616939

research-article2015
JHS0010.1177/1753193415616939Journal of Hand Surgery (European Volume)Rainbow et al.

Review Article
JHS(E)
The Journal of Hand Surgery

Functional kinematics of the wrist (European Volume)

XXE(X) 1­–15
© The Author(s) 2015
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M. J. Rainbow1, A. L. Wolff2, J. J. Crisco3 and S. W. Wolfe4 DOI: 10.1177/1753193415616939
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Abstract
The purpose of this article is to review past and present concepts concerning functional kinematics of the
healthy and injured wrist. To provide a context for students of the wrist, we describe the progression of
techniques for measuring carpal kinematics over the past century and discuss how this has influenced today’s
understanding of functional kinematics. Next, we provide an overview of recent developments and highlight the
clinical relevance of these findings. We use these findings and recent evidence that supports the importance
of coupled motion in early rehabilitation of radiocarpal injuries to develop the argument that coupled motion
during functional activities is a clinically relevant outcome; therefore, clinicians should develop a framework
for its dynamic assessment. This should enable a tailored and individualized approach to the treatment of
carpal injuries.

Keywords
Carpal kinematics, carpus, wrist function, dart thrower’s motion, wrist coupled motion, midcarpal joint,
scapholunate advanced collapse (SLAC)

Date received: 16th April 2015; revised: 21st October 2015; accepted: 22nd October 2015

Introduction deterioration of wrist function (scapholunate advanced

To adequately diagnose and treat carpal injuries, it
is important to understand the basic science and
clinical relevance of functional kinematics of the
wrist – defined as those motions that are necessary
to carry out high-demand activities of daily living.
Consideration must be given to the path of motion
as well as the range of motion, because acute and
chronic injuries limit both. Based on a body of litera-
ture suggesting coupled wrist motions are needed
to complete high-demand activities, we review cur-
rently available clinical assessment tools and iden-
tify areas for improvement in the field.
collapse (SLAC)) through the disruption of normal
proximal carpal row mechanics.
Garcia-Elias developed a kinetic theory of carpal
stability that states the posture of the lunate is main-
tained by a balance between the flexion moment
applied to the lunate by the scaphoid and an equal and
opposite extension moment applied to the lunate by
the triquetrum (Garcia-Elias, 1997a). This theory
stems from known changes in alignment of the lunate
when it is axially loaded or when its supporting struc-
tures are damaged. For example, pathological exten-
sion of the lunate, termed dorsal intercalated segment
instability (DISI), occurs following damage to the

Pathophysiology of scapholunate 1Department of Mechanical and Materials Engineering & Human

advanced collapse arthritis Mobility Research Centre, Queen’s University Kingston, ON,
Canada
The complex articulations of the wrist facilitate motion 2Leon Root Motion Analysis Laboratory, Hospital for Special

and transmit load between the hand and the forearm
through a very complicated set of interactions between
the five metacarpals, eight carpal bones (the carpus),
and the radius and ulna. Disruption of this system
Surgery, New York, NY, USA
3Bioengineering Laboratory, The Warren Alpert Medical School
of Brown University and Rhode Island Hospital, Providence, RI,
USA.
4The Hand and Upper Extremity Center, Weill Medical College of

invariably leads to changes in individual carpal bone Cornell University, New York, NY, USA.
motion and load transmission (collectively termed
Corresponding author:
carpal instability), which in turn leads to pain and loss
S. W. Wolfe, The Hand and Upper Extremity Center, Hospital for
of function. One of the most common pathways to car- Special Surgery, Weill Medical College of Cornell University, 523
pal instability is disruption of the scapholunate liga- E. 72nd Street, New York, NY 1002, USA.
ment, which leads to an inevitable and progressive Email: WolfeS@hss.edu

