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Wrist Arthroscopy

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

49 citationsUpdated Aug 2026

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

Overview

Wrist arthroscopy has evolved from a purely diagnostic modality into an essential therapeutic tool with an expanding list of indications [1, 2, 9]. It serves as a crucial instrument for diagnosing intra-articular pathology and treating multiple wrist conditions [3]. The procedure is generally safe, characterized by minor and transient complications [3], although recent data suggest that previously documented complication rates may underestimate the true incidence [10]. Detailed anatomical knowledge is essential to minimize these risks [2].

Indications for wrist arthroscopy include the management of triangular fibrocartilage complex (TFCC) pathology, carpal instability, fracture reduction assistance, and salvage procedures [9]. Innovations such as new portals and smaller arthroscopes have further expanded its applications [9]. Surgical technique emphasizes the use of traction for joint distention, utilizing various portals and instruments for both diagnostic and therapeutic purposes [6]. The radial anterior wrist arthroscopic portal is particularly invaluable for assessing and treating intraarticular conditions, including dorsal intraarticular fractures of the distal radius, radial styloidectomy, and synovectomy, while respecting safety requirements [25].

Clinical outcomes demonstrate significant utility in specific patient populations. Participants undergoing arthroscopic investigation for persistent wrist pain improved by approximately 50% at one year [4], though most continued to experience some pain and disability [4]. Arthroscopic wrist arthrolysis following wrist fracture is a safe, minimally invasive procedure that significantly improves pain and wrist flexion-extension [8]. Nonrandomized studies also show satisfactory results for arthroscopically assisted reduction of distal radius fractures [12]. Wrist arthroscopy offers distinct advantages for the accurate assessment of articular surfaces and the detection of concomitant soft-tissue injuries [12]. Recent technical and technological developments continue to allow for advanced treatments of difficult wrist disorders [5].

Anatomy & Pathophysiology

Osseous Anatomy

The osseous skeleton of the hand and wrist consists of 27 bones, of which 19 are long bones [27]. The carpus comprises eight ossicles divided into a proximal row (scaphoid, lunate, triquetrum, and pisiform) and a distal row (trapezium, trapezoid, capitate, and hamate) [40, 43]. The distal radius articular surface has two concave facets (scaphoid and lunate) separated by the scapholunate ridge [43]. The sigmoid notch along the ulnar border of the distal radius is a shallow concavity for the articulating ulnar head at the distal radioulnar joint [43]. The distal ulna is covered with hyaline cartilage on its dorsal, lateral, palmar, and distal surfaces [43]. The ulnar styloid projects distally; at its base, the fovea is the insertion for the triangular fibrocartilaginous complex [43].

The scaphoid's primary vascular supply is a branch of the radial artery at the dorsal ridge, with smaller vessels entering the palmar tubercle to supply the distal 30% [43]. The lunate has a dorsal and palmar vascular supply in 80% of wrists, while only a palmar supply is found in 20% of wrists [43]. The hamate consists of the body and the hook (hamulus), which serves as an attachment for the transverse carpal ligament and origins of the flexor digiti minimi and opponens digiti minimi [43]. The capitate head often relies on a retrograde vascular supply [43]. The trapezium has a saddle-shaped articulation with the base of the thumb metacarpal [43]. The pisiform is a sesamoid bone within the flexor carpi ulnaris tendon and is the origin for the abductor digiti minimi [43].

Ligamentous Anatomy

The triangular fibrocartilage complex (TFCC) attaches to the base of the ulnar styloid and separates the hyaline cartilage-covered ulnar head from the styloid [40]. The TFCC arises from the radial border of the distal radius and inserts into the base of the ulnar styloid and distal ulna through the ligamentum subcruentum [43]. The TFCC is formed by the central meniscus homolog, dorsal and volar radioulnar ligaments, the floor of the extensor carpi ulnaris sheath, and volar ulnocarpal ligaments [43]. The dorsal and volar radioulnar ligaments are the primary stabilizers of the distal radioulnar joint [43]. Only the peripheral 10% to 40% of the volar, ulnar, and dorsal TFCC has a vascular supply [43].

The extrinsic wrist ligaments include the dorsal intercarpal ligament and the dorsal radiocarpal ligament [43]. The intrinsic wrist ligaments include the scapholunate interosseous ligament and the lunotriquetral interosseous ligament [43]. The scapholunate interosseous ligament is C-shaped in the sagittal plane, with the dorsal third being the thickest and strongest portion [43]. The volar portion of the lunotriquetral ligament is the thickest [43]. The dorsal radiocarpal ligament originates at the dorsal lip of the distal radius adjacent to Lister tubercle and traverses obliquely to insert into the lunate and triquetrum [43]. The dorsal intercarpal ligament arises from 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 [40, 43]. The space of Poirier is a relatively thin area on the palmar side of the carpus between the radiolunotriquetral ligament and the radioscapocapitate ligament, overlying the palmar surface of the lunate [40]. Dorsal radiocarpal ligament tears are commonly seen with injuries to the primary wrist stabilizers [62].

Vascular Anatomy

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 [46]. The dorsal radiocarpal arch is located at the radiocarpal joint and supplies the lunate and triquetrum [46]. The dorsal intercarpal arch is the largest dorsal arch, located between the proximal and distal carpal rows, supplying the distal carpal row and anastomosing with the radiocarpal arch to supply the lunate and triquetrum [46]. The basal metacarpal arch is located at the base of the metacarpals and supplies the distal carpal row [46].

