2

Anatomy and Kinesiology of the Wrist

David S. Zelouf, Matthew S. Wilson, Haroon Hussain

OUTLINE
Bony Anatomy, 19 Wrist Innervation, 25
Joint Anatomy, 21 Kinematics, 25
Ligament Anatomy, 22 Kinetics, 26
Tendons, 24 Summary, 27
Vascular Anatomy, 24

CRITICAL POINTS
Anatomy Normal Kinetics
• Bones: two rows • Proximal row moves as a unit
• Ligaments: dorsal, palmar, intercarpal • Proximal row is intercalated segment—no tendons attach to it
• Membranes: scapholunate and triquetrolunate • Ligaments provide stability
• Pedicles: radioscapholunate • Lunate is keystone

The wrist is a unique joint interposed between the distal aspect of the
forearm and the proximal aspect of the hand. All three regions have
common or shared elements, which integrate form and function to
maximize the mechanical effectiveness of the upper extremity. The
wrist enables the hand to be placed in an infinite number of positions
relative to the forearm and also enables the hand to be essentially
locked to the forearm in those positions to transfer the forces generated
by the powerful forearm muscles.
Although the wrist is truly a mechanical marvel when it is intact and
functioning, loss of mechanical integrity of the wrist inevitably causes
substantial dysfunction of the hand and thus the entire upper extremity.
It is vital that a thorough understanding of the wrist, including efforts at
diagnosis, treatment, and rehabilitation, be acquired by all who treat the
wrist. This chapter provides such a foundation by exploring the general
architecture of the wrist; the bones; and joints that comprise the wrist and
the soft tissues that stabilize, innervate, and perfuse the wrist. In addition,
an overview of the mechanics of the wrist, with a discussion of its motions
and subparts and the force distribution across the wrist, is provided.
prominence oriented in the sagittal plane called the interfossal ridge
(Figs. 2.1 and 2.2). The scaphoid fossa is roughly triangular in shape
and extends from the interfossal ridge to the tip of the radial styloid
process. The lunate fossa is roughly quadrangular in shape and extends
from the interfossal ridge to the sigmoid notch. On the dorsal cortex
of the distal radius, immediately dorsal and proximal to the interfossal
ridge, is a bony prominence called the dorsal tubercle of the radius, or
Lister’s tubercle (see Fig. 2.1). It serves as a divider between the second
and third extensor compartments and functionally behaves as a troch-
lea for the tendon of extensor pollicis longus. On the medial surface of
the distal radius is the sigmoid notch. This concave surface articulates
Lister’s
tubercle
Sigmoid
ir
notch

BONY ANATOMY
There are eight carpal bones, although many consider the pisiform to sf
If
be a sesamoid bone within the tendon of the flexor carpi ulnaris (FCU)
and thus not behaving as a true carpal bone. The bones are arranged
into two rows (proximal and distal carpal row), each containing four
bones. All eight carpal bones are interposed between the forearm
bones and the metacarpals to form the complex called the wrist joint. Styloid

Distal Radius and Ulna

The distal surface of the radius articulates with the proximal carpal Fig. 2.1  Distal radius from a distal and ulnar perspective. ir, Interfossal
row through two articular fossae separated by a fibrocartilaginous ridge; lf, lunate fossa; sf, scaphoid fossa.
19
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20 PART 1  Anatomy and Biomechanics
Proximal pole of
scaphoid
Lunate Triquetrum
Scaphoid fossa
Lunate TFCC
ifr
fossa
ECU
Ulnar
head
Fig. 2.2 Radiocarpal joint from a distal perspective, prepared by pal-
mar-flexing the proximal carpal row. The triangular disk is seen between
the distal radioulnar (DRU) and palmar radioulnar (PRU) ligaments. The
interfossal ridge (ifr) is seen between the scaphoid and lunate fossae.
TFCC, triangular fibrocartilage complex.
with the ulnar head to form the distal radioulnar (DRU) joint. It has a
variable geometry across a population, both in shape and orientation,
but is largely believed to be symmetrical in any given individual.1,2
Under normal circumstances, the ulna does not articulate directly
with the carpus. Rather, a fibrocartilaginous wafer called the triangular
disk is interposed between the ulnar head and the proximal carpal row
(see Fig. 2.2). Even the ulnar styloid process is hidden from contact
with the carpus by the ulnotriquetral (UT) ligament. The ulnar head
is roughly cylindrical in shape, with a distal projection on its posterior
border, called the ulnar styloid process. Approximately three fourths of
the ulnar head is covered by articular cartilage, with the ulnar styloid
process and the posterior one fourth as exposed bone or periosteum.
A depression at the base of the ulnar styloid process, called the fovea, is
typically not covered in articular cartilage.3  The pisiform, which means “pea shaped,” is oval in profile with a flat
Proximal Carpal Row Bones
The proximal row consists of, from radial to ulnar, the scaphoid (navic-
ular), lunate, triquetrum, and pisiform (Figs. 2.3 and 2.4). The scaphoid
is shaped somewhat like a kidney bean. The scaphoid anatomy is
divided into three regions: the proximal pole, waist, and distal pole.
The proximal pole has a convex articular surface that faces the scaphoid
fossa and a flat articular surface that faces the lunate. The dorsal surface
of the waist is marked by an oblique ridge that serves as an attachment
plane for the dorsal joint capsule. The medial surface of the waist and
distal surface of the proximal pole is concave and articulates with the
capitate. The distal pole also articulates with the capitate medially, but
distally, it articulates with the trapezium and trapezoid. Otherwise, the
distal pole is nearly completely covered with ligament attachments.