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2 The Journal of Hand Surgery (Eur)
scapholunate interosseous ligament and/or loss of the
distal ligamentous support at the scaphotrapeziotrap-
ezoid joint. Damage to the lunotriquetral interosseous
ligament and/or the secondary ligamentous supports
on the ulnar side of the carpus, leads to a flexed lunate
or volar intercalated segment instability (VISI) (Gilford
et al., 1943). A series of in vitro studies have provided
support to this theory (Kamal et al., 2012a; Kobayashi
et al., 1997a). Briefly, these studies utilized a protocol
that allowed proximally directed compression of the
carpus while the wrist was fixed in the neutral posi-
tion. Carpal bone motion was then tracked as the ten-
dons were loaded. In the Kamal study, dynamic DISI
occurred after the distal scaphoid was excised (Kamal
et al., 2012a). This indicated that the trapezium and
trapezoid apply a flexion moment to the scaphoid,
which, when withdrawn, allows lunate extension under
load. Once the lunate is rendered unstable by a break
in the proximal row, inevitable extrinsic carpal liga-
ment attenuation leads to further uncoupling of carpal
motion and posture (Garcia-Elias et al., 1995; Kitay
and Wolfe, 2012).
Untreated, proximal row disruption leads to pro-
gressive and predictable SLAC wrist arthritis, which is
responsible for 55% of cases of degenerative wrist
arthritis. SLAC wrist degenerative changes begin at the
radiocarpal joint between the scaphoid and radius, and
progress over time to the midcarpal joint. Successful
and early surgical repair of the scapholunate ligament
can re-establish proximal carpal row kinematics, pre-
vent carpal instability, and avoid degenerative changes
(Garcia-Elias, 1997b; Pomerance, 2006).
Surgery for SLAC arthritis generally includes abla-
tive procedures, such as a partial wrist arthrodesis or
excision of the proximal carpal row (proximal row
carpectomy (PRC)) (Cohen et al., 2001), and as such,
cannot restore carpal kinematics. The goal of these
procedures is to decrease pain and arrest progres-
sive degenerative changes. While these procedures
are often successful in relieving pain and improving
grip strength, substantial wrist motion is sacrificed,
and progressive degenerative arthritis is delayed, but
not prevented (Wall et al., 2013). Saltzman and col-
leagues conducted a systematic review of both PRC
and four corner fusion (4CF) procedures and reported
improvements in pain and self-reported outcomes in
both groups following surgery (Saltzman et al., 2015),
but the degree to which daily activities, participation
in sports, and occupational function is impaired by
these salvage procedures is largely unknown.
Functional kinematics of the carpus
Given the devastating effects of this frequent injury,
there is vast room for improvement in the treatment,
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early detection, and prevention of degenerative
changes in the wrist. A comprehensive understand-
ing of normal carpal architecture and functions is
essential. Over the last century, techniques for quan-
tifying carpal bone kinematics as a function of wrist
position have dramatically evolved, and this evolution
has been intimately linked to the development of
models to describe and explain wrist function. Here
we describe past and present technological develop-
ments in order to provide some context for the his-
torical progression of the understanding of the
functional kinematics of the carpus.
The advent of planar radiographs enabled the ear-
liest studies of joint kinematics and were first per-
formed in the wrist (Bryce, 1896). In-plane motion
was computed as the change in angle or length of the
carpal bones as the wrist was positioned in varying
amounts of either flexion-extension or radial-ulnar
deviation (McMurtry et al., 1978; Sarrafian et al.,
1977). Planar studies inferred three-dimensional
(3D) (or out-of-plane) motion by measuring length
changes of individual carpal bones as the wrist was
moved in the plane of the radiograph. It was through
the lens of this technology that the row theory of car-
pal kinematics was developed.
Although these studies provided an appreciation of
the wrist’s complexity and gave rise to the first theo-
ries of functional kinematics, they had an inherent
limitation – actual carpal bone motion that occurs
with six degrees of freedom was being inferred from
a two-dimensional (2D)projection. Subtle changes in
the posture of a subject’s forearm, or small incon-
sistencies in wrist positioning across subjects,
resulted in potentially large errors, and multi-planar
rotations of the carpal bones could not be accounted
for (Figure 1). Finally, these studies only investigated
pure flexion-extension and radial-ulnar deviation
motion arcs. Complex motions of the wrist could not
be studied.
Stereoradiography was the first approach that
addressed limitations of 2D approaches by facilitat-
ing 3D tracking of implanted radio-opaque beads in a
cadaveric model (Savelberg et al., 1991). The primary
limitation of this approach was the need to surgically
implant radiographic beads or markers within the
wrist, and the inherent potential for altering normal
kinematics by disrupting the capsule-ligamentous
envelope. In addition, it was difficult to accurately
replicate the actual stresses and strains borne by the
carpus during functional activities in in vitro models.
Despite these limitations, these studies introduced
rigorous six-degree-of-freedom analyses of carpal
bone motion as a function of wrist position.
3D studies using either magnetic resonance imag-
ing (MRI) or CT are inherently capable of assessing
Rainbow et al. 3
Figure 1.  Example of errors that can occur from inferring
3D motion from 2D radiographs. Shown here is a digitally
reconstructed radiograph of a single computed tomogra-
phy (CT) scan. The difference between images is a 15° rota-
tion of the entire CT scan about an axis coincident with the
long axis of the arm. This results in an 8% change in scaph-
oid length, which would be interpreted as scaphoid flexion
in a 2D analysis; however, no scaphoid flexion occurred.
the six-degree-of-freedom kinematics of the carpal
bones in live subjects (Crisco et al., 1999; Feipel et al.,
1992; Kobayashi et al., 1997b; Moojen et al., 2002;
Moritomo et al., 2000). The accuracy of these methods
is in the order of 0.5 mm and 0.5°. These technologies
considerably advanced the understanding of carpal
bone kinematics because they were capable of calcu-
lating out-of-plane rotations and overcame many of
the limitations associated with in vitro models.
Analysis of carpal kinematics during performance of
functional tasks was limited to quasi-static calcula-
tions of frame-by-frame positioning in a chosen arc of
wrist motion (Kamal et al., 2012b; Wolfe et al., 1997).
In other words, these techniques do not sample the
full spectrum of functional wrist motion within a sin-
gle subject.
More recently, dynamic scanning volume technol-
ogy using 4D CT and MRI has been used to study
dynamic motion of carpal bones (Choi et al., 2013;
Edirisinghe et al., 2014; Leng et al., 2011; Zhao et al.,
2015). These techniques allow for precise analysis of
individual carpal motion during true wrist motion.
Because the sampling rates of these methods are
limited by image acquisition time, the wrist has to be
moved slowly through the path of motion, which
affects the kinetics of musculotendinous loading of
the carpal bones. The advantages of four-dimen-
sional (4D) methods over quasi-static methods to
study the healthy carpus during load application have
yet to be demonstrated. There is a negligible hyster-
esis effect in the healthy wrist, which means for a
given wrist motion, the carpal bones move through
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the similar motion paths (within 2°) regardless of
direction of motion (Short et al., 1997). However, it is
plausible that the hysteresis effect may be larger in
injured states and these 4D methods may shed new
light on dynamic pathologies, such as the clunking
wrist (Garcia-Elias, 2008). Additionally, 4D CT or MRI
may have the capability to sample a larger spectrum
of wrist motions within a single subject.
Advanced technologies such as these have allowed
researchers to propose various kinematic groupings
of the carpal bones. The major historical concepts in
this area, along with their strengths and weaknesses,
are summarized in Table 1. Here, we focus on the row
and column theories due to their prevalence in the
literature and in clinical thinking.
Bryce and Destot were the first to describe kine-
matic function of the wrist in terms of two distinct
rows arranged proximally and distally (Figure 2)
(Bryce, 1896; Destot, 1986). The lunate and triquetrum
together comprise the proximal carpal row, which is
referred to as the intercalated segment, because it
lacks musculotendinous attachments, and is inter-
posed between two other moving bones as part of an
articulated link (Gould et al., 2015). Consequently,
proximal carpal row motion occurs indirectly second-
ary to mechanical signals from the distal row (Kauer
et al., 1994; Landsmeer, 1961; Linscheid et al., 1972).
The distal row (trapezium, trapezoid, capitate, and
hamate) is tightly bound to the metacarpals and
essentially moves as a rigid unit. It was observed that
the scaphoid functions as the bridge, or connecting
rod, between the rows because it coordinates the
motion of the two rows (Fick, 1911). Early studies of
carpal function posited that wrist flexion and exten-
sion occurred between the two rows at the midcarpal
joint, while ulnar and radial deviation occurred
through the articulation of the scaphoid with the
radius at the radiocarpal joint (Gilford et al., 1943).
Even the early proponents of the row theory sug-
gested that it was an oversimplification of the carpal
joint mechanism. An alternate proposal was that the
carpal bones should be conceptualized as radial,
central, and ulnar columns (Navarro, 1921) (Figure
2). The radial column consists of the scaphoid, trape-
zium, and trapezoid; the central column consists of
the capitate, hamate, and lunate, and the ulnar col-
umn consists of the triquetrum. The column theory
states that wrist flexion and extension occurs through
articulations in the central column, and wrist radial
and ulnar deviation occur through rotation of the
scaphoid and triquetrum about the central column.
The column theory of carpal joint function has
been revisited and revised several times. 2D radiog-
raphy studies and one 3D CT study posited that there
is a spectrum of wrists from row-type to column-type
 4
Table 1.  Concepts of carpal mechanics.

