You are on page 1of 10

Available online at


Hand Surgery and Rehabilitation 36 (2017) 2–11

Recent advance

Pronation and supination of the hand: Anatomy and biomechanics
Pronation–supination de la main : anatomie et biomécanique
M. Soubeyrand a,b,*, B. Assabah a, M. Bégin b, E. Laemmel c, A. Dos Santos b, M. Crézé a,d
University Paris Sud, Faculty of Medicine, 63, rue Gabriel-Péri, 94270 Le Kremlin-Bicêtre, France
Department of Orthopaedic Surgery, University Hospital of Bicêtre (Public Assistance Hospitals of Paris), 78, rue du Général-Leclerc,
94270 Le Kremlin-Bicêtre, France
Laboratory of microcirculation, université Paris-Diderot, Faculty of Medicine Lariboisière, 10, avenue de Verdun, 75010 Paris, France
Department of Radiology, University Hospital of Bicetre (Public Assistance Hospitals of Paris), 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France
Received 31 May 2016; received in revised form 29 August 2016; accepted 1st September 2016
Available online 27 October 2016

Proper functioning of the hand relies on its capacity to rotate and point the palm upward (i.e. supination) or downward (i.e. pronation) when
standing up with the elbow in 908 flexion. Hand rotation is possible because of forearm rotation and also rotation of the whole upper limb at the
shoulder. Two distinct mechanisms contribute to hand rotation: one in which the ulna is immobile and another in which the ulna is mobile. In this
review, we first summarize how evolution of the human species has led to the progressive development of specific forearm anatomy that allows for
pronation and supination. Then we analyze how the three joints of the forearm (i.e. proximal, middle and distal radioulnar joints), in association
with the characteristic shape of both forearm bones, allow the forearm to rotate around a single axis. Lastly, we describe the neuromuscular
anatomy that controls these complex rotational movements. The anatomical and biomechanical points developed in this paper are analyzed while
considering clinical applications.
# 2016 SFCM. Published by Elsevier Masson SAS. All rights reserved.

Keywords: Forearm rotation; Pronation; Supination; Interosseous membrane; Anatomy; Proximal radioulnar joint; Middle radioulnar joint; Distal radioulnar joint

Le fonctionnement correct de la main repose sur sa capacité à tourner et diriger la paume vers le haut (supination) ou vers le bas (pronation)
lorsque le sujet est debout avec le coude fléchi à 908. La rotation de la main est rendue possible par la rotation de l’avant-bras, qui est elle-même
complétée par la rotation de l’ensemble du membre supérieur au niveau de l’épaule. Il est ainsi possible de distinguer deux mécanismes aboutissant
à la rotation de la main: une rotation à ulna fixe et une autre à ulna mobile. Dans cet article, nous résumons les grandes étapes évolutives de l’espèce
humaine qui ont conduit au développement d’une anatomie spécifique de l’avant-bras permettant la pronation–supination. Puis nous analysons
comment les trois articulations de l’avant-bras (radio-ulnaires proximale, moyenne et distale) associées aux géométries caractéristiques des deux
os de l’avant-bras permettent la rotation de l’avant-bras autour d’un axe unique. Enfin, nous décrivons l’anatomie neuromusculaire qui motorise ces
mouvements complexes de rotation. Les aspects anatomiques et biomécaniques développés dans cet article sont envisagés à la lumière de leurs
applications cliniques.
# 2016 SFCM. Publié par Elsevier Masson SAS. Tous droits réservés.

Mots clés : Rotation de l’avant-bras ; Pronation ; Supination ; Membrane interosseuse ; Anatomie ; Articulation radio-ulnaire proximale ; Articulation radio-
ulnaire moyenne ; Articulation radio-ulnaire distale

* Corresponding author. University Paris Sud, Faculty of Medicine, 63, rue Gabriel-Péri, 94270 Le Kremlin-Bicêtre, France.
E-mail address: (M. Soubeyrand).
2468-1229/# 2016 SFCM. Published by Elsevier Masson SAS. All rights reserved.
M. Soubeyrand et al. / Hand Surgery and Rehabilitation 36 (2017) 2–11 3