The palmar radiocarpal arch is located at the level of the radiocarpal joint on the palmar surfaces of the lunate and triquetrum [46]. 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 [46]. The deep palmar arch is located at the level of the metacarpal bases, is consistent, and communicates with the dorsal basal metacarpal arch and palmar metacarpal arteries [46].

Carpal Kinematics and Biomechanics

The wrist functions as a two-joint system linking the hand to the forearm around the highly mobile proximal carpal row, consisting of the radiocarpal and midcarpal joints [44]. The proximal carpal row has no muscular or tendinous attachments and is an intercalary segment [43]. With ulnar deviation, the proximal row extends relative to the forearm/distal row; with radial deviation, the proximal row flexes relative to the forearm/distal row [43]. 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 [43]. With wrist flexion, 60% of the motion is midcarpal and 40% is radiocarpal; with wrist extension, 33% of the motion is midcarpal and 66% is radiocarpal [43].

In most individuals, the proximal carpal row rotates predominantly around the flexion-extension axis during radioulnar deviation [44]. The dart-thrower’s path of motion occurs almost exclusively through the midcarpal joint [44]. The lunate, capitate, hamate, trapezium, and trapezoid function collectively as the stable central column, controlled by the scaphoid and stabilized by the triquetrum [44].

Pathophysiology of Instability and Arthritis

Scapholunate interosseous ligament injury and extrinsic ligament complex attenuation lead to palmar flexion of the scaphoid and extension of the lunate (dorsal intercalated segment instability) [31]. In scapholunate advanced collapse (SLAC) wrist, the radioscaphoid joint becomes incongruous, leading to arthrosis at the capitolunate joint due to proximal migration of the capitate [31]. The radiolunate joint is typically spared in SLAC wrist because of its spheroid shape [31]. 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) [31].

Rheumatoid wrist deformity involves cartilage destruction, synovial expansion, and ligamentous laxity, leading to ulnar-palmar translocation and wrist supination [53]. In rheumatoid arthritis, attenuation of the scapholunate interval causes dissociation and collapse of the radial column [53]. Early-to-midstage rheumatoid wrists may exhibit volar flexion of the lunate relative to the scaphoid (volar intercalated segment instability) due to intrinsic ligament laxity [53]. At later rheumatoid stages, midcarpal instability from extrinsic ligament weakening leads to dorsal flexion of the capitate and decreased carpal height [53].

Classification

Wrist arthroscopy is an essential diagnostic and therapeutic tool with an ever-expanding list of indications, having evolved from a purely diagnostic modality to a valuable adjunctive procedure for myriad wrist disorders [1, 2]. It serves as a crucial tool for diagnosing intra-articular pathology and treating multiple conditions, including triangular fibrocartilage complex (TFCC) pathology, carpal instability, fracture reduction assistance, and salvage procedures [3, 9]. Arthroscopy holds a pivotal role in assessing scapholunate ligament complex derangements and distal radioulnar joint instability [11]. It remains the gold standard for detecting TFCC tears [58]. Furthermore, wrist arthroscopy plays an important role in assessing painful degenerative wrists, as there is only a fair correlation between arthroscopy and MRI for assessing wrist cartilage [35].

Palmer Classification: This system categorizes TFCC tears as traumatic (Class 1) or degenerative (Class 2), with subtypes based on specific location within the TFCC [58]. * Class 1 (Traumatic): Includes subclass 1A (central perforation or tear), 1B (ulnar avulsion with or without ulnar styloid fracture), 1C (distal avulsion of origins of ulnolunate and ulnotriquetral ligaments), and 1D (radial avulsion involving dorsal and/or volar radioulnar ligaments) [58]. * Class 1A: Horizontal tears usually one to two millimeters wide, located two to three millimeters ulnar to the radial attachment on the sigmoid notch where the articular disc is thinnest [26]. These are inherently stable and treated with débridement if persistently symptomatic because the area is devoid of vascularity and unable to heal; a key point is to maintain a 2-mm peripheral rim [58]. * Class 1B: Traumatic avulsions of the TFCC from its insertion into the distal aspect of the ulna, which may or may not be accompanied by a fracture of the ulnar styloid process at its base [26]. These are amenable to arthroscopic or open repair because the rim is well vascularized; concurrent fractures of the ulnar styloid with persistent instability are either excised or fixed [58]. * Class 1C: Rare tears amenable to arthroscopic or open repair [58]. * Class 1D: Frequently associated with distal radius fractures and often respond to reduction of the radius [58]. * Class 2 (Degenerative): Categorized as 2A (TFCC wear/thinning), 2B (2A plus lunate and/or ulnar chondromalacia), 2C (TFCC perforation plus lunate and/or ulnar chondromalacia), 2D (2C plus lunotriquetral ligament disruption), and 2E (2D plus ulnocarpal and distal radioulnar joint arthritis) [58].

All acute traumatic (Class 1) TFCC injuries are initially managed with immobilization and NSAIDs [58]. Surgical treatment for Class 1 TFCC injuries, in cases of failure of nonoperative treatment, involves wrist arthroscopic and/or open repair [58]. Repair of a traumatic TFCC tear within 3 months of injury allows a patient to regain 80% of wrist range of motion and grip strength [58].

Geissler Classification: Scapholunate ligament lesions are classified according to Geissler [56]. These lesions are graded as partial or complete [56].