Theory Author Year Classification Brief summary Supporting evidence Strengths Weaknesses References
proposed (row, column,
or both)

Foundational Bryce, 1926 Row The carpus is composed Linscheid and colleagues Establishes Although the row Bryce,1896;
row theory Destot of 2 arched rows – one conducted a radiographic a systematic model survives as Landsmeer,
‘antebrachial’ (proximal) and investigation of 47 framework for a way of organizing 1961;
one ‘metacarpal’ (distal). patients with various wrist further investigation the carpus (into Linscheid
The proximal row contains pathologies. Radiographic of the carpus; proximal and et al., 1972
3 bones – scaphoid, lunate, evidence supported the elucidates the distal rows), the
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triquetrum. It is characterized scaphoid’s proposed importance of theory itself is too

as mobile (in radiocarpal and role as an intercarpal both wrist joints simplistic from a
midcarpal joints) and supple stabilizer. Linscheid also (radiocarpal and carpal kinematics
(bony articulations adapt to introduced the idea that midcarpal) acting standpoint: many
the position of the hand). The the lunate and triquetrum together to produce of the bones that
distal row consists of 4 bones constitute an ‘intercalated the wide range Destot dismissed
– trapezium, trapezoid, capitate, segment’, which moves of carpal motion; as unimportant
hamate. Destot extolled the synchronously in flexion/ provides insight are now regarded
head of the capitate as the extension and radial/ulnar into the mechanism as functionally
centre of wrist movement and deviation. of compressive relevant.
the scaphoid as an external force transmission
pillar that stabilizes the carpus through the carpus.
in extension.
Screw-vice MacConaill 1941 Both Mechanism of wrist extension: Cadaveric study by Leon- Thoroughly explains Fails to address MacConaill,
the scaphoid (jaw of the vice) Lopez and colleagues alterations in wrist flexion in 1941; León-
becomes fixed to the distal investigated carpal carpal position with adequate detail; Lopez
carpal row (base of the vice), destabilization in the wrist extension; overall applicability et al., 2013;
then the hamate (screw) pins the setting of lunotriquetral reconciles with the of this theory is Sarrafian
lunate and triquetrum against ligament disruption; study scaphoid’s proposed limited due to its et. al., 1977
the scaphoid. Movement from found that the ECU is the role as a connecting narrow focus on

The Journal of Hand Surgery (Eur)

radial to ulnar deviation entails
transmission of muscular forces
from forearm bones to proximal
carpal row: triquetrum moves
most, lunate second, scaphoid
least.
only muscle capable of rod between wrist extension
extending and pronating proximal and distal
the collapsed triquetrum. rows
Radiographic study by
Sarrafian and colleagues
presented evidence that
the carpal bones become
more closely packed with
extension, supporting the
screw-vice theory.

Table 1. (Continued)
Theory Author Year Classification Brief summary
proposed (row, column,
or both)
Link joint Gilford 1943 Column The wrist in flexion and
extension is mechanically
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analogous to a link joint,
with one pivot spanning the
radiolunate joint and another
spanning the lunocapitate joint;
extension occurs primarily at
the radiolunate joint, while
most flexion occurs at the
lunocapitate joint; ulnarly,
the triquetrum and TFCC act
as a simple hinge; radially,
the scaphoid acts as a bridge
to stabilize the link against
crumpling.
Longitudinal Kauer 1980 Column The wrist is composed of three
chain parallel and interdependent
longitudinal chains, of which the
radial chain and central chain
are most important for carpal
motion. The scaphoid rotates
faster on the radius than the
wedge-shaped lunate. In wrist
flexion, the scaphoid rotates
palmarly and shifts proximally
with respect to lunate and
capitate. In extension, the
scaphoid rotates dorsally and
shifts distally.
Supporting evidence
Radiographic study by
Fisk supported Gilford’s
radius-lunate-capitate
link joint and applied
this model to carpal
instability. Fisk noted
that hyperextension
injury causes backward
rotation of the lunate
and hyperflexion of the
capitate. This results in
intercarpal instability and
a distinct appearance of
the carpus, which Fisk
termed the ‘Concertina’
deformity.
Kobayashi studied carpal
kinematics using biplanar
radiography (coronal and
sagittal) in 22 cadavers.
The results supported
Kauer’s findings: (1) the
scaphoid rotates most
(of the proximal carpal
bones), while the lunate
rotates least; (2) the
anterior scapholunate gap
closes in wrist flexion and
opens in extension.
Rainbow et al.
Strengths Weaknesses References
Resolves the ability Does not comment Fisk, 1970
of the carpus as a on the mechanisms
whole to flex/extend involved in radial
over a greater arc and ulnar deviation;
than any of the fails to account for
bones that comprise the fact that carpal
it; provides a sound malalignment can
explanation for also occur in the
rotational collapse absence of scaphoid
of the carpus (i.e. pathology
the concertina effect
later described by
Fisk).
Accounts for the Focuses primarily Kobayashi
wrist’s ability on the anatomy et al., 1997b
to move at the of the scaphoid
midcarpal and and lunate (i.e.
radiocarpal joints ligaments and
simultaneously; morphology);
relates the kinematics of
morphology of the the rest of the
carpal bones to their carpus are not well
kinematic profile; addressed by this
describes the role model.
of interosseous
ligaments in
intercarpal stability.
(Continued)
5
 6
Table 1. (Continued)

