Wrist Arthroscopy

Standard dorsal wrist arthroscopy portals marked on the skin
Standard dorsal wrist arthroscopy portals marked on the skin. The 3-4 portal lies just distal to Lister’s tubercle, with the 4-5, 6R and 6U portals in line ulnarly and the radial and ulnar midcarpal portals further distal. Image from Atlan F, Pritsch T, Tordjman D, Khabyeh-Hasbani N, Halperin D, Factor S. Wrist arthroscopy for diagnosis and treatment of acute and chronic conditions. SICOT J. 2022, 8, 17. CC BY 4.0.
Wrist Arthroscopy, portals for wrist arthroscopy
Portals for wrist arthroscopy. Image by MaikTenhagen, Wikimedia Commons, CC BY-SA 3.0.

Indications

Diagnostic vs Therapeutic

  • Diagnostic
    • Assess tears of TFCC
    • Chondral damage to carpus
    • Chronic wrist pain of unknown Diagnosis
  • Therapeutic
    • Distal radial & carpal Fracture
      • Aid in ORIF distal radius fracture with mini-open procedure
      • Percutaneous pinning of scaphoid
    • Ligament tears
      • Scapho-lunate instability
      • Luno-triquetral instability
    • Debride TFCC tears
    • Synovectomy
    • Removal of loose bodies
    • Wrist lavage
    • Arthrofibrosis

Setup

  • Tourniquet
  • Traction
    • essential for visualisation
    • Traction tower & finger traps to 2 or 3 digits (usually IF & MF)
    • If don’t have tower use shoulder holder & wt suspended off traps
    • Overhead or traction device – so that elbow lies just off the table
    • 10lb wt
  • 2.7 mm scope
    • essential
    • 2.7mm or 2.9mm 30° or 70° scope
    • 1.9mm scope also available for DRUJ, thumb CMCJ/ STTJ, MCPJ
  • Infuse NS 1st
  • Small joint instrumentation as well

Landmarks

  • KEY IS KNOWLEDGE OF ANATOMY AND ACCURATE PORTAL PLACEMENT
  • Draw portals, bony & tendon landmarks on skin prior to placement

Portals

  • Named according to interspace through which they pass
  • Most common
    • 3-4 portal
    • 4-5 portal
    • 6-R portal
    • 6-U portal
  • 3-4 Portal
    • Feel Lister’s tubercle
    • 1cm distal is soft spot between extensor compartments 3 & 4
  • 4-5 Portal
    • Roll finger over mobile 4th compartment to feel soft spot
    • Is slightly proximal to 3-4 because of slope of radius
  • 6-R & 6-U
    • Named after their position about ECU
  • Then
    • Insufflate wrist with 3-5ml N/Saline into radiocarpal joint
    • All portal incisions longitudinal to protect extensors
    • Only incise skin
    • Use blunt trocars to avoid radial n injury
    • Pass trocar at 30-40° passing volar to conform to shape of radius
  • Midcarpal Portals
    • Two portals to view S-shaped midcarpal joint
    • Made 1cm distal to 3-4 & 4-5 portals
    • In soft spot between capitate & scaphoid
  • 3-4 portal is primary viewing portal
  • 4-5 or 6-R main working portal
  • 6-U is inflow portal
  • Outflow usually through IV tubing attached to scope

Diagnostic Procedure

  • Start at radial styloid & scaphoid
  • Work radial to ulnar
  • Identify RadioScaphoCapitate Ligament & immediately beside is Long Radiolunate Ligament (extremely wide usually 3x width of RSCL)
  • Next is Short RadioLunate Ligament (often see blood vessels along this ligament)
  • Distal to short ligament is Scapholunate Lig
  • Examine from membranous proximal portion to thicker dorsal ligamentous portion
  • Follow ulnarly along lunate & its fossa to TFCC
  • Articular disc should be taut like a trampoline (actual ballottement with probe should give same feeling = Trampoline test)
  • Examine for tears » central or peripheral if not taut
  • Don’t be caught out by ulnar styloid recess is normal finding at base of styloid not a tear
  • Then to triquetrum
  • Must probe both scapholunate joint & lunotriquetral joint for instability
  • Next move to midcarpal joint with scope & probe using both midcarpal portals
  • Most prominent feature is curve of head of capitate
  • Reverse look & view scapholunate joint & lunotriquetral joint
  • STTJ can be seen by passing completely radially

Carpal Instability

  • Must look from radiocarpal & midcarpal joints
  • Both joint ligaments should be tight & concave
  • Can do “poor man’s arthrogram”
    • Ie inflow in RCJ outflow in MCJ
    • If flow then have tear in ligament

Arthroscopic Classification

GradeDescriptionTreatment
IAttenuation or haemorrhage within ligament. No stepCast immobilisation
IIIncongruency or step-off in midcarpal spaceArthroscopic pinning. Use K wire as joystick to reduce
IIIStep-off on both sides. Probe may be passed between bonesArthroscopic or open repair
IVGross instabilityOpen repair

Original publication Geissler WB, Freeland AE, Savoie FH, McIntyre LW, Whipple TL. Intracarpal soft-tissue lesions associated with an intra-articular fracture of the distal end of the radius. J Bone Joint Surg Am. 1996;78(3):357-65.

TFCC Injuries

  • Use 4-5 portal as visual portal & 6-R as working portal
  • Degenerative or Traumatic
  • Central or Peripheral
  • With or without DRUJ instability
  • Radial or Ulnar avulsions
  • ± Styloid Fracture
  • Debride central tears acute or degenerative
  • Attempt repair of peripheral tears
  • If unstable DRUJ have to reinforce DRUL or PRUL with strip of ECU
  • If degenerative tear & ulnar plus need to add ulnar shortening to debridement

Distal Radial Fractures

  • Critical tolerance for articular incongruity = 2mm
  • Recent evidence now says 1mm
  • A/scopic assisted helps to achieve congruity
  • Also now are seeing high incidence of scapholunate & lunotriquetral ligament injuries
  • Technique
    • Usually wait 2-7/7 for bleeding
    • Usual set up
    • 3-4 visual portal, 4-5 or 6-R as working portals,6-U as inflow
    • Occasionally use 1-2 portal
    • Use K-wires placed under I-I control to joystick fragments as well as small pick etc through working portal
    • Wire fixation as per usual once reduction obtained
    • If see die punch have to open

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.