1. Introduction mesopodium (with the carpal bones) and the autopodium (with
the hand skeleton) [2,3] (Fig. 2).
An essential prerequisite for proper functioning of the hand In several classes of the phylum Chordata including
is its positioning in space, in terms of location and orientation. Mammalians, Reptilians, and Amphibians, the upper limb/
The hand’s orientation relies on its capacity to rotate and tilt. forelimb is composed of a humerus, a radius and an ulna. The
Forearm rotation makes it possible to point the palm upward oldest known specimen with this forelimb pattern is
(i.e. supination) or downward (i.e. pronation) and is inseparable Eusthenopteron, a lobe-finned fish that lived 380 million years
from the radius’ own orientation, given the strong attachments ago [4]. The forelimb evolved because of changes in the
between both of these structures. behavior of our ancestors. The common ancestor of the
Forearm rotation can be viewed as rotation of the ‘‘hand– Primates lived about 56 million years ago. He was an arboreal
radius’’ unit around the ulna (Fig. 1). However, the entire animal who grasped branches to move in and between trees.
forearm (i.e. ‘‘radius + ulna’’) can also rotate because of With the progressive appearance of bipedalism, the upper limb
movements of the upper limb and trunk. Therefore, one must has gradually gained the ability to interact with the surrounding
distinguish between the forearm’s rotation around an immobile environment (grasping, manipulating, modifying, interacting
ulna and the forearm’s rotation with a mobile ulna. This with objects, animals, vegetals) as well as with its own body
conceptual distinction is artificial as daily movements use both (feeding, hygiene, self-care). The upper limb needed to be very
these mechanisms in synergy, but it will simplify the precise in order to position the autopodium (the hand) to
biomechanical analysis of these complex motions. manipulate objects and hang from branches. Pronation and
The goal of this review is to outline the anatomical and supination developed gradually due to an increase in mobility
biomechanical bases of these mechanisms. between the radius and ulna. Conversely, the hind limb was
tasked with providing support and propulsion — activities that
2. Evolutionary view require considerable stability — thereby explaining why there
is very little motion between the bones in the lower leg (i.e. tibia
According to the taxonomic classification of species and fibula).
(Retrieved May 23, 2016, from the Integrated Taxonomic Consequences of this differential evolution between species
Information System – derived from works are now visible when various mammalians are compared. In
of Carl Linnaeus (1707–1778) [1], Homo sapiens belongs to the purely quadruped mammalians like elephants, horses or
phylum Chordata, class Mammalia, order Primates, family rhinoceros, the radioulnar mobility is almost non-existent.
Hominidae, and genus Homo. The two forearm bones are joined by a short, strong and wide
Human upper limbs have a similar structure to the forelimbs ligament that allows very little range of motion and, moreover,
of the other pentadactylous tetrapods given that they are undergoes ossification with advancing age. In mainly qua-
composed of four separate segments: the stylopodium (with the druped mammalians that have the ability to temporarily stand
humerus), the zeugopodium (with the radius and ulna), the on their hind limbs (i.e. transitory bipedalism) like rodents or

Fig. 1. The two units of hand rotation (a). There are two types of hand rotation, depending on whether the ulna is mobile or immobile (b).
4 M. Soubeyrand et al. / Hand Surgery and Rehabilitation 36 (2017) 2–11

Fig. 2. Comparative anatomy of the upper limb.

felidae, there is a moderate capacity for forearm rotation. The 4.1. Humeroulnar and radio-hand unit
presence of a considerable range of forearm rotation appears
specific to the Primates order and especially humans. Hence, At the elbow, the connection between the humerus and the
the human forearm can be regarded as an exceptional structure forearm mainly consists of the humeroulnar joint. The
in terms of shape and biomechanics. humeroradial joint participates in flexion–extension but it also
allows rotation of the radius. This explains the clinical impact
3. Forearm rotation with mobile ulna of malunions involving the humeral capitulum or the radial
fovea on forearm rotation [5]. At the wrist, the connection
The ulna provides the primary mechanical connection between the forearm and the hand mainly consists of the
between the forearm and the upper arm thanks to the radiocarpal joint, with the ulnocarpal joint being less important.
humeroulnar joint. If we consider the configuration in which Therefore, one can distinguish the humeroulnar unit from the
the forearm and the hand form a single unit, the orientation and
position of the hand are driven by the ulna. The latter is
controlled by the positions and orientations of the elbow,
glenohumeral, and scapulothoracic joints as well as those of the
This is illustrated by the fact that patients with radioulnar
synostosis (congenital or posttraumatic) still have fairly good
hand rotation. Another example is the ability of the upper limb
to rotate pinched fingers around several axes (Fig. 3).
However, the involvement of joints distant to the hand limits
de facto the precision of the hand’s orientation and positioning.
It is therefore obvious that the addition of intrinsic mobility in
the forearm is a major biomechanical contribution.

