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Wrist Arthroscopy

Diagnostic and therapeutic wrist arthroscopy — what it is, when it's used, and recovery.

123 citationsUpdated Sep 2026

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Wrist arthroscopy has evolved from a primary diagnostic tool into an essential therapeutic adjunct for a wide range of wrist disorders [2, 8]. It serves as the gold standard for diagnosing intra-articular pathology and remains particularly well suited to directly visualize and treat multiple causes of ulnar-sided wrist pain simultaneously [9, 10]. The procedure’s indications are extensive, including the management of triangular fibrocartilage complex (TFCC) pathology, carpal instability, fracture reduction assistance, and salvage procedures [16]. Recent technical and technological developments, such as new portals and smaller arthroscopes, continue to expand its applications for difficult wrist disorders [13, 16]. While arthroscopy has proven superiority in diagnosis [4], its therapeutic value is evolving and requires further clinical studies to refine specific indications and outcomes [4].

The procedure is generally safe, with complications believed to be uncommon and largely minor and transient [1, 10]. However, the previously documented rate of complications may underestimate the true incidence [39]. Meticulous attention to detail and anticipation of potential problems are essential to minimize these risks [15]. Detailed anatomical knowledge is critical to prevent complications during the procedure [8]. For patients with persistent wrist pain, arthroscopic investigation yields an average improvement of approximately 50% at one year, though most participants continue to experience some degree of pain and disability [5].

Wrist arthroscopy is beneficial for improving anatomical reduction of fracture steps and gaps in intra-articular distal radius fractures [37], although literature correlating functional outcomes with arthroscopy use in these fractures remains limited [37]. Nonrandomized studies report satisfactory results for arthroscopically assisted reduction of distal radius fractures [77]. The technique is advantageous for accurate assessment of articular surfaces and detection of concomitant soft-tissue injuries [77]. It is also a feasible treatment option for translunate perilunate injury, offering advantages such as a lower risk of arthrofibrosis and avascular necrosis [75]. Arthroscopic wrist arthrolysis after wrist fracture is a safe, minimally invasive procedure that significantly improves pain and wrist flexion-extension [55].

Anatomy & Pathophysiology

Bony Anatomy

The wrist constitutes the anatomic region between the forearm and hand, encompassing the distal radioulnar, radiocarpal, and ulnocarpal joints along with the eight carpal bones and their associated ligaments [90]. The carpus consists of a proximal row comprising the scaphoid, lunate, triquetrum, and pisiform, and a distal row comprising the trapezium, trapezoid, capitate, and hamate [90]. The distal radius features two concave articular facets for the scaphoid and lunate, separated by the scapholunate ridge, while the sigmoid notch along the ulnar border provides a shallow concavity for the ulnar head at the distal radioulnar joint [93]. The distal ulna is covered with hyaline cartilage on its dorsal, lateral, palmar, and distal surfaces, and the ulnar styloid projects distally with a base containing the fovea for triangular fibrocartilage complex insertion [93].

Vascular supply to the carpus is specific and critical. The scaphoid receives its primary blood supply from a branch of the radial artery at the dorsal ridge, with smaller vessels entering the palmar tubercle to supply the distal 30% [93]. The lunate possesses both dorsal and palmar vascular supplies in 80% of wrists, whereas only a palmar supply is present in 20% [93]. The capitate head often relies on a retrograde vascular supply [93]. The pisiform functions as a sesamoid bone within the flexor carpi ulnaris tendon and serves as the origin for the abductor digiti minimi [93].

The distal radial articular surface exhibits a double obliquity of 12–15 degrees in the lateral view and 15–20 degrees in the anteroposterior view [98]. The carpal articular surface has a smaller diameter of curvature than the radius, with medial and palmar stability dependent on ligamentous and capsular resistance [98]. Consequently, the carpus is more stable in flexion than extension due to its anterior concavity [98]. The triquetrum does not contact the ulnar head directly; a fibrocartilage disc separates the two bones [98]. The scaphoid long axis is inclined 45 degrees to the long axis of the radius [98]. The lunate sits on the capitate with anterior and posterior horns, the line between which lies perpendicular to the wrist long axis in neutral position [98]. The ulnar head sits proximal to the distal radius and exerts only an indirect effect on wrist stability [98]. The triangular ligament extends the distal radial articular surface to the ulnar styloid, forming the principal link between the two bones [98].

Ligaments

Wrist ligaments are classified as extrinsic or intrinsic. Extrinsic ligaments include the dorsal intercarpal and dorsal radiocarpal ligaments [93]. Intrinsic ligaments include the scapholunate and lunotriquetral interosseous ligaments [93]. The scapholunate interosseous ligament is C-shaped in the sagittal plane, with the dorsal third being the thickest and strongest portion [93]. The volar portion of the lunotriquetral ligament is the thickest [93].

The triangular fibrocartilage complex (TFCC) comprises the central meniscus homolog, dorsal and volar radioulnar ligaments, the floor of the extensor carpi ulnaris tendon sheath, and volar ulnocarpal ligaments [93]. It arises from the radial border of the distal radius and inserts into the base of the ulnar styloid and distal ulna via the ligamentum subcruentum [93]. The dorsal and volar radioulnar ligaments serve as the primary stabilizers of the distal radioulnar joint [93]. Vascular supply to the TFCC is limited to the peripheral 10% to 40% of the volar, ulnar, and dorsal regions [93].

Specific ligamentous origins and insertions define wrist stability. The radial collateral ligament originates from the radius 0 mm from the radial styloid and inserts on the scaphoid waist and distal palmar trapezium [93]. The radioscaphocapitate ligament originates from the radius 4 mm from the radial styloid and inserts on the scaphoid waist and midpalmar capitate [93]. The radiolunatotriquetral ligament originates from the radius 10 mm from the radial styloid and inserts on the lunate or triquetrum [93]. The ulnotriquetral and ulnolunate ligaments originate from the volar radioulnar ligament and insert on the triquetrum and lunate, respectively [93]. The ulnocapitate ligament originates from the volar margin of the ulnar head and inserts on the capitate [93]. The dorsal radiocarpal ligament originates from the dorsal radius at the Lister tubercle and inserts on the lunate and triquetrum [93]. The dorsal intercarpal ligament originates from the triquetrum and inserts on the scaphoid, trapezoid, and capitate [93].

The TFCC attaches to the ulnar margin of the lunate fossa of the radius and includes the ulnar collateral ligament, dorsal and volar radioulnar ligaments, articular disc, meniscal homologue, extensor carpi ulnaris sheath, and ulnolunate and ulnotriquetral ligaments [90]. Interosseous ligaments connect the proximal carpal row (scapholunate and lunotriquetral) and the distal row (trapezium to trapezoid, trapezoid to capitate, and capitate to hamate) [90]. Extrinsic or crossing ligaments include the radial collateral ligament from the radial styloid to the scaphoid waist, the ulnar collateral ligament from the base of the ulnar styloid to the pisiform, and the transverse carpal ligament [90]. Volar extrinsic ligaments on the radial side include the radioscapocapitate, radiolunotriquetral, and radioscapolunate ligaments, while the ulnar side comprises the ulnolunate and ulnotriquetral components of the TFCC [90]. The space of Poirier is a relatively thin area on the palmar side of the carpus between the radiolunotriquetral and radioscapocapitate ligaments, overlying the palmar surface of the lunate [90]. The dorsal radiocarpal ligament attaches along the dorsal radial articular margin of the lunate fossa from the Lister tubercle to the lesser sigmoid notch, spans the lunotriquetral joint, and inserts on the dorsal surface of the triquetrum [90]. The dorsal intercarpal ligament attaches to the distal dorsal surface of the triquetrum and passes across the midcarpal joint to attach to the dorsal surfaces of the scaphoid waist and trapezoid [90].

Most carpal ligaments lengthen only during one half of a full movement cycle, constraining either dorsal- or palmar-directed, or ulnar- or radial-directed motion [105]. The ulnocarpal ligaments are likely to be stretched tensely in wrist radial extension and wrist extension [137].

