Wrist arthroscopy: wrist joint

Wrist arthroscopy is a minimally invasive diagnostic and therapeutic procedure that allows for the assessment of cartilage, wrist ligaments, triangular fibrocartilage complex, and intra-articular surfaces, as well as correction of identified abnormalities through minimal approaches. Current reviews consider this method the standard for verifying damage to the triangular fibrocartilage complex and diagnosing instability between the scaphoid and lunate bones when conventional imaging yields inconclusive results. [1]

In recent years, the indications for arthroscopy have expanded: in addition to injuries to the triangular fibrocartilaginous complex and interosseous ligaments, arthroscopy is used for intra-articular fractures of the distal radius, synovial diseases, postoperative assessment of reduction, removal of loose bodies, treatment of ganglia, and impaction syndromes. The role of this method is especially important when it is important to combine accurate diagnosis and immediate treatment in a single procedure. [2]

The tool is evolving thanks to the standardization of portals and safe anatomy of the dorsal and volar walls, refinement of injury and instability classifications, and the implementation of educational programs by specialized societies. European and international societies regularly publish guidelines on indications, portal selection, and intra-articular examination protocols. [3]

It is important to understand the limitations: most of the data are prospective series and meta-analyses of observational studies; there are few randomized comparisons; and interobserver reproducibility of some diagnoses depends on the surgeon's experience. Therefore, when making decisions, the method is combined with clinical testing and imaging, and training and skill development are critical to quality. [4]

Indications, contraindications and patient choice

Absolute indications include symptomatic tears of the triangular fibrocartilaginous complex with instability of the ulnar-radial joint pair, documented intra-articular instability between the scaphoid and lunate bones, intra-articular loose bodies, and the need to revise the quality of reduction after fractures. In these scenarios, arthroscopy provides the most accurate assessment and the possibility of immediate intervention. [5]

Relative indications include ulnar impaction syndrome, wrist ganglia, chronic pain of unknown origin with a suspected intra-articular cause, and the need to confirm the effectiveness of ligament reconstruction. The choice in favor of arthroscopy is strengthened by a discrepancy between the clinical and radiographic findings. [6]

Contraindications include active infection, severe cicatricial contracture with the inability to create a safe working space, uncontrolled coagulation disorders, and severe comorbidities that make anesthesia and positioning unsafe. A relative limitation is severe generalized osteoarthritis, where arthroscopic correction will not change the prognosis. [7]

The key to success is stratifying the patient's expectations. Goals (diagnosis and simultaneous treatment), potential alternatives to conservative therapy, the possible need for open correction when complex pathology is identified, and individual risks of complications are discussed. [8]

Table 1. Indications and limitations for wrist arthroscopy

Situation	Arthroscopy is preferred	Comments
Triangular fibrocartilaginous complex injury	Diagnosis and arthroscopic restoration	Benchmark instability verification
Instability between the scaphoid and lunate bones	Diagnosis of the degree and arthroscopic stabilization techniques	Selecting tactics based on instability classifications
Intra-articular fracture of the distal radius	Control of reduction, removal of fragments, sanitation	Impact on clinical outcomes is debated
Ganglion, loose bodies, synovitis	Optics-guided resection and biopsy	Rapid restoration of function
Chronic pain with suspected intra-articular cause	Diagnostics and targeted intervention	When clinical findings and images differ

Anatomy of portals, positioning and security

The standard technique is performed in the supine position with the wrist suspended and traction applied in a controlled manner, creating working space within the wrist joint. Traction should be minimally sufficient, and the time should be limited; precise orientation to anatomical landmarks reduces the risk of injury to nerve branches and extensor tendons. [9]

Classic dorsal portals are placed along the radial and ulnar aspects of the extensor apparatus, maintaining safe distances to the superficial nerves. Volar portals are used less frequently and primarily by experienced surgeons for specific tasks. Modern guidelines detail the trocar insertion line, angle, and depth, as well as the mandatory initial examination of the joint compartments. [10]

The diagnostic walkthrough sequence includes assessment of the articular cartilage, triangular fibrocartilage complex, interosseous ligaments, and carpal compartments. The stability of the scaphoid and lunate bones, the quality of surface contact, and the presence of synovitis are visualized. This sequence improves reproducibility and reduces omissions. [11]

Safety is ensured by strict portal identification, clear communication with the anesthesiologist, and irrigation pressure control. Publications emphasize that systematic adherence to a checklist and training according to society standards significantly reduce the incidence of complications. [12]

Table 2. Frequent portals and risk zones

Portal	Purpose	Nearby risk structures	Security commentary
Dorsal radial	Review of the radial half of the joint	Dorsal branches of the radial nerve	Blunt dissection, tendon landmarks
Dorsal central	Overview of the central zone and fovea	Extensor tendons	Under visualization and traction control
Dorsal ulnar	Access to the triangular fibrocartilaginous complex	Dorsal branch of the ulnar nerve	Minimizing the portal diameter
Volar radial	Rarely for selected tasks	Palmar branch of the median nerve	For experienced surgeons according to strict indications