The lunate is crescent shaped in the sagittal plane, such that the
proximal surface is convex and the distal surface concave, and it is
somewhat wedge shaped in the transverse plane. With the exception
of ligament attachment planes on its dorsal and palmar surfaces, the
lunate is otherwise covered with articular cartilage. It articulates with
the scaphoid laterally, the radius and triangular fibrocartilage proxi-
mally, the triquetrum medially, and the capitate distally. In some indi-
viduals, the lunate has a separate fossa for articulation with the hamate,
separated from the fossa for capitate articulation by a prominent
ridge.4–6
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PCH C PCT
Td
V
I
H TT
TH Tm
TC STT
P S
PLT SC
L
RSC
UT
LRL
UL SRL
U R
Fig. 2.3  Wrist from palmar perspective. Bones: C, Capitate; H, hamate;
I, first metacarpal; L, lunate; P, pisiform; R, radius; S, scaphoid; Td, trap-
ezoid; Tm, trapezium; U, ulna; V, fifth metacarpal. Ligaments: LRL, Long
radiolunate; PCH, palmar capitohamate; PCT, palmar trapezocapitate;
PLT, palmar lunotriquetral; RSC, radioscaphocapitate; SC, scaphocap-
itate; SRL, short radiolunate; STT, scaphoid-trapezium-trapezoid; TC,
triquetrocapitate; TH, triquetrohamate; TT, trapezium-trapezoid; UL,
ulnolunate; UT, ulnotriquetral.
The triquetrum has a complex shape, with a flat articular surface on
the palmar surface for articulation with the pisiform; a concave distal
articular surface for articulation with the hamate; a flat lateral surface
for articulation with the lunate; and three tubercles on the proximal,
medial, and dorsal surfaces, respectively. The proximal tubercle is cov-
ered in cartilage for contact with the triangular disk, and the medial
and dorsal tubercles serve as ligament attachment surfaces.
articular facet covering the distal half of the dorsal surface for articula-
tion with the triquetrum. Otherwise, it is entirely enveloped within the
tendon of the FCU and serves as a proximal origin of the flexor digiti
minimi muscle. 
Distal Carpal Row Bones
The distal carpal row consists of, from radial to ulnar, the trapezium,
trapezoid, capitate, and hamate (see Figs. 2.3 and 2.4). The trapezium,
historically referred to as the greater multangular, has three articular
surfaces. The proximal surface is slightly concave and articulates with
the distal pole of the scaphoid. The medial articular surface is flat and
articulates with the trapezoid. The distal surface is saddle shaped and
articulates with the base of the first metacarpal. The remaining sur-
faces are nonarticular and serve as attachment areas for ligaments. The
anterolateral edge of the trapezium forms an overhang, referred to as
the beak, which is part of the fibro-osseous tunnel for the tendon of
flexor carpi radialis (FCR).
The trapezoid, referred to historically as the lesser multangular, is a
small bone with articular surfaces on the proximal, lateral, medial, and
distal surfaces for articulation with the scaphoid, trapezium, capitate,
and base of the second metacarpal, respectively. The palmar and dorsal
surfaces serve as ligament insertion areas.
The capitate is the largest carpal bone and is divided into head,
neck, and body regions. The head is almost entirely covered in articular
 CHAPTER 2  Anatomy and Kinesiology of the Wrist 21

DCT C DCH
V The geometry of the wrist is complex, demonstrating a transverse arch
I created by the scaphoid and triquetrum–pisiform column proximally
H and the trapezium and hamate distally. In addition, the proximal carpal
Td
DIC
Tm
T two additional degrees of motion to the wrist–forearm joint. The DRU
S joint is the distal of two components of the forearm joint (with the
DRC
R U
Fig. 2.4  Wrist from dorsal perspective. Bones: C, Capitate; H, hamate;
I, first metacarpal; R, radius; S, scaphoid; T, triquetrum; Td, trapezoid;
Tm, trapezium; U, ulna; V, fifth metacarpal. Ligaments: DCH, Dorsal
capitohamate; DCT, dorsal trapezocapitate; DIC, dorsal intercarpal;
DRC, dorsal radiocarpal.
cartilage and forms a proximally convex surface for articulation with the
scaphoid and lunate. The neck is a narrowed region between the body
and the head and is exposed to the midcarpal joint without ligament
attachment. The body is nearly cuboid in shape with articular surfaces
on its medial, lateral, and distal aspects for articulation with the trape-
zoid, hamate, and base of the third metacarpal, respectively. The large,
flat palmar and dorsal surfaces serve as ligament attachment areas.
The hamate has a complex geometry, with a pole, body, and ham-
ulus (hook). The pole is a conical proximally tapering projection that
is nearly entirely covered in articular cartilage for articulation with
the triquetrum, capitate, and variably the lunate. The body is relatively
cuboid, with medial and distal articulations for the capitate and fourth
and fifth metacarpal bases, respectively. The dorsal and palmar surfaces
serve as ligament attachment areas, except the most medial aspect of
the body, where the hamulus arises. The hamulus forms a palmarly
directed projection that curves slightly lateral at the palmar margin.
This also serves as a broad area for ligament attachment.4–6  concave contiguous distal articulating surfaces of the scaphoid and
JOINT ANATOMY
Before a discussion of the anatomy of the wrist can be pursued, it is
important that a consensus be reached on term definitions. The terms
proximal and distal are universally understood, but some confusion may
exist regarding terms defining relationships in other planes. Although
the terms medial and lateral are anatomically correct, they require a
virtual positioning of the upper extremity in the classic anatomic posi-
tion to be interpretable. Therefore, the terms radial and ulnar have been
introduced by clinicians to enable an instant understanding of orienta-
tion independent of upper extremity positioning because the reference
to these terms (the orientation of the radius and ulna) does not change
significantly relative to the wrist. Likewise, the terms anterior, volar,
and palmar all describe the front surface of the wrist, whereas dorsal
and posterior describe the back surface of the wrist. Some may object
to using the term palmar in reference to the wrist, but they should be
reminded that the palmar, glabrous skin covers the anterior surface of
the carpus; therefore, it seems to have an acceptable use in the wrist.
Composed of eight carpal bones as the wrist proper, the wrist
should be functionally considered as having a total of 15 bones. This is
because of the proximal articulations with the radius and ulna and the
distal articulations with the bases of the first through fifth metacarpals.
row demonstrates a substantial arch in the frontal plane.
