The trapeziometacarpal joint (TMC) is a saddle joint that is subjected to tremendous repetitive loads through our lifetime. This joint is apparently congruent, but only a small part of the articular surface is loaded during pinch grips. This design implies a perfect bony anatomy, high quality articular cartilage and no ligament laxity. Under certain circumstances, where these different anatomical variables are imperfect, symptoms and pain can start at a very early stage in life. They are mainly acquired, but can be posttraumatic in origin. High quality radiographic views are needed: these radiographs must be done methodically by well-trained radiologists. The symptoms and radiographic changes may not match, such as when radiographic changes are minimal but functional impairment is significant. The primary goal of treatment is conservative. This cannot be stressed enough since conservative treatment can be successful with good follow-up by the hand surgeon: resting splint, good postures at work and if necessary, anti-inflammatory drugs and paracetamol. If this fails after a minimum of 6 months, different osteotomies can be proposed, combined with ligament augmentation in some cases. These osteotomies are mainly extra-articular, can be at the level of the base of the first metacarpal and the trapezium, or can be solely at the base of the first metacarpal. Isolated osteotomies of the trapezium should be avoided since they tend to close the first web space. In certain posttraumatic cases, intra-articular osteotomy of the malunion can be done to restore congruency and provide pain relief.