Theory Author Year Classification Brief summary Supporting evidence Strengths Weaknesses References
proposed (row, column,
or both)

Oval ring Lichtman 1981 Row The relationship between Cadaveric study by Horii Explains the In Lichtman’s own Horii, 1991;
carpal bones is described as and colleagues analysed fact that carpal cadaveric study, Litchman,
a ring with two mobile links the effect of lunotriquetral instability does division of the dorsal 1981
(the trapezioscaphoid and ligament division on not always occur triquetrohamate
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triquetrohamate joints) and carpal motion. They found longitudinally ligaments in

a rigid post (the distal carpal that when the wrist was (i.e. between the 15 specimens
row). Radial disruption of the axially loaded and moved columns); sheds did not reliably
ring leads to instability of from neutral to ulnar light on the role induce midcarpal
the scaphoid-lunate-capitate deviation, the lunate of intercarpal instability.
articulation; ulnar disruption rotated quickly leading ligaments in
leads to midcarpal instability. to an audible ‘clunk’ and allowing the
instability of the midcarpal proximal row
joint. to rotate as one
functional unit.
Triquetrum- Weber 1984 Column The carpus is comprised of Ruby and colleagues Addresses all Weber’s idea that Ruby
hamate three longitudinal columns: a (1988) conducted a four motions of the majority of et al., 1988;
articulation force-bearing column centrally, cadaveric study in which the wrist (flexion, control occurs at Tomaino
a control column ulnarly, and they actively loaded extension, radial, the triquetrohamate et al., 1994;
a thumb-axis column radially. the wrist, assessed and ulnar deviation); joint (fails to Weber, 1984
As the wrist is flexed/extended carpal alignment provides a kinematic reconcile) is
or radially/ulnarly deviated, using radiographs, and foundation for inconsistent with
the triquetrum translates on measured carpal position. understanding the scaphoid’s
the slope of the hamate. In They found that the distal pathologic proposed role as an

The Journal of Hand Surgery (Eur)

extension and ulnar deviation,
the lunate is displaced palmarly
and compressed by the capitate;
this elevates the distal pole
of the scaphoid resulting in
scaphoid extension. The reverse
phenomenon occurs for flexion
and radial deviation.
row displaces dorsal-
to-palmar as the wrist
moves from ulnar to
radial deviation. This is
consistent with Weber’s
theory.
conditions, external pillar that
including tears of spans both carpal
the lunotriquetral rows and provides
ligament and DISI a major stabilizing
(which can progress effect on the wrist.
to SLAC).
 Rainbow et al.
Table 1. (Continued)

Theory Author Year Classification Brief summary Supporting evidence Strengths Weaknesses References
proposed (row, column,
or both)

Carpal Garcia-Elias 1997 Both Four mechanisms of carpal Cadaveric studies by Sheds the one-size- By treating the wrist Kamal
stability stabilization work in concert: Kamal and Kobayashi fits-all approach of as four independent et al., 2012a;
through proximal row stabilization, distal applied an axial many predecessors systems, this theory Kobayashi
balanced row stabilization, midcarpal compressive load to the by dividing the fails to truly unify et al., 1997a
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moments stabilization, and radiocarpal wrist and tracked the carpus into four carpal kinematics;
applied to the stabilization. The lunate’s motion of the carpal constituents and further, if a theory
lunate position is held in balance by the bones under various assessing the does not permit one
scaphoid’s tendency to flex and conditions. The former kinematics of each to conceptualize
the triquetrum’s tendency to found that DISI occurred systematically; the mechanics
extend. SL ligament disruption after excision of the distal this theory is also of the wrist as a
can lead to DISI when the scaphoid; the latter found appealing for its whole, the practical
scaphoid subluxes dorsally that the scaphoid had simplicity: Garcia- applicability of such
and produces an extension/ a larger magnitude of Elias approaches a theory may be
supination moment on the rotation than either the wrist stability by called into question.
lunate. LT ligament disruption lunate or triquetrum. Both harkening back to
can lead to VISI when the lunate results support Garcia- the very foundation
follows the scaphoid into a Elias’ carpal mechanics of mechanics –
flexion/pronation moment. theory. balance of forces.
Central Sandow 2013 Column The carpus is a central column As yet, no subsequent Sandow’s theory Sandow’s study Kamal
column (lunate-capitate-hamate- investigations have is derived directly found no isometric et al., 2012b
trapezoid-trapezium) that links examined this theory, from 3D computer- constraint between
the radius to the bases of the likely due to its recent generated models; hamate and
metacarpals. The scaphoid publication and novel by definition, triquetrum; this
comprises a lateral column – a computational methods. it is therefore conclusion fails to
‘two gear four bar linkage’ – to more organic reconcile with the
support the central column, than most other established work
while the triquetrum functions theories, which of others (originally
as a restraint against ulnar are first proposed Weber, and later
translation. The trapezoid subjectively and Kamal). The
functions to rotate the axis of later supported with two-gear four bar
the central column as observed objective data. linkage model has
in dart thrower’s motion. not been tested for
all wrist motions.

