6 Biomechanics of The Elbow and Forearm, Wrist and Hand - Compressed

Biomechanics of the elbow and
forearm
Human Movement | 2023/2024
António Mesquita Montes PT, MSc, PhD | Carlos Crasto PT, MSc, PhD | Diogo Silva PT, MSc, PhD
antonio.montes@santamariasaude.pt | carlos.crasto@santamariasaude.pt | diogo.silva@santamariasaude.pt
Mod. 45 1
Human Movement – Biomechanics of the elbow and forearm
qOsteokinema+cs
Humero-ulnar and humeroradial joints
145°
Hinged joint
130°
Flexion/ extension
- Movement in the sagi/al plane, along a mediolateral axis
- The forearm rota8on occurs around an axis of rota8on that extends

from the capitulum through the trochlea)
30°
A –5°
Mod. 45 FIGURE 6-16. Range of motion at the elbow. 2 A, A
from 5 degrees beyond neutral extension through 1

30 to 130 degrees of flexion (in red) is based on th
of motion at the elbow typically needed to perfo
pouring from a pitcher, rising from a chair, holdin
mouth, bringing a glass to the mouth, and holdin
qOsteokinematics
Chapter 6 Elbow and Forearm 183
140
145°
120
Elbow flexion (degrees)

130°
100
80
60
40
20
0
Door Pitcher Chair News- Knife Fork Glass Tele-
30° phone
paper
A –5° B
Activities of daily living
FIGURE 6-16. Range of motion at the elbow. A, A healthy person showing an average range of elbow motion
from 5 degrees beyond neutral extension through 145 degrees of flexion. The 100-degree “functional arc” from
30 to 130 degrees of flexion (in red) is based on the data in the histogram. B, The histogram shows the range
of motion at the elbow typically needed to perform the following activities of daily living: opening a door,
pouring from a pitcher, rising from a chair, holding a newspaper, cutting with a knife, bringing a fork to the
mouth, bringing a glass to the mouth, and holding a telephone. (Modified from Morrey BF, Askew LJ, Chao
EY: A biomechanical study of normal functional elbow motion, J Bone Joint Surg Am 63:872, 1981.)
Mod. 45 3
convexity of the capitulum (Figure 6-19). During active flexion,

rus
the radial fovea is pulled firmly against the capitulum by con-

Hume
tracting muscles.46
Compared with the humero-ulnar joint, the humeroradial
joint provides minimal sagittal plane stability to the elbow.
The humeroradial joint does, however, provide about 50% of
qArthrology
Normal “Valgus Angle” of the

Elbow
Normal cubitus valgus
- 5º a 10º in males
- 10º a 15º in females
Mod. 45 4
Human Movement – Biomechanics of the elbow and forearm Chapter 6 Chapter
Elbow6andElbow and Forearm 179
Forearm 179
qArthrology
Humerus Coronoid fossa
Coronoid fossa
Humerus
Humerus
Humerus
M
ed
M
le
ia
ed
pi
Periarticular connective tissues le
ia
pi
co
Radial fossa
ndyle
co
Radial fossa
ndyle
Trochlea
Trochlea
The articular capsule of the elbow encloses: yle Capitulum
e
dial epicondyl
teral epicond
yle Capitulum Articular
e
dial epicondyl
- Humero-ulnar joint capsule (cut)
teral epicond
Articular
Articular
capsule capsule (cut)
- Humeroradial joint
La
Articular
Lateral
Me
collateral
capsule Synovial membrane
La
Lateral
- Proximal radio-ulnar joint ligament Medial
Me
collateral Annular collateral
Synovial membrane Longitudinal
ligament ligament Medial ligament crest
Annular collateral Longitudinal
ligament ligament crest
The ligaments of the elbow:
Fovea
Oblique cord Annular ligament

- Medial collateral Fovea
Annular ligament
- Lateral collateral Oblique cord
- Annular
Radius Ulna Radius Ulna
Radius Ulna Radius Ulna

Anterior view
FIGURE 6-10. An anterior view of the right elbow showing the FIGURE 6-11. Anterior view of the right elbow disarticulated to
capsule and collateral ligaments. expose the humero-ulnar and humeroradial joints. The margin of
Anterior view the proximal radio-ulnar joint is shown within the elbow’s capsule.
Note the small area on the trochlear notch lacking articular cartilage.
FIGURE 6-10. An anterior view of the right elbow showing the FIGURE 6-11.The
Anterior
synovialview of thelining
membrane right the
elbow disarticulated
internal side of the to
capsule is
capsule and collateralTABLE 6-1. Motions That Increase Tension
ligaments. expose the humero-ulnar
shown in blue.and humeroradial joints. The margin of
in the Collateral Ligaments of the Elbow the proximal radio-ulnar joint is shown within the elbow’s capsule.
Motions That Note the small area on the trochlear notch lacking articular cartilage.
Mod. 45 Ligament
TABLE 6-1. Motions That Increase Tension
Increase Tension The synovial membrane lining the internal side of the capsule is 5
shown in blue.
in the Collateral Ligaments of the
Medial collateral Elbow
ligament Valgus
(anterior fibers*) Extension and flexion least some fibers are taut throughout sagittal plane move-
Motions That
Medial collateral ligament Valgus ment. The anterior fibers therefore provide articular stability
Ligament Increase Tension
(posterior fibers) Flexion throughout the entire range of motion.10
Radial collateralValgus
Medial collateral ligament ligament Varus The posterior fibers of the medial collateral ligament are less
(anterior fibers*) External rotation
Extension and flexion least some defined thantaut
fibers are the anterior
throughoutfibers sagittal
and are essentially
plane move-thickenings
Lateral (ulnar) collateral Varus of the posterior-medial capsule. As depicted in Figure 6-12,
Medial collateral ligament Valgus ment. The anterior fibers therefore provide articular stability
ligament* External rotation and flexion the posterior fibers attach on the 10 posterior part of the medial
Human Movement – Biomechanics of the elbow and forearm Chapter 6 Elbow and Forearm 181
Lateral aspect
qArthrology
Humerus
Annular ligament
PeriarBcular connecBve Bssues
Radial
Lateral collateral collateral ligament
ligament complex Radius
Lateral (ulnar)
collateral ligament
Ulna
Supinator crest
FIGURE 6-14. The components of the lateral collateral ligament complex of the right elbow.
180 Section II Upper Extremity
Medial aspect
sive external rotation of the forearm with subsequent KINEMATICS
Humerus
subluxation of both the humero-ulnar and humeroradial
Functional Considerations of Flexion and Extension
joints.19,54
The ligaments around the elbow are endowed with mech- Elbow flexion performs several important physiologic func-
anoreceptors consisting of Golgi organs, Ruffini terminals, tions, such as pulling, lifting, feeding, and grooming.77 The
Medial
Pacinian corpuscles, and free nerve endings.59 These recep- inabilityepicondyle
to actively bring the hand to the mouth for feeding,
tors may supply important information to the nervous
Annular ligament for example, significantly limits the level of functional inde-
system for augmenting proprioception and detecting safe pendence. Persons with a spinal cord injury above the C5
Oblique cord
limits of passive tension in the structures around the nerve root may experience this profound functional impair-
elbow. ment because of paralysis of elbow flexor muscles.
As all joints do, theRadius
elbow joint has an intracapsular air Elbow extension
Anterior part occurs with activities such as throwing,
pressure. This pressure, which is determined by the ratio of pushing, and reaching.
Posterior part Medial
Loss of complete extension because
the volume of air to the volume of space, is lowest at about of an elbow flexion collateral ligament
contracture is often caused by marked
Transverse part
80 degrees of flexion.24 This joint position is often considered stiffness in the elbow flexor muscles. The muscles become
the “position of comfort” for persons with joint inflammation
Ulna abnormally stiff after long periods of immobilization in a
and swelling. Maintaining a swollen elbow in a flexed posi- flexed and shortened position. Long-term flexion may be the
tion may improve comfort but may predispose the person to result of casting for a fractured bone or of posttraumatic
Mod. 45 FIGURE 6-12. The components of the medial collateral ligament of the right elbow.
an elbow flexion contracture (from the Latin root contractura, heterotopic ossification, osteophyte formation, elbow 6joint
to draw together). inflammation and effusion, muscle spasticity, paralysis of the
S P E C I A L F O C U S 6-1
qArthrology
Periarticular connective tissues
Medial collateral ligament
Mod. 45 7
qArthrokinema+cs
Humero-ulnar joint
Ulnar nerve
Humerus
rs
icondyle
o
x
Fle
AC
Ex
P
te
Medial Ep
FIGURE 6-18. A sagittal section through the
nsors
C
le
Anterio lexors
is
humero-ulnar joint. A, The joint is resting in full
ps u
Derm
extension. B, The joint is passively flexed through
r ca
E
F
full flexion. Note that in full flexion the coronoid
ID
lear notch
ROLL
r
process of the ulna fits into the coronoid fossa of
-Posterio
SL
MCrLio- r
hlea
the humerus. The medial-lateral axis of rotation is
e
Ant
shown through the center of the trochlea. The
oc
CL
Tr M
ch
stretched (taut) structures are shown as thin elon- o
Tr
gated arrows, and slackened structures are shown
as wavy arrows. AC, anterior capsule; MCL-Ante-
rior, some anterior fibers of the medial collateral
ligament; MCL-Posterior, posterior fibers of the
F
E
Ulna
medial collateral ligament; PC, posterior capsule.
L
X
IO
N
A B
Resting in extension
Mod. 45 8
Most elbow flexors, and essentially all primary supinator

umerus
and pronator muscles, have their distal attachment on the

radius. As a consequence, contraction of these muscles pulls
forearm (relative pronation-supination), body mass in- in the direction of the groove will alter the pathway of the
(indicating overweight) has been identified as a factor lim an
dex, and the position of the shoulder. The range of active forearm, so that when the elbow is passively flexed, the fore- pr
iting elbow range of motion;9,51however, this finding is con
arm will come to rest either medial (Fig. 8–15B) or lateral ra
troversial. Golden 58 measured the range of motion of 22
(Fig. 8–15C) to the humerus in full flexion.
9 su
elbows in 113 healthy children between the ages of 2 an 14
18. The authors
Mobility and Stability found a decrease in elbow range of motio
an
Human Movement – Biomechanics of the elbow and forearm of 2° to 3° for each Z score increase (indicating an increas
A number of factors that
in weight)—so determine
an AZthebodyamountmassof index
motionscore
fle
that of pr
5.
is available at the elbow joint. These factors include
would limit the elbow range of motion by 11° to 17°. pr the
type ofThemotion (active
position of theorshoulder
passive),may position
the affect the of the of mo
range fo
qArthrokinematics forearm (relative pronation-supination), body mass
tion available to the elbow because of the two joint muscle in- (in
dex, and the position of the shoulder. The range of active
that cross both the shoulder and elbow. These muscles, iti th
biceps brachii and the triceps brachii, may limit rangetro o
Humero-ulnar joint motion at the elbow if a full range of motion is attempted a elb
both joints simultaneously. 18
of
Flexion in
wo
- The configuration of the trochlear groove determines the trajectory of Concept Cornerstone 8-3
the forearm during flexion and extension. tio
Two-Joint Muscle Effects on Elbow th
Range of Motion bi
m
Two or multijoint muscles do not have sufficient lengt
A B C bo
to allow a simultaneous full range of motion at all joint
Figure 8–15 Position of the forearm in passive flexion. A. In crossed. For example, in passive motion, passive ten
the most common configuration of the trochlear groove, the ulna sion in the triceps brachii may limit full elbow flexio
is guided progressively medially from extension to flexion so that when the shoulder is simultaneously moved into fu
in full flexion the forearm comes to rest in the same plane as the flexion (Fig. 8–16A). In active motion, torque produce
humerus. B. The forearm comes to rest slightly medially to the by the long head of the biceps brachii may diminish a
humerus in passive flexion. C. The forearm comes to rest slightly the muscle is excessively shortened over both joints i
laterally in the least common configuration of the trochlear full active shoulder and elbow flexion (Fig. 8–16B).
groove. A B C
Figure 8–15 Position of the forearm in passive flexion. A. In
Mod. 45 the most common configuration of the trochlear groove, the ulna 9
is guided progressively medially from extension to flexion so that
in full flexion the forearm comes to rest in the same plane as the
humerus. B. The forearm comes to rest slightly medially to the
humerus in passive flexion. C. The forearm comes to rest slightly
laterally in the least common configuration of the trochlear
A
Resting in extension