4. Forearm rotation with immobile ulna: the forearm

The forearm, contrary to the lower leg — its counterpart in
the lower limb — is not only a segment intercalated between the
elbow and the wrist. Although they both have support, load
transfer and muscular insertion functions, the forearm has a Fig. 3. The hand can be rotated around multiple axes. Proper alignment with
supplementary function: hand rotation. Its osteoarticular this axis recruits the forearm but also the elbow and the shoulder, thereby
anatomy is precisely designed to achieve these goals. implying mobility of the ulna.
M. Soubeyrand et al. / Hand Surgery and Rehabilitation 36 (2017) 2–11 5

radiocarpal–hand unit. The humeroulnar joint allows flexion– arthrodesis — does not compromise the range of motion [9].
extension of the elbow while the radiocarpal joint allows In this procedure, segmental resection of the ulna induces intra-
flexion–extension and radial and ulnar tilt of the hand. The ulnar mobility that compensates for loss of the DRUJ. Given the
remaining motion (i.e. the rotation of the forearm) can be distal location of this resection, it remains close to the DRUJ
therefore assigned to the remaining articulations, namely the and the rotational axis of the forearm is just slightly deviated
radioulnar joints. ulnarly. Using the same logic, it is possible to fuse the PRUJ and
to resect a proximal segment of the radius in order to create a
4.2. Joints involved in forearm rotation neo-PRUJ inside the radius. This can be likened to a ‘‘reverse
Sauvé-Kapandji’’ procedure [10].
Forearm rotation typically involves three joints, namely the The motion and stability of the three radioulnar joints are
proximal and distal radioulnar joints (PRUJ and DRUJ) and the intimately entangled, as is their pathology. It is noteworthy to
humeroradial joint (Fig. 4). The PRUJ and the DRUJ are recap two clinical facts to illustrate that:
cylindrical joints while the humeroradial joint is spheroid joint.
The PRUJ corresponds to the joint between the perimeter of the  first, forearm rotation can be preserved even though one joint
radial head and the radial notch of the ulna, completed by the is removed, if the other two remain intact. This explains why
annular ligament. The humeroradial joint is between the procedures such as resection of the radial or ulnar head can
humeral capitulum and the fovea radialis. In the DRUJ, the have satisfactory outcomes [11];
ulnar head is articulated with the ulnar notch of the radius.  second, stiffness of a single radioulnar joint is enough to
Along with the PRUJ and DRUJ, a third radioulnar joint has compromise the forearm’s rotation. Therefore, general
recently been described, the middle radioulnar joint (MRUJ) forearm stiffness can be the result of various pathological
[6,7]. This joint consists of both the ulnar and radial shafts conditions involving individually the MRUJ (e.g. radioulnar
linked by the interosseous membrane (IOM) [8]. Conversely to synostosis, IOM retraction, radial/ulnar shaft malunion, etc.),
the cylindrical PRUJ and DRUJ, the MRUJ may be considered the PRUJ or the DRUJ (e.g. infectious or inflammatory
as a particular kind of syndesmosis, i.e. a joint in which the arthritis, etc.) [12–14].
bony surfaces are connected by an interosseous ligament.
In the clinical setting, all three joints must be taken into 4.3. Bone anatomy applied to biomechanics of the forearm
consideration when managing a case of forearm instability,
stiffness or deformity — a classical mistake is to focus on the 4.3.1. Bone curvatures
elbow or wrist while ignoring the overall forearm. Both forearm bones are curved (Fig. 5). When considering
The Sauvé-Kapandji procedure used to manage DRUJ the forearm in the anatomical (reference) position (i.e. maximal
pathologies is a rare example of a procedure in which supination), the radius and the ulna are curved anteriorly in the
modifying the anatomy — loss of the DRUJ due to sagittal plane and also in the frontal plane. The two radius

Fig. 4. The three radioulnar joints, the forearm stabilizers and the concepts of vertical and transverse instability.
6 M. Soubeyrand et al. / Hand Surgery and Rehabilitation 36 (2017) 2–11

Fig. 5. The curvatures of the forearm bones are essential to forearm physiology. If these bones were straight, forearm rotation would be limited.

