236 Section II   Upper Extremity

Anterior (palmar)

ra
r
to
ev r

Fl de
r d xo

d
ia

ex vi
ia
n a F le

l
or ato
Flexor Flexor carpi
carpi Flexor
radialis

ul
digitorum

r
ulnaris
superficialis
Abductor
Pis Trapezium pollicis
ifo Flexor longus
rm Flexor
uetr digitorum
pollicis Sc

Triq
profundus a

um

(Lateral) radial
Medial (ulnar)
longus Extensor

ph
pollicis brevis

oi d
ML
Axis Ca
pit Extensor carpi
Hamate ate radialis longus
Extensor Extensor carpi Extensor
carpi radialis brevis pollicis
Extensor longus
ulnaris
digitorum

vi r
or
Ex r d

de so
ul

at
na

al n
te evi

di xte
ns at

E
or or

Axis
AP

ra
1 cm Posterior (dorsal)

FIG. 7.24 A cross-sectional view looking distally through the right carpal tunnel, similar to the perspective shown in
Fig. 7.5. The plot depicts the cross-sectional area, position, and length of the internal moment arms for most muscles
that cross the wrist at the level of the head of the capitate. The area within the red boxes on the grid is proportional
to the cross-sectional area of the muscle’s belly and therefore indicative of the relative maximal force production. The
small black dot within each red box indicates the position of the muscle’s tendon. The wrist’s medial-lateral (ML) axis
of rotation (dark gray) and anterior-posterior (AP) axis of rotation (red) intersect within the head of the capitate bone.
Each muscle’s moment arm for a particular action is equal to the perpendicular distance between the particular axis
and the position of the muscle’s tendon. The length of each moment arm (expressed in centimeters) is indicated by
the major tick marks. Assume that the wrist is held in a neutral position.

from repetitive or forceful activities that increase tension on the
associated tendons.17 The tendons and surrounding synovial
membranes within compartment I are particularly susceptible to
inflammation, a condition called de Quervain’s tenosynovitis. Activ-
ities that frequently cause this painful condition include repeti-
tively pressing the trigger switch on a power tool, gripping tools
while simultaneously supinating and pronating the forearm, or
wringing out clothes. De Quervain’s tenosynovitis is typically
treated conservatively by using phonophoresis or iontophoresis,
administering corticosteroid injections, applying ice, wearing a
hand-wrist–based thumb splint, and modifying the activities that
caused the inflammation.51 If conservative therapy fails to reduce
the inflammation, surgical release of the first compartment may
be indicated.
Biomechanical Assessment of Wrist Muscles’ Action and
Torque Potential
Data are available on the relative position, cross-sectional area,
and length of the internal moment arms of most muscles that
cross the wrist.5,46,79,101 By knowing the approximate location of
the axes of rotation of the wrist, these data provide a useful
method for estimating the action and relative torque potential of
the wrist muscles (Fig. 7.24). Consider, for instance, the extensor
carpi ulnaris and the flexor carpi ulnaris. By noting the location
of each tendon from the axis of rotation, it is evident that the
extensor carpi ulnaris is an extensor and ulnar deviator and the
flexor carpi ulnaris is a flexor and ulnar deviator. Because both
muscles have similar cross-sectional areas, they likely produce
comparable levels of maximal force. To estimate the relative torque
production of the two muscles, however, each muscle’s cross-
sectional area must be multiplied by each muscle’s specific moment
arm length. The extensor carpi ulnaris therefore is considered a
more potent ulnar deviator than an extensor; the flexor carpi
ulnaris is considered both a potent flexor and a potent ulnar
deviator.
Wrist Extensor Activity While Making a Fist
The main function of the wrist extensors is to position and sta-
bilize the wrist during activities involving active flexion of the
digits. Of particular importance is the role of the wrist extensor
muscles in making a fist or producing a strong grip. To demon-
strate this, rapidly tighten and release the fist and note the strong
synchronous activity from the wrist extensors. The extrinsic finger
flexor muscles, namely the flexor digitorum profundus and flexor
digitorum superficialis, possess a significant internal moment arm
as wrist flexors. The leverage of these muscles for wrist flexion is
evident in Fig. 7.24. The wrist extensor muscles must counterbal-
ance the significant wrist flexion torque produced by the finger
flexor muscles (Fig. 7.25). As a strong, static grip is applied to an
object, such as a hammer, the wrist extensors typically hold the
wrist in about 30 to 35 degrees of extension and about 5 to 15
degrees of ulnar deviation.45,67 The extended position optimizes
the length-tension relationship of the extrinsic finger flexors,
thereby facilitating maximal grip strength (Fig. 7.26).
The naturally large mechanical demands placed on the wrist
extensors during grasp may be associated with pathology. Ana-
tomic factors have implicated greater pathomechanical involve-
ment in the extensor carpi radialis brevis compared with the other
 Chapter 7   Wrist 237