qArthrokinema+cs Most elbow flexo
Humerus
and pronator musc
radius. As a consequ
the radius proximal
Humeroradial joint Anteri
or
ca
especially when the
ps cal analysis indicate
the humeroradial j
ul
Capi
e
weight during maxim
ROLL
SLIDE
tul
ter Radius
nism described in
al
La
um
Epic.
Po
helps shunt some
ste L
rior capsule c ateral (ulnar
) forces from the radiu
ollateral Ulna membrane helps pr
ligament
myogenic compress
N
membrane can caus
IO
X radius due to activa
E
FL
increased loading an
radial joint.32,55 In ca
FIGURE 6-19. A sagittal section through the humeroradial joint
during passive flexion. Note the medial-lateral axis of rotation in the surgically removed b
center of the capitulum. The stretched (taut) structures are shown is typically pronou
as thin elongated arrows, and slackened structures are shown as wavy of the radius can
arrows. Note the elongation of the lateral (ulnar) collateral ligament distal radio-ulnar jo
during flexion. function.16
The predominan
Mod. 45 brane is not10 aligne
radius. For example
extended causes a d
located within the “ulnocarpal space.”57 Because of the fiber the radius (Figure 6-
direction of the central bands of the interosseous membrane, rather than tenses,
part of the proximal directed force through the radius is thereby placing larg
Radius
Ulna
2 3
cranon
Ole
qInterosseous membrane Trochlear notch

5
Head
Function Radiocarpal joint Ulnocarpal space 4
1 Oblique cord
- Fibers are directed distal-medially from the radius, connecting to and
intersecting with the shaft of the ulna at about 20 degrees Radius Ulna
Radius
Ulna
2 3
Styloid process
COMPRESSION
FORCE
w of the right forearm, highlighting the
us membrane. Interosseous membrane
FIGURE 6-21. A compression force through the hand is transmitted

Radiocarpal joint Ulnocarpal space
primarily through the wrist (1) at the radiocarpal joint and to the
radius (2). This force pulls the interosseous membrane taut (shown 1
by two black arrows), thereby transferring a significant part of the

iter carrying a tray of food, directs compression force to the ulna (3) and across the elbow at the
ugh the radius, so that the interos- humero-ulnar joint (4). The compression forces that cross the Styloidelbow
process
t with dispersing the load more are finally directed toward the shoulder (5). The stretched (taut) COMPRESSION
FORCE
structures are shown as thin elongated
FIGURE arrows.
6-20. An anterior view of the right forearm, highlighting the
m. components of the interosseous membrane.
FIGURE 6-21. A compression force through the hand is transmitted
primarily through the wrist (1) at the radiocarpal joint and to the
Mod. 45 11
radius (2). This force pulls the interosseous membrane taut (shown
by two black arrows), thereby transferring a significant part of the
level, for example, like a waiter carrying a tray of food, directs compression force to the ulna (3) and across the elbow at the
the weight proximally through the radius, so that the interos- humero-ulnar joint (4). The compression forces that cross the elbow
are finally directed toward the shoulder (5). The stretched (taut)
HE PROXIMAL AND DISTAL seous membrane can assist with dispersing the load more
structures are shown as thin elongated arrows.
tion provide a mechanism that allows independent “rotation”
evenly through the forearm.
of the hand without anJoints

obligatory rotation of the ulna or
of the Forearm
About 75% of the ring is formed by
25% by the radial notch of the ulna
The annular (from the Latin an
thick circular band of connective tis
on either side of the radial notch (
ligament fits snugly around the r
Human Movement – Biomechanics of the elbow and forearm 186
proximal radius against the ulna. Th
of the
Section IIannular ligament is lined wit
Upper Extremity
friction against the radial head durin nation
qInterosseous membrane tion. The external surface of the hand l

joint p
ments from the elbow capsule, the during

only a
r
8
and the supinator muscle. Theduring qu
the rad
fibrous ligament that arises just belofr also

FuncBon ulna and attaches to the medial su
Taut annular
radius (see Figure 6-24, B). This
ligament JOINT
Brachioradialis
CONN
- Fibers are directed distal-medially from the radius, connec8ng to and defined ligament is not clear, altho Proxim
co lique
capsule of the proximal radio-ulnar The pj
rd
Ob
intersec8ng with the shaL of the ulna at about 20 degrees rotation. 70 the hu
this ca
by a
notch
Distal Radio-Ulnar Joint About
25% b
What happens when the interosseous membrane is damaged?

DISTRACTING The distal radio-ulnar joint consists o The
thick c
Importance of the brachioradialis. FORCE ulna resting on the shallow concav on eit
ligame
notch on the radius and the proxim proxim
of the
disc (Figure 6-26). This important j frictio
tion.
distal ends of the radius and ulna. ments
FIGURE 6-22. Holding a load, such as a suitcase, places a distal- irregularly shaped ulnar notch of and th
fibrou
directed distracting force predominantly through the radius. This dis- marginal osseous containment to th ulna a
traction slackens most of the interosseous membrane (shown by the distal radio-ulnar joint is furnish
radius
define
wavy arrows over the membrane). Other structures, such as the capsul
oblique cord, the annular ligament, and the brachioradialis, must
muscles,28 plus an elaborate set of lo rotatio
assist with the support of the load. The stretched (taut) structures The articular disc at the distal Distal
are shown as thin elongated arrows, and the slackened structures are known as DISTRACTING the
FORCEtriangular fibrocartilage, The d
ulna r
shown as wavy arrows. predominant tissue type. As depicte notch
disc (F
lateral side of the disc attaches
FIGURE 6-22. Holding a load, such as a suitcase, places a distal-
alo
distal
irregul
Mod. 45 ulnar notch of the radius. The
traction slackens most of the interosseous membrane (shown 12 by main
directed distracting force predominantly through the radius. This dis- margin
the di
horizontally into a triangular
wavy arrows over the membrane). Other structures, such as the
oblique cord, the annular ligament, and the brachioradialis, must
shape
muscl
The
In the anatomic position the forearm is fully supinated medially into the depression
assist with the support of the load. The stretched (taut) structures
are shown as thin elongated arrows, and the slackened structures are
on the
known
when the ulna and radius lie parallel to each other (see Figure shown styloid
as wavy arrows.process. The anterior and po
predo
lateral
6-23, A). During pronation the distal segment of the forearm are continuous with the palmar (ante ulnar
horizo
complex (i.e., the radius and hand) rotates and crosses over radio-ulnar
In the anatomic position joint capsular
the forearm is fullyligaments
supinated (see
media
when the ulna and radius lie parallel to each other (see Figure styloid
qOsteokinematics
Proximal and distal radio-ulnar joints 0° (Neutral)
Pivot joint
Prona
50° 50°
Supination/ Pronation
- Movement in the transverse plane, along a longitudinal axis Neutr
75°
- The forearm rotation occurs around an axis of rotation that extends
85°
from near the radial head through the ulnar head—an axis that Supin
intersects and connects both radio-ulnar joints Supination Pronation
Mod. 45 FIGURE 6-27. Range of motion at the forearm13 comp

of supination and 0 to 75 degrees of pronation. The 0
ing straight up. As in the elbow, a 100-degree “funct
the data in the histogram in B. B, Histogram showi
healthy persons to perform the following activities o
fork to the mouth, rising from a chair, opening a doo
telephone, and reading a newspaper. (Modified from M
qOsteokinema+cs
0° (Neutral)
80
60
Pronation
40
50° 50°
20
Degrees
Neutral 0
75° 20
85°
Supination 40
Supination Pronation 60
80
Glass Fork Chair Door Pitcher Knife Tele- News-