The DRU joint is mechanically linked to the wrist and provides
proximal radioulnar [PRU] joint). The motion exhibited through the
DRU joint is a combination of translation and rotation, created as a
pivot of the radius about the ulna through an obliquely oriented axis
of rotation passing between the radial head proximally and the ulnar
head distally.1,2
From an anatomic standpoint, the carpal bones are divided into
proximal and distal carpal rows, each consisting of four bones. This
effectively divides the wrist joint spaces into radiocarpal and midcarpal
spaces. Although mechanically linked to the DRU joint, the wrist is
normally biologically separated from the DRU joint space by the trian-
gular fibrocartilage complex (TFCC).3
Radiocarpal Joint
The radiocarpal joint is formed by the articulation of confluent surfaces
of the concave distal articular surface of the radius and the triangular
fibrocartilage, with the convex proximal articular surfaces of the prox-
imal carpal row bones. 
Midcarpal Joint
The midcarpal joint is formed by the mutually articulating surfaces
of the proximal and distal carpal rows. Communications are found
between the midcarpal joint and the interosseous joint clefts of the
proximal and distal row bones, as well as to the second through fifth
carpometacarpal joints. Under normal circumstances, the midcarpal
joint is isolated from the pisotriquetral, radiocarpal, and first carpo-
metacarpal joints by intervening membranes and ligaments. The geom-
etry of the midcarpal joint is complex. Radially, the scaphotrapezial
trapezoidal (STT) joint is composed of the slightly convex distal pole
of the scaphoid articulating with the reciprocally concave proximal
surfaces of the trapezium and trapezoid. Forming an analog to a “ball-
and-socket joint” are the convex head of the capitate and the combined
the lunate. In 65% of normal adults, it has been found that the hamate
articulates with a medial articular facet at the distal ulnar margin of the
lunate, which is associated with a higher rate of cartilage eburnation
of the proximal surface of the hamate. The triquetrohamate region of
the midcarpal joint is particularly complex, with the mutual articu-
lar surfaces having both concave and convex regions forming a heli-
coid-shaped articulation. 
Interosseous Joints: Proximal Row
The interosseous joints of the proximal row are relatively small and pla-
nar, allowing motion primarily in the flexion–extension plane between
mutually articulating bones. The scapholunate (SL) joint has a smaller
surface area than the lunotriquetral (LT) joint. Often, a fibrocartilag-
inous meniscus extending from the membranous region of the SL or
LT interosseous ligaments is interposed into the respective joint clefts. 
Interosseous Joints: Distal Row
The interosseous joints of the distal row are more complex geomet-
rically and allow substantially less interosseous motion than those of

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22 PART 1  Anatomy and Biomechanics
the proximal row. The capitohamate joint is relatively planar, but the
mutually articulating surfaces are only partially covered by articular
cartilage. The distal and palmar region of the joint space is devoid of
articular cartilage, being occupied by the deep capitohamate interosse-
ous ligament. Similarly, the central region of the trapeziocapitate joint
surface is interrupted by the deep trapeziocapitate interosseous liga-
ment. The trapezium–trapezoid joint presents a small planar surface
area with continuous articular surfaces.4–6 
LIGAMENT ANATOMY
Overview
The ligaments of the wrist have been described in a number of ways, lead-
ing to substantial confusion in the literature regarding various features
of the carpal ligaments. Several general principles have been identified
to help simplify the ligamentous architecture of the wrist. No ligaments
of the wrist are truly extracapsular. Most can be anatomically classified
as capsular ligaments with collagen fascicles clearly within the lamina
of the joint capsule. The ligaments that are not entirely capsular, such
as the interosseous ligaments between the bones within the carpal row,
are intraarticular. This implies that they are not ensheathed in part by a
fibrous capsular lamina. The wrist ligaments carry consistent histologic
features, which are, to a degree, ligament specific. The majority of capsu-
lar ligaments are made up of longitudinally oriented laminated collagen
fascicles surrounded by loosely organized perifascicular tissue, which are
in turn surrounded by the epiligamentous sheath. This sheath is generally
composed of the fibrous and synovial capsular lamina. The perifascicular
tissue has numerous blood vessels and nerves aligned longitudinally with
the collagen fascicles. The function of these nerves is currently not well
understood. It has been hypothesized that these nerves are an integral part
of a proprioceptive network, following the principals of Hilton’s law of
segmental innervation. The palmar capsular ligaments are more numer-
ous than the dorsal, forming almost the entire palmar joint capsules of
the radiocarpal and midcarpal joints. The palmar ligaments tend to con-
verge toward the midline as they travel distally and have been described
as forming an apex–distal V. The interosseous ligaments between the
individual bones within a carpal row are generally short and transversely
oriented and, with specific exceptions, cover the dorsal and palmar joint
margins. Specific ligament groups are briefly described in the following
sections and are divided into capsular and interosseous groups.  the radiolunatotriquetral ligament historically, but the paucity of fibers
Distal Radioulnar Ligaments
Although a description of the DRU joint is beyond the scope of this
chapter, a brief description of the anatomy of the palmar and dorsal radi-
oulnar ligaments is required to understand the origin of the ulnocarpal
ligaments. The dorsal and palmar DRU joint ligaments are believed to
be major stabilizers of the DRU joint. These ligaments are found deep
(proximal) in the TFCC and form the dorsal and palmar margins of the
TFCC in the region between the sigmoid notch of the radius and the sty-
loid process of the ulna (see Fig. 2.2). Attaching radially at the dorsal and
palmar corners of the sigmoid notch, the ligaments converge ulnarly and
attach near the base of the styloid process, in the region called the fovea.