3D: three-dimensional; DISI: dorsal intercalated segment instability; ECU: ; LT: lunotriquetral; SL: scapholunate; SLAC: scapholunate advanced collapse; TFCC: triangular fibrocartilage
complex; VISI: volar intercalated segment instability.

7
8 The Journal of Hand Surgery (Eur)
Figure 2.  The row and column theory of carpal joint func-
tion. The row theory organizes the carpus into proximal and
distal rows. It states that wrist flexion and extension occur
between the two rows while wrist radial and ulnar devia-
tion primarily occurs at the articulation of the scaphoid and
radius. The column theory organizes the carpal bones into
a radial, central, and ulnar column and states that wrist
flexion and extension occurs about the central column,
while wrist radial and ulnar deviation occurs by rotations
of the radial and ulnar column about the central column.
(Craigen and Stanley, 1995; Garcia-Elias et al., 1995;
Moojen et al., 2002), dependent in part on differences
in carpal bone shape (Bain et al., 2015) and ligamen-
tous laxity. One study found a strong correlation
between clinically measured joint laxity and scaphoid
extension with wrist ulnar deviation (Garcia-Elias
et al., 1995). These researchers concluded that dur-
ing wrist ulnar deviation, a person with lax ligaments
exhibits more scaphoid extension (column-type
wrist), whereas a person with stiffer ligaments exhib-
its more scaphoid ulnar deviation (row-type wrist).
However, the relationships among laxity, 3D carpal
bone kinematics, and the onset and progression of
wrist instability remain unclear.
3D studies using these techniques have revealed
that throughout its range of motion, the carpus func-
tions neither as two horizontal rows or three vertical
columns. While these groupings remain convenient
for anatomical descriptions, they do not provide a
comprehensive model of functional carpal motion
throughout the spectrum of wrist motion. Kinematics
studies have determined that the proximal row of car-
pal bones do not move as a single rigid body, even
when they are rotating in the same plane as the wrist.
For example, as the wrist moves from neutral to 60°
of flexion, the scaphoid flexes approximately 70% of
the amount the capitate flexes, while the lunate flexes
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45% of the amount the capitate flexes. The interpreta-
tion of this is that as the wrist flexes, approximately
half of wrist flexion occurs at the midcarpal joint and
half of wrist flexion occurs at the radiocarpal joint.
This distribution changes as the wrist moves from
neutral to 60° of extension. Here, the scaphoid extends
in synchrony with the capitate, while the lunate
extends 65% of radio-capitate extension (Kobayashi
et al., 1997b; Ruby et al., 1988; Wolfe et al., 2000). This
means that during extension (from neutral) more
motion occurs at the radiocarpal joint than the mid-
carpal joint. It is interesting to note that in extreme
extension the distribution of scaphoid and lunate
extension to capitate extension is reduced by 25%.
This means that more motion occurs at the midcarpal
joint during extreme wrist extension compared with
60° extension. This may be due to restraint by the
volar ligaments (Rainbow et al., 2013). During wrist
radial-ulnar deviation, it has been well-documented
that the scaphoid and lunate move in the same direc-
tion, but to different degrees, flexing when the wrist
radial deviates and extending when the wrist ulnar
deviates (Crisco and Neu, 2000; Goto et al., 2005;
Moojen et al., 2002). It is important to note that no
past or present concept of carpal mechanics explains
or predicts this complex behaviour.
3D studies of carpal bone motion are inherently
capable of measuring wrist coupled motion, which
refers to the composite motion that occurs simulta-
neously about the flexion/extension and radial/ulnar
deviation axes of the wrist (Figure 3). These studies
found that as the wrist moved from radial-extension
toward ulnar-flexion, the tendency of the scaphoid
and lunate to extend during wrist ulnar deviation is
balanced by their tendency to flex during wrist flex-
ion, resulting in minimal scaphoid and lunate rota-
tion during a large range of wrist rotation (Crisco
et al., 2005; Edirisinghe et al., 2014; Moritomo et al.,
2007; Werner et al., 2004). In other words, during a
path from wrist radial-extension to ulnar-flexion,
nearly all wrist motion occurs at the midcarpal joint.
This direction of coupled motion is referred to as the
dart thrower’s path. The study of the dart thrower’s
path was prompted by the pioneering cadaveric wrist
motion studies of Werner and colleagues (Werner
et al., 1997, 2004). An early fundamental in vivo study
utilizing sequential computerized tomographic
scans of 28 subjects in 504 distinct wrist positions
demonstrated that scaphoid and lunate motion
approaches zero in a pure (45° obliquity to the
orthogonal axes) dart throwers plane when the cou-
pling ratio of flexion-extension to radial-ulnar devia-
tion is 1:1 (Crisco et al., 2005). It was hypothesized
that a motionless proximal carpal row would provide
a stable platform for precision and targeted activities
Rainbow et al. 9
Figure 3. The wrist is approximated as a two-degree-
of-freedom universal joint. Motion has traditionally been
defined in terms of two orthogonal anatomical axes; the
flexion-extension axis and ulnar-radial deviation axis. With
a fully pronated right wrist, the directions of wrist rotation
can be mapped onto a clock face where extension and flex-
ion occur at 12:00 and 6:00, radial and ulnar deviation occur
at 9:00 and 3:00. The wrist more commonly moves along
paths that are oblique to these orthogonal motions, and
these coupled motions are represented by the intermedi-
ate times on the clock face.
(Crisco et al., 2005; Rohde et al., 2010). Further
research has demonstrated that the mechanical axis
of the skeletal ligamentous wrist is oriented along
the dart-thrower’s plane (Crisco et al., 2011) and
demonstrated that it is fundamental to all ballistic
(throwing, hammering) motions, as well as many
occupational and household activities (Garg et al.,
2014; Palmer et al., 1985). Further evidence that the
wrist is pre-disposed to a dart thrower’s motion is
the orientation of the muscle insertions – the exten-
sor carpi radialis longus and brevis, and flexor carpi
ulnaris insert at an oblique axis that is oriented in
the transverse view to the dart-throwing motion
(DTM) plane (Braidotti, 2015). In addition to generat-
ing motion along the DTM plane, the muscles serve
to supinate the scaphoid, thus stabilizing the scapho-
lunate joint, and further protecting the dorsal
scapho-lunate ligament (Salva-Coll et al., 2011).
Functional kinematics of the wrist
The dart-thrower’s path is an example of a coupled
motion that has emerged as a translational concept
linking in vivo and in vitro carpal kinematic analyses
with clinical wrist function (Li et al., 2005). It is a
compelling approach for rehabilitation protocols fol-
lowing reconstructions of the scapholunate interos-
seous ligament because the scaphoid and lunate
effectively are protected, while early range of motion
Downloaded from jhs.sagepub.com at University of British Columbia Library on November 15, 2015
is accomplished. There remain, however, open ques-
tions that require further analysis, in order to pro-
vide clinicians with insight on techniques to isolate
the particular DTM plane for a specific patient. First,
while population studies of the DTM, such as Crisco
et al. (2005), have determined that the average path
is 45° oblique to the flexion extension plane with a
coupling ratio of 1:1, it is unknown how the path ori-
entation or the coupling ratio that minimizes scaph-
oid and lunate motion varies among subjects and
how clinically important this variability is.
Furthermore, there may be subtle differences in