phone paper
A B
Activities of daily living
FIGURE 6-27. Range of motion at the forearm complex. A, A healthy person generally allows 0 to 85 degrees
of supination and 0 to 75 degrees of pronation. The 0-degree neutral position is shown with the thumb point-
ing straight up. As in the elbow, a 100-degree “functional arc” exists (shown in red). This arc is derived from
the data in the histogram in B. B, Histogram showing the amount of forearm rotation usually required for
healthy persons to perform the following activities of daily living: bringing a glass to the mouth, bringing a
fork to the mouth, rising from a chair, opening a door, pouring from a pitcher, cutting with a knife, holding a
telephone, and reading a newspaper. (Modified from Morrey BF, Askew LJ, Chao EY: A biomechanical study
of normal functional elbow motion, J Bone Joint Surg Am 63:872, 1981.)
Mod. 45 14
KINEMATICS TABLE 6-2. Structures That Can Restrict Supination
Functional Considerations of Pronation and Supination and Pronation
Forearm supination occurs during many activities that involve Restriction Structures
rotating the palmar surface of the hand toward the face, such
Limit supination Pronator teres, pronator quadratus
as feeding, washing, and shaving. Forearm pronation, in con- TFCC, especially the palmar capsular
trast, is used to place the palmar surface of the hand down ligament at the distal radio-ulnar joint
Radius Radius Ulna
segment of the forearm complex. Note that the thumb
stays with the radius during pronation.
Ulnar notch
PR
ONA
Dorsal capsular ligamentDistal TION
188 radio-ulnar joint
Section II Upper Extremity
Articular capsule (cut)
A B
Ulnar head
Human Movement – Biomechanics of the elbow and forearm Palmar
S P E C I A L F O C U S 6 - 2
capsular Attachment of articular disc
Dislocations of the Proximal Radio-Ulnar Joint: the “Pulled-Elbow” Syndrome
ligament Ulnar collateral ligament (cut)
A strenuous pull on the forearm through the hand can cause and the increased likelihood of others forcefully pulling on their
qArthrology
the radial head to slip through the distal end of the annular arms—such as a parent, or even a pet dog (Figure 6-25). One of Radial notch
ligament. Young children are particularly susceptible to this the best ways to prevent this dislocation is to explain to parents Radial notch (on ulna) Olecranon process Ulnarcollateral
(with cartilage)
“pulled-elbow” syndrome because of ligamentous laxity, a nonos- how a sharp Articular
pull on the disc
child’s (proximal
hand can cause surface)
such a
sified radial head, relative reduced strength and slowed reflexes, dislocation. Fovea ligament (cut)
A Palmar capsular ligament B Annular ligament
Radial (with cartilage)
collateral Articular surface on
Periarticular connective tissues
FIGURE 6-25. An example of a cause of “pulled-elbow syndrome” ligament (cut) trochlear notch
in a child. (Redrawn from Letts RM: Dislocations of the child’s
elbow. In Morrey BF, ed: The elbow and its disorders, ed 3, Phila- Annular ligament Scaphoid facet Lunate facet Articular disc
delphia, 2000, Saunders. By permission of the Mayo Foundation (distal surface)
for Medical Education and Research.) Quadrate ligament (cut)
- Annular ligament
Radius
FIGURE 6-26. An anterior view of the right distal radio-ulnar joint. A, The ulnar head has been pulled away
U l na
Ulna
- Triangular fibrocartilage
fromcomplex (including
the concavity articular
formed by the proximal surfaceA of the articular disc and the ulnar notch of the radius. B B,
disc) The distal forearm has been tilted slightly to exposeFIGURE
part6-24.
of The
theright
distal surface of the articular disc and its con-
proximal radio-ulnar joint as viewed from above. A, The radius is held against the
nections with the palmar capsular ligament of the distal radio-ulnar joint. The scaphoid and lunate facets on
radial notch of the ulna by the annular ligament. B, The radius is removed, exposing the internal surface of
the concave component of the proximal radio-ulnar joint. Note the cartilage lining the entire fibro-osseous
the distal radius show impressions made by these carpal bonesligament
ring. The quadrate at theis radiocarpal jointto the
cut near its attachment of neck
theofwrist.
the radius.
Ulna
Radius Radius Ulna Experimentally cutting the capsular ligaments in fresh cadaver
of the wrist. Several adjacent connective tissues are typically
specimens causes marked increases in multidirectional trans-
included with this complex, such as the capsular ligaments of
Ulnar notch lations of the distal radius in all positions of supination and
the distal radio-ulnar joint and ulnar collateral ligament (see
eralized instability of the distal radio-ulnar joint,
Dorsal capsular ligament making
pronation.pro-
80
Figure 6-26, B). The TFCC is the primary stabilizer of the
nation andUlnarsupination
Articular capsule (cut)
motions, as well as motions of the Stabilizers of the Distal Radio-Ulnar Joint
distal radio-ulnar joint. 80
head Introduction to the Triangular Fibrocartilage Complex Other structures that provide stability to the distal radio-
wrist, painful and ligament
difficult
Attachment of articular disc
to perform. (The triangular
PalmarThecapsular
fibro-
articular Triangular
disc is part of a larger • fibrocartilage
set of connective tissue complex
ulnar joint are(TFCC)
the pronator quadratus, the tendon of the
Ulnar collateral
cartilage complex is anatomically and functionally
(cut) ligament
known as the triangular fibrocartilage
associated Pronator •
complex—typically
quadratus
TFCC.25,34,67 The TFCC occupies most of the “ulnocar-
abbre- extensor carpi ulnaris, and the more distal fibers of the inter-
osseous membrane.22,82 Tears or disruptions of the TFCC,
Ulnarviated
with other structures of the wrist, and hence is discussed
Articular disc (proximal surface)
collateral
pal
ligament space”
(cut) between the head ofTendon
the ulna •of the
and theulnar
extensor
side carpi ulnaris
especially the disc,39 may cause complete dislocation or gen-
B
A Palmar capsular ligament
further in Chapter 7.)
B
• Distal fibers of the interosseous membrane
Scaphoid facet Lunate facet Articular disc
(distal surface)
FIGURE 6-26. An anterior view of the right distal radio-ulnar joint. A, The ulnar head has been pulled away
from the concavity formed by the proximal surface of the articular disc and the ulnar notch of the radius. B,
The distal forearm has been tilted slightly to expose part of the distal surface of the articular disc and its con-
nections with the palmar capsular ligament of the distal radio-ulnar joint. The scaphoid and lunate facets on
Mod. 45 the distal radius show impressions made by these carpal bones at the radiocarpal joint of the wrist. 15
eralized instability of the distal radio-ulnar joint, making pro-

nation and supination motions, as well as motions of the Stabilizers of the Distal Radio-Ulnar Joint
wrist, painful and difficult to perform. (The triangular fibro- • Triangular fibrocartilage complex (TFCC)
cartilage complex is anatomically and functionally associated • Pronator quadratus
with other structures of the wrist, and hence is discussed • Tendon of the extensor carpi ulnaris
further in Chapter 7.)
• Distal fibers of the interosseous membrane
40
20
Degrees
utral 0
20 190 Section II Upper Extremity
pination 40
Anterior
60
PINATION
SU
80
SUPINA ular ligam
qArthrokinema+cs TIO
N caps
Lateral
en
d
ar
ixena
t
Palm
Glass Fork Chair Door Pitcher Knife
Tele-FIGURE
News-
6-28. Illustration on the left l Radius
SLIDE
phone paper
ROLL
u
B shows the anterior aspect of a right Lateral
Activities of daily living forearm after completing full supina- Styloid
tion. During supination, the radius and process Do r
Proximal
mplex. A, and distal
A healthy person radio-ulnar
generally allows 0 to 85 joints
degrees carpal bones rotate around the fixed rsal
capsula
ligament
e 0-degree neutral position is shown with the thumb point- humerus and ulna. The inactive but
Distal radio-ulnar joint from above
nctional arc” exists (shown in red). This arc is derived from stretched pronator teres is also shown.
amount of forearm rotation usually required for Viewed as though looking down at your
SupinaBon
wing the Anterior
own right forearm, the two insets depict
s of daily living: bringing a glass to the mouth, bringing a the arthrokinematics at the proximal
door, pouring from a pitcher, cutting with a knife, holding a and distal radio-ulnar joints. The at
on s
or
SU
Pr re Bicipital PI
Morrey BF, Askew LJ, Chao EY: A biomechanical study stretched (taut) structures are shown as
te
tuberosity Pr
o
N ator teres
urg Am 63:872, 1981.) thin elongated arrows, and slackened
AT
Radius
n
structures are shown as wavy arrows. Lateral
ION
T IO N
xed
notch
TA
See text for further details. Fi lna
RO
u
ial
ad R
TABLE 6-2. Structures That Can Restrict Supination
and Pronation Annular ligament
Proximal radio-ulnar joint from above
ve Restriction Structures
h
n- directions on the head of the ulna (see Figure 6-28, top box).5
TFCC, especially the palmar capsular S P E C I A L F O C U S 6-3
n Duringjoint
ligament at the distal radio-ulnar supination the proximal surface of the articular disc
a Interosseous membrane remains in contact with the ulnar head. At the end range of
supination, the palmar capsular ligament is stretched to its Preventing Forearm Pronation Contractures
Limit pronation Biceps or supinator muscles maximal length, creating a stiffness that naturally stabilizes
n
T
TFCC, especially the dorsal capsular
the joint.17,67,78 This stiffness provides increased stability at a he axis of rotation for pronation and supination is oriented
o- ligament at the distal radio-ulnar joint roughly parallel with the central bands of the interosseous
position of reduced joint congruency. At the extremes of
es both supination and pronation, only about 10% of the membrane (compare Figures 6-20 and 6-23,A), deviating by
of TFCC, surface of the ulnar notch of the radius is in direct contact only about 10 to 12 degrees. This relatively parallel arrange-
B, Mod.triangular
45 fibrocartilage complex.
with the ulnar head.20 This is in sharp contrast to the 60% ment limits the change in length (or tension) of the membrane16
es contact area in the neutral (midposition) of pronation and throughout a pronation to supination movement. (Recall from
supination. Chapter 1 that any force that acts exactly parallel to an axis of
n rotation produces no resistive torque.) Because the axis and the
a of these joints would restrict the overall movementPronation
of forearm membrane are not precisely parallel, however, some change in
de rotation. Restrictions in passive range of motionThe can occur
arthrokinematics of pronation at the proximal and distal length occurs throughout a full arc of forearm rotation. Although
30 from tightness in muscle and/or connective tissues. Table 6-2joints occur by mechanisms similar to those
radio-ulnar some data conflict, most studies indicate that the interosseous
ll lists a sample of these tissues. described for supination (Figure 6-29). As depicted in the top membrane, as a whole, is most slack in pronation.32,42 Long-
40
20
Degrees
utral 0
20 Chapter 6 Elbow and Forearm 191
pination 40
Anterior
60
PRON
AT
80 I
O
qArthrokinematics Medial
N
PRON Dor
ATIO
IDE
sa
N
SL
LL
Radius
lc
Glass Fork Chair Door Pitcher Knife Tele- News- ed
Fix ul
RO
aps
phone paper FIGURE 6-29. Illustration on the left shows the
na
B
ular lig
ligament
right forearm after completing full pronation.
Palma
Activities of daily living rc
apsu During pronation the radius and carpal bones
a
me
lar
rotate around the fixed humerus and ulna. The
nt
Proximal
mplex. A, and distal
A healthy person radio-ulnar
generally allows 0 to 85 joints
degrees Styloid process inactive but stretched biceps muscle is also shown.
e 0-degree neutral position is shown with the thumb point- Viewed as though looking down at your own right
nctional arc” exists (shown in red). This arc is derived from Distal radio-ulnar joint from above forearm, the two insets show a superior view of the
arthrokinematics at the proximal and distal radio-
Pronation
wing the amount of forearm rotation usually required for Anterior
ulnar joints. The stretched (taut) structures are
s of daily living: bringing a glass to the mouth, bringing a shown as thin elongated arrows, and slackened
door, pouring from a pitcher, cutting with a knife, holding a structures are shown as wavy arrows. The asterisks
Morrey BF, Askew LJ, Chao EY: A biomechanical study Annular ligament P mark the exposed point on the anterior aspect of
urg Am 63:872, 1981.) the ulnar head, which is apparent once the radius
RO
Medial Radius rotates fully around the ulna into complete prona-
NA
ed
Fixna tion. See text for further details.
ial notch
TION
ul
RO
TA
TION
ad
R
Biceps
TABLE 6-2. Structures That Can Restrict Supination

and Pronation Biceps on bicipital tuberosity
Proximal radio-ulnar joint from above
ve Restriction Structures
h
n- TFCC, especially the palmar capsular
n ligament at the distal radio-ulnar joint
a Interosseous membrane of the radial head against the rounded capitulum of the
Limit pronation Biceps or supinator muscles humerus. Figure 6-30 shows the arthrokinematics during active
n TFCC, especially the dorsal capsular Humerus pronation under the power of the pronator teres muscle. Con-
o- ligament at the distal radio-ulnar joint traction of this muscle—as well as others inserting into the
es radius—can generate significant compression forces on the
humeroradial joint, especially when the joint is near extension.
of TFCC, This compression force is associated with a proximal migration
B, Mod.triangular
45 fibrocartilage complex.
Medial 17
Capitulum epicondyle of the radius, which is greater during active pronation than
es 46
during supination. Because the interosseous membrane as a
n whole is relatively slackened in pronation,32,42 it is likely less
able to resist the proximal pull on the radius imparted by
a of these joints would restrict the overall movement of forearm SPIN Pronator teres pronator muscle contraction. The natural proximal migration
na
de rotation. Restrictions in passive range of motion can occur