Diagnosis and treatment of injuries of the triangular fibrocartilaginous complex

For patients with suspected triangular fibrocartilage complex injury, arthroscopy remains a crucial diagnostic step, allowing differentiation of tear types and assessment of foveal fixation and ulnar radial stability. This is especially important when noninvasive methods provide an incomplete picture. [13]

Depending on the location and nature of the rupture, tissue-sparing debridement, peripheral suturing, foveal fixation, or reconstruction are used. The choice of technique is based on stability, tissue quality, and associated impaction features. The goal is to restore stability and eliminate the mechanical source of pain while maximizing structural preservation. [14]

Long-term results demonstrate consistent improvements in pain and function with appropriate technique and rehabilitation. However, surgeon experience and protocol rigor impact reproducibility: studies indicate only moderate interobserver agreement in arthroscopic classification, emphasizing the importance of standards. [15]

Practical algorithm: in case of central degenerative defects without instability, gentle debridement is usually sufficient; in case of peripheral ruptures with instability, suturing or foveal fixation is preferable; in case of severe impact syndrome, concomitant correction of the elbow variant is considered. [16]

Table 3. Tactics for typical variants of damage to the triangular fibrocartilaginous complex

Option	Signs	Preferred tactics	Expected effect
Central defect without instability	Pain on exertion, stability maintained	Gentle sanitation	Reduced pain, rapid return to function
Peripheral rupture	Pain and instability of the ulnar radial pair	Suturing the periphery	Restoring stability
Foveal detachment	Marked instability	Foveal fixation or reconstruction	Functional gain, pain reduction
Impact syndrome	Pain with u-lateral load	Combined correction according to indications	Prevention of recurrence of symptoms

Instability between the scaphoid and lunate bones: the role of arthroscopy

Arthroscopy not only allows for confirmation of the degree of instability according to accepted classifications but also allows for minimally invasive stabilization procedures: capsular suturing, dorsal ligament suturing, capsulodesis, or combined techniques. Current guidelines and reviews systematize the indications and stages of intervention. [17]

Recent publications include a wide range of arthroscopically assisted techniques using anchor-type fixators and specialized sutures, focusing on maintaining biomechanics and minimizing tissue trauma. Correct classification of the degree of instability is critical for the choice of tactics and prognosis. [18]

The clinical effect is more pronounced in the early stages, before secondary changes in the hand develop. In chronic instability, a combination of arthroscopic and open reconstructions may be required, which should be discussed with the patient in advance. [19]

Regardless of the technique, the decision to fixate is combined with a rigorous rehabilitation protocol and early weight-bearing restrictions to ensure tissue integration. This influences the final functional outcomes. [20]

Table 4. Arthroscopic approaches for instability between the scaphoid and lunate bones

Situation	Approach	Strengths	Restrictions
Early instability without secondary changes	Suture of the capsule and dorsal complex	Low invasiveness, tissue preservation	Requires strict immobilization
Partial disunity	Suture with anchor fixation	Targeted stabilization	The need for accurate classification
Chronic instability	Combined techniques	Greater influence on biomechanics	Higher requirements for rehabilitation

Distal Radius Fractures: What Arthroscopic Treatment Can Do

Arthroscopically assisted fixation of distal radius fractures allows for precise control of step and gap reduction on the articular surface, removal of intra-articular fragments, and diagnosis of associated ligamentous injuries. This approach improves the anatomical accuracy of reduction, according to several reviews. [21]

However, the question of clinical superiority over standard radiographic guidance remains controversial. Meta-analyses in recent years show comparable functional outcomes between groups, although they note better visual accuracy of reduction with arthroscopic assistance; a recent analysis from 2025 revealed no significant advantage for a number of endpoints. The decision should be individualized, taking into account the resource intensity and objectives of the surgery. [22]

Practical approach: Arthroscopy is advisable in cases of complex intra-articular geometry, in patients with high functional demands, and in cases of suspected concomitant intra-articular injuries requiring immediate intervention. In other cases, a selective strategy is acceptable. [23]

It is important to consider that the increase in surgical time and the need for additional equipment must be justified by the expected clinical benefit for the individual patient. This should be discussed during informed consent. [24]

Table 5. Arthroscopic assistance for fractures: pros and cons

Parameter	Arguments in favor	Arguments against
Reduction control	Better control of the articular surface	Prolongation of the operation time
Associated damage	Immediate elimination of ligament and cartilage problems	Requires additional experience and equipment
Functional outcome	Comparable to traditional tactics on average	Clinical superiority has not been demonstrated in all samples.