Vascular Supply

The terminal branches of the radial, ulnar, and anterior interosseous arteries provide extraosseous blood supply to the carpus through three dorsal and three palmar transverse arterial arches with longitudinal connections [95]. The dorsal radiocarpal arch is located at the radiocarpal joint and supplies the lunate and triquetrum [95]. The dorsal intercarpal arch is the largest, located between the proximal and distal carpal rows, supplying the distal carpal row and, through anastomoses with the radiocarpal arch, the lunate and triquetrum [95]. The basal metacarpal arch is located at the base of the metacarpals, is the most variable, and supplies the distal carpal row [95]. The palmar radiocarpal arch is located at the level of the radiocarpal joint on the palmar surfaces of the lunate and triquetrum [95]. The intercarpal arch is located between the proximal and distal carpal rows, is the most variable, and does not contribute to nutrient vessels in the carpus [95]. The deep palmar arch is located at the level of the metacarpal bases, is consistent, and communicates with the dorsal basal metacarpal arch and the palmar metacarpal arteries [95].

Kinematics and Biomechanics

The wrist functions as a two-joint system linking the hand to the forearm around the highly mobile bones of the proximal carpal row [94]. The two principal articulations are the radiocarpal and midcarpal joints, situated proximal and distal to the mobile proximal carpal row [94]. The proximal carpal row has no muscular or tendinous attachments and is an intercalary segment [93]. With ulnar deviation, the proximal row extends relative to the forearm/distal row, and with radial deviation, the proximal row flexes relative to the forearm/distal row [93]. With axial loading through the neutral wrist, approximately 80% of forces are transmitted through the distal radius (60% scaphoid facet, 40% lunate facet) and 20% through the distal ulna [93]. With wrist flexion, 60% of the motion is midcarpal and 40% is radiocarpal [93]. With wrist extension, 33% of the motion is midcarpal and 66% is radiocarpal [93].

The wrist behaves kinematically consistent but kinetically variable, implying that mechanical behavior is predominantly determined by articular geometry rather than ligament constraints [89]. Despite complex carpal bone anatomy and kinematics, computed fiber elongations were found to vary linearly with wrist position [92]. The scaphoid, lunate, and capitate move synergistically throughout planar wrist motion [132]. The row theory more clearly accounts for the function of the wrist than the column theory [134]. All bones of each carpal row rotate in the same plane during any direction of global wrist motion [94]. In all but pure flexion/extension of the uninjured wrist, the proximal and distal rows move in divergent directions [94]. Division of either of the proximal row’s interosseous ligaments in isolation does not result in a postural deformity of the lunate [94]. Similar collapse deformities of proximal row alignment (VISI or DISI) can occur with or without disruption of an interosseous ligament [94].

The dart-thrower’s path of radial extension to ulnar flexion defines the transition between flexion and extension of the scaphoid and lunate, and a path of motion during which the proximal row motion approaches zero [94]. The dart-thrower’s motion occurs almost exclusively through the midcarpal joint, and rotation occurs along the mechanical axis of the wrist [94]. The lunate, capitate, hamate, trapezium, and trapezoid function collectively as the stable central column, controlled by the scaphoid in a two-gear, four-bar linkage system and stabilized by the triquetrum [94]. The computation of the total hysteresis area is a sensitive technique to determine the subtle onset of abnormal carpal motion, with significant increases seen after just scapholunate interosseous ligament sectioning during wrist radioulnar deviation [138].

Pathophysiology

Scapholunate interosseous ligament injury and extrinsic ligament complex attenuation lead to palmar flexion of the scaphoid and extension of the lunate (DISI) [68]. The radioscaphoid joint becomes incongruous following scapholunate injury, leading to alteration in normal radioscaphoid contact forces and development of arthrosis [68]. As the scaphoid flexes and the scapholunate diastasis increases, the capitate migrates proximally [68]. Altered intercarpal contact forces result in arthrosis at the capitolunate joint in SLAC wrist [68]. The styloscaphoid, radioscaphoid, and capitolunate joints are affected by SLAC wrist arthritic changes [68]. The radiolunate joint is typically spared in SLAC wrist because of its spheroid shape [68].

Ulnocarpal impingement is a degenerative condition resulting from a discrepancy in the relative length of the distal articular surfaces of the radius and ulna (positive ulnar variance) [68]. Posttraumatic causes of ulnocarpal impingement include distal radius fracture with shortening, Galeazzi or Essex-Lopresti fracture, and childhood epiphyseal plate injuries [68]. Congenital causes of ulnocarpal impingement include dyschondroplasia (Madelung deformity) and naturally occurring positive ulnar variance [68].

The classic pattern of rheumatoid wrist deformity involves the radiocarpal and radioulnar joints with destabilization of the carpus caused by attenuation of the extrinsic wrist ligaments, resulting in ulnar-palmar translocation and wrist supination [141]. Three main pathophysiological factors play the greatest role in rheumatoid wrist deformation: cartilage destruction, synovial expansion, and ligamentous laxity [141]. Cartilage thinning in rheumatoid arthritis is caused by cytochemical effects with continuous degradation [141]. Bony erosion in rheumatoid arthritis arises due to synovial expansion, particularly at the site of vascular penetration into the bone such as the radial origin of the Testut ligament [141]. The scapholunate interval starts to dissociate in rheumatoid arthritis and continues to disintegrate the internal carpal architecture [141]. The force vector across the rheumatoid wrist predominately acts in a palmar-ulnar direction [141]. Flexion of the scaphoid through the weakening of the scapholunate ligament leads to collapse of the radial column in rheumatoid arthritis [141]. Stretching of the wrist ulnar collateral ligament attenuates ulnar column support, leading to a typical carpal supination pattern in rheumatoid arthritis [141]. Carpal supination in rheumatoid arthritis contributes to radial deviation of the metacarpals and accentuates ulnar deforming forces on the fingers at the MCP joints [141]. Volar flexion of the lunate relative to the scaphoid in early-to-midstage rheumatoid wrists is caused by intrinsic ligament laxity, mainly of the scapholunate ligament [141]. In later rheumatoid arthritis stages, the capitate tends to flex dorsally due to midcarpal instability as a result of extrinsic ligament weakening [141].

In juvenile arthritis, uncontrolled joint synovitis stretches essential ligaments and eventually erodes cartilage and bone [142]. Uncontrolled synovitis in juvenile arthritis results in a progressive shift of the carpus ulnarward and volarward [142]. The movement of the hand-carpus unit in juvenile arthritis leaves the ulna dorsally dislocated and creates a dorsal wrist step-off because of the subluxed carpus [142]. Destruction of joint mechanics in juvenile arthritis is accompanied by loss of active and passive wrist extension and weakness of grip [142]. If juvenile arthritis disease spreads to the distal radioulnar joint, forearm rotation becomes limited [142]. Injury to the dorsal wrist extrinsic carpal ligaments exacerbates volar radiocarpal instability after intra-articular distal radius fracture [124]. Biomechanical findings support early diagnosis, targeted reconstruction, and the need to restore both primary and secondary stabilizers to prevent progressive scapholunate instability [67].

Classification

TFCC Injuries (Palmer Classification)

Palmer Classification: This system categorizes triangular fibrocartilage complex (TFCC) tears into traumatic (class 1) or degenerative (class 2) categories, with subtypes defined by the specific location of the injury within the TFCC [29]. The class and location of a TFCC tear carry significant implications for treatment [29].

• Class 1A: Central perforation or tear [29].
• Class 1B: Ulnar avulsion with or without ulnar styloid fracture [29].
• Class 1C: Distal avulsion involving the origins of the ulnolunate and ulnotriquetral ligaments [29].
• Class 1D: Radial avulsion involving the dorsal and/or volar radioulnar ligaments [29].
• Class 2A: TFCC wear or thinning [29].
• Class 2B: TFCC wear plus lunate and/or ulnar chondromalacia [29].
• Class 2C: TFCC perforation plus lunate and/or ulnar chondromalacia [29].
• Class 2D: TFCC perforation, lunate and/or ulnar chondromalacia, and lunotriquetral ligament disruption [29].
• Class 2E: TFCC perforation, lunate and/or ulnar chondromalacia, lunotriquetral ligament disruption, and ulnocarpal and distal radioulnar joint arthritis [29].

The classification of central triangular fibrocartilage complex lesions as traumatic or degenerative depends on the information provided upon viewing the lesion at arthroscopy [161].