Ul
of the radius and associated increased joint compression of the

30 from tightness in muscle and/or connective tissues. Table 6-2 humeroradial joint during active pronation has been referred
ius
ll lists a sample of these tissues. to as the “screw home” mechanism of the elbow.45
qMyofascial system Chapter 6 Elbow and Forearm 199
Transverse ligament Chapter 6 Elbow and Forearm 203
Coracoid
process Biceps brachii
Biceps brachii
(long head)
(short head)
Acromion
racoid
cess Biceps brachii
Biceps brachii
(long head) Biceps brachii
(short head) Biceps brachii
(long head) (short head)
Triceps brachii
Brachialis (long head) Triceps brachii
Brachialis (lateral head)
Medial Triceps brachii Triceps brachii

brachii epicondyle (lateral head) (medial head)
ead)
Fibrous
Brachioradialis Tendon of
lacertus
Brachialis biceps brachii
Triceps brachii
hialis (long head) Ulna
ial
ondyle
Ulna Olecranon Anconeus Olecranon
process process
ous FIGURE 6-34. Anterior view of the right brachialis shown deep to
Tendon of
rtus the biceps muscle.
biceps brachii
Ulna
(see Figure 6-33). Maximal shortening of the brachioradialis
causes full elbow flexion and rotation of the forearm to the
near neutral position. EMG studies suggest that the brachio-
radialis is a primary elbow flexor, especially during rapid
Styloid process FIGURE 6-39.
movements againstA aposterior view shows
high resistance. 6,15,21the right triceps brachii and FIGURE 6-40. A posterior view shows the right medial head of the
anconeus
The muscles. muscle
brachioradialis The medial head
can be of the
readily triceps on
palpated is deep
the to the triceps brachii. The long head and lateral head of the triceps are
FIGURE 6-34. Anterior view of the right brachialis shown deep to long and lateral heads and therefore not entirely visible. partially removed to expose the deeper medial head. The anconeus
FIGURE 6-33. Anterior view of the right biceps brachii and brachio- anterior-lateral aspect of the forearm. Resisted elbow flexion,
Mod.
the biceps45
muscle.
radialis muscles. The brachialis is deep to the biceps. from a position of about 90 degrees of flexion and neutral is not illustrated. 18
forearm rotation, causes the muscle to stand out or “bow-
string” sharply across the elbow (Figure 6-35). The bowstring-
(see Figure 6-33). Maximal shortening of the brachioradialis ing of this muscle increases its flexion moment arm to a
causes full elbow flexion and rotation of the forearm to the biceps has a cross-sectional area of only 2.5 cm2. Based on its length that exceeds that of the other flexors (see Table 6-5).
large physiologic cross-section, the brachialis is expected to The anatomy of the pronator teres is described under the
generate the greatest force of any muscle crossing the elbow. section on pronator muscles (see Figure 6-48). As a point of
radialis is a primary elbow flexor, especially during rapid The brachioradialis is the longest of all elbow muscles, comparison,
movements against a high resistance.6,15,21 TABLEthe
6-7.pronator teresand
Structural hasRelated
a similar flexor moment
Biomechanical Variables of the Primary Elbow Extensor Muscles*
attaching proximally on the lateral supracondylar ridge of the arm as the brachialis, but only about 50% of its physiologic
The brachioradialis muscle can be readily palpated on the humerus and distally near the styloid process of the radius cross-sectional area (see Table 6-5). Work Capacity Contraction Excursion
B Peak Force Leverage
achio- anterior-lateral aspect of the forearm. Resisted elbow flexion, Physiologic Cross-sectional Area Internal Moment Arm
3 † 2 ‡
qMyofascial system Chapter 6 Elbow and Forearm 199
Transverse ligament

Flexors Coracoid
process Biceps brachii
(long head)
Biceps brachii
(short head)
Brachialis
Biceps
racoid
Biceps brachii
Brachioradialis
cess Biceps brachii
(long head) Biceps brachii
(short head) Biceps brachii
(long head) (short head)
Brachialis
Brachialis
Brachioradialis Medial
brachii epicondyle
ead)
Fibrous
Brachioradialis Tendon of
lacertus
Brachialis biceps brachii
hialis
Ulna
ial
ondyle
Ulna
ous
rtus
Tendon of FIGURE 6-36. A lateral view showing the line of force of three
FIGURE 6-34. Anterior view of the right brachialis shown deep to
the biceps muscle.
biceps brachii
primary elbow flexors. The internal moment arm (thick dark lines) for
Ulna
each muscle is drawn to approximate scale. Note that the elbow has
(see Figure 6-33). Maximal shortening of the brachioradialis
been
causes full elbow flexion flexed
and rotationabout 100to the
of the forearm degrees, placing the biceps tendon at 90
degrees
radialis is a primary elbow of insertion
flexor, with
especially during the radius. See text for further details. The
rapid
elbow’s medial-lateral axis of rotation is shown piercing the
6,15,21
Styloid process movements against a high resistance.
The brachioradialis muscle can be readily palpated on the
FIGURE 6-34. Anterior view of the right brachialis shown deep to
FIGURE 6-33. Anterior view of the right biceps brachii and brachio- anterior-lateralcapitulum.
aspect of the forearm. Resisted elbow flexion,
Mod.
the biceps45
muscle.
radialis muscles. The brachialis is deep to the biceps. from a position of about 90 degrees of flexion and neutral 19
forearm rotation, causes the muscle to stand out or “bow-
string” sharply across the elbow (Figure 6-35). The bowstring-
(see Figure 6-33). Maximal shortening of the brachioradialis ing of this muscle increases its flexion moment arm to a
causes full elbow flexion and rotation of the forearm to the biceps has a cross-sectional area of only 2.5 cm2. Based on its length that exceeds that of the other flexors (see Table 6-5).
large physiologic cross-section, the brachialis is expected to The anatomy of the pronator teres is described under the
generate the greatest force of any muscle crossing the elbow. section on pronator muscles (see Figure 6-48). As a point of
radialis is a primary elbow flexor, especially during rapid
movements against a high resistance.6,15,21
The brachioradialis is the longest of all elbow muscles, TABLE 6-6. Average Maximal Isometric Internal Torques
comparison, the pronator teres has a similar flexor moment
attaching proximally on the lateral supracondylar ridge of the arm as the brachialis, but only about 50% of its physiologic
The brachioradialis muscle can be readily palpated on the
anterior-lateral aspect of the forearm. Resisted elbow flexion,
humerus and distally near the styloid process of the radius across the Elbow and Forearm
cross-sectional area (see Table 6-5). B
achio-
torque as a muscle with a larger moment arm (B).
force is directed to stabilizing or destabilizing the segment around the joint. Fortunately, the resistance offered by the
by pulling the bone into or away from the joint. forearm weight is at a minimum in the extended position.
Muscular force is primarily directed along the length of Thus, the small muscular force available to move the seg-
the bone and into the joint when the tendon angle is acute ment is usually sufficient. Both the force directed along the

or lying flat on the bone. When the forearm is extended,
the tendon of the biceps brachii inserts into the radius at a
length of the bone and that which is applied perpendicular
to the bone to create joint movement can be determined by
low angle. Initiating an arm curl from this position requires resolving the angle of the muscular force application into
greater muscle force than from other positions because its respective parallel and rotary components. Figure 3-18
qMyofascial system most of the force generated by the biceps brachii is directed shows the parallel and rotary components of the biceps
into the elbow rather than into moving the segments brachii force for various attachment angles.
Biceps
What is the acBon

on the humeroradial?
- Rota8on
- Compression
- Trac8on
FIGURE 3-18 When muscle attachment angles are acute, the parallel component of the force (P) is high-
est and is stabilizing the joint. The rotatory component (R) is low (A). As the angle increases, the rotatory
component also increases (B). The rotatory component increases to its maximum level at a 90° angle of
attachment (C). Beyond a 90° angle of attachment, the rotatory component diminishes, and the parallel
component increases to produce a dislocating force (D and E).
Mod. 45 20
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CHAPTER 8 ■ The Elbow Complex 285
Human Movement – Biomechanics of the elbow and forearm Medial head Olecranon
of triceps brachii process
ulnaris and the pronator teres overlay the anterior bundle
of the medial collateral ligament and contribute to medial
support of the elbow.19 The bony components provide
half of the resistance to varus stress in full extension, and
160 SECTION II Functional Anatomy the lateral collateral complex and joint capsule provide
qMyofascial system
Long head Ulna
of triceps the other half of the resistance.32 Resistance to joint dis-
Radius traction in the extended position is provided entirely by
Infraglenoid
tubercle soft tissue structures. The anterior portion of the joint
capsule provides the majority of the resistance to anterior
displacement of the distal humerus out of the trochlear
Lateral head notch; the medial and lateral collateral ligaments con-
of triceps
tribute only slightly.24,32
Biceps Scapula
Head of
humerus Approximation of the coronoid process with the coro-
noid fossa and of the rim of the radial head in the radial
fossa limits extremes of flexion. In 90° of flexion, the ante-
rior part of the medial collateral ligament provides the pri-
Tension is affected by arm position mary resistance to both distraction and valgus stress. If the
A anterior portion of the medial collateral ligament becomes
lax through overstretching, medial instability will result
when the elbow is in flexed positions. The majority of the
- If the arm is extension, passive tension of the Biceps brachii
resistance to varus stress when the elbow is flexed to 90° is
provided by the osseous structures of the joint; only a
biceps can limit elbow extension – passive slight amount is provided by the lateral collateral ligament
and the joint capsule. The anterior joint capsule con-
insufficiency Brachialis tributes only slightly to varus and valgus stability and pro-
vides little resistance to distraction when the elbow is
flexed.24,32 Co-contractions of the flexor and extensor
muscles of the elbow, wrist, and hand help to provide sta-
- If the arm is flexed, the active tension of the Biceps
brachii bility for the elbow during forceful motions of the wrist
and fingers and in activities in which the arms are used to
biceps may be reduced due to excessive support the body weight. During pulling activities, such as
when a person grasps and attempts to pull a fixed rod to-
shortening of the muscle – active insufficiency Brachioradialis ward the body, the elbow joints are compressed by the
contractions of muscles that cross the elbow and act on the
wrist and hand.64
Swelling and/or pain also may limit the range of elbow
Tension is affected by arm position motion. McGuigan and Bookout65 investigated the effects
of intra-articular fluid on range of motion. They found that
- If the arm is flexed, the active tension of the B
the flexion arc of motion decreased 2.1° for every millime-
ter of injected fluid.
biceps may be reduced due to excessive Figure 8–16 A. Passive tension created in the long head of the
triceps by passively stretching the muscle over both the shoulder FIGURE
Muscle 5-20 When the forearm is pronated, the attachment of the
Action
shortening of the muscle – active insufficiency and elbow joints may limit elbow flexion. B. Active tension in the
long head of the biceps brachii may drcrease and therefore limit
biceps brachii to the radius is twisted under. This position interferes with
A great deal of our information regarding muscle action
the flexion-producing action of the biceps brachii, which is more efficient
FIGURE 5-19 The the lineactive
of range
actionof motion
of theinthree
elbow forearm
flexion because the muscle
muscles. The is comes from studies using electromyography (EMG). This
in producing flexion when the forearm is supinated and the tendon is
Mod. 45 brachialis (BRA) is excessively shortened by contracting over both the elbow and
a large muscle, but it has the smallest moment arm, not twisted under the radius. 21
shoulder.
case 8–4
giving it the poorest mechanical advantage. The biceps brachii (BIC) also CASE APPLICATION
has a large cross-section and has a longer moment arm, but the bra- Swelling
Other
chioradialis (BRD) ,with factorscross-section,
its smaller that limit the has
range
theoflongest
motion moment
but help to
provide stability for the elbow are the configuration of the
arm, giving it the best mechanical advantage in this position.
joint surfaces, the ligaments, and the joint capsule. The small
Whenvolume
we first metand very
James, long
he was fibers;
holding his rightitelbow
is ainvery efficient
slight flexion. It is possible but not probable that excess
elbow has inherent articular stability at the extremes of muscle,
fluid has accumulated within the joint, which could stretch mechanical
however, because of its excellent
extension and flexion.24,32 In full extension, the humeroul- advantage. Theandbrachioradialis
the joint capsule cause pain. To reduceflexes
the pain,thepa- elbow most
nar joint is in a close-packed position. In this position,
smaller cross-section but ofthe
bony contact thebest mechanical
olecranon process inadvantage
the olecranon effectively when
tients will often the
assume forearm
a position is stretching
in which in midpronation,
of the and it
joint capsule is at a minimum. Elbow flexion of about 80°
qMyofascial system
Biceps | Stability/ muscle synergy
Mod. 45 22
2362_Ch08-271-304.qxd 1/31/11 6:02 PM Page 280
qMyofascial system
280 SECTION 3 ■ Upper Extremity Joint Complexes
The PRONATOR TERES (+++), as well as the flexors