Other Considerations: Lesions of the triangular fibrocartilage complex are categorized according to Palmer [56]. Lesions of the cartilage are classified according to Outerbridge [56].

Clinical Presentation

Wrist arthroscopy serves as an essential diagnostic and therapeutic tool with an expanding list of indications, including triangular fibrocartilage complex (TFCC) pathology, carpal instability, fracture reduction assistance, and salvage procedures [1, 9]. Innovations such as new portals and smaller arthroscopes have further expanded these applications [9]. The procedure is safe and associated with minor, transient complications [3]. It plays a pivotal role in assessing scapholunate ligament complex derangements and distal radioulnar joint (DRUJ) instability [11], while offering advantages for accurate assessment of articular surfaces and detection of concomitant soft-tissue injuries [12].

A careful history and physical examination are prerequisites before using wrist arthroscopy for diagnosis or treatment [15]. The natural inclination to review imaging prior to a thorough history and physical examination should be avoided, as this introduces cognitive bias [54]. History taking must emphasize the mechanism of injury, acuity, location, duration, and characteristics of pain, including aggravating/relieving factors and previous treatments [54]. For chronic problems, inquiry should cover jobs, hobbies, exposure to repetitive stress or vibrating tools, and history of ligamentous laxity or multiple joint instabilities [54].

The wrist comprises eight carpal bones, 27 capsular and interosseous ligaments, and surrounding tendons and neurovascular structures [15]. In many cases, the diagnosis is obvious after evaluating the history, physical examination (including provocative maneuvers), and standard radiographs [15]. Except in cases with an open dislocation, the external appearance of most wrist dislocations may not be dramatic [54]. Swelling is generally moderate, and bone displacements may be evident only if the patient is seen immediately after trauma [54]. Skin abrasions, contusions, or ecchymosed areas may help determine the mechanism of injury and potential areas of damage [54].

Palpation for areas of maximal tenderness is one of the most useful tools for diagnosing wrist pathology, especially in chronic dysfunctions [54]. In acute dislocations, tenderness is seldom elicited at specific points but rather diffusely due to extensive soft tissue damage [54]. Palpation should be performed methodically, starting from the basal joint of the thumb and proceeding across the proximal carpal row from scaphoid to triquetrum, then across the distal row and CMC joints [54]. A careful assessment of neural and vascular status is imperative, with particular attention to the median and ulnar nerves [54].

Range of motion is usually limited by pain in acute injuries but may be reduced or normal in chronic cases [54]. Passive assessment of mobility is valuable in chronic cases for determining abnormal motion, crepitus, and reproduction of pain [54]. Examination should begin in a nontender area and proceed rotationally around the carpus, ending at the most symptomatic area [54]. A typical examination begins at the radial column with assessment of stress instability of the thumb basal joint [54].

A thorough set of provocative maneuvers should be performed to concentrate on suspected diagnosis and rule out alternative or concurrent diagnoses [54]. Special maneuvers are applied to stress the scapholunate joint, lunotriquetral joint, TFCC, DRUJ, and midcarpal joint [60]. The ligamentous habitus of a given individual must be assessed using information from the normal wrist due to wide variation in mobility and laxity [60].

Scapholunate Assessment: Watson’s scaphoid shift test is performed at the scaphoid tubercle [54]. The test is performed first on the normal side and then on the symptomatic wrist to note areas of tenderness, clicks, or clunks [60]. Watson’s test involves placing one hand on the radial border of the distal forearm with the thumb on the palmar aspect of the scaphoid [60]. During the test, the wrist is moved to create ulnar then radial deviation while maintaining thumb pressure on the scaphoid [60]. Bringing the wrist into radial deviation causes dorsal subluxation of the scaphoid, accompanied by a painful click [60]. A positive Watson shift test results when the scaphoid subluxates dorsally out of the scaphoid fossa with pressure directed over the palmar scaphoid tuberosity during movement from ulnar to radial deviation [31].

Lunotriquetral and Midcarpal Assessment: Ballotment and shear tests are used for lunotriquetral (LT) instability [54]. Ballotment tests demonstrate abnormal movements between adjacent bones by exerting pressure in opposite directions [60]. These tests can show instability of the scapholunate joint, lunotriquetral joint, capitolunate joint, or DRUJ [60]. Triquetral hamate instability is demonstrated with the wrist straight with ulnar deviation, producing a firm block after about 20 degrees of motion [60]. Forcing a sharp click accompanied by discrete posterior movement of the wrist during triquetral hamate testing indicates movement from VISI to DISI position [60]. Nondissociative instability of the carpus is assessed with Lichtman’s midcarpal shift test and the associated “catch up clunk” [54]. Louis’ CLIP maneuver is used for midcarpal instability [54]. The midcarpal joint pivot shift test involves supinating and volar subluxing the distal row of the carpus [60]. During this test, the hand is moved from radial to full ulnar deviation while held in supination and volar subluxation [60]. The normal wrist will notch into a less supinated position as the capitate head engages the lunate during the pivot shift test [60]. Rupture, attenuation, or excess laxity of the anterior capsule and triquetrolunate interosseous ligaments allow the capitate to drift out of the lunate during the pivot shift test [60].

TFCC and DRUJ Assessment: The TFCC must be carefully examined and the DRUJ assessed for instability in neutral, supination, and pronation [54]. Significant pain precipitated by holding the hand in full ulnar deviation and pressing the ulna head forward suggests DRUJ pathology [60]. Pain precipitated by pronosupination while the ulna head is pressed volarward and the pisiform pressed dorsally is usually indicative of ulnar impingement or abutment syndrome [60]. Ulnar impaction and ulnar styloid impingement are assessed in pronation and supination [54].