wrist extensors. Part of the proximal attachment of the short radial
wrist extensor blends with the capsule of the humeroradial joint
and adjacent radial collateral ligament of the elbow.63,96 Applica-
tion of excessive and repetitive force in this muscle may therefore
overstress these connective tissues, predisposing them to patho-
logic or degenerative changes. Furthermore, the proximal tendon
of the extensor carpi radialis brevis naturally contacts the lateral
margin of the capitulum (of the distal humerus) during flexion
and extension of the elbow. This contact may abrade the under-
surface of this muscle.7
As evident in Fig. 7.26, grip strength is significantly reduced
when the wrist is fully flexed. The decreased grip strength is
caused by a combination of two factors. First, and likely foremost,
the finger flexors cannot generate adequate force because they are
functioning at an extremely shortened length respective to their
600

Compressive force (newtons)

3rd me
tac 400
ar
pa

Extensor carpi radialis brevis

l

ate

Radius
pit

Lunate

Ca

Flexor digitorum profundus

Flexor digitorum superficialis
200

FIG. 7.25 Muscle mechanics involved with the production of a strong

grip. Contraction of the extrinsic finger flexors (flexor digitorum super-
ficialis and profundus) flexes the fingers but also creates a simultaneous
wrist flexion torque. Activation of the wrist extensors, such as the extensor 0
90 60 30 0 30 60 90
carpi radialis brevis, is necessary to block the wrist flexion tendency
caused by the activated finger flexor muscles. In this manner the wrist Wrist angle (degrees)
extensors maintain the optimal length of the finger flexors to effectively FIG. 7.26 The compression forces produced by a maximal-effort grip are
flex the fingers. The internal moment arms for the extensor carpi radialis shown for three different wrist positions (for three subjects). Maximal
brevis and extrinsic finger flexors are shown in dark bold lines. The small grip force occurs at about 30 degrees of extension. (With permission from
circle within the capitate marks the medial-lateral axis of rotation at the Inman VT, Ralston HJ, Todd F: Human walking, Baltimore, 1981, Wil-
wrist. liams & Wilkins.)

S PE C I A L F O C U S 7 . 4

Overuse Syndrome of the Wrist Extensor Muscles: “Lateral Epicondylalgia”