B
and extensors of the wrist are elbow flexors. A
Posterior view
Right arm
Lateral
epicondyle
Anconeus
Anterior view
Right arm Supinator
What is the clinical relevance?
Medial
Ex.: Wrist extensor stretch epicondyle
Lateral
epicondyle
Medial
epicondyle Extensor carpi
radialis longus
Extensor carpi
Pronator teres ulnaris Extensor carpi
radialis brevis
Palmaris Extensor digitorum
longus communis
Flexor carpi
radialis
Flexor carpi Extensor digiti
ulnaris minimi
Flexor digitorum
superficialis
Extensor
Flexor retinaculum retinaculum
Figure 8–11 A. Insertion of the flexor muscles on the medial epicondyle of the humerus. B. Insertion of the extensor muscles on the
lateral epicondyle of the humerus.
Mod. 45 23
process. Both the biceps and brachioradialis insert into
the radius. CASE APPLICATION
The two extensors of the elbow are the triceps brachii
case 8–3
Muscles and
and the anconeus. The triceps brachii has three heads:
long, medial, and lateral. The long head crosses both the Tendons
glenohumeral joint at the shoulder as well as the elbow The extensor carpi radialis longus and brevis and the
joint. It arises from the infraglenoid tubercle of the scapula extensor carpi ulnaris are active in gripping, hammering,
by a flattened tendon that blends with the glenohumeral and sawing activities. Therefore, the repetitive pull of
produces a shoulder flexion torque that drives the limb simi
forward and neutralizes the shoulder extension tendency of two
the long head of the triceps. From a physiologic perspective, degr
combining shoulder flexion with elbow extension minimizes sion
the rate and amount of shortening required by the long head thick
of the triceps to completely extend the elbow. and
The elbow extensor muscles produce maximal-level torque The
Human Movement – Biomechanics of the elbow and forearm when the elbow is flexed to about 90 degrees.14,62 This is
approximately the same angle at which the elbow flexor
degr
mus
muscles, as a group, produce maximum-flexion
Chapter 6 Elbow and Forearm torque. The
205 whe
90-degree flexed elbow therefore is the most actively isometric torq
qMyofascial system flexion function of the anterior deltoid is an important syn- stable position of the joint. Of interest, although both muscle
ergistic component of the forward push. The anterior deltoid groups produce peak, maximal-effort torques at roughly
produces a shoulder Chapter flexion torque that 203
6 Elbow and Forearm
drives the limb similar joint angles, the largest internal moment arms for the
forward and neutralizes the shoulder extension tendency of two groups occur at very different joint angles: about 90
the long head of the triceps. From a physiologic perspective, degrees of flexion for the elbow flexors, and near full exten-
s
Triceps
Humeru
combining shoulder flexion with elbow extension minimizes sion for the triceps and anconeus.3 Full extension places the
the rate and amount of shortening required by the long head thick olecranon process between the joint’s axis of rotation
ofAcromion
the triceps to completely extend the elbow. and the line of force of the tendon of the triceps (Figure 6-42).
eps
Triceps
The elbow extensor muscles produce maximal-level torque The fact that peak elbow extensor torque occurs near 90
Tric
when the elbow is flexed to about 90 degrees.14,62 This is degrees of flexion instead of near extension suggests that
approximately the same angle at which the elbow flexor muscle length, not leverage, is very influential in determiningFIGURE 6-
muscles, asTricepsa brachii
group, produce maximum-flexion torque. The where in the range of motion that peak elbow extensionflexed to
90-degree flexed elbow therefore is the most
(long head)
actively isometric
Triceps brachii
(lateral head)
torque naturally occurs. moment
increases
Triceps brachii
(lateral head)
Triceps brachii
(medial head)
distance b
with the l
Ulna
s
Triceps brachii
Humeru
(long head)
A B
eps
Olecranon Anconeus Olecranon
Triceps
process
Tric
process
FIGURE 6-42. The moment arm of the triceps is shown with the elbow
flexed to 90 degrees (A) and fully extended to near 0 degrees (B). The
moment arms are shown as thick black lines. Note that the moment arm
FIGURE 6-39. A posterior view shows the right triceps brachii and FIGURE 6-40. A posterior view shows the right medial head of the
increases in extension (B) because the olecranon process extends the
anconeus muscles. The medial head of the triceps is deep to the triceps brachii. The long head and lateral head of the triceps are distance between the axis of rotation and the perpendicular intersection
with the line ofSforce
P EofCthe
I A L F O C U S 6 - 6
long and lateral heads and therefore not entirely visible. partially removed to expose the deeper medial head. The anconeus
is not illustrated. triceps.
Ulna
Mod. 45 24
Using Shoulder Muscles to Substitute for Triceps Paralysis
F
A
TABLE 6-7. Structural and Related Biomechanical Variables of the Primary Elbow Extensor Muscles* B ractures of the cervical spine may result in C6 quadriplegia, nerve
Work Capacity Contraction Excursion Peak Force Leverage
with loss of motor and sensory function below the C6 nerve the a
Physiologic Cross-sectional Area Internal Moment Arm
Muscle Volume (cm3) Length (cm)† (cm2) (cm)‡ root level. Symptoms may include total paralysis of the trunk and up in
Triceps brachii (long head) 66.6 10.2 6.7 1.87 lower extremity muscles with partial paralysis of the upper extrem- diffic
Triceps brachii (medial head)
Triceps brachii (lateral head)
38.7
47.3
6.3
8.4
6.1
6.0
1.87
1.87
ity muscles. Because of the sparing of certain muscles innervated tion
sion (see Table 6-7). Although the anconeus is not capable of through isometric contraction or very-low–velocity eccentric
producing large elbow extension torque, it still provides activation. In contrast, these same muscles are required to
important longitudinal and medial-lateral stability across the generate much larger and dynamic extensor torques through
humero-ulnar joint. This stability is beneficial during exten- high-velocity concentric or eccentric activations. Consider
sion activities, but also during active pronation and supina- activities such as throwing a ball, pushing up from a low chair,
tion. The anconeus has a similar topographic orientation at or rapidly pushing open a door. As with many explosive
the elbow as the oblique fibers of the vastus medialis have at
the knee. This orientation is best appreciated by visually
pushing activities, elbow extension is typically combined with
some degree of shoulder flexion (Figure 6-41). The shoulder
internally rotating the upper limb by 180 degrees, such that
the olecranon faces anteriorly—a position more structurally
qMyofascial system and functionally analogous to the lower limb.
Electromyographic Analysis of Elbow Extension

Maximal-effort elbow extension generates near maximum
Triceps | Stability/ muscle
levels of synergy
EMG activity from all components of the elbow
extensor group. During submaximal efforts of elbow exten-
sion, however, different parts of muscles are recruited only at
certain levels of effort.74 The anconeus is usually the first Anterior
muscle to initiate and maintain low levels of elbow extension deltoid
force.36 As extensor effort gradually increases, the medial head
of the triceps is usually next in line to join the anconeus.74
The medial head remains active for most elbow extension
movements.21 The medial head has therefore been termed the
“workhorse” of the extensors, functioning as the extensor
ION
EX
counterpart to the brachialis.74
EX
TE
Only after extensor demands at the elbow increase to
FL
N
Triceps
SIO
moderate-to-high levels does the nervous system recruit the
N
lateral head of the triceps, followed closely by the long head.
The long head functions as a “reserve” elbow extensor,
equipped with a large volume suited for tasks that require
high work performance.
FIGURE 6-41. The triceps muscle is shown generating an extensor
torque across the elbow to rapidly push open a door. Note that the
Torque Generation by the Elbow Extensors
elbow is extending as the anterior deltoid is flexing the shoulder.
The elbow extensor muscles provide static stability to the The anterior deltoid must oppose and exceed the shoulder extensor
elbow, similar to the way the quadriceps muscles are often torque produced by the long head of the triceps. See text for further
used to stabilize the knee. Consider the common posture of description. The internal moment arms are shown as bold lines
Mod. 45 bearing weight through the upper limb with elbows held originating at the joints’ axes of rotation. 25
S P E C I A L F O C U S 6 - 5
n of the Supinator andsystem
qMyofascial Pronator Muscles Supinators Pronators
s of force of most pronator and supinator muscles of

arm are shown in Figure 6-44. In order to be even
ed as aSupinators
pronator orand
a supinator,
pronatorsa given muscle must Biceps Pronator
wo fundamental features. First, the muscle must attach teres
sides of the axis of rotation—that is, a proximal attach- Supinator
Trac8onor
the humerus ofthe
theulna
radius
and a distal attachment on Flexor
carpi radialis
s or the hand. Muscles such as the brachialis or exten- Extensor
cis brevis therefore cannot pronate or supinate the pollicis
regardless of any other biomechanical variable. longus
he muscle must produce a force that acts with an Pronator
moment arm around the axis of rotation for pronation quadratus
nation. The muscle’s moment arm is greatest if its line
is perpendicular to the axis of rotation. Although no Extensor PR
or supinator muscle (at least when considered in the indicis ON
A
SU TION
c position) has such an ideal line of force, the pronator P INA
TION
s comes very close (see Figure 6-44, B).
tion and supination of the forearm are functionally
d with internal and external rotation at the shoulder. A B
r internal rotation often occurs with pronation, FIGURE 6-44. The line of force of supinators (A) and pronators (B)
shoulder external rotation often occurs with supina- of the forearm. Note the degree to which all muscles intersect the
mbining these shoulder and forearm rotations allows forearm’s axis of rotation (dashed line).
d to rotate nearly 360 degrees in space, rather than
to 180 degrees
Mod. 45 by pronation and supination alone. 26
onal association in strength has also been demon- is not clear but may involve the biceps muscle—the primary
at least between shoulder external rotation and supinator of the forearm. External rotation may elongate
supination. Supination torques are 9% greater when the long head of the biceps slightly as its tendon crosses
ed with the shoulder externally rotated as compared the humeral head, thereby augmenting the muscle’s force-
ernally rotated.66 The mechanism for this difference generating ability.
qMyofascial system qMyofascial system
Supinators
CHAPTER 8 ■ The Elbow Complex 293 Stability/ muscle synergy Chapter 6 Elbow and Forearm 209
FIGURE 6-47. Vigorous contraction is

shown of the right biceps, supinator,
and extensor pollicis longus muscles to
tighten a screw using a clockwise rota-
tion with a screwdriver. The triceps
muscle is activated isometrically to
neutralize the strong elbow flexion ten-
Triceps
dency of the biceps.
Biceps
pinator or pollicis
Su ens
Ext gus
A B lon
Figure 8–27 Supination of the right forearm. A. In the

pronated position, the supinator muscle wraps around the proxi- Active
mal radius. A contraction of the supinator, the biceps, or both supination
pulls the radius over the ulna. B. The supinator muscle and the
insertion
Mod. 45 site of the biceps are shown in the supinated position. 27
supination in all positions of the elbow or forearm. It

can also act alone during unresisted fast supination when the
elbow is extended. However, activity of the biceps is always tion is an excellent example of how two muscles can function S P E C I A L F O C U S 6 - 7
evident when supination is performed against resistance and as synergists for one activity while at the same time remaining
Styloid process inactive but stretched biceps muscle is also shown.
Viewed as though looking down at your own right
Distal radio-ulnar joint from above forearm, the two insets show a superior view of the
arthrokinematics at the proximal and distal radio-
Anterior
ulnar joints. The stretched (taut) structures are
shown as thin elongated arrows, and slackened
structures are shown as wavy arrows. The asterisks
Annular ligament P mark the exposed point on the anterior aspect of
the ulnar head, which is apparent once the radius
RO
Medial