Tendon and Other Assessments: Finkelstein and Eichhoff maneuvers are used for first dorsal compartment tendinopathy [54]. Manually resisted flexion/radial deviation of the wrist tests for flexor carpi radialis tendinitis [54]. Synergy test is used to rule out extensor carpi ulnaris (ECU) tendinopathy [54]. Frank ECU instability is assessed with supination while maximally flexed and ulnar deviated [54]. Resisted ulnar flexion helps rule out flexor carpi ulnaris (FCU) tendinopathy [54]. A pisotriquetral “shuck” test is used for synovitis or osteoarthritis [54]. Osteoarthritis is assessed by compression testing [54].

Strength may be diminished due to muscle atrophy, pain inhibition, or learned behaviors [54]. Bilateral grip and pinch strength are useful to uncover underlying pathology in chronic cases [54]. Rapid alternating grip assessment may be helpful in determining voluntary effort [54]. A local injection of anesthetic to a painful joint or selected tendon sheath may help normalize dynamometer readings and narrow the diagnostic spectrum [54]. Sensory testing should always accompany an examination of suspected nerve compression, using threshold or density testing [54].

An exaggeration of normal ulna head prominence is seen in dorsal subluxation or articular effusion [60]. The prominence of the ulna head may be temporarily reduced by direct pressure over the ulna head [60]. In the rheumatoid wrist, ulna head prominence is further exaggerated by a supination deformity of the carpus [60]. The radio-carpal and midcarpal joint anteroposterior drawer test involves applying axial traction to the hand while stabilizing the forearm and applying anteroposterior force [60]. A marked drawer test at the midcarpal joint is a sign of congenital laxity [60].

Arthroscopy is more sensitive than arthrography for evaluating TFCC tears and interosseous ligament tears [15]. The presence of certain apparent joint abnormalities, such as a ligamentous disruption diagnosed by arthrography or MR imaging, may not represent a clinically significant process [15]. When a magnetic resonance technique that does not employ a dedicated wrist coil is used, a negative MRI scan does not exclude TFCC or scapholunate ligament injuries [22]. MRI should be added for evaluation of the TFCC, DRUJ, and vascularity of carpal bones, extrinsic ligaments, joint surfaces, and surrounding soft tissues to confirm clinical suspicion [29]. A dedicated wrist coil provides enhanced resolution of wrist structures [29]. A high rate of false-positive findings on MR images of normal subjects has been reported [29].

Routine radiographic series for a painful wrist includes posteroanterior, lateral, oblique, and ulnar-deviated posteroanterior scaphoid views [29]. Spot views of the carpal bones for detail include the carpal tunnel view [29]. Fluoroscopic spot views of the wrist are useful for evaluating a painful wrist [29]. Series of views for instability include anteroposterior clenched fist, posteroanterior in neutral/radial/ulnar deviation, lateral in neutral/flexion/extension, semipronated oblique 30 degrees from posteroanterior, and semisupinated oblique 30 degrees from lateral [29]. Diagnostic ultrasound is a radiographic technique useful in evaluating a painful wrist [29]. Cine or video fluoroscopy is a radiographic technique useful in evaluating a painful wrist [29]. Bone scanning is a radiographic technique useful in evaluating a painful wrist [29]. Arthrography of the wrist, including triple injection when indicated, is a radiographic technique useful in evaluating a painful wrist [29]. CT is a radiographic technique useful in evaluating a painful wrist [29].

Indications for diagnostic wrist arthroscopy include chronic wrist pain of uncertain etiology, failed conservative treatment for over 3 months, assessment of ligament and chondral lesions in acute wrist fractures, and assessment of Kienböck disease and posttraumatic arthritis [32]. Patients without positive provocative signs on examination seldom yield positive findings at wrist arthroscopy [32]. Arthroscopic findings need to correlate with clinical examination [32]. Diagnostic arthroscopy performed in the setting of an unclear preoperative diagnosis yielded limited diagnostic benefit [33].

For chronic ulnar wrist pain, the ulnocarpal joint should be inspected from the 3-4 portal before creating a portal on the ulnar wrist [32]. Adequate traction with controllable traction force is key to joint access in wrist arthroscopy [32].

Investigations

Wrist Arthroscopy: Wrist arthroscopy is an essential diagnostic and therapeutic tool for orthopaedic surgeons [1]. Technical and technological developments allow for advanced treatments of difficult wrist disorders [5]. It has a pivotal role in the assessment and treatment of scapholunate ligament complex derangements [11] and distal radioulnar joint (DRUJ) instability [11]. Arthroscopic assessment of intercarpal ligament injuries and instability is considered by many to be the "gold standard" for evaluation of these conditions [28]. Arthroscopy is more accurate than arthrography in identifying the location and size of TFCC and interosseous ligament injuries [28]. It is also more accurate than triple-injection cinearthrography in detecting tears of the dorsal sensory branch of the ulnar nerve during arthroscopic repair of the TFCC [28] and in detecting injury to sensory nerves during insertion of Kirschner wires [28].