Scapholunate Ligament Injuries (Geissler Classification)

Geissler Classification: Arthroscopy is the gold standard for identifying and grading scapholunate injuries [162]. The classification defines four grades based on visual inspection and probe testing:

• Grade 1: Attenuation or hemorrhage of the membranous portion of the ligament with a smooth and intact scapholunate interval [162]. This is also defined as attenuation or hemorrhage seen from the radiocarpal space with no incongruency of carpal alignment in the midcarpal space [81].
• Grade 2: An attenuated fibrocartilaginous membrane with a step-off between the scaphoid and lunate where a 1-mm probe may be placed between the bones [162]. This corresponds to attenuation or hemorrhage seen from the radiocarpal space with incongruency or step-off in the midcarpal space and a possible gap less than the width of a probe [81].
• Grade 3: A step-off visualized from both the radiocarpal and midcarpal joints where a 1-mm probe may be inserted into and freely rotated in the scapholunate interval [162]. This is defined as incongruency or step-off of carpal alignment seen from both radiocarpal and midcarpal spaces where a probe may be passed through the gap between carpal bones [81].
• Grade 4: Complete disruption of the ligament allowing a 2.7-mm arthroscope to be passed between the radiocarpal and midcarpal joints [162]. This is defined as incongruency or step-off of carpal alignment seen from both radiocarpal and midcarpal spaces [81].

Chondral Lesions (Outerbridge Classification)

Outerbridge Classification: Chondral pathology is graded according to the modified Outerbridge classification [81]. Cartilage lesions are classified according to the Outerbridge system [152].

Scapholunate Instability Stages

Scapholunate Instability Stages: A four-stage classification system for scapholunate instability includes predynamic instability, dynamic instability, static instability, and scapholunate advanced collapse (SLAC) [162].

Clinical Presentation

Diagnostic Indications and Role

Wrist arthroscopy serves as an essential diagnostic and therapeutic tool for the orthopaedic surgeon, offering an ever-expanding list of indications and procedures [2]. It is a safe procedure with minor and transient complications, functioning as a crucial tool for diagnosing intra-articular pathology and treating multiple wrist conditions [10]. As an effective adjunctive tool, it aids in the diagnosis of wrist derangements [28]. In rare but difficult cases of posttraumatic pain where clinical and radiological examinations fail to provide a diagnosis, arthroscopy enables new diagnostic possibilities [19]. Despite technical progress in imaging modalities, wrist arthroscopy remains the 'gold standard' for diagnosing TFCC pathologies [36]. It is particularly well suited to directly visualize and treat multiple causes of ulnar-sided wrist pain simultaneously [9]. Diagnostic arthroscopy is a useful adjunct in the diagnosis and treatment of intra-articular wrist pathology, provided it follows a careful history and physical examination [6].

Indications for diagnostic wrist arthroscopy include: Chronic pain: Chronic wrist pain of uncertain etiology with more than 3 months interval, unresponsive to conservative treatment [23]. Acute ligamentous injuries: Assessment of scapholunate, lunotriquetral, and TFCC injuries [23]. Instability and cartilage: Evaluation of carpal instability and assessment of chondral lesions [23]. Fracture-associated injury: Evaluation of associated soft tissue injury in fracture conditions such as distal radius, scaphoid, and ulnar styloid fractures [23]. Scaphoid healing: Assessment of scaphoid healing in delayed union and nonunion [23]. Arthritis staging: Staging of posttraumatic arthritis such as SLAC, SNAC, and distal radius fractures [23]. Other pathologies: Evaluation of monoarticular arthritis, synovial biopsy, and Kienböck disease [23].

Patients without positive provocative signs on examination seldom yield positive findings at wrist arthroscopy [69]. Consequently, arthroscopic findings need to correlate with clinical examination [69].

Preoperative Assessment and Imaging

A careful history and physical examination are prerequisites before using wrist arthroscopy for either diagnosis or treatment [31]. The natural inclination to study radiographs or special imaging studies and reports prior to a thorough history and physical examination should be avoided, as this introduces cognitive bias [50]. Physical examination always needs to be preceded by a thorough investigation of the patient’s medical history, with special emphasis on the mechanism of injury and acuity [50]. Palpation for areas of maximal tenderness is one of the most useful tools in the diagnosis of wrist pathology, especially in patients with chronic dysfunctions [50]. A thorough set of provocative maneuvers should be performed to rule out alternative or even concurrent diagnoses [50]. Bilateral grip and pinch strength are useful to uncover underlying pathology in chronic cases [50].

Standard radiographs are nearly always required to evaluate chronic wrist pain [117]. MRI should be added for evaluation of the triangular fibrocartilage, the distal radioulnar joint, and vascularity of the various carpal bones to confirm clinical suspicion [47]. However, a high rate of false-positive findings on MR images of normal subjects has been reported [47]. Recent studies have shown that arthroscopy is more sensitive than arthrography for evaluating TFCC tears and interosseous ligament tears [31]. Negative results of MRI or clinical provocative tests are still unable to safely rule out the possibility of clinically relevant tears to the TFCC and other wrist ligaments, which makes further diagnostic evaluation with wrist arthroscopy necessary [63]. While MRI is a useful adjunct for determining the cause of ulnar wrist pathologies, findings are often discordant when compared with diagnostic arthroscopy [49]. The report strongly suggests that the arthrogram should not be considered a definitive study for the diagnosis of a clinically important injury of a ligament in the wrist [128]. Clinicians should be careful ascribing symptoms to anatomical variations on radiographs in patients with nonspecific wrist pain [60].

Determining the etiology of ulnar-sided wrist pain is often challenging due to overlapping history and physical examination findings; a detailed history, systematic physical examination with provocative maneuvers, and appropriate diagnostic imaging are essential for diagnosis [115]. Ulnar-sided wrist pain is a common cause of upper extremity disability with a complex differential diagnosis [106]. Disorders of the distal radioulnar joint are a common source of ulnar-sided wrist pain, but increased understanding of anatomy and pathology has facilitated accurate diagnosis and successful treatment in most cases [114]. Diagnostic wrist arthroscopy for a wrist with normal radiological alignment has poor interobserver agreement [22].

Outcomes and Prognosis

Participants who underwent arthroscopic investigation for persistent wrist pain improved on average by approximately 50% at one year; however, most continued to have some pain and disability [5]. Patients with persistent wrist pain undergoing arthroscopy may expect approximately 50% improvement in pain and disability within one year, though moderate levels of pain and disability often persist [35]. This procedure results in resolution of symptoms in 87% of patients with dorsal wrist syndrome [53].

Complications and Safety

Complications associated with wrist arthroscopy are fortunately believed to be uncommon [1]. As with any surgical procedure, complications associated with wrist arthroscopy may largely be avoided by paying meticulous attention to detail and by anticipating potential problems before they occur [15]. This systematic review suggests that the previously documented rate of wrist arthroscopy complications may be underestimating the true incidence [39]. Based on the findings of this study, there may be more instances of trauma to the PIN during routine wrist arthroscopy than have been previously reported [54].

Specific procedural risks include: Portal creation: A direct stab wound with a scalpel can damage cutaneous nerves and extensor tendons during portal creation [69]. Use of excessive force, especially during portal creation, may create cartilage damage in the midcarpal joint and DRUJ [69]. Traction and distraction: Excessive traction produces joint pain [69]. Overdistraction, or use of wire finger traps may cause postoperative finger joint pain or localized contusion to soft tissue or digital nerves [23]. Fluid management: A mechanical pump may cause fluid extravasation and compartment syndrome, especially in a fracture situation [69].

Investigations

Gold Standard Status: Wrist arthroscopy is the gold standard for the diagnosis and treatment of longitudinal split tears of the ulnotriquetral ligament [7], triangular fibrocartilage complex (TFCC) tears [29, 30], and intercarpal ligament injuries and instability [46]. It remains the definitive diagnostic tool for wrist ligamentous pathology, particularly when scapholunate interosseous ligament (SLIL) or lunotriquetral interosseous ligament (LTIL) involvement is suspected based on history and physical examination, even in the face of negative MRI findings [151]. Arthroscopic surgery is broadly considered the gold standard for diagnosing wrist ligament pathology [172].