T he most active wrist extensor muscle during a light grasp is

the extensor carpi radialis brevis.76 As the force of grip
increases, the extensor carpi ulnaris and extensor carpi radialis
longus also become active. Activities that require repetitive and
forceful grasp, such as hammering or playing tennis, may over-
stress the proximal attachment site of the wrist extensor muscles.
This situation may lead to a painful, chronic condition called lateral
epicondylalgia or, more informally, “tennis elbow.” The stress
placed on this region of the elbow may be great; the large muscle
force required for grasp is spread across a relatively small attach-
ment site on the lateral epicondyle of the humerus.
The incidence of lateral epicondylalgia is associated with high
physical demands placed on the wrist and elbow, often occurring
at the workplace.31 Symptoms include a painful and weakened
grip, as well as pain with passive wrist flexion and forearm prona-
tion, and tenderness over the lateral epicondyle. Traditional con-
servative treatment includes splinting or bracing, manual therapy
(including cross-friction massage), nonsteroidal anti-inflammatory
drugs, stretching and strengthening of wrist extensor and
other muscles, eccentric muscle training, and other physical
modalities such as ultrasound, ice, electrotherapy, and
iontophoresis.3,4,11,78,104
The pathophysiology of lateral epicondylalgia is not totally
understood. In the past, the condition was often called lateral
epicondylitis, reflecting the belief that the stressed proximal
tendon of the wrist extensors, especially the extensor carpi radialis
brevis, was actually inflamed (hence the suffix -itis). Several dif-
ferent lines of research have reported, however, that the affected
tendons do not show indicators of inflammation, but of degenera-
tion.1,43,75 What has traditionally been thought to be a primary
inflammatory process is now believed to be degenerative with an
incomplete reparative process, similar to that observed with
advanced aging, vascular compromise, and repetitive micro-
trauma.81,103 It is possible that, in some cases, both inflammatory
and degenerative processes are at work. Regardless of the actual
pathologic process, the root of the problem is at least partially of
biomechanical origin: a large stress is placed on the wrist extensor
muscles to balance the strong wrist flexion potential of the extrin-
sic finger flexors.
238 Section II   Upper Extremity

FIG. 7.27 A person with paralysis of her right wrist

extensor muscles (after a radial nerve injury) is perform-
ing a maximal-effort grip using a dynamometer. (A)
Despite normally innervated finger flexor muscles,
maximal grip strength measures only 10 pounds (about
4.5 kg). (B) The same person is shown stabilizing her
wrist to prevent it from flexing during the grip effort.
Note that the grip force has nearly tripled.

A B

length-tension curve. Second, the overstretched finger extensors,

particularly the extensor digitorum, create a passive extensor
torque at the fingers, which further reduces effective grip force.
This combination of physiologic and biomechanical events
explains why a person with paralyzed or weakened wrist extensor Anterior view
muscles (from a radial nerve injury for example) has difficulty
producing an effective grip, even though the finger flexor muscles
are fully innervated. Trying to produce a maximal-effort grip with
markedly weakened extensors results in an abnormal posture of
finger flexion and wrist flexion (Fig. 7.27A). Stabilizing the wrist
in greater extension enables the finger flexor muscles to nearly
triple their grip force (see Fig. 7.27B). Manually or orthotically Medial epicondyle
preventing the wrist from flexing maintains the extrinsic finger
flexors at an elongated length more conducive to a higher force
production.
Ordinarily the person depicted in Fig. 7.27 wears a splint that Pronator teres
holds the wrist in 10 to 20 degrees of extension. If the radial nerve
fails to reinnervate the wrist extensor muscles, a tendon from
Palmaris longus
another muscle may be surgically re-routed to provide wrist exten-
sion torque. For example, the pronator teres muscle, innervated Flexor carpi radialis
Flexor carpi ulnaris
by the median nerve, is sutured to the tendon of the extensor carpi
radialis brevis. Of the three primary wrist extensors, the extensor
carpi radialis brevis is located most centrally at the wrist, and has Flexor digitorum
the greatest moment arm for wrist extension (see Fig. 7.24). superficialis

FUNCTION OF THE WRIST FLEXORS Palmar carpal

ligament
Muscular Anatomy
The three primary wrist flexors are the flexor carpi radialis, the Pisiform
flexor carpi ulnaris, and the palmaris longus (Fig. 7.28). The pal-
maris longus is typically absent in about 15% of people, although Pa
lma
this frequency may vary significantly according to ethnicity.88,100 r apo
neurosis
Even when present, the muscle often exhibits variation in shape
and number of tendons. The tendon of this muscle is often used
as a donor in tendon grafting surgery. FIG. 7.28 Anterior view of the right forearm showing the primary wrist
The tendons of the three primary wrist flexor muscles are easily flexor muscles: flexor carpi radialis, palmaris longus, and flexor carpi
identified on the anterior distal forearm, especially during strong ulnaris. The flexor digitorum superficialis (a secondary wrist flexor) and
isometric activation. The palmar carpal ligament, not easily pronator teres muscles are also shown.