INTRODUCTION: This retrospective study examines the diagnostic work-up and results of ulnar sided wrist pain when treated with ulnar shortening osteotomy in 227 cases not responding to conservative management. METHODS: Routine X-rays, bone scans, and arthrograms were reviewed and correlated with arthroscopic findings as relating to lesions of the TFCC, lunotriquetral ligament (L-T), ulnar variance, and chondromalacia. RESULTS: There was a positive ulnar variance in 84.9% of the cases, 11.6% were neutral, and 3.6% were negative. The mean ulnar variance was +1.7 mm preoperatively, and -0.6 mm postoperatively. Arthrograms were done on most patients, with 76% having positive results. Of the bone scans reviewed, 75% were positive. Results of wrist arthroscopy were 119 TFCC lesions, 72 associated with L-T ligament tears, and 58 isolated L-T ligament tears. Postoperative results of the 145 patients evaluated include; 52 excellent, 54 good, 38 fair, and 1 poor according to Chun and Palmer’s grading system. CONCLUSION: Complete and systematic work-up is important in the diagnosis and treatment of ulnar sided wrist pain. The algorithm includes: history, physical examination, and a period of conservative management. Conservative management with no improvement is followed with bone scan and arthrogram. Bone scan and arthrogram have been more reliable than MRI in diagnosing lesions associated with ulnar impaction syndrome and interosseous ligament tears. The gold standard for diagnosing TFCC tears and L-T ligament tears is wrist arthroscopy. Ulnar sided wrist pain due to ulnar impaction syndrome or traumatic TFCC and L-T ligament tears in this study have been effectively treated with Ulna Shortening Osteotomy.