Plain radiography: Conventional radiography should be the first imaging modality to exclude or diagnose wrist pathology [130]. When radiographic findings are inconclusive, high-resolution 3 Tesla MRI is advised [130]. Cineradiography has a high diagnostic value for diagnosing scapholunate dissociations [182].

MRI: MRI is a useful adjunct for determining the cause of ulnar wrist pathologies, although findings are often discordant when compared with diagnostic arthroscopy [49]. A stable distal radioulnar joint upon clinical examination and normal MRI findings do not rule out foveal TFCC injury [158]. Negative results of MRI or clinical provocative tests are unable to safely rule out clinically relevant tears to the TFCC and other wrist ligaments, necessitating further diagnostic evaluation with wrist arthroscopy [63]. Wrist ligament pathology cannot be ruled out by a negative magnetic resonance imaging [172]. With only a fair correlation between arthroscopy and MRI, it cannot be concluded that the two methods are equivalent for assessing wrist cartilage [139].

3T MRI proved to be of good value in diagnosing cartilage lesions, especially in the distal carpal row, whereas wrist arthroscopy provided therapeutic options [131]. However, a 3 tesla MRI was neither sensitive nor specific enough to correctly diagnose lesions in small pediatric wrists [181]. For young subjects, MRI is still valuable, especially in diagnosing ulnar detachment, although the ability to distinguish between proximal and distal laminae remains questionable [179]. When the appropriate pulse sequence is used, magnetic resonance imaging is an accurate and effective method for the non-invasive evaluation of pain in the wrist [183]. MRI demonstrated an identifiable dorsal abnormality in 84% of patients with dorsal wrist pain associated with weight bearing on the extended wrist [154]. MRI-detectable carpal lesions at the time of the radial fracture are common, but only a few of them seem to decompensate later, give symptoms and became of therapeutic relevance [155].

Magnetic Resonance Arthrography (MRA): Single compartment direct wrist magnetic resonance arthrography can provide high diagnostic accuracy for full-thickness triangular fibrocartilage lesions, intrinsic carpal ligament tears and chondral lesions in the radiocarpal joint, but is much less accurate in diagnosing synovitis of the radiocarpal joint [163]. Superior contrast resolution, joint distention, and the flow of contrast facilitate the diagnosis of lesions of the TFCC and intrinsic ligaments on contrast-sensitive sequences, making MRA the preferred modality for imaging internal derangements of the wrist [175].

CT: Four-dimensional CT complements conventional imaging and arthroscopy by providing functional information on wrist biomechanics and should be used selectively when dynamic instability is suspected and conventional imaging is inconclusive [45].

Arthrography: Although arthrography of the wrist is a well accepted diagnostic modality in the evaluation of pain in the wrist, normal arthrographic findings do not necessarily rule out the possibility of internal derangement of the wrist [173]. Arthroscopy has been found to be more accurate than arthrography in identifying the location and size of triangular fibrocartilage and interosseous ligament injuries [46]. Arthroscopy is more accurate than triple-injection cinearthrography in detecting tears of the dorsal sensory branch of the ulnar nerve during arthroscopic repair of the triangular fibrocartilage [46].

Clinical Examination: The physical examination of the wrist is more important than ever [65]. The natural inclination to study radiographs or special imaging studies and reports prior to a thorough history and physical examination should be avoided, as this introduces cognitive bias, which can affect one’s thinking and decision making [50]. A careful assessment of neural and vascular status is imperative, with particular attention being paid to the median and ulnar nerves [50]. Sensory testing should always accompany an examination of suspected nerve compression, using threshold or density testing [50].

Other Considerations: A thorough understanding of the 3-D anatomy of the wrist is essential to optimize efficiency and to minimize complications associated with improper instrument placement [6]. To be successful with wrist arthroscopy and mitigate iatrogenic injury, a clear understanding of the topographical and 3-dimensional spatial anatomic relationships in the wrist as well as a patient’s unique anatomic variances is critical [12]. Detailed knowledge of anatomy is essential to minimize complications [8]. A knowledge of wrist anatomy, the use of correct technique, and an understanding of the equipment and its use may help to avoid significant complications [46]. Wrist arthroscopy is here to stay with proven superiority in diagnosis, but its value in treatment is evolving and requires more clinical studies to refine indications and outcomes [4].

Treatment

Non-Operative

Most cases of pediatric ulnar-sided wrist pain resolve with nonsurgical management, while persistent pain may require advanced imaging and arthroscopy for diagnosis and treatment [160]. Wrist arthroscopy and an ulnar shortening procedure are indicated for patients with neutral to positive ulnar variance and persistent ulnar-sided wrist pain despite conservative treatment to unload the ulnocarpal joint [140].

Operative

Indications: Diagnostic arthroscopy is indicated for the evaluation of chronic wrist pain of uncertain etiology with more than 3 months interval, unresponsive to conservative treatment [23]. It is also indicated for the assessment of acute ligamentous injuries, including scapholunate, lunotriquetral, and TFCC injuries [23], as well as for the evaluation of carpal instability [23]. Further indications include the assessment of chondral lesions [23], the evaluation of associated soft tissue injury in fracture conditions such as distal radius, scaphoid, and ulnar styloid fractures [23], and the assessment of scaphoid healing in delayed union and nonunion [23]. Diagnostic arthroscopy is further indicated for the staging of posttraumatic arthritis, including SLAC and SNAC wrists [23], the evaluation of monoarticular arthritis and synovial biopsy [23], and the evaluation of Kienböck disease [23].

Surgical Approach / Technique: The patient is positioned supine on the operating table with a traction device applied to distract the wrist joint [23]. Traction force of 10 to 12 lb is applied through plastic finger traps over the index and middle fingers, or more preferably, the middle three fingers [23]. Nylon finger traps are more comfortable and atraumatic to the patient, especially in awake cases [23]. For arthroscopy over the scaphotrapeziotrapezoid joint, an additional trap and traction can be put on the thumb [23]. When an overhead traction boom is employed, countertraction is provided by securing the arm to the hand table, and the operated limb is draped free up to the elbow level [23]. When a dedicated wrist traction device is being used, the limb is draped up to the axilla level and the lower arm is wrapped to the basal plate of the device close to the elbow level [23]. A traction device should be sterilizable and allow flexible positioning of the wrist intraoperatively in varying degrees of extension, flexion, and radial and ulnar deviation [23]. Traction is essential for visualization in wrist arthroscopy [79]. The space available for manipulation of the arthroscope and instrumentation in the wrist is substantially smaller than that available for arthroscopy of larger joints [79]. Wrist arthroscopy requires accurate placement and smaller instrumentation so that all areas can be examined, probed, and treated [79]. Inappropriate placement of portals either too distal or too proximal along the wrist may cause injury to the articular cartilage or the triangular fibrocartilage [79].

Joint visibility is maintained by saline inflow, as the small volume of the wrist makes fluid distention rather impractical compared to the knee or shoulder [23]. The main maneuver in creating the working space is controlled traction, while saline maintains a clear view by removing intraarticular debris through the outflow portal [23]. The hydrostatic pressure generated by saline serves a hemostatic role when arthroscopy is performed without tourniquet [23]. Continuous irrigation is achieved with a 3 L bag of normal saline suspended 1.5 m above the patient and instilled under gravity [23]. Caution should be used to avoid extravasation of fluid that may lead to compartment syndrome [23]. A pressure control device is not essential for wrist arthroscopy [23].

Adjuncts: Tourniquet use is optional and is often unnecessary, especially for diagnostic and uncomplicated therapeutic procedures performed under local anesthesia without sedation [23]. The PSLA technique is a feasible mode of anesthesia in selected patients for wrist arthroscopy, offering a success rate of 95% with high patient satisfaction and no complications [168]. The PSLA technique without a tourniquet is a feasible and preferred mode of anesthesia for wrist arthroscopic surgery in the hands of experienced wrist arthroscopists [188]. Wrist arthroscopy was performed under general anesthetic augmented with a peripheral nerve block and using a tourniquet for established scaphoid nonunion [81]. The wrist was suspended using finger traps, and a 5-lb counterweight was used to provide distraction of the carpus in the management of established scaphoid nonunion [81]. Standard 'wet' wrist arthroscopy was performed through the 3/4, 4/5, and midcarpal portals for established scaphoid nonunion [81]. Comprehensive assessment was made of both the radiocarpal and midcarpal joints and, where possible, the pisotriquetral and head of the ulna during wrist arthroscopy for scaphoid nonunion [81]. Tears of the intercarpal ligaments (scapholunate ligament [SLL] and lunotriquetral ligament [LTL]) were classified according to Geissler et al during wrist arthroscopy for scaphoid nonunion [81]. Chondral pathology was graded according to the modified Outerbridge classification during wrist arthroscopy for scaphoid nonunion [81].