Radius rotates fully around the ulna into complete prona-
NA
ed
Fixna tion. See text for further details.
ial notch
TION
ul
RO
TA
TION
ad
R
Biceps
qMyofascial system Note! Triceps is an important synergist by

Biceps on bicipital tuberosity
Proximal radio-ulnar joint from above neutralizing the flexor torque of the pronator teres.
Pronators
Anterior view head against the rounded capitulum of the Distal radio-ulnar joint from below
of the radial
Rad
humerus. Figure 6-30 shows the arthrokinematics during active
Humerus pronation under the power of the pronator teres muscle. Con-
ius
traction of this muscle—as well as others inserting into the
radius—can generate significant compression forces on the
Pronator quadratus
humeroradial joint, especially when the joint is near extension. N SLIDE
This compression Pronforce
ator is associated with a proximal migration O
I
AT
Medial quadra
of the radius, which tus
is greater during active pronation than R O LL
Capitulum
ON
epicondyle Pronator quadratus
during supination.46 Because the interosseous membrane as a
PR
whole is relatively slackened in pronation,32,42 it is likely less
Ra d
able to resist the proximal pull on the iradius
us imparted by Internal
SPIN Pronator teres pronator muscle contraction. The natural proximal migration
na
moment
Ul
of the radius and associated increased joint compression of the arm Internal
humeroradial joint during active pronation has been referred moment
Radius
to as the “screw home” mechanism of the elbow.45 arm

Based on location, the humeroradial joint is mechanically Ulna Ulna
linked to the kinematics of both the elbow and forearm. Any
P RO
motion performed at the elbow or forearm requires move-
NATION A at this joint. A postmortem study ofB 32 cadavers (age
ment C
at death In
ranging from
full supination 70 to 95 years) showed more frequent
In full supination In midposition
and severe degeneration across the humeroradial than the
FIGURE 6-30. An anterior view of a right humeroradial joint during FIGURE 6-49. A, Anterior view of
humero-ulnar joint.1 The increased wear on the lateral com- the distal radio-ulnar joint shows the line of force of the pronator quadratus
active pronation of the forearm. During pronation the fovea of the intersecting the forearm’s axis of
partment of the elbow can be explained in part by the fre- rotation (dashed line) at a near right angle. B, The line of force of the pronator
radial head spins against the capitulum. The spinning occurs around quadratus, with its internal moment arm, is shown with the carpal bones removed and forearm in full supina-
an axis that is nearly coincident with the axis of rotation through quent and complex arthrokinematics (spin and roll-and-slide),
the proximal and distal radio-ulnar joints. The pronator teres muscle combined tion. The pronator
with varying amountsquadratus produces a pronation
of muscular-produced com- torque, which is the product of the pronator muscle’s
is shown active as it pronates the forearm and pulls the radius proxi- forcePain
pression force. times or the internal
limited moment
motion at the arm, and a compression force between the joint surfaces (opposing arrows).
humeroradial
mally against the capitulum. The opposing small arrows indicate an C, This dualdisrupt
joint can significantly functionthe of the pronator
functional quadratus
mobility of the is shown as the muscle pronates the forearm to the midposi-
increased
Mod. 45compression force at the humeroradial joint. entire distaltion.
upperThe roll-and-slide arthrokinematics are also indicated.
extremity. 28
B
SYNOPSIS Essentially all muscles acting on the elbow and forearm

have their distal attachment on either the ulna or the radius.
The shape of the proximal and distal ends of the radius and Those muscles that attach to the ulna—namely the brachialis
ulna provides insightful clues to the kinesiology of the regions. and triceps—flex or extend the elbow but have no ability to
The large, C-shaped proximal end of the ulna provides a rigid, pronate or supinate the forearm. The remaining muscles, in
Biomechanics of the wrist and
hand
Mod. 45 29
A B
FIGURE 7-12. Osteokinematics of the wrist. A, Flexion and extension. B, Ulnar and radial deviation. Note that
flexion exceeds extension and ulnar deviation exceeds radial deviation.
Kinematics of Wrist Motion
Human Movement – Biomechanics of the wrist and hand

OSTEOKINEMATICS
The osteokinematics of the wrist are defined for 2 degrees of
freedom: flexion-extension and ulnar-radial deviation (Figure
7-12). Wrist circumduction—a full circular motion made by
qOsteokinematics the wrist—is a combination of the aforementioned move-

ments, not a distinct third degree of freedom.
Most natural dynamic movements of the wrist combine
elements of both frontal and sagittal planes: extension tends 3
to occur with radial deviation, and flexion with ulnar devia- r
d
tion.41 The resulting natural path of motion for the wrist m
e
follows a slightly oblique path, similar to a dart thrower’s t
Radiocarpal joint
a
motion.50 This natural combination of movements occurs c
a
with other functions, such as tying shoelaces or combing hair. r
p
These natural kinematics should be considered during reha- a
l
te
bilitation of the wrist after injury.
it a
Ellipsoid joint
C ap
The axis of rotation for wrist movements is reported to pass
through the head of the capitate (Figure 7-13).94 Generally, the
axis runs in a near medial-lateral direction for flexion and
extension and near anterior-posterior direction for radial and
Radius
Flexion/ extension ulnar deviation. Although the axes are depicted as stationary,
Ulna
in reality they migrate slightly throughout the full range of
motion.60 The firm articulation between the capitate and the
- Movement in the sagittal plane, along a mediolateral axis (line
base of the third metacarpal bone causes the rotation of the FIGURE 7-13. The medial-lateral (green) and anterior-posterior (purple)
capitate to direct the osteokinematic path of the entire hand.
passing through the head of the capitate bone) The wrist rotates in the sagittal plane about 130 to 160 degrees
axes of rotation for wrist movement are shown piercing the head of
the capitate bone.
Chapter 7 Wrist
(see Figure 7-12, A). On average, the wrist flexes from 0 degrees
to about 70 to 85 degrees and extends from 0 degrees to about to about 15 to 20 degrees. Primarily because of the ulnar tilt of
60 to 75 degrees.67,69 As with any diarthrodial joint, wrist range the distal radius (see Figure 7-4, A), maximum ulnar deviation
Radial/ ulnar deviation of motion varies with age and health and whether the motion
is performed actively or passively. Total flexion normally exceeds
normally is double the maximum amount of radial deviation.
Ryu and colleagues tested 40 healthy subjects using a Ulnar deviation
- Movement in the frontal plane, along an anteroposterior axis
extension by about 10 to 15 degrees. End-range extension is
naturally limited by stiffness in the thick palmar radiocarpal liga-
biaxial electrogoniometer to determine
motion needed to perform 24 activities
Radialthe range of wrist
deviation of daily living
(line passing through the head of the capitate bone)
ments. In some persons, a greater than average palmar tilt of the
distal radius may also limit extension range (see Figure 7-4, B).
(ADLs).67 Flexion
The ADLs included personal care, hygiene, food
preparation, writing, and using various tools or utensils. The
The wrist rotates in the frontal plane approximately 50 to 60
Extension researchers concluded that these ADLs could be comfortably
degrees (see Figure 7-12, B).67,94 Radial and ulnar deviation of the performed using 40 degrees of flexion, 40 degrees of exten-
wrist is measured as the angle between the radius and the shaft sion, 10 degrees of radial deviation, and 30 degrees of ulnar
of the third metacarpal. Ulnar deviation occurs from 0 degrees deviation. These functional ranges were 50% to 80% of the
to about 35 to 40 degrees. Radial deviation occurs from 0 degrees subjects’ maximal range of wrist motion. B
A B
Mod. 45 flexion exceeds extension and ulnar deviation exceeds radial deviation. 30

OSTEOKINEMATICS
A B
flexion exceeds extension and ulnar deviation exceeds radial deviation.

OSTEOKINEMATICS
qOsteokinema+cs the wrist—is a combination of the aforementioned move-

ments, not a distinct third degree of freedom.
Most natural dynamic movements of the wrist combine
elements of both frontal and sagittal planes: extension tends 3
to occur with radial deviation, and flexion with ulnar devia- r
d
tion.41 The resulting natural path of motion for the wrist m
e
follows a slightly oblique path, similar to a dart thrower’s t
Radiocarpal joint
a
motion.50 This natural combination of movements occurs c
a
with other functions, such as tying shoelaces or combing hair. r
p
These natural kinematics should be considered during reha- a
l
te
bilitation of the wrist after injury.
it a
Flexion/ extension
C ap
The axis of rotation for wrist movements is reported to pass
through the head of the capitate (Figure 7-13).94 Generally, the
- 70º a 85º of flexion axis runs in a near medial-lateral direction for flexion and
extension and near anterior-posterior direction for radial and
Radius
- 60º a 75º of extension ulnar deviation. Although the axes are depicted as stationary,
Ulna
in reality they migrate slightly throughout the full range of
motion.60 The firm articulation between the capitate and the
base of the third metacarpal bone causes the rotation of the FIGURE 7-13. The medial-lateral (green) and anterior-posterior (purple)
capitate to direct the osteokinematic path of the entire hand.
Radial/ ulnar deviaBon The wrist rotates in the sagittal plane about 130 to 160 degrees
axes of rotation for wrist movement are shown piercing the head of
the capitate bone.
Chapter 7 Wrist
(see Figure 7-12, A). On average, the wrist flexes from 0 degrees
- 15º a 20º of radial devia8on to about 70 to 85 degrees and extends from 0 degrees to about to about 15 to 20 degrees. Primarily because of the ulnar tilt of
60 to 75 degrees.67,69 As with any diarthrodial joint, wrist range the distal radius (see Figure 7-4, A), maximum ulnar deviation
- 35º a 40º of cubital devia8on of motion varies with age and health and whether the motion
is performed actively or passively. Total flexion normally exceeds
normally is double the maximum amount of radial deviation.
Ryu and colleagues tested 40 healthy subjects using a Ulnar deviation
extension by about 10 to 15 degrees. End-range extension is biaxial electrogoniometer to determine Radialthe range of wrist
naturally limited by stiffness in the thick palmar radiocarpal liga- motion needed to perform 24 activities deviation of daily living
Range of moBon required for acBviBes of daily living
ments. In some persons, a greater than average palmar tilt of the
distal radius may also limit extension range (see Figure 7-4, B).
(ADLs).67 Flexion
The ADLs included personal care, hygiene, food
preparation, writing, and using various tools or utensils. The
- 50% to 80% of the total range of movement of the wrist:
The wrist rotates in the frontal plane approximately 50 to 60
Extension
degrees (see Figure 7-12, B).67,94 Radial and ulnar deviation of the
researchers concluded that these ADLs could be comfortably
performed using 40 degrees of flexion, 40 degrees of exten-
40º of flexion wrist is measured as the angle between the radius and the shaft
of the third metacarpal. Ulnar deviation occurs from 0 degrees
sion, 10 degrees of radial deviation, and 30 degrees of ulnar
deviation. These functional ranges were 50% to 80% of the
B
40º of extension to about 35 to 40 degrees. Radial deviation occurs from 0 degrees subjects’ maximal range of wrist motion.
10º of radial devia8on

30º of ulnar devia8on
A B
Mod. 45 flexion exceeds extension and ulnar deviation exceeds radial deviation. 31