curvatures are referred to as the ‘‘supinator curvature’’ and the coincidental but rather extremely logical from a biomechanical
‘‘pronator curvature’’. The former corresponds to the proximal standpoint. The importance of the specific geometry of both
third of the radial shaft including the radial tuberosity, while the bones is illustrated by the potential stiffness in forearm rotation
latter corresponds to the distal two-thirds of the radial shaft. induced by malunion of forearm fractures [15–17].
The term ‘‘supinator curvature’’ stems from the fact that the two
most important supinator muscles (i.e. biceps brachii and the 4.3.2. Asymmetry of the epiphyses
supinator) insert on it. The ‘‘pronator curvature’’ draws its name The proximal and distal epiphyses of both bones are
from the insertion of the pronator muscles (pronator quadratus asymmetric. At the elbow, the ulnar epiphysis is larger than the
and pronator teres). The ulna has two opposite curvatures in the radial one, while it is the opposite at the wrist. Moreover, the
frontal plane that make it resemble a stretched-out ‘‘S’’. In the proximal ulna is more proximal than the radius while the distal
sagittal plane, it has an anterior concavity. radius ends more distally than the ulna (i.e. radioulnar variance).
These curvatures in both bones are essential to forearm This asymmetric configuration helps to explain why, at the level
rotation; if the ulna and/or radius were perfectly straight, the of the wrist, most of the longitudinal forces pass from the carpus
radius would abut against the ulna too early during pronation, to the radius, while at the level of the elbow, most of the
significantly limiting pronation amplitude. To illustrate this longitudinal forces travel from the ulna to the humerus [18–23].
point, forearm rotation can be compared to a high jump event in This biomechanical asymmetry implies a load transfer between
which the radius is the jumper and the ulna is the bar: the radius and ulna. This transfer is primarily performed by the
supination, neutral rotation and pronation would correspond taut IOM between the radius and ulna, and is essential to the
respectively to the approach, take-off/bar crossing and landing. forearm’s longitudinal stability [24]. In fact, the radius naturally
Two actions can make it easier to crossover the bar: (1) lower tends to migrate proximally because of the constant action of
the bar and (2) twist the jumper’s body. This allows each part of several muscles pulling it proximally, in a direct or indirect
the body to successively pass above the bar like in the Fosbury manner: the extrinsic muscles of the hand inserted on the ulna or
flop technique. The ulna’s curvature corresponds to lowering of the humerus (pulling proximally the hand with the radius) and
the bar. The pronator curvature of the radius corresponds to the the muscles inserted above the elbow and on the radius (biceps
jumper’s twist. Together, both of these morphological features brachii and brachioradialis). Pathological proximal migration of
project the radius epiphysis as far as possible and allow a the radius occurs in Essex-Lopresti injuries (ELI) and leads to
maximum pronation of about 908. Therefore, insertion of the ulnocarpal impingement as a consequence of the inversion of
pronator muscles on the ‘‘pronator curvature’’ is not distal radioulnar index [25].
M. Soubeyrand et al. / Hand Surgery and Rehabilitation 36 (2017) 2–11 7

4.3.3. Rounded epiphyses intersects the center of the radial head and the base of the ulnar
The radial and ulnar heads are rounded, which is essential styloid process, at the center of the ulnar head cylinder.
for forearm rotation. Kapandji compared the rotation of the radius to the opening and
At the PRUJ, the radial head can be roughly approximated to closing of a book: the forearm’s rotational axis corresponds to
a cylinder. But more detailed analysis reveals that the radial the book’s binding [27]. The open and closed positions
head is slightly oval in the transverse plane, given that it has a correspond to supination and pronation, respectively. Inter-
greater and a lesser diameter (about 28 mm and 24 mm, estingly, this axis intersects a protuberance on the interosseous
respectively). It is covered with cartilage on its superior edge of the radius referred to as the interosseous tubercle of the
concave surface (i.e. the fovea) and on its rim (i.e. its articular radius. This tubercle is of major importance as it corresponds to
circumference). Interestingly, the height of the rim is not the insertion of the IOM’s central band.
constant: it is thinner in an area that is never in contact with the
ulnar notch of the radius. This area is important when the radial 4.5. Stabilization of the forearm
head must be stabilized surgically because it is the exact
location where a plate needs to be positioned to avoid any The corollary of forearm rotation is the need for perfect
impingement with the ulna during forearm rotation. stability. Stability is required in the longitudinal (i.e. vertical)
At the DRUJ, the ulnar head can be also approximated to a and transverse (i.e. horizontal) directions. Transverse stability
cylinder. The ulnar styloid process is offset from the center of guarantees that the distance between both bones is maintained,
the cylinder. Comparing these epiphyses to cylinders allows us as is their physiological relationships in the axial plane.
to introduce the concept of rotation and to determine the Longitudinal stability maintains the height of the radius relative
forearm’s rotational axis. to the ulna (i.e. radioulnar variance). This longitudinal and
transverse stability is made possible by a series of ligaments.
4.4. Rotational axis of the forearm
4.5.1. At the PRUJ
The rotation of the radius, which is connected to the hand, Transverse stability is mainly due to the annular ligament
occurs around a single axis [26] (Fig. 6). This axis roughly and to a lesser extent, the squared ligament.
The annular ligament surrounds the radial head since it
inserts on the anterior and posterior rims of the radial notch of
the ulna. As opposed to conventional ligaments, its inner aspect
is covered with fibrocartilage that makes it easier for the radial
head to slide during forearm rotation.
The squared ligament is located at the inferior part of the
PRUJ; it tightens in pronation and supination by wrapping
around the radial neck, thereby drawing the radial head closer
to the ulna [28]. As a consequence, it provides transverse
stability to the PRUJ and also longitudinal stability by limiting
vertical migration of the radius.