The palmar ligament has substantial connections to the carpus through
the ulnolunate (UL), UT, and ulnocapitate (UC) ligaments. The dorsal
ligament integrates with the sheath of extensor carpi ulnaris (ECU). The
concavity of the TFCC is deepened by more superficial fibers of the DRU
ligament complex, which attaches to the styloid process.2,7  The dorsal radiocarpal (DRC) ligament arises from the dorsal rim
Palmar Radiocarpal Ligaments
The palmar radiocarpal ligaments arise from the palmar margin of
the distal radius and course distally and ulnarly toward the scaphoid,
lunate, and capitate (see Figs. 2.3 and 2.5). Although the course of the
fibers can be defined from an anterior view, the separate divisions of
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LF IR
SF
TFCC LRL
SRL
RSC
UL
RSL
L
S
SLI
Fig. 2.5 Radiocarpal joint from distal perspective after palmar-flexing the
proximal carpal row. IR, Interfossal ridge; L, lunate; LF, lunate fossa of dis-
tal radius; LRL, long radiolunate ligament; RSC, radioscaphocapitate liga-
ment; RSL, radioscapholunate ligament; S, scaphoid; SF, scaphoid fossa
of distal radius; SLI, scapholunate interosseous; SRL, short radiolunate
ligament; TFCC, triangular fibrocartilage complex; UL, ulnolunate ligament.
the palmar radiocarpal ligament are best appreciated from a dorsal
view through the radiocarpal joint (see Fig. 2.5). The palmar radio-
carpal ligament can be divided into four distinct regions. Beginning
radially, the radioscaphocapitate (RSC) ligament originates from the
radial styloid process, forms the radial wall of the radiocarpal joint,
attaches to the scaphoid waist and distal pole, and passes palmar to
the head of the capitate to interdigitate with fibers from the UC lig-
ament. Very few fibers from the RSC ligament attach to the capitate.
Just ulnar to the RSC ligament, the long radiolunate (LRL) ligament
arises to pass palmar to the proximal pole of the scaphoid and the SL
interosseous ligament to attach to the radial margin of the palmar horn
of the lunate. The interligamentous sulcus separates the RSC and LRL
ligaments throughout their courses. The LRL ligament has been called
continuing toward the triquetrum across the palmar horn of the lunate
renders this name misleading. Ulnar to the origin of the LRL ligament,
the radioscapholunate (RSL) “ligament” emerges into the radiocarpal
joint space through the palmar capsule and merges with the SL interos-
seous ligament and the interfossal ridge of the distal radius. This struc-
ture resembles more of a “mesocapsule” than a true ligament because
it is made up of small-caliber blood vessels and nerves from the radial
artery and anterior interosseous neurovascular bundle. Very little orga-
nized collagen is identified within this structure. The mechanical stabi-
lizing effects of this structure have recently been shown to be minimal.
The final palmar radiocarpal ligament, the short radiolunate (SRL) lig-
ament, arises as a flat sheet of fibers from the palmar rim of the lunate
fossa, just ulnar to the RSL ligament. It courses immediately distally to
attach to the proximal and palmar margin of the lunate.8 
Dorsal Radiocarpal Ligament
of the radius, essentially equally distributed on either side of Lister’s
tubercle (see Fig. 2.4). It courses obliquely distally and ulnarly toward
the triquetrum, to which it attaches on the dorsal cortex. There are
some deep attachments of the DRC ligament to the dorsal horn of the
lunate. Loose connective and synovial tissue forms the capsular mar-
gins proximal and distal to the DRC ligament.9 
 CHAPTER 2  Anatomy and Kinesiology of the Wrist
TH
TC T
P TT
LT UT
L DCH
UL UC
R
PRU
U
IOM
Fig. 2.6  Ulnocarpal and distal radioulnar joint complex from palmar per-
spective. IOM, interosseous membrane. Bones: L, Lunate; P, pisiform;
R, radius; T, triquetrum; U, ulna. Ligaments: LT, Palmar lunotriquetral;
PRU, palmar radioulnar; TC, triquetrocapitate; TH, triquetrohamate; UC,
ulnocapitate; UL, ulnolunate; UT, ulnotriquetral.
Ulnocarpal Ligaments
The ulnocarpal ligament arises largely from the palmar margin of the
TFCC, the palmar radioulnar ligament, and in a limited fashion, the
head of the ulna. It courses obliquely distally toward the lunate, tri-
quetrum, and capitate (Fig. 2.6). The ulnocarpal ligament has three
divisions, designated by their distal bony insertions. The UL ligament
is essentially continuous with the SRL ligament, forming a continu-
ous palmar capsule between the TFCC and the lunate. Confluent with
these fibers is the UT ligament, connecting the TFCC and the palmar
rim of the triquetrum. In 60% to 70% of normal adults, a small orifice
is found in the distal substance of the UT ligament, which leads to a
communication between the radiocarpal and pisotriquetral joints. Just
proximal and ulnar to the pisotriquetral orifice is the prestyloid recess,
which is generally lined by synovial villi and variably communicates
with the underlying ulnar styloid process. The UC ligament arises from
the foveal and palmar region of the head of the ulna, where it courses
distally, palmar to the UL and UT ligaments, and passes palmar to the
head of the capitate, where it interdigitates with fibers from the RSC
ligament to form an arcuate ligament to the head of the capitate. Few
fibers from the UC ligament insert to the capitate.10  ligament passes directly palmar to the LT interosseous ligament with
Midcarpal Ligaments
The midcarpal ligaments on the palmar surface of the carpus are true
capsular ligaments, and as a rule, they are short and stout, connect-
ing bones across a single joint space (see Figs. 2.3 and 2.6). Beginning
radially, the STT ligament forms the palmar capsule of the STT joint,
connecting the distal pole of the scaphoid with the palmar surfaces of
the trapezium and trapezoid. Although no clear divisions are noted,
it forms an apex-proximal V shape. The scaphocapitate (SC) ligament
is a thick ligament interposed between the STT and RSC ligaments,
coursing from the palmar surface of the waist of the scaphoid to the
palmar surface of the body of the capitate.11 There are no formal con-
nections between the lunate and capitate, although the arcuate liga-
ment (formed by the RSC and UC ligaments) has weak attachments
to the palmar horn of the lunate. The thick triquetrocapitate (TC) lig-
ament, which is analogous to the SC ligament, passes from the palmar
and distal margin of the triquetrum to the palmar surface of the body
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23
CH
CT
DCT
C
H
T
Fig. 2.7  Transverse section of the distal carpal row from distal and radial
perspective. C, Capitate; CH, dorsal capitohamate ligament; CT, dor-
sal trapezocapitate ligament; DCH, deep capitohamate ligament; DCT,
deep trapezocapitate ligament; H, hamate; T, trapezoid; TT, dorsal tra-
pezium-trapezoid ligament.