For arthroscopic TFCC reconstruction with free tendon graft, the surgery was performed with the patients under general anesthesia [196]. An upper arm tourniquet was applied, and the pressure was set between 200 and 250 mmHg for arthroscopic TFCC reconstruction [196]. The wrist was elevated and distracted with a traction towel and finger traps applied over the index and middle fingers for arthroscopic TFCC reconstruction [196]. The 3–4 portal and 6R (or 6U) portal were created for arthroscopic TFCC reconstruction [196]. All patients underwent an arthroscopic wrist examination, and the lesions of the TFCC tears were identified and classified according to Palmer’s classification [196]. PL tendon harvesting was performed via the volar approach for arthroscopic TFCC reconstruction [196]. A 2 cm dorsal incision was made proximally from the 4/5 portal for bony tunnel creation in arthroscopic TFCC reconstruction [196]. A 1.1 mm guide pin was inserted toward the volar surface as the radial tunnel for arthroscopic TFCC reconstruction [196]. The exit point of the radial tunnel was around 5 mm from the sigmoid notch edge confirmed by fluoroscopy and out of the skin from the PL harvesting wound [196]. Stepwise drilling of the radial tunnel to 2.5 mm was performed for the passage of the PL tendon through the volar side to the dorsal side [196]. The tears and inflammatory synovium were debrided using a small joint power shaver during arthroscopic TFCC reconstruction [196]. The fovea region of the distal ulnar head was identified and prepared for arthroscopic TFCC reconstruction [196]. Another 2 cm wound was made for the ulnar tunnel in arthroscopic TFCC reconstruction [196].

For short radiolunate avulsion injury repair, the patient was prepped and draped in the usual sterile fashion and placed in a traction tower with the wrist slightly flexed and the digits free [190]. Ten pounds of traction was applied for short radiolunate avulsion injury repair [190]. Diagnostic arthroscopy was performed using a 2.3-mm wrist arthroscope placed in the 3-4 portal for short radiolunate avulsion injury repair [190]. The radiocarpal joint was examined using a bent probe through the 4-5 portal for short radiolunate avulsion injury repair [190]. An extensile exposure of the volar wrist joint was performed after arthroscopic evaluation for short radiolunate avulsion injury repair [190]. Flexor tenosynovitis was identified within the carpal tunnel and a flexor tenosynovectomy was performed for both therapeutic and visualization purposes [190]. A transverse defect in the volar wrist capsule was noted corresponding to the location of the short radiolunate ligament injury described on MRI before surgery [190]. The defect extended along the edge of the distal radius, representing a continuous injury of the volar wrist capsule and the short radiolunate ligament complex [190]. The injury included the insertion of the short radiolunate ligament on the lunate [190]. The volar wrist capsule defect was repaired by placing sutures [190].

For temporary dorsal staple fixation of scapholunate interosseous ligament repair, a 3-cm skin incision centered over scapholunate interval and within a Langer's line is the senior author's preference [189]. A dorsal approach is performed through the third and fourth extensor compartments, using Lister's tubercle as a landmark for temporary dorsal staple fixation [189]. A dorsal capsulotomy is made to expose the scapholunate interval and SLIL injury for temporary dorsal staple fixation [189]. One 1.6 mm K-wire is placed in the dorsal scaphoid in a dorsal to volar trajectory for temporary dorsal staple fixation [189]. One 1.6 mm K-wire is placed in the dorsal lunate in a dorsal to volar trajectory to be used as joysticks to aid in mobilization and reduction for temporary dorsal staple fixation [189]. The K-wires are removed prior to completion of the case and are not left in place for temporary dorsal staple fixation [189]. The patient should be made aware of the planned return to the operating room for hardware removal, which can be performed with local anesthesia and sedation for temporary dorsal staple fixation [189].

The modified capsulotomy allows excellent exposure of the wrist and carpus, particularly for access to the most radial aspect of the wrist or mid-carpal joint [58]. The modified capsulotomy follows established principles for safe and reliable repair [58]. The palpable landmarks for the ligament-splitting dorsal wrist capsulotomy include the sulcus between the scaphoid and trapezoid, the dorsal tubercle of the triquetrum, and the midpoint between Lister's tubercle and the dorsal rim of the sigmoid notch [180]. These points identify the bisection lines of the dorsal intercarpal and dorsal radiocarpal ligaments [180]. A radial-based capsulotomy can be easily elevated by incising the dorsal wrist joint capsule using these landmarks and then extending the incision along the dorsal rim of the distal radius to the radial styloid process [180]. This method of defining capsular incision lines based on palpable landmarks was used on 253 consecutive dorsal wrist arthrotomies with excellent exposure [180].

Other Considerations: Ablative therapeutic procedures include TFCC debridement, debridement of ligament tears, synovectomy, wrist ganglionectomy, removal of loose body, capsulotomy/capsulectomy, lavage, and arthrolysis [23]. Ablative bony therapeutic procedures include scaphoidectomy, radial styloidectomy, wafer procedure, proximal row carpectomy, and proximal hamate excision [23]. Ablative cartilage therapeutic procedures include debridement of chondral and osteochondral lesions [23]. Reparative soft tissue therapeutic procedures include peripheral TFCC tear repair, TFCC foveal avulsion repair, scapholunate ligament injury repair, and lunotriquetral ligament injury repair [23]. Reparative bony therapeutic procedures include arthroscopic-assisted reduction and internal fixation (ARIF) for distal radius and scaphoid fractures [23]. Reparative cartilage therapeutic procedures include drill/abrasion chondroplasty [23]. Reconstructive soft tissue therapeutic procedures include arthroscopic TFCC reconstruction with tendon graft and arthroscopic-assisted scapholunate ligament reconstruction with tendon graft [23]. Reconstructive bony therapeutic procedures include arthroscopic bone grafting for scaphoid nonunion, limited carpal fusion, intraosseous bone cyst, and intraosseous ganglion [23]. Reconstructive cartilage tissue therapeutic procedures include osteochondral grafting [23].

Arthroscopic partial wrist fusion is a salvage operation that should be considered when there is clinical and radiographic evidence of wrist arthritis in chronic scapholunate ligament injury [40]. Arthroscopic wrist arthrolysis after wrist fracture is a safe procedure that significantly improved pain and wrist flexion-extension [55]. Arthroscopic repair of combined triangular fibrocartilage complex, lunotriquetral ligament, and ulnocarpal ligament tears offers a minimally invasive and easily reproducible solution [64]. Arthroscopic TFCC reconstruction with free tendon graft is performed for chronic distal radioulnar joint instability with irreparable TFCC tears [196]. Scapholunate ligament reconstruction using a part of the extensor carpi radialis brevis tendon through a dorsal approach resulted in long-term, improved outcomes compared with other techniques, even in scapholunate advanced collapse type I wrists [41]. The relative simplicity and preservation of wrist function with the all-dorsal reconstruction technique for scapholunate ligament reconstruction justify its continued use, despite high complication and revision incidences [24]. Radio-scapho-capitate ligament reconstruction during proximal row carpectomy stabilizes the wrist despite RSCL insufficiency after PRC [84]. Early detection of carpal instability nondissociative following acute wrist fractures may preserve wrist function by capsular repair, whereas cases with fixed deformity and residual joint incongruity may be best managed with a limited radiocarpal arthrodesis [82]. Dry wrist arthroscopy is an ideal intervention for the management of intra-articular distal radius fractures given the lack of fluid extravasation, and it can assist when performing concomitant open procedures [61]. Dry wrist arthroscopy facilitates the combination of open procedures with arthroscopic visualization, particularly for distal radius fractures and complex fixation [191]. Proximal row carpectomy has gained recent support and its incidence has increased, even in patients under 45 years old [25]. A pyrocarbon capitate resurfacing implant may represent a good alternative to total and partial wrist arthrodesis in chronic wrist disorders [52]. Partial wrist denervation is a reliable motion preserving procedure for patients with chronic wrist pain, with 71% of patients experiencing pain relief and not requiring further salvage procedures at an average of 78 months of follow up [72]. Implant arthroplasty for the distal radio-ulnar joint has produced acceptable results in small numbers of patients [73]. Combined treatment of trapeziometacarpal joint arthritis and scapholunate advanced collapse wrist resulted in an improvement in pain at rest, pain during activity, and quick Disabilities of the Arm, Shoulder and Hand scores [71]. Various surgical techniques can preserve a functional wrist, and wrist arthrodesis is no longer the only solution for arthritic wrists [34]. Total wrist fusion should only be used for exceptional circumstances in the treatment of advanced carpal collapse [184].