4.5.2. At the MRUJ
The IOM prevents both bone shafts from moving apart. The
IOM is made of several groups of fibers arranged in a way to
optimize stability [29].
A first group of ventral fibers is proximally and radially
oriented. This group has several bundles, with the most
important being the so-called ‘‘central band’’. The latter has an
average angle of 218 to the long axis of the ulna and represents
the thickest part of the IOM. It inserts on the interosseous
tubercle of the radius described above.
A second group of fibers is dorsal with fibers oriented
proximally and ulnarly. This group is much thinner than the
ventral fibers. It is also less important from a biomechanical
The final bundle, the oblique cord, is noteworthy because it
is macroscopically distinct from the main body of the IOM. It
runs proximally and ulnarly from the radial tuberosity to the
ulnar metaphysis.
In order to understand the IOM’s stabilizing role, it is
Fig. 6. The forearm’s rotational axis.
necessary to keep in mind that the mechanical role of a
8 M. Soubeyrand et al. / Hand Surgery and Rehabilitation 36 (2017) 2–11

ligament fiber can be represented by a vector parallel to this radiocapitular joint with the development of osteoarthritis.
fiber [30]. Yet, a vector can be divided geometrically into two This phenomenon is observed in ELI cases, when the radial
orthogonal secondary vectors. Therefore, it is possible to head is replaced by a metallic implant that increases wear of the
demonstrate that each oblique IOM fiber provides longitudinal capitular cartilage. This phenomenon emphasizes the fact that
stability (vertical vector) as well as transverse stability isolated resection of the radial head (i.e. without replacement)
(horizontal vector) [31,32]. Because of the proximal and should be avoided as much as possible in case of acute injury.
ulnar angulation of its fibers, the anterior group is the most Moreover, it strengthens the concept of IOM ligament
important as it prevents proximal migration of the radius. For reconstruction to restore longitudinal stability of the forearm
the same reasons, it is also responsible for longitudinal load and to unload the radiocapitular joint.
transfer between the radius and ulna [20,24]. Fibers in the
posterior group, by preventing distal migration of the radius, 4.5.5. Magnitude and limitation of pronation and
are of lesser importance given that the radius naturally tends to supination
migrate proximally [33–35]. The amplitude of forearm rotation ranges from about 908 in
The IOM fibers alternatively tighten and relax during pronation to about 908 in supination when neutral rotation (i.e.
forearm rotation, which corresponds to a phenomenon of thumb parallel to the humerus) is considered as 08. In order to
progressive recruiting [23,36–39]. The latter guarantees that avoid excessive rotation of the forearm, two mechanisms exist.
there are always tight fibers, making the IOM mechanically Supination is limited mainly by soft tissues, with the IOM’s
efficient no matter the amount of forearm rotation. The distal anterior bundle and the squared ligament being the main players.
part is nearly tight in maximum supination and relaxed in Conversely, pronation is limited by the radioulnar abutment that
maximum pronation. The central part is mostly tight in neutral occurs in extreme pronation. Therefore, stiffness in forearm
rotation and the proximal part in pronation. rotation may result from retraction of the IOM or malunion of
In case of IOM disruption as in the ELI, some authors the radius/ulna when the physiological curvatures are compro-
proposed about 20 years ago to reconstruct the IOM with mised.
ligaments or synthetic devices [40–43]. Despite a variety of
grafts and designs, the common approach is to replace only part 4.6. Neuromuscular anatomy of forearm rotation
of the IOM with a single bundle graft. Therefore, they must be
associated with stabilization of the other forearm joints in case 4.6.1. Muscles involved and nerve supply
of overall destabilization. Such reconstruction techniques are The rotator muscles of the forearm can be divided in two
relevant for restoring the stability of the MRUJ but given the groups (Fig. 7). Three muscles are dedicated to supination:
rarity of ELI, the outcomes of these techniques have not yet biceps brachii, brachioradialis and supinator. Two muscles
been reported. provide pronation: pronator quadratus and pronator teres.
The forearm’s rotation is controlled by the C5 to T1 roots.
4.5.3. At the DRUJ More specifically, supination is controlled by C5 and C6
The distal radioulnar ligaments (palmar and dorsal) as well through the musculocutaneous nerve (for the biceps brachii)
as the triangular fibrocartilage (TFC) discus are responsible for and the radial nerve (for the brachioradialis and supinator).
transverse stability [44]. In addition to transverse stabilization The axons for the brachioradialis arise from the radial
of the DRUJ, the TFC also limits vertical migration of the nerve upstream of its division into superficial and deep
radius, thereby contributing to the forearm’s longitudinal branches. Conversely, the axons for the supinator muscle
stability. The TFC is triangle-shaped; at the top of this triangle, arise from the deep branch of the radial nerve (also named
the ulnar styloid process exactly intersects the forearm’s ‘‘posterior interosseous nerve’’), after the division of the
rotational axis. The TFC at the DRUJ and the annular ligament radial nerve.
at the PRUJ have the same mechanical purpose, namely to Pronation is entirely under control of the median nerve. The
guide radius rotation; however, they use two different tools to latter receives axons from C6 and C7 for the pronator teres and
reach this goal. At the PRUJ, the radial head is contained by the from C8 and T1 for the pronator quadratus. The axons for the
annular ligament, while at the DRUJ the radius is held back by pronator teres arise directly from the median nerve while those
the TFC (Fig. 6). for the pronator quadratus arise from the anterior interosseous
The DRUJ is also stabilized by the extensor retinaculum of nerve.
wrist. By surrounding the distal forearm, it holds the radius and
the ulna together, thereby providing transverse stability. 4.6.2. Mechanism of action of the muscles
How does contraction of the muscle fibers of the forearm
4.5.4. Radiocapitular compartment rotators get converted into rotation of the radius? This
A final mechanism contributes to longitudinal stability of the phenomenon is puzzling if we consider that contraction of a
forearm, namely abutment of the radial head against the muscle fiber decreases the distance between both of its
humeral capitulum. If the longitudinal stabilizers of the forearm insertions: the basic motion induced by a muscular contraction
were to fail, proximal migration could occur but radiohumeral therefore corresponds to translation along an axis parallel to the
abutment prevents further migration of the radius. However, in fiber. Transformation of a translation movement into rotation
such a case, the consequence can be overload of the relies on two geometrical conditions.
M. Soubeyrand et al. / Hand Surgery and Rehabilitation 36 (2017) 2–11 9

