The arthroscope is introduced into the joint through the 3-4 viewing portal.
Introduction is done with a blunt probe through the sheath which is then replaced
with the viewing system of the arthroscope. At this point usually the arthroscope lies
directly on the volar capsule so it has to be withdrawn by a few millimeters in order to
gain visualization of the joint.

It is imperative to understand that because the wrist is a small joint, large
movements with the arthroscope are not practical. Consequently, in order to move in
any direction, first the 30° viewing mark on our screen (which lies directly opposite to
the position of the light input of our camera #f)) must be turned towards the direction
that we want to move and then, we move the arthroscope towards that direction.
That rule applies throughout the procedure. A three point standard radiocarpal
arthroscopy is then performed:

Point 1: Scapholunate (SL) ligament

Initially the fibrovascular ligament of Testout is identified. It should lie right opposite
the 3-4 portal, if this has been created correctly. Testout’s ligament is easily visible
because of its vascular content and is the "lighthouse", the place we return to for
orientation whenever we cannot recognize the structures we are viewing. Then, the
30° marking on screen is directed upwards (towards the 12th hour) and the
arthroscope is retracted a few millimeters and the membranous part of the SL
ligament is visualized. It should be noted that inintact SL ligament, its fibers will blend
with the articular cartilage of the scaphoid and the lunate in a continuum, without
distinct boundaries. In order to visualize the dorsal part of the SL ligament, its fibers
are the followed with the arthroscope towards the dorsum of the hand until we reach
the dorsal scapholunate septum (which separates the radiocarpal from the mid-
carpal joint and where we usually find the stalk of dorsal wrist ganglia)

Point 2: Volar radio-carpal ligaments

From viewing the ligament of Testout, now the 30° mark of the arthroscope is
directed radial and the arthroscope is slowly moved along the surface of the

scaphoid. The scaphoid fossa of the radius as well as the radial styloid cartilage can
be appreciated. On the volar surface between the radius and the scaphoid, three
distinct volar ligaments are visualized. These are, from radial to ulnar, the Radio-
scapho-capitate and the Long and Short Radio-lunate ligaments.

Point 3 Triangular fibrocartilage (TFC)

With the arthroscope looking at Testout's ligament, the 30° mark on the screen is
directed in an ulnar direction. First the lunate and lunate fossa of the radius can be
appreciated and then, introducing the arthroscope a little bit deeper and moving it to
the ulnar side of the wrist one can visualize the TFC. It should be noted that in some
patients there is a substantial ridge between the scaphoid and lunate fossa which
has to be overcome in order to visualize the TFC. In the more ulnar border of the
TFC there is usually a “hole”, which is a normal anatomic structure called the
prestyloid recess. Next, the 6R portal is created with the outside-in technique (as
described above) and a probe is introduced. It is imperative to do a “trampoline test”
on the TFC; palpate TFC surface and it should feel tensioned under the probe. Then
the probe is introduced in the prestyloid recess, attempting to lift the TFC off the
ulna; this is the “hook test’ and one should not be able to bring the TFC toward the
arthroscope, if the TFC attachment to the fovea of the ulna is intact. Finally, the
probe is used to palpate the surface of the SL ligament looking for not readily visible
tears.
If one wishes to visualize the Lunotriquetral (LT) ligament, this can be only
accomplished by changing the viewing portal from 3-4 to 6R. First the arthroscope is
placed on the center of the TFC and the 30° mark on the screen is directed to the
12:00 position (looking up). The structure that is then visualized is the membranous
part of the LT ligament, which can be then followed to its dorsal part as for SL
ligament. Note that the volar parts of the SL and LT ligaments are not visible with
standard radiocarpal arthroscopy.