Indications for wrist arthroscopy include the evaluation of ligamentous injuries [28], examination of joint articular surfaces [28], removal of loose bodies [28], biopsy of synovium [28], irrigation and debridement of joints [28], and confirmation and supplementation of wrist arthrography [28]. It is used for the examination of patients with wrist pain of unknown origin [28] and is advantageous for the detection of concomitant soft-tissue injuries [12]. Dry wrist arthroscopy circumvents problems associated with fluid-based paradigms, such as fluid extravasation and tissue swelling [13], and allows for the use of larger portals and instruments [13].

MRI: MRI should be added for evaluation of the TFCC, DRUJ, and vascularity of carpal bones, extrinsic ligaments, joint surfaces, and surrounding soft tissues [29]. There is only a fair correlation between arthroscopy and MRI for assessing wrist cartilage [35]. Consequently, wrist arthroscopy still has an important role to play in the assessment of a painful degenerative wrist because MRI and arthroscopy are not equivalent methods for assessing wrist cartilage [35]. A 3 Tesla MRI was neither sensitive nor specific enough to correctly diagnose lesions in small pediatric wrists [63]. Most pathomorphologic findings of wrist arthroscopy in children and adolescents with chronic wrist pain have not been correctly identified by MRI before arthroscopy [64].

Treatment

Non-Operative

Diagnostic arthroscopy is indicated for chronic wrist pain of uncertain etiology with a more than 3-month interval that remains unresponsive to conservative treatment [23].

Operative

Indications: Diagnostic arthroscopy is indicated for the assessment of acute ligamentous injuries, including scapholunate, lunotriquetral, and triangular fibrocartilage complex (TFCC) injuries [23]. It is also indicated for the evaluation of carpal instability [23], chondral lesions [23], and staging of posttraumatic arthritis, including scapholunate advanced collapse (SLAC), scaphoid nonunion advanced collapse (SNAC), and distal radius fractures [23]. Further indications include the evaluation of associated soft tissue injury in fracture conditions, such as distal radius, scaphoid, ulnar styloid, and other carpal bone fractures [23], as well as the assessment of scaphoid healing in delayed union and nonunion [23]. Diagnostic arthroscopy is also indicated for the evaluation of monoarticular arthritis and synovial biopsy [23] and the assessment of Kienböck disease [23].

Surgical Approach / Technique: Wrist arthroscopy serves as an essential diagnostic and therapeutic tool with an expanding list of indications [1], having evolved from a purely diagnostic tool to a valuable adjunctive procedure for myriad wrist disorders [2]. It is a crucial tool for diagnosing intra-articular pathology and treating multiple wrist conditions [3]. The radial anterior wrist arthroscopic portal is invaluable for assessing and treating intraarticular conditions, particularly dorsal intraarticular fractures of the distal radius, radial styloidectomy, and synovectomy [25]. Wrist arthroscopy has a pivotal role in the assessment and treatment of distal radioulnar joint instability [11]. Dry wrist arthroscopy is an ideal intervention for the management of intra-articular distal radius fractures due to the lack of fluid extravasation [17].

Therapeutic Procedures: Therapeutic arthroscopy encompasses ablative, reparative, and reconstructive procedures. Ablative soft tissue procedures include TFCC debridement [23], debridement of ligament tears including scapholunate, lunotriquetral, and extrinsic or intrinsic ligament injuries [23], synovectomy for inflammatory arthritis, septic arthritis, gouty arthritis, and posttraumatic synovitis [23], wrist ganglionectomy (dorsal and volar) [23], removal of loose body [23], capsulotomy/capsulectomy [23], lavage [23], and arthrolysis [23]. Ablative bone procedures include scaphoidectomy [23], radial styloidectomy [23], wafer procedure [23], proximal row carpectomy [23], and proximal hamate excision [23]. Ablative cartilage procedures include debridement of chondral and osteochondral lesions [23]. Reparative soft tissue procedures include peripheral TFCC tear repair [23], TFCC foveal avulsion repair [23], scapholunate ligament injury repair [23], and lunotriquetral ligament injury repair [23]. Reparative bony procedures include arthroscopic-assisted reduction and internal fixation (ARIF) for distal radius fracture [23] and ARIF for scaphoid fracture [23]. Reparative cartilage procedures include drill/abrasion chondroplasty [23].

Specific clinical applications include arthroscopic debridement as the preferred treatment for Class-IA TFCC tears if symptoms do not resolve after temporary splinting [26]. Arthroscopic debridement of the TFCC can be combined with arthroscopic wafer distal ulnar resection or ulnar shortening osteotomy for ulnocarpal abutment syndrome [19]. Arthroscopic repair of peripheral avulsions of the TFCC is a documented procedure [21], and arthroscopic repair of TFCC injuries is a documented procedure [19]. Arthroscopic treatment of TFCC wrist injuries is utilized in athletes [21]. Arthroscopic TFCC reconstruction with tendon graft is a reconstructive procedure [23]. Arthroscopic-assisted scapholunate ligament reconstruction with tendon graft is a reconstructive procedure [23]. Arthroscopic bone grafting is indicated for scaphoid nonunion, limited carpal fusion, intraosseous bone cyst, and intraosseous ganglion [23]. Osteochondral grafting is a cartilage reconstructive procedure in wrist arthroscopy [23]. Arthroscopic partial wrist fusion is an operative treatment method [14] and a documented procedure [21]. Arthroscopically assisted Sauvé-Kapandji procedure is an advanced technique for distal radioulnar joint arthritis [21]. Arthroscopic resection of dorsal ganglion of the wrist is a documented procedure [21]. Arthroscopic treatment of lunotriquetral ligament injuries is a documented procedure [21]. Arthroscopic management of dorsal wrist impingement is a documented procedure [21]. Radius decompression is a surgical treatment for Kienböck disease [21], and the surgical treatment of Kienböck’s disease by radius and ulna metaphyseal core decompression is a documented procedure [21]. Arthroscopic synovectomy in rheumatoid arthritis of the wrist is a documented procedure [21]. Arthroscopic debridement of TFCC tears is a documented procedure [21]. Arthroscopic treatment of ulnar impaction syndrome is a documented procedure [21]. Arthroscopic assessment and classification of Kienböck’s disease is a documented procedure [21]. Arthroscopy for the diagnosis of post-traumatic wrist pain is a documented procedure [21].