Fig. 7. Description of the pronator and supinator muscles, and mechanism that converts a translation motion into rotation.

The first condition is that the muscular fibers of the rotator inferior relative to patients who have an anatomical insertion
muscles are wrapped around the radius. The fibers of the [45,46].
supinator muscles wrap around the radius when the forearm is It is also interesting to note that the pronator teres, pronator
in pronation, and conversely for the pronator muscles. The quadratus and supinator muscles can be divided into two layers:
second condition is that the insertions of the rotator muscles on deep and superficial. The deep heads of the pronator teres and
the radius do not intersect the forearm’s rotational axis. If this supinator muscles are inserted on the ulna while their
was not the case, rotation would not be induced by contraction superficial heads are inserted on the humerus. From a
of the forearm rotators; instead, a translation motion would biomechanical standpoint, the deep heads contribute to forearm
occur. stabilization, while the superficial heads contribute to forearm
Both of these conditions are present for each of the rotator rotation.
muscles: the biceps brachii wraps around the medial aspect of Along with these five rotator muscles, some other muscles
the supinator curvature (i.e. radial tuberosity), the supinator referred to as ‘‘accessory rotator muscles’’ can contribute to a
muscle wraps around the lateral aspect of the supinator lesser extent to forearm rotation. These are muscles inserted
curvature, the pronator teres wraps around the proximal part of proximally on the medial and lateral epicondyles of the
the pronator curvature and the pronator quadratus wraps around humerus and distally on the hand (carpus, metacarpal or
the distal part of the pronator curvature. One exception is the phalanx). Given that they are not inserted on the radius, they do
brachioradialis because it inserts on the suprastyloid crest not directly induce its rotation. They induce indirect rotation of
(belonging to the pronator curvature), not on the supinator the radius by directly moving the hand skeleton, which
curvature. However, this muscle is considered a supinator subsequently drags the radius. Spasticity of these muscles plays
because it wraps around the radius when the forearm is fully a key role in the pathophysiology of abnormal postures in
pronated, thereby pulling the radius into supination when it neurological diseases involving the upper limb.
The importance of the first condition (i.e. the tendon is 5. Conclusion
wrapped around the radius in pronation) is demonstrated by the
clinical results of distal biceps tendon repair. When the Pronation and supination of the hand require forearm
insertion site is too anterior on the radius, thereby failing to rotation. The radius and the hand form a functional unit, which
reproduce the anatomy, the supination strength is significantly rotates around the ulna thanks to a series of three radioulnar
10 M. Soubeyrand et al. / Hand Surgery and Rehabilitation 36 (2017) 2–11