Complications

General Incidence: A systematic review suggests that previously documented rates of wrist arthroscopy complications may underestimate the true incidence [39]. In a multicenter study of 10,107 arthroscopies, the global incidence of complications aligned with existing literature, but the incidence of serious complications was significantly higher than previously reported [204].

Infection: Postoperative infection is uncommon but clinically relevant, particularly in elderly, male patients with systemic comorbidities or those undergoing synovectomy [122]. In a systematic review of 456 patients with arthroscopic TFCC debridement, septic arthritis occurred in 1 (0.2%) patient [187]. Joint infection is rare, and prophylactic antibiotics are not routinely administered unless implants are used [187]. Administering preoperative antibiotics for routine wrist arthroscopy does not appear to lower the surgical site infection rate [197]. Standard treatment for septic arthritis involves arthroscopic washout combined with 6 weeks of antibiotics [187]. Infection is a very rare complication that may result in wrist fusion, a outcome observed once by the authors [178].

Traction and Setup-Related: Complications directly related to arthroscopic setup include burns from a hot traction tower and neurapraxia of digits from over-zealous traction [187]. These traction-related complications can be prevented by applying padding to areas where the traction tower contacts the patient's skin and ensuring traction does not exceed 15 lbs [187]. Caution is required to avoid extravasation of fluid during irrigation, which may lead to compartment syndrome [23].

Thermal and Energy-Related: The use of radiofrequency may cause iatrogenic injury to neighbouring tissues, ranging from tissues within the joint to the skin at the portal site [187]. Irreversible cell death in cartilage occurs with exposure to 50-C for 5 minutes [187]. Thermal injury causing widespread cartilage damage has been reported after TFCC debridement [187]. The author's experience with more than 150 laser-assisted wrist arthroscopies using the Ho:YAG laser resulted in no laser-related complications [206].

Other Considerations: The all-dorsal reconstruction technique for scapholunate ligament injury is associated with high complication and revision incidences [24]. Arthroscopic repair of Palmer type 1B tears yields satisfactory results, with 63% of patients achieving good to excellent outcomes [87]. Arthroscopically-assisted mini-open proximal row carpectomy resulted in favorable third-month patient-related outcomes attributed to earlier initiation of postoperative wrist motion and the less invasive character of the procedure [205]. Both suture anchor and transosseous suture techniques for arthroscopic-assisted foveal reattachment of TFCC tears yielded good and comparable outcomes, with a lesser incidence of early complications in the anchor repair group [202]. The procedure for ulnotriquetral split tear repair reliably improves pain and function with a low complication and reoperation rate [76]. In a study of arthroscopic treatment of scapholunate ligament lesions associated with intra-articular distal radius fractures, none of the seven patients showed complications related to the scapholunate injury or initial surgical treatment [148]. In the same series, there were no infections or nerve injuries, though one patient required revision surgery for redislocation of the radius fracture [148].

Recovery

Light activity (weeks): Hand coordination following tendon transfer surgery demonstrates a graded recovery, with coordinated movement between wrist and finger joints improving at weeks 8 and 12 [144].

Full activity (months): Return to play may be delayed in athletes with concomitant ulnar-sided wrist injuries [176].

Other Considerations: Patients who underwent arthroscopic investigation for persistent wrist pain improved on average by approximately 50% at one year [5]. Most patients who underwent arthroscopic investigation for persistent wrist pain continued to have some pain and disability at one year [5]. Patients with persistent wrist pain undergoing arthroscopy may expect approximately 50% improvement in pain and disability within one year [35]. Moderate levels of pain and disability often persist in patients with persistent wrist pain undergoing arthroscopy [35]. Once ulnar impaction becomes symptomatic, it remains so and recurs, especially on return to the athletic sport [193]. Patients with persisting or recurrent pain after treatment for ulnar impaction syndrome benefited from ulnar shortening osteotomy as a secondary procedure [80].