Complications: how often and what exactly

A systematic review of more than 10,000 wrist arthroscopies reported an overall complication rate of approximately six percent, with the majority of these being neurological injuries to the dorsal nerve branches, failure to complete the procedure as planned, cartilage damage, and complex regional pain syndrome. Most complications are rare, but their prevention requires discipline and training. [25]

Some publications detail the risks of injury to the dorsal branch of the ulnar nerve, branches of the radial nerve, and complications involving the extensor tendons. These events are most often associated with inaccurate portal positioning and excessive instrumentation. Standardization of technique and the use of blunt guidewires reduce these risks. [26]

Other adverse events include postoperative stiffness, hematomas, tendon sheath fistulas, and extremely rare infectious complications. Their prevention is based on careful technique, adequate pain relief, and early, controlled restoration of motion. [27]

An important organizational factor is the learning curve: as experience increases, procedure time and the frequency of technical errors decrease. Professional societies emphasize the need for gradual training and mentoring. [28]

Table 6. Frequency and structure of complications according to a large review

Complication	Estimated frequency	Key prevention
Nerve damage	About one percent for each group of events	Precise landmarks, minimization of portal diameter
Unable to complete the procedure	About one percent	Alternative Tactical Plan
Cartilage damage	About half a percent	Smooth operation of instruments, traction control
Complex regional pain syndrome	About half a percent	Pain prevention, early mobilization
Other events	Isolated cases	Standards, irrigation pressure control

Rehabilitation

Early rehabilitation begins soon after surgery and focuses on pain and swelling control, incision protection, and preventing stiffness. During the first few days, passive and active movements are performed to a safe range under the supervision of a therapist, with attention to swelling and scarring. [29]

The program then gradually increases the range of active movements, grip, and pinch strength across the functional range, while also working on hand and forearm coordination. Intensity is individualized depending on the extent of the intervention: progress is faster after debridement and removal of loose bodies, while more gradual progress is made after ligament reconstruction. [30]

In the second and third stages, exercises for endurance, proprioception, and closed kinetic chain work are added, developing functional patterns necessary for everyday activities and work. During this period, the immobilization regimen is reviewed and everyday activities are gradually expanded. [31]

Return to sport and heavy work criteria include pain-free, full functional range of motion, strength symmetry with the contralateral hand, and stable performance of functional tests. Timeframes depend on the type of intervention and the underlying pathology. [32]

Table 7. Stages of rehabilitation after wrist arthroscopy

Stage	Main objectives	Examples of exercises	Transition criteria
Early	Pain and swelling control, suture protection	Gentle active and passive movements, scar care	The pain is not more than mild, the wound is clean
Average	Restoring volume and strength	Progressive isometric and functional exercises	Full household volume without pain
Late	Endurance and coordination	Proprioceptive training, closed chains	Power symmetry and robustness tests
Return to sport	Specific skills	Functional complexes for the task	Performing tests without pain or swelling

What to discuss with the patient: expectations and evidence

It's important to explain to patients that arthroscopy combines diagnosis and treatment, but it doesn't always outperform traditional approaches in terms of functional outcomes. For certain applications, such as treating complex intra-articular fractures, improved reduction accuracy is obvious, but clinical benefit is not guaranteed and depends on the specific situation. [33]

For triangular fibrocartilaginous complex tears and early instability between the scaphoid and lunate bones, arthroscopic techniques are associated with high rates of pain reduction and improved function with proper rehabilitation. However, the quality of outcomes is highly dependent on accurate diagnosis and adherence to protocols. [34]

Risks and their prevention should also be discussed: nerve damage due to careless portal manipulation, cartilage injuries, and rare cases of complex regional pain syndrome. Demonstrating portal diagrams and describing safety measures reduce anxiety and improve patient compliance. [35]

And finally, expectations regarding recovery times: after gentle procedures, a return to daily activity is possible quickly; after ligament reconstruction, it is gradual, under the supervision of a therapist and surgeon, with clear criteria for the transition between stages. [36]

Table 8. Informed consent checklist

Paragraph	What to discuss	For what
Target	Diagnosis and targeted treatment in one procedure	Understanding the logic of intervention
Alternatives	Observation and therapy, open surgery	Conscious choice
Efficiency	Strengths and limitations of the evidence base	Realistic expectations
Risks	Nerve and cartilage damage, stiffness, rare infections	Prevention and early recognition
Rehabilitation	Stages, restrictions, criteria for returning to exercise	Commitment and prognosis

Results

Wrist arthroscopy is a versatile tool that combines accurate diagnosis and targeted treatment for wrist pathology. It has the highest evidence support for injuries to the triangular fibrocartilaginous complex and for assessing instability between the scaphoid and lunate bones. When used for fracture fixation, this method improves the quality of reduction, but the clinical benefit is unclear. Safety depends on strict portal technique, traction control, team experience, and consistent rehabilitation. [37]