Outcomes: Arthroscopic wrist arthrolysis after wrist fracture is safe, requires minimal invasive surgery, and significantly improves pain and wrist flexion-extension [8]. Arthroscopic synovectomy of the wrist can provide pain relief and functional improvement with control of synovitis in 75% of rheumatoid wrists that have not responded to medication [38]. Arthroscopic wrist debridement and radial styloidectomy may have advantages in relieving pain while preserving wrist motion for scapholunate advanced collapse (SLAC) stage 2 or 3 disease [24]. 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 [16].

Complications: Complications of thermal ablation in wrist arthroscopy are documented [21]. There may be more instances of trauma to the posterior interosseous nerve (PIN) during routine wrist arthroscopy than previously reported [7]. Complete avulsion of the distal posterior interosseous nerve during wrist arthroscopy is a possible cause of persistent pain after arthroscopy [14].

Comparative Evidence: Clinical comparison of arthroscopic versus open repair of TFCC tears exists [21]. Arthroscopic versus open dorsal ganglion excision shows a prospective, randomized comparison of rates of recurrence and residual pain [21].

Complications

Nerve palsy: Detailed knowledge of wrist anatomy is essential to minimize complications during wrist arthroscopy [2]. There may be more instances of trauma to the posterior interosseous nerve (PIN) during creation of the 3-4 wrist arthroscopy portal than previously reported [7].

Traction-related injury: Overdistraction or use of wire finger traps during wrist arthroscopy traction may cause postoperative finger joint pain, localized contusion to soft tissue, or injury to digital nerves [23].

Compartment syndrome: Extravasation of irrigation fluid during wrist arthroscopy may lead to compartment syndrome [23].

Recovery

Light activity (weeks): Evidence does not provide specific week ranges for light activity, desk work, or driving.

Full activity (months): Evidence does not provide specific month ranges for manual work, sport, or full ROM/strength return.

Complete recovery / outcome plateau (months): Patients undergoing arthroscopic investigation for persistent wrist pain improved by approximately 50% on average at one year [4]. Most patients with persistent wrist pain who underwent arthroscopy continued to have some pain and disability at one year [4].

Rehabilitation protocol: Evidence does not provide specific details on PT phasing, immobilisation duration, weight-bearing/ROM progression, or sling/brace removal timing.

Functional milestones: Patients undergoing arthroscopic investigation for persistent wrist pain improved by approximately 50% on average at one year [4]. Most patients with persistent wrist pain who underwent arthroscopy continued to have some pain and disability at one year [4].

Other Considerations: Arthroscopic wrist debridement and radial styloidectomy may have advantages in relieving pain while preserving wrist motion for SLAC stage 2 or 3 disease [24]. Arthroscopic wrist debridement and radial styloidectomy is indicated for SLAC II or SLAC III wrists as an intermediate step to relieve pain and preserve functional motion [36]. Supplemental wrist arthroscopy does not appear to improve outcomes at 1 year in patients with distal radius fractures treated with volar locking plates [39].