joints: proximal, middle and distal. During this complex [20] Markolf KL, Dunbar AM, Hannani K. Mechanisms of load transfer in the
cadaver forearm: role of the interosseous membrane. J Hand Surg Am
motion, the forearm requires longitudinal and transverse
stabilization. The stabilization is provided by a series of [21] McGinley JC, D’Addessi L, Sadeghipour K, Kozin SH. Mechanics of the
ligaments, among which the interosseous membrane plays a antebrachial interosseous membrane: response to shearing forces. J Hand
key role. Surg Am 2001;26:733–41.
[22] Ofuchi S, Takahashi K, Yamagata M, Rokkaku T, Moriya H, Hara T.
Disclosure of interest Pressure distribution in the humeroradial joint and force transmission to
the capitellum during rotation of the forearm: effects of the Sauve-
Kapandji procedure and incision of the interosseous membrane. J Orthop
The authors declare that they have no competing interest. Sci 2001;6:33–8.
[23] Kaufmann RA, Kozin SH, Barnes A, Kalluri P. Changes in strain
References distribution along the radius and ulna with loading and interosseous
membrane section. J Hand Surg Am 2002;27:93–7.
[1] Linnaeus C. Systemae Naturae, sive regna tria naturae, systematics [24] Shepard MF, Markolf KL, Dunbar AM. The effects of partial and total
proposita per classes, ordines, genera & species. Lugduni Bavatorum interosseous membrane transection on load sharing in the cadaver fore-
arm. J Orthop Res 2001;19:587–92.
(Leiden): Theodore Haak; 1735.
[2] Mariani FV, Martin GR. Deciphering skeletal patterning: clues from the [25] McGlinn EP, Sebastin SJ, Chung KC. A historical perspective on the
limb. Nature 2003;423:319–25. Essex-Lopresti injury. J Hand Surg Am 2013;38:1599–606.
[3] Tickle C. Patterning systems˘from one end of the limb to the other. Dev [26] Hollister AM, Gellman H, Waters RL. The relationship of the interosseous
membrane to the axis of rotation of the forearm. Clin Orthop Relat Res
Cell 2003;4:449–58.
[4] Marzke MW. Upper-limb evolution and development. J Bone Joint Surg 1994;298:272–6.
Am 2009;91(Suppl. 4)26–30. [27] Kapandji IA. Physiologie articulaire, schémas commentés de mécanique
[5] Widhalm HK, Seemann R, Wagner FT, Sarahrudi K, Wolf H, Hajdu S, humaine. Paris: Maloine; 1971 [4e édition revue et corrigée].
[28] Otayek S, Tayeb AA, Assabah B, Viard B, Dayan R, Lazure T, et al.
et al. Clinical outcome and osteoarthritic changes after surgical treatment
of isolated capitulum humeri fractures with a minimum follow-up of five Squared ligament of the elbow: anatomy and contribution to forearm
years. Int Orthop 2016 [Epub ahead of print]. stability. Surg Radiol Anat 2015;38:237–44.
[29] Noda K, Goto A, Murase T, Sugamoto K, Yoshikawa H, Moritomo H.
[6] LaStayo PC, Lee MJ. The forearm complex: anatomy, biomechanics and
clinical considerations. J Hand Ther 2006;19:137–44. Interosseous membrane of the forearm: an anatomical study of ligament
[7] Soubeyrand M, Wassermann V, Hirsch C, Oberlin C, Gagey O, Dumontier attachment locations. J Hand Surg Am 2009;34:415–22.
C. The middle radioulnar joint and triarticular forearm complex. J Hand [30] Soubeyrand M, Lafont C, De Georges R, Dumontier C. Traumatic
pathology of antibrachial interosseous membrane of forearm. Chir Main
Surg Eur Vol 2011;36:447–54.
[8] Pfaeffle HJ, Fischer KJ, Manson TT, Tomaino MM, Woo SL, Herndon JH. 2007;26:255–77.
Role of the forearm interosseous ligament: is it more than just longitudinal [31] Rabinowitz RS, Light TR, Havey RM, Gourineni P, Patwardhan AG,
load transfer. J Hand Surg Am 2000;25:683–8. Sartori MJ, et al. The role of the interosseous membrane and triangular
fibrocartilage complex in forearm stability. J Hand Surg Am 1994;19:
[9] Slater Jr RR. The Sauve-Kapandji procedure. J Hand Surg Am
2008;33:1632–8. 385–93.
[10] Hernández-Cortés P, Gómez-Sánchez R, Pajares-López M, O’Valle- [32] Poitevin LA. Anatomy and biomechanics of the interosseous membrane:
its importance in the longitudinal stability of the forearm. Hand Clin
Ravassa F. Sauve-Kapandji and reverse Sauve-Kapandji procedures for
treating chronic longitudinal radioulnar dissociation with capitellum 2001;17:97–110 [vii].