of the capitate. Immediately adjacent to the TC ligament, the triquetro-
hamate (TH) ligament forms the ulnar wall of the midcarpal joint and
is augmented ulnarly by fibers from the TFCC. The dorsal intercarpal
(DIC) ligament, originating from the dorsal cortex of the triquetrum,
crosses the midcarpal joint obliquely to attach to the scaphoid, trape-
zoid, and capitate (see Fig. 2.4). The attachment of the DIC ligament to
the triquetrum is confluent with the triquetral attachment of the DRC
ligament. In addition, a proximal thickened region of the joint capsule,
roughly parallel to the DRC ligament, extends from the waist of the
scaphoid across the distal margin of the dorsal horn of the lunate to the
triquetrum.4,9 This band, called the dorsal scaphotriquetral ligament,
forms a “labrum,” which encases the head of the capitate, analogous to
the RSC and UC ligaments palmarly. 
Proximal Row Interosseous Ligaments
The SL and LT interosseous ligaments form the interconnections
between the bones of the proximal carpal row and share several ana-
tomic features. Each forms a barrier between the radiocarpal and mid-
carpal joints, connecting the dorsal, proximal, and palmar edges of the
respective joint surfaces (see Fig. 2.5). This leaves the distal edges of the
joints without ligamentous coverage. The dorsal and palmar regions of
the SL and LT interosseous ligaments are typical of articular ligaments,
composed of collagen fascicles with numerous blood vessels and
nerves. However, the proximal regions are made up of fibrocartilage,
devoid of vascularization and innervation and without identifiable
collagen fascicles. The RSL ligament merges with the SL interosseous
ligament near the junction of the palmar and proximal regions. The UC
minimal interdigitation of fibers.12 
Distal Row Interosseous Ligaments
The bones of the distal carpal row are rigidly connected by a complex
system of interosseous ligaments (see Figs. 2.3 and 2.4). As is dis-
cussed later, these ligaments are largely responsible for transforming
the four distal row bones into a single kinematic unit. The trapezium–
trapezoid, trapeziocapitate, and capitohamate joints are each bridged
by palmar and dorsal interosseous ligaments. These ligaments consist
of transversely oriented collagen fascicles and are covered superfi-
cially by the fibrous capsular lamina, also consisting of transversely
oriented fibers. This lamina gives the appearance of a continuous sheet
of fibers spanning the entire palmar and dorsal surface of the distal
row. Unique to the trapeziocapitate and capitohamate joints are the
“deep” interosseous ligaments (Fig. 2.7). These ligaments are entirely
intraarticular, spanning the respective joint spaces between voids in
the articular surfaces. Both are true ligaments with dense, colinear
24 PART 1  Anatomy and Biomechanics
collagen fascicles, but they are also heavily invested with nerve fibers.
The deep trapeziocapitate interosseous ligament is located mid-
way between the palmar and dorsal limits of the joint, obliquely
oriented from palmar–ulnar to dorsal–radial, and each measures
approximately 3 mm in diameter. The respective attachment sites
of the trapezoid and capitate are angulated in the transverse plane
to accommodate the orthogonal insertion of the ligament. The deep
capitohamate interosseous ligament is found transversely oriented at
the palmar and distal corner of the joint. It traverses the joint from
quadrangular voids in the articular surfaces and measures approxi-
mately 5 × 5 mm in cross-sectional area.13  8
TENDONS
The tendons that cross the wrist can be divided into two major groups:
those that are responsible primarily for moving the wrist and those
that cross the wrist in their path to the digits. Both groups impart
some moment to the wrist, but obviously, those that are primary wrist
motors have a more substantial influence on motion of the wrist. The
five primary wrist motors can be grouped as either radial or ulnar devi-
ators and as either flexors or extensors.
The extensor carpi radialis longus (ECRL) and extensor carpi radi-
alis brevis (ECRB) muscles are bipennate and originate from the lateral
epicondyle of the humerus from a common tendon. Over the distal
radius epiphysis, they are found in the second extensor compartment,
from which they emerge to insert into the radial cortices of the bases
of the second and third metacarpals, respectively. The ECRL imparts a
greater moment for radial deviation than the ECRB, whereas the oppo-
site relationship is found for wrist extension. Both the ECRL and the
ECRB muscles are innervated by the radial nerve.
The ECU muscle is bipennate and originates largely from the prox-
imal ulna and passes through the sixth extensor compartment. Within
the sixth extensor compartment, the ECU tendon is contained within a
fibro-osseous tunnel between the ulnar head and the ulnar styloid pro-
cess. Distal to the extensor retinaculum, the ECU tendon inserts into
the ulnar aspect of the base of the fifth metacarpal. The ECU muscle is
innervated by the radial nerve.
The FCR muscle is bipennate and originates from the proximal
radius and the interosseous membrane. The tendon of FCR enters a
fibro-osseous tunnel formed by the distal pole of the scaphoid and
the beak of the trapezium; it then angles dorsally to insert into the
base of the second metacarpal. This fibro-osseous tunnel is sepa-
rate from the carpal tunnel. The FCR muscle is innervated by the
median nerve.
The FCU muscle is unipennate and originates from the medial epi-
condyle of the humerus and the proximal ulna. It is not constrained by
a fibro-osseous tunnel, in distinction to the other primary wrist motors.
It inserts into the pisiform and ultimately continues as the pisohamate
ligament. The FCU muscle is innervated by the ulnar nerve.  is consistently the least vascularized. The capitate is supplied by both
VASCULAR ANATOMY
Extraosseous Blood Supply
The carpus receives its blood supply through branches from three
dorsal and three palmar arches supplied by the radial, ulnar, ante-
rior interosseous, and posterior interosseous arteries (Fig. 2.8). The
three dorsal arches are named (proximal to distal) the radiocarpal,
intercarpal, and basal metacarpal transverse arches. Anastomoses
are often found between the arches, the radial and ulnar arteries,
and the interosseous artery system. The palmar arches are named
(proximal to distal) the radiocarpal, intercarpal, and deep palmar
arches.14,15  of the scaphoid. All vessels penetrate the cortex of the scaphoid distal
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4
7
5
6 9
3
2
R
U
1
Fig. 2.8 Palmar extraosseous blood supply of the wrist. 1, Anterior
interosseous artery; 2–4, transverse anastomotic arches; 5, deep
branch of radial artery; 6–9, longitudinal anastomotic network; R, radial
artery; U, ulnar artery.
