Chapter 06

Chapter 6
Structure and Function of the Wrist

Copyright 2014, 2009 by Mosby, an imprint of Elsevier Inc.
Wrist Structure Terminology
Two major articulations
Radiocarpal joint
Midcarpal joint
Palmar
Synonymous with anterior
Dorsal
Synonymous with posterior
Copyright 2014, 2009 by Mosby, an imprint of Elsevier Inc. 2
Osteology: Distal Radius and Ulna
Form a concavity that articulates with the convex
(proximal) row of carpal bones
Concavity is bordered laterally by the radial styloid
process and medially by the ulnar styloid process
Radial tubercle (Listers tubercle)
Bone projection on dorsal aspect of distal radius; guides
direction of several wrist and thumb extensor muscle
tendons

Osteology: Carpal Bones
Proximal row includes:
Scaphoid, lunate, triquetrum, and pisiform
Distal row includes:
Trapezium, trapezoid, capitate, and hamate
Bones within proximal row are loosely joined; strong
ligaments tightly bind distal row
Distal row stability provides an important rigid base
for articulations with metacarpal bones

Osteology: Carpal Tunnel
Carpal tunnel
Partly formed by transverse carpal ligament bridging palmar
side of carpal bone
Serves as passageway that helps protect median nerve and
tendons of extrinsic flexor muscles of digits
Joint Structure: Radiocarpal Joint
Proximal part consists of concave surface of radius and
adjacent articular disc
Distal part consists primarily of the convex articular
(proximal) surfaces of scaphoid and lunate
Approximately 80% of force that crosses wrist passes
through scaphoid, lunate, and radius

Joint Structure: Radiocarpal Joint contd
Ulnar-located carpal bones and distal ulna are less
likely to fracture from falls because they are not in the
direct path of weight bearing
Ulnocarpal space
Relatively wide space between distal ulna and ulnar carpal
bones
Helps buffer forces that cross wrist

Joint Structure: Midcarpal Joint
Midcarpal joint separates proximal and distal rows of
carpal bones
Most prominent articulation is formed between head
of capitate and socket formed by distal surfaces of
scaphoid and lunate
Ligaments of the Wrist
Wrist joints are enclosed within fibrous capsule,
thickened by extrinsic and intrinsic ligaments
Extrinsic ligaments have proximal attachments
outside carpal bones but attach distally within carpal
bones
Intrinsic ligaments have both proximal and distal
attachments located within carpal bones
Extrinsic Ligaments of the Wrist
Dorsal radiocarpal ligament
Resists extremes of flexion
Attaches between radius and dorsal side of carpal bone
Radial collateral ligament
Resists extremes of ulnar deviation
Strengthened by muscles such as abductor pollicis longus
and extensor pollicis brevis

Extrinsic Ligaments of the Wrist contd
Palmar radiocarpal
Resists extremes of wrist extension
Thickest ligament of wrist
Ulnar collateral
Resists extremes of radial deviation
Helps stabilize distal radioulnar joint
Part of ulnocarpal complex

Intrinsic Ligaments of the Wrist
As a group, intrinsic ligaments:
Interconnect various carpal bones
Help transfer forces between hand and forearm
Maintain natural shapes of radiocarpal and midcarpal joints,
thereby minimizing joint stress during movement

Wrist Instability
Normally, wrist remains stable when compressed,
even under substantial forces
Damage from large force or typical wear and tear
from aging can significantly destabilize this region
Goals for a weak, painful wrist typically include
strengthening, relief of pain, education on ways to
protect the wrist, and splinting

Osteokinematics
Osteokinematics of wrist involve flexion-and-
extension and ulnar-and-radial deviation
Wrist typically does not spin in circular motion relative
to fixed radius
Portions of radiocarpal joint naturally block this
twisting motion
Pronation and supination are motions of forearm
not hand or wrist

Osteokinematics contd
Wrist movements axis of rotation pierces capitate
head
Axis runs medially laterally for flexion and extension and
anteriorly posteriorly for radial and ulnar deviation
Rotation of capitate to direct overall path of entire
hand

Sagittal Plane: Flexion and Extension
From neutral position, wrist flexes about 70-80
degrees and extends about 60-65 degrees
Total flexion normally exceeds extension by about 15
degrees
Extension limited by tension in thicker palmar carpal
ligaments and carpal bones making contact with
dorsal side of distal radius
Frontal Plane:
Radial and Ulnar Deviation
On average, from neutral position:
Full ulnar deviation allows about 30-35 degrees
Radial deviation allows about 15-20 degrees
Maximum ulnar deviation is normally twice that of
radial deviation, mostly because of void created by
ulnocarpal space
Arthrokinematics:
Central Wrist Column
Series of articulations, or links, between the
radius, lunate, capitate, and third metacarpal bone
Radiocarpal joint
Articulation between radius and lunate
Midcarpal joint
Articulation between lunate and capitate
Carpometacarpal joint
Rigid articulation between capitate and base of third
metacarpal
Arthrokinematics:
Extension and Flexion
Wrist extension
Simultaneous convex-on-concave rotations at both
radiocarpal and midcarpal joints
Kinematics occur as roll and slide in opposite directions
simultaneously at radiocarpal and midcarpal joints

