezia joints. Yeah. So it is a very useful joint uh portal to address these joints. OK. Now, when you place this um when you place this portal in needs to be under direct visualization So you, you've done the, the the other portal you put the camera in, you look and be careful because this is a very tight joint space. OK? And I'm gonna show you here you can see in this. Yeah, this is the scaphoid. This is the lunate, you can see the hook, it's very tight joint, it's very easy to damage the cartilage. All right. And also you know that there is the scun uh ligament as well that ca can be also damaged if you go with the arthroscope forcefully inside the joint. OK. So basically, this is all about the anatomy of the porters. OK. Any questions so far? No, thank you. Now for the Excel purposes, very unlikely you are gonna be asked about complex stuff because as you know, wears copy is not performed routinely everywhere. But if they are gonna be asked about this in the exam will be even to draw the landmarks and then to draw the portals. And basically, it's gonna be an anatomy station about where the the portals are placed, what structures are at at risk. So, and maybe maybe set up of the theater, but set up of the theater is not difficult is like any other arthroscopy of the other joint. But remember in this case, elbow is flexed, is flexed, um 90 degrees. Also the the the primary surgeon should be placed on the dorsal aspect of the wrist. OK. Assistant is gonna stay on the volar side. And sometimes if there is a complex procedure that require volar and dorsal approaches that might change and might move around if you need x rays as well, you need to make sure that you have x-ray access. And usually imagine there is like that one surgeon stays here, one surgeon stays here. That means the x-rays is gonna come from this side. Yeah, and it's gonna come like this around the hand. Now, remember in that traction device, you can actually rotate the arm so you can get the pictures you need. All right, or you can basically and who can rotate it if needed if you need access to that. Ok. So that is uh it about my lecture. It was a short brief. One is most about anatomy. Remember four quarters only for the exam. Two at risk joint, two, midcarpal joint, one is 343 and four compartment. The other one is three R uh six R yeah, six radial side. And then you have midcarpal radius, midcarpal ulnar, just remember what nerves and vessels are going in each areas, ok? And the tendons and you'll be fine. Thank you very much for listening. That's great, Maria. Thank you very much for that. It's a nice comprehensive talk. Um Agreed you don't need to know a huge amount of detail um for the exam for arthroscopy and it's not something that's done well as commonly in the UK as it is over in the continent, but it's worth something worth knowing about. Something definitely worth having a bit of knowledge about for your exam. And the structures at risk questions are perfect for the section one of the Fr CS and exactly the sort of thing they'll ask, they'll ask. So it's always worth having a look at that. You haven't got any questions for Maria about this. Hi, Maria. Um How many sensors are actually doing that in the east of England? I, I'm sure it's probably happening right under my nose, but I've, I've not seen any wrist arthroscopy yet. I have no in BFI. I know for sure that they are doing it in Broomfield. Yeah, I think Sharia likes it, doesn't he? But any Norwich is, is, is Mr James? No. So Norwich, they used to do them but they used to use them for diagnostic purposes but since they've got their three Tesla MRI, which they've had for a few years, they don't need it for diagnostic purposes anymore. It gives them all their information and they weren't using it for a huge number of therapeutic purposes. So they don't tend to do it. I was there as a registrar and as a fellow and I never saw him do one. I think Simon Wes does them in Harlow. Um, we certainly don't do any in Cambridge. Um, yeah, you, you just don't, it's not really around that much uh in the continent. The big centers are in Spain and France and they will do most things with this. They really will. But um they also scope in um Peterborough. Sorry. It's George but with Mr Norris and mckee, they do some scopes as well. Ok. Yeah, so it's around but, but yeah, not huge numbers. Thanks. Is, is that because, is that because sort of T FCC type injuries, which II think is the main indication are, are, are just sort of managed differently in different places or is it because it's more kind of tertiary referral? Uh I think it's that there's a number of reasons really. Some people are really into their scopes and the people who are really into it will do a lot more than TF CCS. Um And then if, if that's all you're using it for. So for me, I don't do them, I might do them in the future, but I don't have enough sort of cases apart from TF CCS to really maintain the practice at the moment. So I'd want to be doing a little bit more than just the odd T FCC really to keep my hand in. Um And I think that's where people had it with diagnostic scopes a bit more in the past, but it's not done so much. Um Yeah. Yeah, thank you very much. Just, just wanted to add the following one. I had two questions in my part one with uh with portal placements, structures at risk. So it's definitely worth knowing two questions I had in my exam. And second is um that um yeah, as I said, in part two, it just about drawing an anatomy. And uh yeah, if you want to know more, there are webinars where there is much more extensive information about this, but I suppose you would want to know more only if you are doing that at some point. Yeah. Ok. I think Mr Atkinson Molly has a point here. Yeah. No, just sort of briefly really. I mean, yes, II think the only time I've ever done an a wrist arthroscopy is for an arthroscopic wash out and aseptic arthritis. So clearly some people, you know, are really up to and into wrist arthroscopy and find it very beneficial. But I in my practice, unless I'm just neglecting patients, I don't think I've ever found a patient that would benefit from a wrist arthroscopy. Cos I think as Aaron has said, MRI these days is so good for diagnostic purposes and T FCC tears. Yes, they're very, very common. They're a huge number that, you know, we all know that, you know, many of us will have T FCC tears and it doesn't bother us. Almost everybody that sustains a fracture of their distal radius will sustain a fracture of their T FCC and or worse. So there's some nice papers from Tommy Lindau on wrist arthroscopy and uh wrist arthroscopies. Um at the time of fractures of this steroids and they found a large number of people who sustained associated ligament injuries in association with a fracture of the steroids. Uh, and they were all managed non operatively. And I think they, I don't know if they reopen them again, but basically they found that these injuries abnormalities uh didn't really need treatment. And so I've never seen a patient. I mean, yes, I often see patients who've had a fracture of the steroids and the most common thing is for them at their six week follow up to complain of persisting ulnar sided wrist pain. But in the vast majority of those that gets better. And I've hardly, I don't think I've ever seen a patient who has then come back six months or a year down the line because of persisting ulnar sided wrist pain. So, in my practice, I just don't find a reason to do wrist arthroscopy. Yeah, the same. I, there's really not, not that many indications that I found. Um, as I say, there are people who are real enthusiastic arthroscopist and they will do most things that way. But I'm sort of quite happy with open surgery at the moment for most of the things that I need to do and even the T FCC issues like post is the radius. Most people, if they do have to go to surgery, it will probably be dealt with by an another shortening. Um, cos it'll usually be a bit shortening of the radius as well to deal with. Um, but is it there, there, there are centers out there and it is certainly something that can come up in the exam. Um, but yeah, it tends to be enthusiastic. So we're really into it. Thank you.