Indications for small joint arthroscopy in the hand remain poorly understood. This is due to a paucity of articles discussing these techniques in the literature, as well as inadequate hands-on training in the pearls and pitfalls regarding this application within the routine "scope" of hand surgery. Despite the fact that small joint arthroscopes have been available for more than a decade, hand surgeons have been slow to adopt this technique for the treatment of both traumatic and degenerative conditions involving the thumb and the digital metacarpophalangeal joints. An arthroscopic classification for basal joint osteoarthritis provides additional clinical information and can direct further treatment depending on the stage of disease. This article will also review the brief history of trapeziometacarpal arthroscopy and provide insight as to how this technique can be incorporated into a treatment algorithm in managing this common affliction. Metacarpophalangeal joint arthroscopy is even less commonly utilized, while traumatic and overuse injuries are frequently seen in the thumb and constitute ideal indications in certain scenarios. Painful conditions affecting the metacarpophalangeal joints of the fingers are less commonly seen, yet the small joint arthroscope presents a much clearer picture of the pathology compared with other imaging techniques or even open, potentially deleterious surgery. The application of this technology to the smaller joints will soon make the treating surgeon realize that a myriad of pathologies are readily visible and can augment treatment, as well as diagnosis. Similar to the wrist, small joint arthroscopy may one day supplant imaging techniques such as magnetic resonance imaging or computed tomography for establishing an accurate diagnosis.