Intraosseous Blood Supply
All carpal bones, with the exception of the pisiform, receive their
blood supply through dorsal and palmar entry sites and usually from
more than one nutrient artery. Generally, a number of small-caliber
penetrating vessels are found in addition to the major nutrient vessels.
Intraosseous anastomoses can be found in three basic patterns. First,
a direct anastomosis can occur between two large-diameter vessels
within the bone. Second, anastomotic arcades may form with simi-
lar-sized vessels, often entering the bone from different areas. A final
pattern, although rare, has been identified in which a diffuse arterial
network virtually fills the bone.
Although the intraosseous vascular patterns of each carpal bone
have been defined in detail, studies of the lunate, capitate, and scaphoid
are particularly germane because of their predilection to the develop-
ment of clinically important vascular problems. The lunate has only two
surfaces available for vascular penetration: the dorsal and palmar. From
the dorsal and palmar vascular plexuses, two to four penetrating ves-
sels enter the lunate through each surface. Three consistent patterns of
intraosseous vascularization have been identified based on the pattern
of anastomosis. When viewed in the sagittal plane, the anastomoses
form a Y, an X, or an I pattern with arborization of small-caliber vessels
stemming from the main branches. The proximal subchondral bone
the palmar and dorsal vascular plexuses; however, the palmar supply is
more consistent and originates from larger caliber vessels. Just distal to
the neck of the capitate, vessels largely from the ulnar artery penetrate
the palmar–ulnar cortex, whereas dorsal penetration occurs just distal
to the midwaist level. The intraosseous vascularization pattern consists
of proximally directed retrograde flow, with minimal anastomoses
between dorsal and palmar vessels. When present, the dorsal vessels
principally supply the head of the capitate, whereas the palmar vessels
supply both the body and the head of the capitate. The scaphoid typ-
ically receives its blood supply through three vessels originating from
the radial artery: lateral–palmar, dorsal, and distal arterial branches.
The lateral–palmar vessel is believed to be the principal blood supply
 CHAPTER 2  Anatomy and Kinesiology of the Wrist
to the waist of the scaphoid, coursing in a retrograde fashion to supply
the proximal pole. Although there have been reports of minor vascular
penetrations directly into the proximal pole from the posterior interos-
seous artery, substantial risk for avascular necrosis of the proximal pole
remains with displaced fractures through the waist of the scaphoid.
Overall, it is thought that the remaining carpal bones generally have
multiple nutrient vessels penetrating their cortices from more than one
side, hence substantially reducing their risk of avascular necrosis.14,15  biomechanical investigations of the wrist has increased almost expo-
WRIST INNERVATION
A large area of the cerebral cortical surface area is dedicated to hand
and wrist motion because of the complexity of the hand and wrist to
perform delicate tasks. As described by Hilton in the 19th century,
nerves that cross joints generally send branches innervating the joint
spanned. The wrist is no exception. Nerves to the wrist not only apply to
pain sensation but also proprioception sensation to the wrist. Although
there are numerous terminal articular nerve branches, these terminal
branches stem from the radial, median, lateral antebrachial cutaneous
(LABC), and medial antebrachial (MABC) nerves.16
The radial nerve arborizes at the level of the proximal forearm
giving off the posterior interosseous nerve (PIN) and the dorsal radial
sensory nerve (DRSN). The PIN courses distally giving off motor
branches to the ECU, ECRB, and digit extensors. After giving off the
last motor branch, the nerve courses, with purely sensory fibers, to
the floor of the fourth dorsal compartment terminating at the wrist
capsule. After branching off the radial nerve, the DRSN courses with
the radial artery deep to the brachioradialis muscle, tracking to the
dorsal radial aspect of the forearm piercing the fascia between the
brachial radialis and ECRL tendon. The nerve then arborizes, cross-
ing the radial wrist and radial CMC joints supplying sensation to the
dorsal radial wrist and hand. However, there may be cross innerva-
tion of the DRSN with the LABC at the level of the radial wrist and
hand. A cadaveric study from Mackinnon and Dellon16 noted that
75% of specimens had either complete overlap or partial overlap of
the terminal branches of the LABC and DRSN.
The main contributor of the median nerve to the wrist is the ante-
rior interosseous nerve (AIN) and the palmer cutaneous branch of
the median nerve. The AIN branches off of the median nerve in the
proximal forearm and innervates the motor units of the flexor pollicis
longus, flexor digitorum superficialis of the index and long fingers, and
pronator quadratus (PQ). The terminal branch of the AIN courses deep
to the PQ on the volar aspect of the interosseous membrane, terminat-
ing at the volar wrist capsule.17
The ulnar aspect of the wrist is innervated by the ulnar nerve with
sensory fibers from the ulnar nerve and the dorsal sensory branch of the
ulnar nerve (DSBUN). The DSBUN branches off the ulnar nerve proper
5.5 cm proximal to the ulnar head. It passes volar to the ulnar head before
traveling past the wrist to the dorsum of the hand. After giving off the
DSBUN, the ulnar nerve passes distally to the level of the Guyon’s canal.
The motor division branches off at the level of the hook of the hamate
and courses deep to innervate the hypothenar and interosseous muscles
of the hand. The sensory fibers course palmarly past the ulnar head and
then branch distally to the ulnar two digits of the hand. However, there
may be considerable overlap and variation of the sensory fibers partic-
ularly to the ulnar side of the wrist and TFCC.18 Branches innervating
the TFCC may come from the DSBUN, MABC, volar ulnar nerve, AIN,
PIN, and palmer cutaneous branch of the median nerve.