OSTEOKINEMATICS
with the slightly concave proximal surfaces of the trapezium and ulnarly deviated. This is also the wrist position
tercarpal joints maximal grip strength is obtained.
and the trapezoidJOINT STRUCTURE
(see Figure 7-8). The lateral compartment
lacks the pronounced ovoid shape of the medial compart- Midcarpal Joint
rpal Joint As illustrated in Figure 7-1, the two primary articulations
ment. Cineradiography
within theofwrist
wristare
motion shows less
the radiocarpal andmovement
midcarpal joints. Many The midcarpal joint is the articulation between the p
52
ximal components of the radiocarpal joint are the concave at the lateral than the medial compartment. For thisadjacent
other intercarpal joints also exist between reason,carpal bones and distal rows of carpal bones (see Figure 7-8). The
of the radius and an adjacent articular disc (Figures 7-7 subsequent arthrokinematic
(see Figure 7-7). Intercarpal joints contributejoint
analysis of the midcarpal to wrist motion that surrounds the midcarpal joint is continuous w
. As described in Chapter 6, this articular disc (also called focuses on the through
medial compartment.
small gliding and rotary motions. Compared with of the many intercarpal joints.
ngular fibrocartilage) is an integral part of the distal radio-
int. The distal components of the radiocarpal joint are the
proximal surfaces of the scaphoid and the lunate. The
WRIST LIGAMENTS
the large range of motion permitted at the radiocarpal and
midcarpal joints, motion at the intercarpal joints is relatively
small but nevertheless essential for normal wrist motion.
The midcarpal joint can be divided descriptiv
medial and lateral joint compartments.78 The large
compartment is formed by the convex head of the cap
um is also considered part of the radiocarpal joint because Many of the ligaments of the wrist are small and difficult to apex of the hamate, fitting into the concave recess fo
nar deviation its medial surface contacts the articular disc. isolate. Their inconspicuous nature should not, however, the distal surfaces of the scaphoid, lunate, and triquet
qArthrology
thick articular surface of the distal radius and the
Joints of the Wrist
minimize their extreme kinesiologic
• Radiocarpal joint
importance. Wrist liga- Figure 7-8). The head of the capitate fits into this
r disc accept and disperse the forces that cross the ments are essential to maintaining the natural intercarpal recess much like a ball-and-socket joint.
• Midcarpal joint
The lateral compartment of the midcarpal joint is fo
pproximately 20% of the total compression force that • Medial compartment
alignment and for transferring forces within and across the
the radiocarpal joint passes through the articular disc. carpus. Muscle-produced • Lateral
forces stored in stretched ligaments
compartment the junction of the slightly convex distal pole of the s
• Intercarpal joints 222 Section II Upperwith the slightly concave proximal surfaces of the tr
Extremity
Osteoarticular structures and the trapezoid (see Figure 7-8). The lateral comp
lacks
Dorsalthe
viewpronounced ovoid shape of the medial c
Radiocarpal Joint ment. Cineradiography of wrist motion shows less mo
c a r p
t a a The proximal components of the radiocarpal joint are the concave Ul n a at the lateral
R a di u s than the medial compartment.52 For thi
e surfaces of the radius and an adjacent articularUlnar disc collateral
(Figures 7-7 subsequent arthrokinematic analysis of the midcarp
l
M
ands7-8). As described in Chapter 6, this articularligamentdisc (also(cut)
called focuses on the medial compartment.
the triangular fibrocartilage) is an integral part of the distal radio- Scapholunate
Articular disc
ulnar joint. The distal components of the radiocarpal joint are the WRIST LIGAMENTS
ligament
ez
m ate convex proximal surfaces of the scaphoid and the lunate. The Scaphoid
Trap
oid
Ha
Tr a p
Capsule
triquetrum of considered part of the radiocarpal joint
is also Lunate
because Many of the ligaments of the wrist are small and dif
e
Ulnar collateral ligament

pitat
ziu Scaphotrapezial
m at fullcarpometacarpal joint
e
ulnar deviation its medial surface contacts the articular
Ulnar collateraldisc. isolate. Their inconspicuous ligament (cut) nature should not, h
Ca
Trique
of the thumb ligament (cut)

Prestyloid recess The thick articular surface of the distal radius and the minimize their extreme kinesiologic Trapezium
importance. W
d
articular disc accept and disperse the forces that cross

Triquetrum the ments are essential to maintaining the natural in
tru
oi
m p h
a
Sc
Lunate wrist. Approximately 20% of the total compressionHamate force that alignment and for transferring Scaphotrapezialforces within and ac
ligament (cut)
Radiocarpal joint
Articular disc crosses the radiocarpal joint passes through the articular disc. carpus. Muscle-produced forces stored in stretched li
Sacciform recess
(within distal radio-ulnar joint) Head of
Ulna Radius capitate
a Trapezoid
a c r p
t a
e
l B
M s
A ez
mate
Trap
oid
Ha
Tr a p
Capsule of
e
Ulnar collateral ligament
pitat
ziu
carpometacarpal joint
e
Medial
m compartment
Ca
FIGURE 7-7. A frontal plane cross-section through the right wrist and distal forearm showing the shape of the
Trique
Midcarpal joint of the thumb
Prestyloid recess B Lateral compartment
bones and connective tissues. Observe the many individual intercarpal joints.
Mod. 45 32
d
tru
oi
m h
ap
FIGURE 7-8. Sc
A, Illustration of a dorsal view of a dissected right wrist sho
Lunate
Radiocarpal
with the radiocarpal and midcarpal joints. jointgray colors highlight
Red and
Articular disc
of the midcarpal joint, respectively. B, Photograph of a dissected right wr
Sacciform recess surfaces of the midcarpal joint. (Dissection prepared by Anthony Horn
(within distal radio-ulnar joint) Marquette University.)
Ulna Radius
provide important control to the complex arthrokinematics

Human Movement224– Biomechanics

Section II Upper Extremity of the wrist and hand BO
rpal
1s
Fib
t m
3rd metaca
eta
ca
Th
BOX 7-2. Specific Functions of the Triangular •
rpal
rp
qArthrology
1s
al
Pisiform on
Fibrocartilagee Complex •
t m
3rd metaca
te triquetrum
•
eta
a
at
m
•
pit
Ha
ca
The triangular fibrocartilage complex (TFCC)
Ca
rp
• Is thea primary stabilizer of the distal radio-ulnar jo
al
Pisiform on
• Reinforces
Sc
ph
oid the
a ulnar side of the wrist.
OsteoarBcular structures
te
e te triquetrum un
• Forms partL of the concavity of the radiocarpal join
Ulnocarpal
a
at
m
• Helps transfer part of the compression
pit
Ha
space forces that
TF
Ca
A cross the hand to the forearm. About 20% of the
ap Radius Ulna
compression force that crosses the wrist passes thr
Sc
hoi
te
d na fibrocartilage disc component of the TFCC.
Lu H
Ulnocarpal Refer to Box 7-1 for a summary of the componen (Acc
space colla
TFCC. C
are p
A Radius Ulna exten
ulna
UCL Thes
H allow
(According to the British T edition of Gray’s Anatom
S ulna
BOX 7-2. Specific Functions of the Triangular C collateral ligament and the juxtaposed ulnotriquetr
T
are part of the L same structure.78) Along with the
Fibrocartilage Complex TFC is a p
extensor carpi ulnaris muscles, the palmar ulno know
The triangular fibrocartilage complex (TFCC) ulnar collateral ligaments reinforce the ulnar side the ov
• Is the primary stabilizer of the distal radio-ulnar joint. UCL These
Radius
ligaments must be sufficiently flexible, with
nous
h
• Reinforces the ulnar side of the wrist. T B allow the radius and hand to
Ulna rotate freely aroun
imm
• Forms part of the concavity of the radiocarpal joint. S ulna during pronation and supination.
FIGURE 7-11. A, Radiograph of the wrist showing the carpal bones spac
• Helps transfer part of the compression forces that naturally L The final component yet to be described
and the “ulnocarpal space.” B, Magnetic resonance image of the within
often
cross the hand to the forearm. About 20% of the total TFC is a poorly
wrist highlighting organized
the ulnocarpal spaceand defined
(in red box) andconnective
two com- tissue
arthr
ponents ofknown as the
the triangular meniscuscomplex:
fibrocartilage homologue. 31 triangular to sp
This tissue likely
(1) TFC,
compression force that crosses the wrist passes through the fibrocartilage, and (2) UCL, ulnar collateral ligament. C, capitate; joint
fibrocartilage disc component of the TFCC. H, hamate;the vestige of a more
embryonic conne
L, lunate; S, scaphoid; primitive
T, triquetrum.
Refer to Box 7-1 for a summary of the components Radius of the within the ulnar side of the wrist.78 Referred toIntrin as
TFCC.
Mod. 45 nous filler,”80 the meniscus homologue 33 fills gaps
The
B Ulna of the moreimmediately medialoftothethe
specific functions prestyloid
TFCC recess
is included in of into
the
Box 7-2. Anatomic
space details
(see of
Figure the components
7-7). The of
synovialthe TFCC
lining Shor
within
FIGURE 7-11. A, Radiograph of the wrist showing the carpal bonesare described in the following paragraphs.
often fibrocartilage
and the “ulnocarpal space.” B, Magnetic resonance image of theThe triangular becomes (TFC) distended and painful withpalm
attaches directly or indi- 7-10
r
wrist highlighting the ulnocarpal space (in red box) and two com- arthritis. Tears in the articular disc may
rectly to all components of the TFCC and therefore forms the permit syn
row
(According to the British edition of Gray’s Anatomy, thetriangular
ponents of the ulnar fibrocartilage complex: (1) TFC, triangular
structural to spread of
backbone fromthe the radiocarpal
entire complex. Thejoint
TFCto isthea distal
singl
collateral ligament and the juxtaposed ulnotriquetral ligament
fibrocartilage, biconcavejoint.
and (2) UCL, ulnar collateral ligament. C, capitate; articular disc, composed chiefly of fibrocartilage.78 T
2362_Ch09-305-353.qxd 1/29/11 4:29 PM Page 307
Human Movement – Biomechanics of the wrist and hand CHAPTER 9 ■ The Wrist and Hand Complex 307
qArthrology Concept Cornerstone 9-1
Nomenclature
As is true of many other joints of the body, there
are variations in nomenclature for the wrist and hand.
2_Ch09-305-353.qxd 1/29/11 4:29 PM Page 309 Flexion/extension of the wrist may also be termed volar
Alignment (palmar) flexion/dorsiflexion, respectively. Radial/ulnar
deviation of the wrist may also be called abduction/ inclination
of radius
adduction, respectively. At both the wrist and with joints
What is the clinical relevance? and structures in the hand, the terms volar and palmar
are used virtually interchangeably, whereas reference
12mm
to the posterior aspect of the hand is more consistently 23º
C H A P Treferred
E R 9 to ■ asThe
theWrist and Hand
dorsum. Complex
The terms 309 lateral
medial and
may be used in lieu of ulnar and radial. We will use flexion/
extension and radial/ulnar deviation for the wrist mo- A
tions, although coronal plane motions of the fingers are
referred to most commonly (and we will follow this
line of inclination
convention) as abduction/adduction. The terms volar and of radius
palmar will be used interchangeably in order to accu-
rately represent terms found in the cited literature.
Radiocarpal Joint Structure