Key Evidence

• [L5] Complications associated with wrist arthroscopy are fortunately believed to be uncommon. [1] (10.1016/s0749-0712(21)00187-6)
• [L5] Wrist arthroscopy is an essential diagnostic and therapeutic tool for the orthopaedic surgeon with an ever-expanding list of indications and procedures. [2] (10.1016/j.arthro.2007.11.002)
• [L4] Wrist arthroscopy has taken up a place in the armamentarium of the hand surgeon. [3] (10.1055/s-0033-1351355)
• [L5] Wrist arthroscopy is here to stay with proven superiority in diagnosis, but its value in treatment is evolving and requires more clinical studies to refine indications and outcomes. [4] (10.1054/jhsb.2001.0617)
• [L2] Participants who underwent arthroscopic investigation for persistent wrist pain improved on average by approximately 50% at one year; however, most continued to have some pain and disability. [5] (10.1016/j.jht.2012.03.001)
• [L5] [6] (10.1016/j.hcl.2017.06.004)
• [L4] Wrist arthroscopy remains the gold standard for the diagnosis and treatment of this condition. [7] (10.1016/j.hcl.2010.07.004)
• [L5] Wrist arthroscopy has grown from a diagnostic tool to a valuable adjunctive procedure for myriad wrist disorders, but detailed knowledge of anatomy is essential to minimize complications. [8] (10.1016/j.jhsa.2008.07.015)
• [L5] Arthroscopy is particularly well suited to both directly visualize and treat multiple causes of ulnar-sided wrist pain simultaneously. [9] (10.1016/j.hcl.2013.09.001)
• [L4] Although nearly all procedures were performed by surgeons who had completed a hand and upper extremity fellowship, there was a decrease in the utilization of wrist arthroscopy among surgeons without hand and upper extremity fellowship training. [11] (10.5435/jaaosglobal-d-25-00158)
• [L5] To be successful with wrist arthroscopy and mitigate iatrogenic injury, a clear understanding of the topographical and 3-dimensional spatial anatomic relationships in the wrist as well as a patient’s unique anatomic variances is critical. [12] (10.1016/j.eats.2024.103223)
• [L5] Recent technical and technological developments in wrist arthroscopic surgery allow for advanced treatments of difficult wrist disorders. [13] (10.1177/17531934211030861)
• [L5] As with any surgical procedure, complications associated with wrist arthroscopy may largely be avoided by paying meticulous attention to detail and by anticipating potential problems before they occur. [15] (10.1016/s0749-0712(21)00029-9)
• [L5] Wrist arthroscopy has evolved into an essential diagnostic and therapeutic tool with a wide list of indications, including management of TFCC pathology, carpal instability, fracture reduction assistance, and salvage procedures, with innovations like new portals and smaller arthroscopes expanding its applications. [16] (10.5435/jaaos-20-11-725)
• [L4] Arthroscopy is a simple method that enables new diagnostic possibilities in rare but difficult cases of posttraumatic pain of the wrist, particularly when clinical and radiological examinations fail to provide a diagnosis. [19] (10.1007/bf00420331)
• [L4] The most common indications for repeat wrist arthroscopy were ligamentous instability and osteoarthritis from dynamic impaction. [21] (10.1055/s-0033-1364090)
• [L4] Diagnostic wrist arthroscopy for a wrist with normal radiological alignment has poor interobserver agreement. [22] (10.1016/j.jhsa.2022.07.001)
• [L4] The relative simplicity and preservation of wrist function with the all-dorsal reconstruction technique justify its continued use, despite high complication and revision incidences. [24] (10.1177/17531934261428319)
• [L2] Surgical management of wrist arthritis remains a controversial issue, but proximal row carpectomy has gained recent support and its incidence has increased, even in patients under 45 years old. [25] (10.1016/j.jhsa.2023.11.009)
• [L5] Wrist arthroscopy is an effective adjunctive tool in the diagnosis of wrist derangements. [28] (10.1016/j.hcl.2016.08.005)
• [L5] [31] (10.5435/00124635-200105000-00006)
• [L5] Various surgical techniques can preserve a functional wrist, and wrist arthrodesis is no longer the only solution for arthritic wrists. [34] (10.1016/j.otsr.2013.06.015)
• [L5] The commentary concludes that patients with persistent wrist pain undergoing arthroscopy may expect approximately 50% improvement in pain and disability within one year, though moderate levels of pain and disability often persist. [35] (10.1016/j.jht.2012.04.002)
• [L5] Wrist arthroscopy remains the 'gold standard' for diagnosing TFCC pathologies despite technical progress in imaging modalities, although MR arthrography may have the potential to become a real alternative in the future. [36] (10.1007/s00402-015-2153-6)
• [L5] Wrist arthroscopy is beneficial in improving anatomical reduction of fracture steps and gaps in intra-articular distal radius fractures, though literature correlating functional outcomes with arthroscopy use is limited. [37] (10.1007/s00402-020-03373-y)
• [L4] This systematic review suggests that the previously documented rate of wrist arthroscopy complications may be underestimating the true incidence. [39] (10.1016/j.arthro.2012.01.008)
• [L5] A salvage operation, such as a partial wrist fusion, should be considered when there is clinical and radiographic evidence of wrist arthritis. [40] (10.1016/j.hcl.2015.04.013)
• [L4] This technique, even in scapholunate advanced collapse type I wrists, resulted in long-term, improved outcomes compared with other techniques. [41] (10.1177/17531934221143679)
• [L5] Four-dimensional CT complements conventional imaging and arthroscopy by providing functional information on wrist biomechanics and should be used selectively when dynamic instability is suspected and conventional imaging is inconclusive. [45] (10.1530/eor-2026-0051)
• [L2] While MRI is a useful adjunct for determining the cause of ulnar wrist pathologies, findings are often discordant when compared with diagnostic arthroscopy. [49] (10.1016/j.jhsa.2024.04.015)
• [L4] This surgical procedure may represent a good alternative to total and partial wrist arthrodesis. [52] (10.1177/1753193413501730)
• [L4] This procedure results in resolution of symptoms in 87% of patients with dorsal wrist syndrome. [53] (10.1016/s0749-0712(21)00079-2)
• [L5] Based on the findings of this study, there may be more instances of trauma to the PIN during routine wrist arthroscopy than have been previously reported. [54] (10.1016/j.arthro.2017.01.010)
• [L4] The procedure is safe, required minimal invasive surgery, and significantly improved pain and wrist flexion-extension. [55] (10.1016/j.arthro.2006.11.001)
• [L4] The modified capsulotomy allows excellent exposure of the wrist and carpus, particularly for access to the most radial aspect of the wrist or mid-carpal joint, while following established principles for safe and reliable repair. [58] (10.1177/1753193412453414)
• [L3] Clinicians should be careful ascribing symptoms to anatomical variations on radiographs in patients with nonspecific wrist pain. [60] (10.1016/j.jhsa.2017.02.002)
• [L5] Dry wrist arthroscopy is an ideal intervention for the management of intra-articular distal radius fractures given the lack of fluid extravasation, and it can assist when performing concomitant open procedures. [61] (10.1016/j.jhsa.2020.01.012)
• [Letter] Negative results of MRI or clinical provocative tests are still unable to safely rule out the possibility of clinically relevant tears to the TFCC and other wrist ligaments, which makes further diagnostic evaluation with wrist arthroscopy necessary. [63] (10.1016/j.arthro.2015.08.001)
• [L5] This method offers a minimally invasive and easily reproducible solution, addressing a challenging set of ulnar wrist injuries. [64] (10.1016/j.eats.2024.102995)
• [L5] The physical examination of the wrist is more important than ever. [65] (10.1016/s0749-0712(21)00076-7)
• [L4] These biomechanical findings support early diagnosis, targeted reconstruction and the need to restore both primary and secondary stabilizers to prevent progressive scapholunate instability. [67] (10.1177/17531934261466074)
• [L4] All 3 procedures resulted in an improvement in pain at rest, pain during activity, and quick Disabilities of the Arm, Shoulder and Hand scores. [71] (10.1016/j.jhsa.2021.05.002)
• [L4] Partial wrist denervation is a reliable motion preserving procedure for patients with chronic wrist pain, with 71% of patients experiencing pain relief and not requiring further salvage procedures at an average of 78 months of follow up. [72] (10.1016/j.jhsa.2015.06.059)
• [L3] Implant arthroplasty for the distal radio-ulnar joint has produced acceptable results in small numbers of patients. [73] (10.1177/1753193417692506)
• [L4] Wrist arthroscopy is a feasible treatment option with advantages including lower risk of arthrofibrosis and avascular necrosis. [75] (10.1055/s-0040-1712518)
• [L4] The procedure reliably improves pain and function for patients with ulnar-sided wrist pain secondary to a UT split tear with a low complication and reoperation rate. [76] (10.1177/1753193419876066)
• [L5] Wrist arthroscopy is advantageous for accurate assessment of articular surfaces and detection of concomitant soft-tissue injuries, with nonrandomized studies showing satisfactory results for arthroscopically assisted reduction of distal radius fractures. [77] (10.1016/j.arthro.2007.10.006)
• [L5] [79] (10.2106/00004623-199908000-00015)
• [L3] Patients with persisting or recurrent pain benefited from ulnar shortening osteotomy as a secondary procedure. [80] (10.1055/s-0037-1607073)
• [Paper] [81] (10.1055/s-0039-1692929)
• [L4] Early detection may preserve wrist function by capsular repair, whereas cases with fixed deformity and residual joint incongruity may be best managed with a limited radiocarpal arthrodesis. [82] (10.1016/j.jhsa.2019.11.018)
• [L4] With the RSCL reconstruction, it was possible to stabilize the wrist despite the RSCL insufficiency after PRC. [84] (10.1177/1753193417752319)
• [L4] Arthroscopic repair of Palmer type 1B tears yields satisfactory results with 63% of patients achieving good to excellent outcomes. [87] (10.1016/j.arthro.2008.06.022)
