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Arthroscopy of the radiocarpal and midcarpal articulation can be performed safely and effectively once the anatomy is mastered and the appropriate equipment is obtained. Its usefulness as a diagnostic and therapeutic modality for pathology of the wrist has been demonstrated. As our understanding of wrist pathology and our technical ability increase, arthroscopy will play a larger role in the treatment of disorders of the wrist.

Arthroscopic wrist anatomy is best learned from cadaveric bioskills first, and reinforced through experience. Correlating focal clinical findings with arthroscopic anatomy, both normal and pathologic, can expand the clinician’s understanding and nuanced-interpretation of presenting complaints. Wrist arthroscopy has been shown to be more effective and predictable than all but the most sophisticated MRI and has an added benefit of real-time assessment of dynamic instability and partial cartilage lesions. Visualizing wrist pathology with the arthroscope is often more reliable than a physical examination or imaging studies such as MRI, arthrography, or plain radiographs. It is essential to alternate viewing and instrumentation portals to properly view normal and abnormal anatomy from various angles. Once arthroscopic wrist anatomy is understood and mastered, the surgeon can best plan and perform treatment based on the patient’s internal wrist pathology.

Numerous modalities are available for the evaluation of the painful wrist. Plain films will suffice in the vast majority of cases. Specialized views are ordered when the patient’s history, physical exam, or plain film evaluation indicates the need. A static wrist instability series still has a place in diagnosis of the painful wrist. CT scanning is of limited utility for most wrist pathology except for DRUJ subluxation. Bone scans are less frequently indicated, given the increasing use of MRI, but are generally indicated when evaluating complex cases with minimal findings on other tests. MRI will become increasingly common in the place of arthrography, but currently is the gold standard for the diagnosis of carpal osteonecrosis. Its role in the diagnostic armamentarium is still being defined as technology improves.

Wrist arthroscopy is a sensitive modality to evaluate for tears of the triangular fibrocartilage complex. It allows precise identification of the tear pattern as well as the severity of the tear. Wrist arthroscopy allows evaluation of the integrity of the articular disk through palpation with a probe and documents when the tear extends to involve radioulnar ligaments. When a radial-sided tear of the articular disk includes the volar and/or dorsal radioulnar ligaments, arthroscopic repair of the TFCC should be considered. Although anatomic studies have shown decreased vascularity on the radial side of the triangular fibrocartilage complex, several studies have shown successful repair of the articular disk, both clinically and by objective imaging with arthrograms and MRI. Arthroscopic repair of radial-sided tears of the TFCC is safe and effective. Several surgical techniques have been described in the literature. Arthroscopic techniques have less morbidity and potentially accelerated rehabilitation for patients compared to open repair. New techniques continue to be developed to further simplify the procedure.

Though the Palmer classification of TFCC tears has added tremendous value in terms of grouping lesions into traumatic and degenerative categories, it is important to remember that it is more useful in terms of differentiating etiology than in designating distinct treatment recommendations. Both Type I and Type II tears may reflect the biomechanical effects of increased ulnar variance, and both, in that light, may require more than simple debridement. Careful examination and the use of preoperative MR imaging and fastidious diagnostic use of the arthroscope may reveal whether an element of ulnar impaction exists and, for that matter, whether other pathology, such as an LT tear, needs to be addressed. For the most part, however, Type IC tears can be treated effectively with debridement alone and Type IIC tears by debridement and an arthroscopic wafer procedure.

Arthroscopic wafer resection of the distal ulna has several distinct advantages that make it the surgical procedure of choice for the treatment of UIS with symptomatic Palmer IIC and select IID tears. Contraindications to the use of the arthroscopic wafer procedure include: LTJ instability typical of a Palmer IIE degenerative pattern, DRUJ instability or arthrosis, and excision of the ulnar dome in excess of 4 mm. Recent clinical reviews of the arthroscopic wafer procedure indicate very good results; minimal complications when compared to open surgical procedures; minimal need for subsequent repeat surgery, such as plate removal, following osteotomy; and the ability to thoroughly evaluate the wrist joint for any associated intra-articular injuries. There is greater patient acceptance of the arthroscopic procedure over competing open surgical procedures. The rehabilitation following arthroscopy is relatively quick and better tolerated by patients.