optimal paths for the scaphoid as compared with the
lunate. Although not verified in 3D, 2D evidence sug-
gests that laxity plays a role in scaphoid and lunate
kinematics. Whether laxity alters the ideal DTM
within an individual is unknown. Finally, it is not
known whether deviation from a subject-specific
dart thrower’s path during a rehab protocol would
affect patient outcomes.
The unique kinematics of the dart-thrower’s plane
and the measurement of different degrees of coupled
motion during functional activities lead to several
fundamental questions. What correlates best with
functional restoration following injury or treatment –
traditional parameters of orthogonal motion or one’s
ability to perform coupled motion? How critical is the
degree of coupled motion and circumduction area to
function? What do patients most desire out of treat-
ment for wrist injury? Is relief of pain more important
than restoration of motion? And most importantly,
how do we measure wrist function?
It is likely that several parameters are required to
adequately quantify wrist function. One aspect of wrist
function may be wrist motion required for task perfor-
mance. Previous studies measured the minimum
amount of required motion to perform specific func-
tional activities (Nelson et al., 1997; Palmer et al.,
1985; Ryu et al., 1991), yet did not identify the path or
plane of motion required. Furthermore, although pla-
nar wrist motion (flexion/extension and radial/ulnar
deviation) is typically used as a primary outcome for
clinical assessment and wrist research, it has not
been found to correlate with performance (Wilcke
et al. 2007). Similarly, moderate to low correlations
are reported between PRWE scores (patient-rated
wrist evaluation, a widely used self-reported outcome
for wrist injuries), and physical impairment measure-
ments of wrist range of motion and grip strength
(MacDermid et al., 2007; Mehta et al., 2012, 2015).
Measurement of dynamic wrist motion during func-
tional tasks may be a more accurate reflection of wrist
function. If different wrist tasks demonstrate different
coupling and kinematic path lengths, are these also
critical for successful performance?
10 The Journal of Hand Surgery (Eur)
Garg et al. (2014) compared kinematic coupling
during seven activities in a free and restricted condi-
tion and showed a significant difference in the degree
of coupling and performance of tasks between con-
ditions in dart and hammering tasks, demonstrating
implications of restricted radial/ulnar deviation for
wrist sparing procedures.
Wrist circumduction, a coupled motion, is a con-
tinuous elliptical movement that combines all extreme
postures of the wrist. The circumduction envelope is
the area enclosed by this movement, and can there-
fore provide important information about the range of
motions of the wrist during functional tasks (Singh
et al., 2014). Crisco et al. (2011) have demonstrated
that the principal orientation of the circumduction
ellipse is along a DTM path, the functional direction of
the wrist, and not along the anatomical direction of
pure flexion-extension. Both DTM and circumduction
are associated with performance of functional tasks
in healthy subjects (Brigstocke et al., 2013; Franko
et al., 2008; Garg et al., 2014), and have been proposed
as useful parameters of wrist function. Franko et al.
(2008) artificially restrained the wrists of healthy vol-
unteers using a partially restricted and highly
restricted splint and demonstrated a correlation
between decreased wrist mobility (range of motion)
and functional ability (functional timed tests) (Franko
et al., 2008). The study concluded that under simu-
lated conditions progressive loss of motion results in
incrementally significant functional deficits, and sug-
gests that these limitations apply to pathologic wrist
conditions with similar motion restrictions. We agree
that a compromised circumduction area may be
related to restricted task performance.
Given the emerging need to assess functional
wrist kinematics, robust, clinically feasible assess-
ment techniques are required. Historically, wrist
range-of-motion has been assessed by physicians
and therapists using manual goniometric measure-
ment of flexion-extension and radial-ulnar deviation.
While reliability and validity of goniometric measure-
ment have been established (Carter et al., 2009), they
are limited to static measurements in flexion, exten-
sion, radial, and ulnar deviation. The difficulties of
measuring coupled motion via a standard goniometer
have recently been illustrated by Bugden (2013). The
stable, rigid third metacarpal is not practical for
goniometric alignment in this plane. The second
metacarpal is proposed as an alternative, however,
the technique, while perhaps useful for a gross
measure, is cumbersome and impractical, and has
not been tested for reliability and validity (Bugden,
2013). 3D motion analysis (3DMA) provides an alter-
native, albeit a more time-intensive and costly
method of assessing dynamic movement. Various
Downloaded from jhs.sagepub.com at University of British Columbia Library on November 15, 2015
forms of 3D motion capture have been used to quan-
tify dynamic wrist motion during functional activities.
Li et al. (2005) utilized a marker-based optical sys-
tem to document wrist-coupled motion in ten healthy
volunteers performing wrist flexion/extension, radial/
ulnar deviation, and circumduction (Li et al., 2005).
Brigstocke et al. (2013) calculated dart-thrower’s
motion using 3DMA technology based on the marker
set described by Li (2005) in a series of activities of
daily living and confirmed dart-throwers motion
pathway during hammering, throwing a ball, pouring,
drinking, and opening and closing a jar (Brigstocke
et al., 2013). Hillstrom et al. (2014) designed and
developed a robust wrist joint coordinate system
(WJCS) that could be used to conduct real-time wrist
kinematic coupling evaluations of individuals in vivo
while performing functional tasks (Hillstrom et al.,
2014). This system accounts for individual differences
in anatomy and bone morphology by including pal-
pated anatomic landmarks that are used to build the
joint coordinate system. A series of validation studies
examining WJCS accuracy and repeatability were
performed, identifying the 3DMA method as the most
accurate (mean absolute difference = 3.6°) com-
pared with fluoroscopy and repeatable (average intra-
class correlation coefficient (ICC) (2,1) = 0.76) when
compared with manual and electro-goniometry
(Hillstrom et al., 2014). Several WJCS definitions
were further tested for reliability in a cadaveric study
in both intact and surgically reconstructed wrists
(PRC and 4CF). The functional WJCS that is based on
both bony landmarks and functional wrist flexion/
extension was found to be most accurate (Kraszewski
et al., 2015), and was subsequently used to quantify
wrist-coupled motion during seven functional activi-
ties (Garg, 2014).
Other techniques have been proposed for the
measurement of wrist circumduction. Franko et al.
(2008) designed, developed, and validated a circum-
duction measuring device and demonstrated high
inter-rater and intra-rater reliability. While simple
and cost effective, it cannot be utilized to quantify the
circumduction envelope utilized during functional
tasks. Singh et al. (2014) demonstrated accuracy and
reliability of an electro-goniometer in measuring
velocity, range, and smoothness of circumduction in
healthy volunteers. Gehrmann et al. (2008) utilized
motion capture to examine the effect of finger con-
straints on circumduction area.
Recently, several investigative groups have applied
dynamic motion measurement techniques to assess
wrist injury and arthritis. Wolff et al. (2015) quantified
the dart thrower’s plane of coupled motion during
functional activities using 3DMA in individuals who
have undergone 4CF and PRC, compared with healthy
Rainbow et al. 11