• [L5] However, the wrist behaves kinematically consistent but kinetically variable, implying that mechanical behavior is predominantly determined by articular geometry rather than ligament constraints. [89] (10.1002/jor.1100100620)
• [L5] Despite complex carpal bone anatomy and kinematics, computed fiber elongations were found to vary linearly with wrist position. [92] (10.1016/j.jhsa.2012.04.025)
• [L5] Most carpal ligaments lengthen only during one half of a full movement cycle, constraining either dorsal- or palmar-directed, or ulnar- or radial-directed motion. [105] (10.1002/jor.1100090509)
• [L5] Ulnar-sided wrist pain is a common cause of upper extremity disability with a complex differential diagnosis. [106] (10.1016/j.jhsa.2012.04.036)
• [L5] Disorders of the distal radioulnar joint are a common source of ulnar-sided wrist pain, but increased understanding of anatomy and pathology has facilitated accurate diagnosis and successful treatment in most cases. [114] (10.5435/00124635-199503000-00005)
• [L5] Determining the etiology of ulnar-sided wrist pain is often challenging due to overlapping history and physical examination findings; a detailed history, systematic physical examination with provocative maneuvers, and appropriate diagnostic imaging are essential for diagnosis. [115] (10.5435/jaaos-d-16-00407)
• [L5] [117] (10.5435/00124635-200001000-00005)
• [L3] Postoperative infection after wrist arthroscopy is uncommon but clinically relevant, particularly in elderly, male patients with systemic comorbidities or undergoing synovectomy. [122] (10.1016/j.otsr.2026.104771)
• [L5] Injury to the dorsal wrist extrinsic carpal ligaments exacerbates volar radiocarpal instability. [124] (10.1177/1558944719851210)
• [L4] The report strongly suggests that the arthrogram should not be considered a definitive study for the diagnosis of a clinically important injury of a ligament in the wrist. [128] (10.2106/00004623-199508000-00010)
• [L2] Conventional radiography should be the first imaging modality to exclude or diagnose wrist pathology; when inconclusive, high resolution 3 Tesla MRI is advised. [130] (10.1177/1753193416683876)
• [L3] 3T MRI proved to be of good value in diagnosing cartilage lesions, especially in the distal carpal row, whereas wrist arthroscopy provided therapeutic options. [131] (10.1007/s00402-017-2747-2)
• [L5] The scaphoid, lunate, and capitate move synergistically throughout planar wrist motion. [132] (10.1055/s-0036-1588025)
• [L5] The article summarizes current thinking regarding the diagnosis and treatment of clinically important carpal instabilities, emphasizing that the row theory more clearly accounts for the function of the wrist than the column theory. [134] (10.2106/00004623-199503000-00019)
• [L4] The ulnocarpal ligaments are likely to be stretched tensely in wrist radial extension and wrist extension. [137] (10.1016/j.jhsa.2008.04.033)
• [L5] The computation of the total hysteresis area is a sensitive technique to determine the subtle onset of abnormal carpal motion, with significant increases seen after just scapholunate interosseous ligament sectioning during wrist radioulnar deviation. [138] (10.1016/j.jhsa.2005.12.028)
• [L3] With only a fair correlation between arthroscopy and MRI, it cannot be concluded that the two methods are equivalent for assessing wrist cartilage and, as such, wrist arthroscopy still has an important role to play in the assessment of a painful degenerative wrist. [139] (10.1177/1753193408090395)
• [L5] Wrist arthroscopy and an ulnar shortening procedure are indicated for patients with neutral to positive ulnar variance and persistent ulnar-sided wrist pain despite conservative treatment to unload the ulnocarpal joint. [140] (10.1016/j.hcl.2017.07.002)
• [L4] Hand coordination following tendon transfer surgery demonstrated a graded recovery, with coordinated movement between wrist and finger joints improving at weeks 8 and 12. [144] (10.1177/1753193420987523)
• [L4] [148] (10.1007/s001670050172)
• [L5] Until further advances and refinements are made with noninvasive MRI techniques, the gold standard for diagnosis of wrist ligamentous pathology remains diagnostic wrist arthroscopy and should be considered particularly if involvement of the SLIL or LTIL is suspected on the basis of history and physical examination, even in the face of negative MRI findings. [151] (10.1016/j.arthro.2024.05.014)
• [Paper] [152] (10.1016/s0363-5023(09)60080-0)
• [L3] MRI demonstrated an identifiable dorsal abnormality in 84% of patients with dorsal wrist pain associated with weight bearing on the extended wrist. [154] (10.1055/s-0037-1599829)
• [L3] MRI-detectable carpal lesions at the time of the radial fracture are common, but only a few of them seem to decompensate later, give symptoms and became of therapeutic relevance. [155] (10.1007/s00402-015-2357-9)
• [L4] Having a stable distal radioulnar joint upon clinical examination and normal MRI findings does not rule out foveal TFCC injury, and a high index of clinical suspicion is needed when managing patients with ulnar sided wrist pain. [158] (10.1177/17531934231206426)
• [L5] Most cases resolve with nonsurgical management, while persistent pain may require advanced imaging and arthroscopy for diagnosis and treatment. [160] (10.5435/jaaos-d-21-01029)
• [L2] Classification of central triangular fibrocartilage complex lesions as traumatic or degenerative depends on the information provided upon viewing the lesion at arthroscopy. [161] (10.1177/1753193416684658)
• [Paper] [162] (10.1016/j.hcl.2009.08.006)
• [L3] Single compartment direct wrist magnetic resonance arthrography can provide high diagnostic accuracy for full-thickness triangular fibrocartilage lesions, intrinsic carpal ligament tears and chondral lesions in the radiocarpal joint, but that it is much less accurate in diagnosing synovitis of the radiocarpal joint. [163] (10.1177/1753193417695180)
• [L4] PSLA technique is a feasible mode of anesthesia in selected patients for wrist arthroscopy, offering a success rate of 95% with high patient satisfaction and no complications. [168] (10.1055/s-0032-1326726)
• [L5] Wrist ligament pathology cannot be ruled out by a negative magnetic resonance imaging, and arthroscopic surgery is considered the gold standard for diagnosing wrist ligament pathology. [172] (10.1016/j.arthro.2015.07.006)
• [L3] Although arthrography of the wrist is a well accepted diagnostic modality in the evaluation of pain in the wrist, this study suggests that normal arthrographic findings do not necessarily rule out the possibility of internal derangement of the wrist. [173] (10.2106/00004623-199603000-00005)
• [L4] Superior contrast resolution, joint distention, and the flow of contrast facilitate the diagnosis of lesions of the TFCC and intrinsic ligaments on contrast-sensitive sequences, making MRA the preferred modality for imaging internal derangements of the wrist. [175] (10.1007/s11552-008-9149-4)
• [L4] Return to play may be delayed in athletes with concomitant ulnar-sided wrist injuries. [176] (10.1177/0363546508325921)
• [L5] [178] (10.1054/jhsb.2001.0578)
• [L3] For young subjects, MRI is still valuable, especially in diagnosing ulnar detachment, although the ability to distinguish between proximal and distal laminae remains questionable. [179] (10.1177/17531934221141986)
• [L4] [180] (10.1016/j.jhsa.2007.07.023)
• [L4] A 3 tesla MRI was neither sensitive nor specific enough to correctly diagnose lesions in small pediatric wrists. [181] (10.1016/j.asmr.2022.04.029)
• [L3] Cineradiography has a high diagnostic value for diagnosing scapholunate dissociations. [182] (10.1177/1753193413489056)
• [L2] When the appropriate pulse sequence is used, magnetic resonance imaging is an accurate and effective method for the non-invasive evaluation of pain in the wrist. [183] (10.2106/00004623-199711000-00009)
• [L4] Total wrist fusion should only be used for exceptional circumstances. [184] (10.1054/jhsb.2000.0434)
• [L4] [187] (10.1177/17531934231218608)
• [L4] The PSLA technique without a tourniquet is a feasible and preferred mode of anesthesia for wrist arthroscopic surgery in the hands of experienced wrist arthroscopists. [188] (10.1016/j.hcl.2017.06.001)
• [L4] [189] (10.1016/j.jhsg.2025.100891)
• [Case_report] [190] (10.1016/j.jhsa.2020.11.002)
• [L5] It facilitates the combination of open procedures with arthroscopic visualization, particularly for distal radius fractures and complex fixation. [191] (10.1016/j.jhsa.2014.08.042)
• [L5] Once ulnar impaction becomes symptomatic, it remains so and recurs, especially on return to the athletic sport. [193] (10.1016/j.hcl.2012.05.021)
• [L4] [196] (10.1186/s13018-021-02827-2)
• [L4] Administering preoperative antibiotics for routine wrist arthroscopy does not appear to lower the surgical site infection rate. [197] (10.1016/j.jhsa.2018.03.040)
• [L2] Both techniques yielded good and comparable outcomes with a lesser incidence of early complications in the anchor repair group. [202] (10.1016/j.jhsa.2022.01.021)
• [L4] Although the global incidence of complications was in keeping with the literature, the incidence of serious complications was much higher than previously reported. [204] (10.1055/s-0036-1584163)
• [L4] Arthroscopically-assisted mini-open PRC resulted in increased wrist motion and improved Mayo wrist scores in the long-term compared to open PRC, with favorable third-month patient-related outcomes attributed to earlier initiation of postoperative wrist motion and the less invasive character of the procedure. [205] (10.1016/j.jhsa.2022.03.005)
• [L4] The author's experience with more than 150 laser-assisted wrist arthroscopies using the Ho:YAG laser has been excellent, with no laser-related complications. [206] (10.1016/s0749-0712(21)00185-2)

See Also

• Distal Radius Fracture
• TFCC Injury
• Proximal Row Carpectomy
• Scapholunate Ligament Injury
• Partial Wrist Fusion (Four-Corner and Capitolunate Arthrodesis)
• Total Wrist Fusion

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