Given the known innervation pattern of the wrist, multiple wrist
denervation procedures have been described, which vary from total
wrist denervation to PIN neurectomy alone.19 Although outside the
scope of this chapter, various studies have revealed fair results with
wrist denervation procedures.  ing to their bases. The hand unit, made up of the metacarpals and
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25
KINEMATICS
Overview
Within 1 year after the announcement of the discovery of x-rays in
1895, Bryce published a report of a roentgenographic investigation
of the motions of the carpal bones. This marked a turning point for
basic mechanical investigations of the wrist. The number of published
nentially over the past 3 decades. As such, a review of all mechanical
analyses of the wrist is well beyond the scope of this chapter. Rather,
an overview of basic biomechanical considerations of the wrist is pre-
sented in the following categories: kinematics, kinetics, and material
properties.
The global range of motion (ROM) of the wrist, measured clinically,
is based on angular displacement of the hand about the “cardinal” axes
of motion: palmar flexion–dorsiflexion and radioulnar deviation. The
conicoid motion generated by combining displacement involving all
four directions of motion is called circumduction. A functional axis of
motion has also been described as the dart thrower’s axis, which moves
the wrist–hand unit from an extreme of dorsiflexion–radial deviation
to an extreme of palmar flexion–ulnar deviation. The magnitude of
angular displacement in any direction varies greatly among individ-
uals, but in “normal” individuals, it generally falls within the ranges
of palmar flexion (65–80 degrees), dorsiflexion (65–80 degrees), radial
deviation (10–20 degrees), ulnar deviation (20–35 degrees), forearm
pronation (80 degrees), and forearm supination (80 degrees).
Several attempts to define the “functional” ranges of wrist motion
required for various tasks of daily living, as well as vocational and rec-
reational activities, have been performed using axially aligned electro-
goniometers fixed to the hand and forearm segments of volunteers.
Although some variability among results was found, the vast majority
of tested tasks could be accomplished with 40 degrees of dorsiflexion,
40 degrees of palmar flexion, and 40 degrees of combined radial and
ulnar deviation. The concept of a “center of rotation” of the wrist has
been tested by a number of techniques and widely debated. It is gen-
erally agreed, however, that an approximation of an axis of flexion–
extension motion of the hand unit on the forearm passes transversely
through the head of the capitate, as does a separate orthogonal axis for
radioulnar deviation. It must be remembered that the global motion of
the wrist is a summation of the motions of the individual carpal bones
through the intercarpal joints as well as the radiocarpal and midcarpal
joints. Thus, although easier to understand, the concept of a center of
rotation of the wrist is at best an approximation and of limited basic
and clinical usefulness. 
Individual Carpal Bone Motion
The bones within each row display kinematic behaviors that are more
similar than those observed between the two rows. Because the kine-
matic behaviors of the carpal bones are measurably different between
palmar flexion–dorsiflexion and radioulnar deviation, these two arcs
of motion are considered separately (Figs. 2.9 and 2.10). More recently,
attention has been drawn to the importance of the “dart thrower’s”
axis of motion. This is a combination of the cardinal motions defined
later on, in which the wrist passes from radial deviation and exten-
sion through flexion and ulnar deviation. This represents a more phys-
iologic motion pattern than pure flexion–extension and radial–ulnar
deviation. It is being analyzed extensively in the laboratory for possible
implications in injury patterns and rehabilitation advantages.20,21 
Palmar Flexion–Dorsiflexion
The metacarpals are pulled through the range of palmar flexion
and dorsiflexion by the action of the extrinsic wrist motors attach-
26 PART 1  Anatomy and Biomechanics

In general, the proximal row bones follow the direction of motion

of the distal row bones during palmar flexion–dorsiflexion of the wrist
R (see Fig. 2.9). However, the scaphoid, lunate, and triquetrum are not as
tightly secured to the hand unit as are the distal row bones by virtue of
the midcarpal joint. In addition, the interosseous ligaments between
the proximal row bones allow for substantial intercarpal motion. Thus,
measurable differences occur between the motions of the proximal and
C
distal row bones, as well as between the individual bones of the prox-
S imal carpal row. This is most pronounced between the scaphoid and
lunate. From the extreme of palmar flexion to the extreme of dorsiflex-
A ion, the scaphoid undergoes substantially more angular displacement
than the lunate, primarily in the plane of hand motion. Measurable
“out-of-plane” motions occur between the scaphoid and lunate as well
because the scaphoid progressively supinates relative to the lunate as the
C wrist dorsiflexes. The effect of the differential direction and magnitude
of displacement between the scaphoid and lunate is to create a relative
R separation between the palmar surfaces of the two bones as dorsiflex-
ion is reached and a coaptation of the two surfaces as palmar flexion is
S reached. The extremes of displacement are checked by the “twisting” of
the fibers of the interosseous ligaments. When this limit is reached, the
B scaphoid and lunate move as a unit through the radiocarpal and mid-
Fig. 2.9  Schematic of carpal bone motion during wrist palmarflexion (A) carpal joints. Similar, although of lesser magnitude, behaviors occur
and dorsiflexion (B). Note that all three bones essentially move in the through the LT joint. In all, the lunate experiences the least magnitude
same plane synchronously. C, Capitate; R, radius; S, scaphoid (lunate of rotation of all carpal bones during palmar flexion and dorsiflexion.
shown as shaded bone).
The radiocarpal and midcarpal joints contribute nearly equally to the
range of dorsiflexion and palmar flexion of the wrist when measured
through the capitolunate–radiolunate joint column. In contrast, when
measured through the radioscaphoid–STT joint column, more than
R two thirds of the ROM occurs through the radioscaphoid joint.22,23 
C
Radioulnar Deviation
As with palmar flexion and dorsiflexion, the bones of the distal row
move essentially as a unit with themselves as well as with the second
S
through fifth metacarpals during radial and ulnar deviation of the wrist
A (see Fig. 2.10). However, the proximal row bones display a remarkably
different kinematic behavior. As a unit, the proximal carpal row dis-
plays a “reciprocating” motion with the distal row, such that the prin-
cipal motion during wrist radial deviation is palmar flexion (see Fig.