fracture. Acta Orthop Traumatol Turc 2014;48:593–7. [33] Smith AM, Urbanosky LR, Castle JA, Rushing JT, Ruch DS. Radius pull
[11] De Witte PB, Wijffels M, Jupiter JB, Ring D. The Darrach procedure for test: predictor of longitudinal forearm instability. J Bone Joint Surg Am
post-traumatic reconstruction. Acta Orthop Belg 2009;75:316–22.
[12] Bert JM, Linscheid RL, McElfresh EC. Rotatory contracture of the [34] Green JB, Zelouf DS. Forearm instability. J Hand Surg Am 2009;34:
forearm. J Bone Joint Surg Am 1980;62:1163–8. 953–61.
[13] Beyer W, Stolzenburg T, Paris S. Functional limitation of the forearm after [35] Loeffler BJ, Green JB, Zelouf DS. Forearm instability. J Hand Surg Am
shaft fracture in childhood. Possible role of the antebrachial interosseous
membrane: MRI and ultrasound studies. Unfallchirurgie 1995;21:275–84. [36] Nakamura T, Yabe Y, Horiuchi Y. A biomechanical analysis of
[14] Okamoto S, Nakamura T, Yamabe E, Takayama S, Toyama Y. Pronation pronation-supination of the forearm using magnetic resonance imag-
contracture of the forearm due to iatrogenic scar formation of the distal ing: dynamic changes of the interosseous membrane of the forearm
during pronation-supination. Nippon Seikeigeka Gakkai Zasshi
membranous part of the forearm interosseous membrane. J Hand Surg Br
2006;31:397–400. 1994;68:14–25.
[15] Tynan MC, Fornalski S, McMahon PJ, Utkan A, Green SA, Lee TQ. The [37] Nakamura T, Yabe Y, Horiuchi Y. Functional anatomy of the interosseous
membrane of the forearm - dynamic changes during rotation. Hand Surg
effects of ulnar axial malalignment on supination and pronation. J Bone
Joint Surg Am 2000;82:1726–31. 1999;4:67–73.
[16] Dumont CE, Thalmann R, Macy JC. The effect of rotational malunion of [38] Nakamura T, Yabe Y, Horiuchi Y, Seki T, Yamazaki N. Normal kinematics
the radius and the ulna on supination and pronation. J Bone Joint Surg Br of the interosseous membrane during forearm pronation-supination˘a
three-dimensional MRI study. Hand Surg 2000;5:1–10.
[17] McHenry TP, Pierce WA, Lais RL, Schacherer TG. Effect of displacement [39] Moritomo H, Noda K, Goto A, Murase T, Yoshikawa H, Sugamoto K.
of ulna-shaft fractures on forearm rotation: a cadaveric model. Am J Interosseous membrane of the forearm: length change of ligaments during
Orthop 2002;31:420–4. forearm rotation. J Hand Surg Am 2009;34:685–91.
[40] Chloros GD, Wiesler ER, Stabile KJ, Papadonikolakis A, Ruch DS,
[18] Markolf KL, Lamey D, Yang S, Meals R, Hotchkiss R. Radioulnar load-
sharing in the forearm. A study in cadavera. J Bone Joint Surg Am Kuzma GR. Reconstruction of Essex-Lopresti injury of the forearm:
1998;80:879–88. technical note. J Hand Surg Am 2008;33:124–30.
[41] Drake ML, Farber GL, White KL, Parks BG, Segalman KA. Restoration of
[19] Pfaeffle HJ, Fischer KJ, Manson TT, Tomaino MM, Herndon JH, Woo SL.
A new methodology to measure load transfer through the forearm using longitudinal forearm stability using a suture button construct. J Hand Surg
multiple universal force sensors. J Biomech 1999;32:1331–5. Am 2010;35:1981–5.
M. Soubeyrand et al. / Hand Surgery and Rehabilitation 36 (2017) 2–11 11

[42] Brin YS, Palmanovich E, Bivas A, Sagiv P, Kotz E, Nyska M, et al. [45] Hertel R. Considerations of distal biceps tendon reinsertion: commentary
Treating acute Essex-Lopresti injury with the TightRope device: a case on an article by Christopher C, Schmidt, MD, et al.: factors that determine
study. Tech Hand Up Extrem Surg 2014;18:51–5. supination strength following distal biceps repair. J Bone Joint Surg Am
[43] Grassmann JP, Hakimi M, Gehrmann SV, Betsch M, Kropil P, Wild M, 2016;98:e61.
et al. The treatment of the acute Essex-Lopresti injury. Bone Joint J Br [46] Schmidt CC, Brown BT, Qvick LM, Stacowicz RZ, Latona CR, Miller
2014;96:1385–91. MC. Factors that determine supination strength following distal biceps
[44] Gofton WT, Gordon KD, Dunning CE, Johnson JA, King GJ. Soft-tissue repair. J Bone Joint Surg Am 2016;98:1153–60.
stabilizers of the distal radioulnar joint: an in vitro kinematic study. J Hand
Surg Am 2004;29:423–31.