The indication for wrist arthroscopy is established after careful history, clinical
examination as well as appropriate imaging. The specifics of this work-up are
beyond the scope of this book, however the key points are the following:

The history of the present illness as well as the patient’s general medical history
should be recorded. Consideration should be given to the possibility of referred pain
to the wrist from pathology at the elbow, shoulder,thoracic outlet and cervical spine
as well as neurologic conditions.

Clinical examination should include assessment of the range of motion, careful
palpation of the tender points of the joint including the anatomic snuffbox, the
scapholunate interval (distal to Lister’s tubercle) and the base of the ulnar styloid
(fovea sign). Thorough assessment of the nerves including superficial sensory
branches of the radial and ulnar nerve must be performed. Joint laxity must
be assessed in both upper extremities. Watson’s test for scapholunate instability
should be performed. It is considered positive if there is pain or clicking with direct
pressure on the proximal pole of the scaphoid with the examiner’s thumb and radial
deviation of the wrist. The Nakamura stress test includes placing the wrist in ulnar
deviation, axonic compression and supination. If acute pain is elicited the diagnosis
of a TFC tear is highly possible.

Radiographic assessment should include standardized x-rays of the wrist (with the
shoulder in 90° flexion and the elbow in 90° flexion). They should include a
posteroanterior (PA) view of the wrist in neutral and a PA view of the wrist in grip
(dynamic grip view) as well as in a true lateral view. In the PA views dynamic
scapholunate instability as well as ulnar variance and ulnocarpal abutment can be
assessed. In the lateral views, we look for carpal bone malalignment DISI and VISI.

A computer tomography scan of the wrist is useful to assess carpal alignment as well
as the presence of arthritis. Magnetic resonance (MRI) scans are useful for
interosseous ligament tears and TFC tears, however it must be kept in mind that
even with modern 3 Tesla magnets their sensitivity and specificity rarely exceeds
80% and the negative prognostic value of MRI remains low. MR arthrograms are

said to improve the diagnostic accuracy of MRI (especially triple arthrograms),
however, the negative prognostic value remains low as we often encounter tears of
the interosseous ligaments and the TFC sealed with scar tissue during arthroscopy.

Finally, because of the relatively low accuracy of MRI, there is a role for diagnostic
arthroscopy in patients with undetermined pain to the wrist after six months of
negative Imaging and conservative treatment.