Key Evidence

  • [L5] Wrist arthroscopy is an essential diagnostic and therapeutic tool for the orthopaedic surgeon with an ever-expanding list of indications and procedures. [1] (10.1016/j.arthro.2007.11.002)
  • [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. [2] (10.1016/j.jhsa.2008.07.015)
  • [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. [4] (10.1016/j.jht.2012.03.001)
  • [L5] Recent technical and technological developments in wrist arthroscopic surgery allow for advanced treatments of difficult wrist disorders. [5] (10.1177/17531934211030861)
  • [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. [7] (10.1016/j.arthro.2017.01.010)
  • [L4] The procedure is safe, required minimal invasive surgery, and significantly improved pain and wrist flexion-extension. [8] (10.1016/j.arthro.2006.11.001)
  • [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. [9] (10.5435/jaaos-20-11-725)
  • [L4] This systematic review suggests that the previously documented rate of wrist arthroscopy complications may be underestimating the true incidence. [10] (10.1016/j.arthro.2012.01.008)
  • [L5] Wrist arthroscopy has a pivotal role in the assessment and treatment of scapholunate ligament complex derangements and distal radioulnar joint instability. [11] (10.1016/j.jhsa.2012.06.028)
  • [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. [12] (10.1016/j.arthro.2007.10.006)
  • [L5] Dry wrist arthroscopy circumvents problems associated with fluid-based paradigms, such as fluid extravasation and tissue swelling, while allowing larger portals and instruments. [13] (10.1016/j.jhsa.2014.08.042)
  • [L5] [15] (10.5435/00124635-200105000-00006)
  • [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. [16] (10.1016/j.jht.2012.04.002)
  • [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. [17] (10.1016/j.jhsa.2020.01.012)
  • [L3] When a magnetic resonance technique that does not employ a dedicated wrist coil is used, a negative magnetic resonance imaging scan does not exclude triangular fibrocartilage complex or scapholunate ligament injuries. [22] (10.1054/jhsb.2001.0645)
  • [L4] The procedure studied may have advantages in relieving pain while preserving wrist motion for SLAC stage 2 or 3 disease. [24] (10.1177/1558944717725383)
  • [L4] The radial anterior wrist arthroscopic portal is invaluable for assessing and treating intraarticular conditions, particularly dorsal intraarticular fractures of the distal radius, radial styloidectomy, and synovectomy, while respecting safety requirements. [25] (10.1054/jhsb.1999.0166)
  • [L5] [26] (10.2106/00004623-199908000-00015)
  • [L4] Diagnostic arthroscopy performed in the setting of an unclear preoperative diagnosis yielded limited diagnostic benefit. [33] (10.1177/1558944716661993)
  • [L5] Dry wrist arthroscopy is a technique that can be used to manage multiple orthopaedic conditions including soft-tissue and osseous injuries. [34] (10.1016/j.arthro.2023.02.002)
  • [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. [35] (10.1177/1753193408090395)
  • [L4] The procedure is indicated for SLAC II or SLAC III wrists as an intermediate step to relieve pain and preserve functional motion. [36] (10.1016/j.arthro.2012.04.108)
  • [L4] Arthroscopic synovectomy of the wrist can provide pain relief and functional improvement with control of synovitis in 75% of rheumatoid wrists that have not responded to medication. [38] (10.1016/j.jhsa.2014.04.022)
  • [L5] Supplemental wrist arthroscopy does not appear to improve outcomes at 1 year in patients with distal radius fractures treated with volar locking plates, despite improved reduction of articular stepoff. [39] (10.1016/j.arthro.2023.07.041)
  • [L5] Dry wrist arthroscopy is suitable for diagnosing and treating ulnar-sided wrist disorders, offering advantages such as no fluid extravasation and the ability to perform concomitant open procedures, though it requires specific technical considerations to avoid thermal injury and shaver blockage. [51] (10.1016/j.jhsa.2020.08.011)
  • [Paper] [56] (10.1016/s0363-5023(09)60080-0)
  • [L4] DRCL tears are commonly seen with injuries to the primary wrist stabilizers. [62] (10.1016/j.jhsa.2007.11.026)
  • [L4] A 3 tesla MRI was neither sensitive nor specific enough to correctly diagnose lesions in small pediatric wrists. [63] (10.1016/j.asmr.2022.04.029)
  • [L3] However, most of these lesions have not been correctly identified by MRI before arthroscopy. [64] (10.1016/j.arthro.2012.04.152)

See Also

References

[1] New Advances in Wrist Arthroscopy. Arthroscopy. 2008. DOI: 10.1016/j.arthro.2007.11.002

[2] Wrist Arthroscopy: Current Concepts. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2008.07.015

[3] Chapter 39 Wrist Arthroscopy. 2019.

[4] Prognosis and Prognostic Factors for Patients with Persistent Wrist Pain Who Proceed to Wrist Arthroscopy. Journal of Hand Therapy. 2012. DOI: 10.1016/j.jht.2012.03.001

[5] Revolutions in arthroscopic wrist surgeries. Journal of Hand Surgery (European Volume). 2021. DOI: 10.1177/17531934211030861

[6] Wrist Arthroscopy. 2021.

[7] Incidence of Posterior Interosseous Nerve Trauma During Creation of the 3‐4 Wrist Arthroscopy Portal in Cadavers. Arthroscopy. 2017. DOI: 10.1016/j.arthro.2017.01.010

[8] Arthroscopic Wrist Arthrolysis After Wrist Fracture. Arthroscopy. 2007. DOI: 10.1016/j.arthro.2006.11.001

[9] Advances in Wrist Arthroscopy. Journal of the American Academy of Orthopaedic Surgeons. 2012. DOI: 10.5435/jaaos-20-11-725

[10] Complications of Wrist Arthroscopy. Arthroscopy. 2012. DOI: 10.1016/j.arthro.2012.01.008

[11] Current Innovations in Wrist Arthroscopy. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2012.06.028

[12] Current Concepts in Wrist Arthroscopy. Arthroscopy. 2008. DOI: 10.1016/j.arthro.2007.10.006

[13] Dry Wrist Arthroscopy. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2014.08.042

[14] Green S Operative Hand Surgery. AUTHOR'S PREFERRED METHOD OF TREATMENT: ARTHROSCOPIC PARTIAL WRIST FUSION > REFERENCES.

[15] Wrist Arthroscopy: Principles and Clinical Applications. Journal of the American Academy of Orthopaedic Surgeons. 2001. DOI: 10.5435/00124635-200105000-00006

[16] Clinical Commentary in Response to: Prognosis and Prognostic Factors for Patients with Persistent Wrist Pain Who Proceed to Wrist Arthroscopy. Journal of Hand Therapy. 2012. DOI: 10.1016/j.jht.2012.04.002

[17] Dry Wrist Arthroscopy for Radial-Sided Wrist Disorders. The Journal of Hand Surgery. 2020. DOI: 10.1016/j.jhsa.2020.01.012

[19] Miller S Review Of Orthopaedics. DISTAL RADIOLNAR JOINT, TRIANGULAR FIBROCARILAGE COMPLEX, AND WRIST ARTHROSCOPY.