Arthrokinematics:
Extension and Flexion contd
Full wrist extension elongates palmar radiocarpal
ligaments, palmar capsule, and wrist and finger flexor
muscles
Helps stabilize wrist in extended position; useful
when weight is borne through upper extremity
Arthrokinematics of wrist flexion are similar but occur
in reverse fashion
Ulnar and Radial Deviation of Wrist
Motions of ulnar and radial deviation occur through
simultaneous convex-on-concave rotations, at both
radiocarpal and midcarpal joints
Radial deviation at wrist is limited; radial aspects of
carpal bones abut against styloid process of radius,
thereby limiting extent of radial deviation across wrist

Muscle and Joint Interaction
Innervation of wrist muscles
Radial nerve courses down posterior aspect of forearm and
supplies all muscles that extend wrist
Median and ulnar nerves travel down anterior aspect of
forearm and innervate all primary wrist flexor muscles
Function of Muscles of the Wrist
Wrist muscles can be classified into:
Primary set that attaches to wrist or nearby regions
Secondary set that bypasses wrist and attaches more
distally to digits
All muscles of wrist cross axes of rotation located at
capitate bone and therefore produce movement at
wrist
Function of Muscles of the Wrist contd
Flexion and extension occur about the medial-lateral
axis of rotation
Radial and ulnar deviation occurs about an anterior-
posterior axis of rotation
Specific action of each wrist muscle determined by
location of its tendon relative to each axis of rotation
Wrist Extensors:
Extensor Carpi Radialis Brevis
Proximal attachment
Lateral epicondyle of humeruscommon extensor tendon
Distal attachment
Base of third metacarpaldorsal aspect
Innervation
Radial nerve
Actions
Wrist extension
Radial deviation
Wrist Extensors:
Extensor Carpi Radialis Longus
Proximal attachment
Distal attachment
Base of second metacarpaldorsal aspect
Innervation
Radial nerve
Actions
Wrist extension
Radial deviation
Wrist Extensors: Extensor Carpi
Ulnaris

Proximal attachment
Distal attachment
Base of fifth metacarpaldorsal aspect
Innervation
Radial nerve
Actions
Wrist extension
Ulnar deviation

Functional Consideration: Wrist
Extensor Activity during a Grasp
Wrist extensors position and stabilize wrist for
activities involving fingers
e.g., making strong fist or grasp
Contraction of wrist extensors is necessary to prevent
wrist from collapsing into flexion because of strong
flexion pull of extrinsic finger flexor muscles
Functional Consideration: Wrist Extensor
Activity during a Grasp contd
Wrist extensor muscles, therefore, must contract every
time a grasp is made; if not, wrist collapses into
unwanted flexion
Functional Consideration: Wrist
Extensor Activity during a Grasp contd
Person with paralyzed wrist extensor muscles usually
has difficulty making a grip, even when finger flexor
muscles are normal
Because wrist extensors are paralyzed, gripping
results in finger flexion combined with wrist flexion
Unless strength is returned to wrist extensor muscles,
wrist extension splint is required to brace the wrist in
extension
Wrist Flexors: Anatomy
Primary wrist flexors include:
Flexor carpi radialis, flexor carpi ulnaris, and palmaris longus
Secondary set wrist flexors include:
Extrinsic flexors to the digits (flexor digitorum profundus,
flexor digitorum superficialis, and flexor pollicis longus)
Wrist Flexors: Flexor Carpi Radialis
Proximal attachment
Medial epicondyle of humeruscommon flexor tendon
Distal attachment
Base of second metacarpalpalmar aspect
Innervation
Median nerve
Actions
Wrist flexion
Radial deviation

Wrist Flexors: Flexor Carpi Ulnaris
Proximal attachment: medial epicondyle of
humeruscommon flexor tendon
Distal attachment: base of fifth metacarpal and
pisiformpalmar aspect
Actions
Wrist extension
Ulnar deviation
Wrist Flexors: Palmaris Longus
Proximal attachment
Medial epicondyle of humeruscommon flexor tendon
Distal attachment
Transverse carpal ligament and palmar apneurosis
Innervation
Median nerve
Action
Wrist flexion

Functional Consideration:
Synergistic Action of the Wrist Muscles
Simultaneous activity of flexor carpi radialis radially
and flexor carpi ulnaris is required for pure wrist
flexion
Strong activation of all three flexors is usually
required in conjunction with making a power grip
Palmaris longus also helps stabilize proximal
attachment of many intrinsic hand muscles

Radial and Ulnar Deviators
Primary set of radial deviators
Extensor carpi radialis longus and extensor carpi radialis
brevis
Secondary set of radial deviators
Extensor pollicis longus, extensor pollicis brevis, flexor carpi
radialis, abductor pollicis longus, and flexor pollicis longus
Radial and Ulnar Deviators contd
Muscles in both sets radially deviate wrist
Extensor pollicis brevis has greatest moment arm of
all radial deviators but typically has small torque
production
Abductor pollicis longus and extensor pollicis brevis
provide important stability to radial side of wrist along
with radial collateral ligament

Functional Consideration: Grasping
and Controlling Objects in the Hand

Radial and ulnar deviator muscles are frequently
used for activities that involve grasp and control of
objects held within hand
Because of strong functional association between
flexor and extensor carpi ulnaris muscles, injury to
either muscle can disrupt overall muscular action of
ulnar deviation
For example, rheumatoid arthritis often causes
inflammation and pain in extensor carpi ulnaris
tendon
Summary
Wrist joint is actually composed of two separate
joints: radiocarpal joint and midcarpal joint
Although only 2 degrees of freedom are allowed at
the wrist, simple flexion/extension or radial/ulnar
deviation motion requires motion at both joints
Most often, wrist muscles are responsible for
positioning hand

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Structure and Function of the Wrist

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