Figure 4. Left: flexion/extension vs radial/ulnar deviation in unconstrained (green), semi-constrained (red), and con-
strained (blue) wrist circumduction. Right: kinematic path length for specific tasks; winding (black), hammering (red), and
dart throwing (blue) within the unconstrained circumduction.
Note: how the kinematic path length for specific tasks falls outside the circumduction envelope of the restricted conditions.

individuals. Differences in wrist kinematics and per-
formance were identified between the groups.
Coupling, kinematic path length and performance
were all significantly reduced in 4CF and PRC com-
pared with healthy subjects during hammer use and
dart throwing. PRC subjects performed better than
the 4CF group on kinematic and performance varia-
bles. Singh and colleagues reported a similar finding
in an electro-goniometric study that assessed the
circumduction envelopes of motion between these
two groups and found that the PRC motion area, while
limited, was concentric and closer matched the nor-
mal envelope of movement (Singh et al., 2014).
Most recently, Wolff et al. (2014) measured the cir-
cumduction envelope of motion while computing cou-
pling parameters and performance for three tasks
(hammering, dart throwing, and winding a spool of
thread) in a cohort of healthy subjects across three
increasingly restricted wrist conditions (presented at
the 37th American Society of Hand Therapists (ASHT)
Annual Meeting, Boston). These conditions were
designed to artificially constrain the wrist as repre-
sentative of the effects of injury or surgery. The three
tasks in this study were found to require different wrist
kinematics. The kinematic parameters of each task
fell into a task-specific area within the circumduction
envelope (Figure 4). When the circumduction area was
restricted, the essential coupling and path lengths fell
outside the available envelope of wrist motion, which
was reflected as a restriction in the ability to perform
the task. These findings suggest that injuries or treat-
ments that restrict portions of the circumduction
envelope and/or wrist coupling will differentially
impair performance of functional tasks. Circumduction
parameters thus may provide important information
regarding wrist function.
The biomechanical studies cited above that sup-
port the kinetic theory of carpal stability and describe
the relative position and motion of the carpal bones
during the DTM plane provide substantial evidence
for rehabilitation protocols that minimize motion
between the scaphoid and lunate following surgical
procedure performed to stabilize the proximal carpal
row (Crisco et al., 2005; Moritomo et al., 2000; Werner,
2004, 2005). As stress to the scapho-lunate interos-
seous ligament is minimized during this motion
(Salva-Coll et al., 2011), gentle DTM is regarded as a
safe and protected range of motion for postoperative
radiocarpal surgeries. It is important to note, how-
ever, that no study of carpal bone motion during the
DTM has been conducted post-scapho-lunate inter-
osseous reconstruction, and caution is recommended