2.10). Conversely, during wrist ulnar deviation, the proximal carpal
C R row dorsiflexes. In addition to the palmar flexion–dorsiflexion activity
of the proximal carpal row, a less pronounced motion occurs, result-
ing in ulnar displacement during wrist radial deviation and radial dis-
S
placement during wrist ulnar deviation. Additional longitudinal axial
displacements occur between the proximal carpal row bones, as they
B do during palmar flexion and dorsiflexion. Although of substantially
lower magnitude than the principal directions of rotation, these longi-
Fig. 2.10  Schematic of carpal bone motion during wrist radial deviation
(A) and ulnar deviation (B). Note that the scaphoid and lunate primar- tudinal axial displacements contribute to a relative separation between
ily palmarflex during radial deviation and dorsiflex during ulnar devia- the palmar surfaces of the scaphoid and lunate in wrist ulnar deviation
tion. This behavior is called conjunct rotation. C, Capitate; R, radius; S, and a relative coaptation during wrist radial deviation, limited by the
scaphoid (lunate shown as shaded bone). tautness of the SL interosseous ligament. When maximum tension is
achieved, the two bones displace as a single unit. As with palmar flexion
phalanges, is securely associated with the distal carpal row through and dorsiflexion, the lunate experiences the least magnitude of rotation
the articular interlocking and strong ligamentous connections of of all carpal bones during radial and ulnar deviation. The magnitude of
the second through fifth carpometacarpal joints. The trapezoid, rotation through the midcarpal joint is approximately 1.5 times greater
capitate, and hamate undergo displacement with their respective than the radiocarpal joint during radial and ulnar deviation.22,23 
metacarpals with no significant deviation of direction or magni-
tude of motion (see Fig. 2.9). Because of the strong interosseous KINETICS
ligaments, the trapezium generally tracks with the trapezoid but
remains under the influence of the mobile first metacarpal. The Force Analysis
major direction of motion for this entire complex is palmar flexion Force analyses of the wrist have been attempted using a variety of
and dorsiflexion, with little deviation in radioulnar deviation and methods, including the analytical methods of free-body diagrams
pronation–supination. and rigid-body spring models and experimental methods using force

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 CHAPTER 2  Anatomy and Kinesiology of the Wrist
31
21
19
29
46
8
32
14
Fig. 2.11 Schematic of the wrist showing the approximate load per-
centages transmitted across the midcarpal joint and the percentages
transmitted across the radiocarpal joint.
transducers, pressure-sensitive film, pressure transducers, and strain
gauges. Because of the intrinsic geometric complexity of the wrist, the
large number of carpal elements, the number of tissue interfaces that
loads are applied to, and the large number of positions that the wrist
can assume, these analyses have been difficult and are riddled with
assumptions. Thus relative changes and trends in forces brought about
by the introduction of experimental variables are generally more useful
than absolute values.  distal radius. Abstracts Uppsala Diss Faculty Med. 1984;505:1–174.
Normal Joint Forces
Experimental and analytical studies of force transmission across the
wrist in the neutral position are in general agreement that approxi-
mately 80% of the force is transmitted across the radiocarpal joint and
20% across the ulnocarpal joint space (Fig. 2.11). This can be further
compartmentalized into forces across the UL articulation (14%) and
the UT articulation (8%). In the neutral position, one study reported
that 78% of the longitudinal force across the wrist is transmitted
through the radiocarpal articulation, with 46% transmitted by the
radioscaphoid fossa and 32% by the lunate fossa. Forces across the mid-
carpal joint in a neutrally positioned joint have been estimated to be
31% through the STT joint, 19% through the SC joint, 29% through the
lunatocapitate joint, and 21% transmitted through the triquetrohamate
joint. In general, it has been shown that forearm pronation increases
ulnocarpal force transmission (up to 37% of total forces transmitted),
with a corresponding decrease in radiocarpal force transmission. This
has been theoretically linked to the relative distal prominence of the
ulna that occurs in forearm pronation. The ulnocarpal force trans-
mission increases to 28% of the total in ulnar deviation of the wrist,
whereas radiocarpal forces increase to 87% of the total in radial devi-
ation. Wrist palmar flexion and dorsiflexion have only a modest effect
on the relative forces transmitted through the radiocarpal and ulnocar-
pal joints.21,24,25  anatomy of the human carpus. Part I: the extraosseous vascularity. J Hand
Normal Joint Contact Area and Pressure
With use of pressure-sensitive film placed in the radiocarpal joint
space, three distinct areas of contact through the radiocarpal joint have
been identified: radioscaphoid, radiolunate, and UL. Overall, it has
been determined that the actual area of contact of the scaphoid and
lunate against the distal radius and TFCC are quite limited, regardless
of joint position, averaging 20% of the entire available articular sur-
face. The scaphoid contact area was greater than that of the lunate by
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27
an average factor of 1.5. The centroids of the contact areas shift with
varying positions of the wrist, as do the areas of contact. For example,
palmar flexion of the scaphoid results in a dorsal and radial shift of the
radioscaphoid contact centroid and a progressive diminution of con-
tact area. With externally applied loads, the peak articular pressures
are low, ranging from 1.4 to 31.4 N/mm.2 The midcarpal joint has been
difficult to evaluate using pressure-sensitive film because of its complex
shape. It has been estimated that less than 40% of the available articular
surface of the midcarpal joint is in actual contact at any one time. The
relative contributions to the total contact of the STT, SC, lunatocapi-
tate, and triquetrohamate joints have been estimated to be 23%, 28%,
29%, and 20%, respectively. Thus, it may be surmised that more than
50% of the midcarpal load is transmitted through the capitate across
the scaphocapitate and lunatocapitate joints.21,24,25 
SUMMARY
The wrist is a complex joint and truly a mechanical marvel. A thorough
understanding of the anatomy and kinesiology of the wrist is required
by all involved in any aspect of diagnosis, treatment, and rehabilitation
of wrist disorders. This understanding provides the insight and foun-
dation needed in the approach to conservative, operative, or rehabili-
tation management.
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