[21] Campbell S Operative Orthopaedics 4 Volume Set. ANATOMIC RECONSTRUCTION OF THE DISTAL RADIOULNAR LIGAMENTS > ARTHROSCOPY OF THE WRIST.

[22] A Comparison of the Findings of Wrist Arthroscopy and Magnetic Resonance Imaging in the Investigation of Wrist Pain. Journal of Hand Surgery. 2001. DOI: 10.1054/jhsb.2001.0645

[23] Green S Operative Hand Surgery. AUTHOR'S PREFERRED METHOD OF TREATMENT: ARTHROSCOPIC PARTIAL WRIST FUSION > SURGICAL TECHNIQUE FOR DIAGNOSTIC ARTHROSCOPY > Setup.

[24] Arthroscopic Wrist Debridement and Radial Styloidectomy for Advanced Scapholunate Advanced Collapse Wrist: Long-term Follow-up. HAND. 2017. DOI: 10.1177/1558944717725383

[25] An Anterior Portal for Wrist Arthroscopy. Journal of Hand Surgery. 1999. DOI: 10.1054/jhsb.1999.0166

[26] Techniques of Wrist Arthroscopy . The Journal of Bone and Joint Surgery-American Volume*. 1999. DOI: 10.2106/00004623-199908000-00015

[27] Exam Of The Hand Wrist 2Ed. 1.1 SKELETON OF THE HAND > The osseous skeleton.

[28] Campbell S Operative Orthopaedics 4 Volume Set. NERVE INJURIES AT THE LEVEL OF THE HAND AND WRIST > ARTHROSCOPY OF THE WRIST.

[29] Campbell S Operative Orthopaedics 4 Volume Set. NERVE INJURIES AT THE LEVEL OF THE HAND AND WRIST > RADIOGRAPHIC TECHNIQUES.

[30] Green S Operative Hand Surgery. Indication for Wrist Surgery.

[31] Aaos Comprehensive Orthopaedic Review 3. Arthritides of the Hand and Wrist* > IV. Posttraumatic Arthritis.

[32] Green S Operative Hand Surgery. AUTHOR'S PREFERRED METHOD OF TREATMENT: ARTHROSCOPIC PARTIAL WRIST FUSION > Diagnostic Wrist Arthroscopy.

[33] Diagnostic Wrist Arthroscopy for Nonspecific Wrist Pain. HAND. 2016. DOI: 10.1177/1558944716661993

[34] Dry Wrist Arthroscopy: Technique and Rationale. Arthroscopy. 2023. DOI: 10.1016/j.arthro.2023.02.002

[35] Comparison of MRI and Wrist Arthroscopy for Assessment of Wrist Cartilage. Journal of Hand Surgery (European Volume). 2008. DOI: 10.1177/1753193408090395

[36] Arthroscopic Wrist Debridement and Radial Styloidectomy for Late‐stage Scapholunate Advanced Collapse Wrist (SS‐49). Arthroscopy. 2012. DOI: 10.1016/j.arthro.2012.04.108

[38] Long-Term Results of Arthroscopic Wrist Synovectomy in Rheumatoid Arthritis. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.04.022

[39] Editorial Commentary: Supplemental Wrist Arthroscopy May Not Be the Key to Improving Outcomes in Surgical Treatment of Distal Radius Fractures. Arthroscopy. 2024. DOI: 10.1016/j.arthro.2023.07.041

[40] Campbell S Operative Orthopaedics 4 Volume Set. NERVE INJURIES AT THE LEVEL OF THE HAND AND WRIST > ANATOMY.

[43] Aaos Comprehensive Orthopaedic Review 3. Anatomy of the Hand and Wrist > VII. The Wrist.

[44] Green S Operative Hand Surgery. WRIST BIOMECHANICS > Carpal Kinematics.

[46] Campbell S Operative Orthopaedics 4 Volume Set. NERVE INJURIES AT THE LEVEL OF THE HAND AND WRIST > CIRCULATION.

[51] Dry Wrist Arthroscopy for Ulnar-Sided Wrist Disorders. The Journal of Hand Surgery. 2021. DOI: 10.1016/j.jhsa.2020.08.011

[53] Green S Operative Hand Surgery. WRIST INVOLVEMENT IN RA.

[54] Green S Operative Hand Surgery. Diagnosis and Treatment > Assessment of the Symptomatic Wrist.

[56] Interobserver Reliability and Intraobserver Reproducibility of Digital Photograph Documentation of Wrist Arthroscopy. The Journal of Hand Surgery. 2009. DOI: 10.1016/s0363-5023(09)60080-0

[58] Miller S Review Of Orthopaedics. DISTAL RADIOULNAR JOINT, TRIANGULAR FIBROCARTILAGE COMPLEX, AND WRIST ARTHROSCOPY > 2. TFCC tears.

[60] Exam Of The Hand Wrist 2Ed. Examination.

[62] The Incidence of Dorsal Radiocarpal Ligament Tears in Patients Having Diagnostic Wrist Arthroscopy for Wrist Pain. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2007.11.026

[63] Wrist Arthroscopy Is Effective for the Diagnosis and Treatment of Chronic Wrist Pain in Pediatric Patients. Arthroscopy, Sports Medicine, and Rehabilitation. 2022. DOI: 10.1016/j.asmr.2022.04.029

[64] Pathomorphologic Findings of Wrist Arthroscopy in Children and Adolescents With Chronic Wrist Pain. Arthroscopy. 2012. DOI: 10.1016/j.arthro.2012.04.152

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