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12 The Journal of Hand Surgery (Eur)
when considering rehabilitation in the DTM plane
after an unrepaired acute injury (Garcia-Elias et al.,
2014). Several designs for custom orthoses have
been proposed for early post-operative use (Braidotti
et al., 2015). These orthoses are designed to allow
oblique motion along the DTM plane, while inhibiting
movement of the proximal carpal row following injury
and surgery. In addition, to mobilize orthoses, early
functional movements that utilize coupled motion
along the DTM plane, such as dart throwing and ham-
mering, can be incorporated later in the rehabilita-
tion algorithm by activating the extensor carpi radialis
longus and brevis, and flexor carpi ulnaris muscles to
apply controlled loads.
Future directions and conclusion
A comprehensive unifying model of functional carpal
kinematics remains elusive. There are three inherent
limitations of the functional kinematics measure-
ments reviewed here. First, true dynamic carpal kine-
matics have not been measured throughout the
spectrum of wrist motion in live subjects. Since CT
techniques use ionizing radiation and MRI techniques
still require considerable time to acquire adequate
resolution images, it is presently not feasible to scan
the wrist in more than ten to 15 wrist positions.
Therefore, the number of reconstructed motion paths
is limited. 4D CT may be able to overcome this limita-
tion by providing rapid acquisition as the wrist is moved
through its full range, including coupled motion with
variable coupling ratios or circumduction.
Second, motion capture techniques designed to
measure motion during functional performance can-
not simultaneously capture individual carpal bone
kinematics or kinetics. Emerging methods in mark-
erless tracking with biplanar videoradiography cou-
pled with optical motion capture may ultimately
overcome this limitation by allowing simultaneous
capture of skeletal motion and upper extremity
motion (Miranda et al., 2013).
Finally, the functional methods reviewed here are
unable to measure cartilage contact and ligament
forces. Computational modelling is a promising
approach that can overcome this limitation by estimat-
ing these forces, but most studies to date have focused
on model validation with low subject numbers
(Carrigan et al., 2003; Fischli et al., 2009; Marai et al.,
2009; Schuind et al., 1995). An additional limitation of
computational models is that model assumptions,
tuning of parameters, model validation, and hypothe-
sis testing are challenging to separate. For example, if
the ligaments are assigned hyper-elastic properties,
and the model is tuned to these properties, one may
be tempted to conclude that the wrist ligaments are
hyper-elastic. However, if these limitations can be
Downloaded from jhs.sagepub.com at University of British Columbia Library on November 15, 2015
overcome, computational models may have the poten-
tial to better elucidate the carpal mechanism.
Sandow and colleagues have made the most
recent progress in this area. The authors created a
data-driven computational model of carpal kinemat-
ics (Sandow et al., 2014) using ten cadaveric wrists
positioned in three positions (neutral, 30° radial devi-
ation, and 30° ulnar deviation). Ligaments were
defined by finding origin and insertion sites that mini-
mized the change in length of the ligament across the
measured range of motion. In vivo evidence for the
validity of isometric ligaments was recently supplied
by Rainbow and colleagues, who found that selected
capsular ligaments elongate minimally relative to
their maximum length as the wrist moved through a
large range of motion (Rainbow et al., 2015).
Based on their results, Sandow et al. (2014) pro-
posed that the carpus functions as a stable central
column formed by the lunate and the distal row, and
argued that the carpus can be conceptualized as a
two-gear, four-bar linkage. While an exciting and
innovative approach, the concept of a central load-
bearing column based on the radiolunate articulation
is difficult to fully reconcile with other kinetic studies
that demonstrate up to 60% of wrist load during
power grip is transmitted through the radioscaphoid
articulation (Ulrich et al., 1999). Further, this model
will need to be validated through a complete range of
wrist motion.
In summary, while the preliminary results of
Sandow et al. (2014) may be premature for determin-
ing a unifying theory of carpal kinematics, their novel
approach to reconstruct ligament courses using an
isometric lengthening assumption is important and
may lead to tremendous insight into the subtle
nuances of carpal mechanics. At this time, a unifying
theory of carpal kinematics is still elusive, given the
wide variability in wrist ligament laxity, anatomic var-
iability, and bone morphology. Inter-subject differ-
ences due to laxity, morphology, and functional
activities may be the largest contributing factor to the
development of chronic wrist instability. This ques-
tion will likely remain unanswered until functional
carpal and wrist kinematics and kinetics are simulta-
neously acquired over the full spectrum of wrist
motion and functional tasks in a large cohort of
patients and controls.
The link between wrist kinematics and wrist func-
tion is clearly multifaceted, and is confounded by
other factors, including pain, ipsilateral joint involve-
ment, and systemic disease. A comprehensive under-
standing of carpal bone mechanics and global wrist
motion is essential to analyse the deleterious effects
of injury and the restorative effects of surgery and
rehabilitation on achieving satisfactory patient out-
comes. There is a limit to what can be recreated in the
Rainbow et al. 13
mechanical laboratory or simulated with cadaveric or
computational models. Measurement of complex
wrist motions on normal and injured patients during
dynamic functional activity provides important infor-
mation concerning the behaviour of the carpus, and
the relationship of motion loss to functional ability. An
improved understanding of patient expectations and
functional needs following injury or surgery, coupled
with a dynamic assessment of wrist and carpal bone
motion, would enable truly tailored care, where sur-
geon and patient together select the treatment that is
optimal for the clinical presentation.
Acknowledgment
We would like to acknowledge Heath P. Gould, B.S., Case
Western Reserve University School of Medicine, for his
assistance compiling Table 1.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of
this article.
Funding
The authors received no financial support for the research,
authorship, and/or publication of this article.
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