The radiocarpal joint is formed by the radius and radioul-
nar disc as part of the triangular fibrocartilage complex
(TFCC) proximally and by the scaphoid, lunate, and 11º
triquetrum distally (see Fig. 9–1A, B). B
Figure 9–2 A. A normal angle of 23° of inclination of the ra-
Proximal and Distal Segments dius in the frontal plane, with the distal radius about 12 mm long
of the Radiocarpal Joint on the radial side than on the ulnar side. B. A normal angulation
Figure 9–4 Ulnar variance: The distal radius has a single, continuous, biconcave cur- of inclination of about 11° of the radius volarly in the sagittal
negative (A) and positive (B). A B plane.
vature that is long and shallow from side to side (in the
frontal plane) and shorter and sharper anteroposteriorly
Mod. 45 complex.31(inAthe sagittal “long”
relatively plane). ulna
The proximal joint surface
may be present after ais com- continuation of the articular cartilage of the distal radius.
34
posed of (1) the lateral radial facet, which articulates with The disc is connected medially via two dense, fibrous con-
distal radius fracture (see Fig. 9–5A) that healed in a short-
the scaphoid; (2) the medial radial facet, which articulates nective tissue laminae. The upper laminae include the
ened position. Pain is commonly present with end-range
with the lunate; and (3) the triangular fibrocartilage com- dorsal and volar radioulnar ligaments, which attach to
pronationplex,
andwhich
ulnararticulates
deviationpredominantly
because thesewith motions in-
the triquetrum, the ulnar head and ulnar styloid. The lower lamina has
crease the likelihood
although of impingement
it also has some contactof the
withulnar struc- in the
the lunate connections to the sheath of the extensor carpi ulnaris
tures. Surgical
neutral intervention may include
wrist. The radioulnar disc, aacomponent
joint-leveling
of the tri- (ECU) tendon and to the triquetrum, hamate, and the
procedureangular
such asfibrocartilage
ulnar shortening to unload the
complex, also serves ulnar side of the
as part base of the fifth metacarpal through fibers from the ulnar
of the wrist.32
Human Movement – Biomechanics of the wrist and hand Chapter 7 Wrist
Lateral view
qArthrokinema+cs NEUTRAL
EX
TE N
NS IO
IO 3 rd X
Metacarpal
E
FL
N
Carpometacarpal
Flexion ROL
L
joint ROLL
- +++ in the mediocarpal joint (60%) R

LL
OL
- Typically associated with ulnar devia8on Midcarpal joint
RO
SL
L
ID ra E
E li g d SL
ID
Dooca ents
and prona8on
i m
mentsal
rsarpal
a
Lunate
Palmar
E
carp
SL
IDE ID
SL
l
radio
ga
D o b e r cl e
tu
li
rsal
Radiocarpal
joint
Radius
Extension
- +++ in the radiocarpal joint (66.5%)
- Typically associated with radial devia8on
and supina8on
FIGURE 7-15. A model of the central column of the right wrist showing flexion and extension. The wrist in the
center is shown at rest, in a neutral position. The roll-and-slide arthrokinematics are shown in red for the radiocarpal
joint and in white for the midcarpal joint. During wrist extension (left), the dorsal radiocarpal ligaments become
slackened and the palmar radiocarpal ligaments taut. The reverse arthrokinematics occur during wrist flexion (right).
Mod. 45 arthrokinematics and transfer of force within the proximal row tion and slight extension, and ulnar deviation
35 and
of carpal bones.81,91 Damage to this ligament can occur through flexion. This “dart-throwing” movement pattern obser
trauma, chronic synovitis from rheumatoid arthritis,5 or even the midcarpal joint is similar to that observed during
surgical removal of a ganglion cyst. natural wrist movements.
Ulnar and Radial Deviation of the Wrist Additional Arthrokinematics Involving

Dynamic Interaction between the Radiocarpal and Midcarpal Joints the Proximal Row of Carpal Bones
qArthrokinematics 228 Section II Upper Extremity
Radial deviation
- +++ in the mediocarpal joint
- Proximal row slides over distal carpal row
- Proximal row slides towards the ulna
Palmar view
Ulnar deviation D EVIA

TION NEUTRAL
RADIAL
DEVIATI
ON
- +++ na articulação mediocárpica U
LN
AR
3rd
tacarpal
me
- Proximal row slides over distal carpal row RO
LL
Carpometacarpal
joint ROLL
- Proximal row slides towards radius C

LL
Hama
te Capita
te Midcarpal
H
ROL
C
O
joint
L
R
H E Scaphoid
T SL
Triqu
ID tubercle ID
SL S E
etr
m S
T Radiocarpal
u
L Lu oi L
d
Articular
nate ph joint
SLIDE disc Sca SLIDE
Ulna Radius
FIGURE 7-16. Radiographs and mechanical depiction of the arthrokinematics of ulnar and radial deviation for
the right wrist. The roll-and-slide arthrokinematics are shown in red for the radiocarpal joint and in white for
Mod. 45 the midcarpal joint. 36
S P E C I A L F O C U S 7- 3
Passive Axial Rotation at the Wrist: How Much and Why?
I n addition to flexion-extension and radial-ulnar deviation, the

wrist possesses some passive axial rotation between the carpal
tension in the obliquely oriented radiocarpal ligaments.64 The rela-
tively limited axial rotation permitted at the radiocarpal joint has
deviation. In the neutral position, four ligaments appear as two in the opposite diagonal by a stretch in the medial leg of the
inverted Vs, which have been referred to as the double-V system palmar intercarpal ligament and fibers of the palmar radiocarpal
of ligaments.80 The distal inverted V is formed by the medial and ligament. A gradual increase in tension within these ligaments
lateral legs of the palmar intercarpal ligament; the proximal provides an important source of control to the movement, as well
inverted V is formed by the lunate attachments of the palmar as dynamic stability to the carpal bones. Tensions in stretched
ulnocarpal and palmar radiocarpal ligaments (see Figure 7-10). All collateral ligaments of the wrist may assist the double-V system
four legs of the ligamentous mechanism are under slight tension in determining the end range of radial and ulnar deviation.
Palmar view
Human Movement – Biomechanics of the wrist and hand DE V

IATION NEUTRAL
RADIAL
DEVIATI
ON
AR
LN
U Metacarpal
qArthrokinema+cs 228 Section II

Lateral
Upper Extremity
ate Capitate
Ham g l le
g
La
leg l le Palmar Midcarpal dia
dia intercarpal Me
te
r
Me
al
joint
leg
ligament
l
ra
Triq
Ra d
e n te
t
ligam olla
l Radiocarpal
ial ament
etr
Ulnar c
Radial deviaBon
ig
joint
Lunate oi
coll ral
u
al P
d
arp rad alma
m
lnoc ar Pa ph
ate
ioc r
ar u lm
al ra lm Sca liga arpa
alm n t Pa
- +++ in the mediocarpal joint
ar
P
liga
me carp t li dioc me l
o n ga ar nt
uln ame me pal
lig nt
- Proximal row slides over distal carpal row Ulna Radius
- Proximal row slides towards the ulna FIGURE 7-17. The tensing and slackening of the “double-V” system ligaments of the wrist are illustrated. The
collateral ligaments are also shown. The bones have been blocked together for simplicity. Taut lines represent
ligaments under increased tension.
Palmar view
Ulnar deviaBon ligament (or ligaments) and

VIATIO
the
N severity of the damage. Carpal
DE (demonstrated at rest) or dynamic (dem-
instability may be static
NEUTRAL
Compression AL DEVIATIO
RADIforce N
- +++ na ar8culação mediocárpica U
LN
A
onstrated only during
R
free or resisted movement). 3rd
tacarpal Meta-
The following examples describe two of many forms of me
- Proximal row slides over distal carpal row carpal instability. More detail on
RO
Lthis
L
subject is contained in
Carpometacarpal
carpal
joint ROLL
other sources.18
- Proximal row slides towards radius C
LL
amate H Capita
te Stable
Midcarpal
H
ROL
C
O distal
joint
L
R
Two Common Forms
H of Carpal
E Instability row Scaphoid
T SL
Triqu
ID tubercle ID
SL
1. Rotational collapse of wrist: theS “zigzag” deformity E
etr
S
• Dorsal intercalated
T segment instability (DISI) m
Radiocarpal
u
L Lu oi L
d
• Volar intercalatedSsegment
LIDE
instability (VISI) Articular
disc
nate ph
Sca Mobile
joint
SLIDE
2. Ulnar translocation of the carpus al proximal D
Pa ligament rp
or ligam
row
sal
r radioc
Ulna Radius
radiocarpa
ROTATIONAL COLLAPSE OF THE WRIST
ent
lma
Forearm
Mechanically, the wrist consists of a mobile proximal row of l
carpal bones intercalated or interposed between two rigid
FIGURE 7-16. Radiographs and mechanical depiction of the arthrokinematics of ulnar and radial deviation for
structures: the forearm and the distal row of carpal bones. Like
Palmar
Dorsal
the right wrist. The roll-and-slide arthrokinematics are shown in red for the radiocarpal joint and in white for
cars of a freight train
the that are subject
joint. to derailment, the proxi-
Mod. 45 midcarpal Compression force 37
mal row of carpal bones is susceptible to a rotational collapse
in a “zigzag” fashion when compressed from both ends (Figure FIGURE 7-18. A highly diagrammatic depiction of a “zigzag” collapse
S P E C forces
7-18). The compression I A LthatF cross
O C the
U Swrist7 -arise
3 from of the central column of the wrist after a large compression force.
Passive Axial Rotation at the Wrist: How Much and Why?
I n addition to flexion-extension and radial-ulnar deviation, the

wrist possesses some passive axial rotation between the carpal
tension in the obliquely oriented radiocarpal ligaments.64 The rela-
tively limited axial rotation permitted at the radiocarpal joint has
FC
equipped with moment arms to produce torques in both
F Y 25° sagittal and frontal planes. The extensor carpi radialis longus,
for example, passes dorsally to the medial-lateral axis of rota-
tion and laterally to the anterior-posterior axis of rotation.
Contraction of only this muscle would produce a combina-
FIGURE 7-27. A person with paralysis of her right tion of wrist extension and radial deviation. Using the exten-
wrist extensor muscles (after a radial nerve injury) is sor carpi radialis longus to produce a pure radial deviation
performing a maximal-effort grip using a dynamom- motion, for example, would necessitate the activation of
eter. A, Despite normally innervated finger flexor FIGURE 7-21. This shows how the ulnar tilt of the distal radius can other muscles to neutralize the undesired wrist extension
muscles, maximal grip strength measures only 10 predispose to ulnar translocation of the carpus. Compression forces
potential of the aforementioned muscle. Muscles of the wrist

pounds (about 4.5 kg). B, The same person is shown (F C) that cross the wrist are resolved into (1) a force vector acting
stabilizing her wrist in order to prevent it from flexing perpendicularly to the radiocarpal joint (FY) and (2) a force vector and hand rarely act in isolation when producing a meaningful
during the grip effort. Note that the grip force has (FX) running parallel to the radiocarpal joint. The FY force com- movement. This theme of intermuscular cooperation will be
nearly tripled. presses and stabilizes the radiocarpal joint with a magnitude of about further developed in this chapter and Chapter 8.
90% of F C (cosine 25° × F C). The FX force tends to translate the
carpus in an ulnar direction, with a magnitude of 42% of F C (sine FUNCTION OF THE WRIST EXTENSORS
qMyofascial system
25° × F C). Note that the fiber direction of the palmar radiocarpal
ligament resists this natural ulnar translation of the carpus. The Muscular Anatomy
greater the ulnar tilt and/or compression force across the wrist, the The primary wrist extensors are the extensor carpi radialis
greater the potential for the ulnar translation. longus, the extensor carpi radialis brevis, and the extensor carpi
A B
ulnaris (Figure 7-22). The extensor digitorum is also capable
brevis, and extensor carpi ulnaris. The median and ulnar nerves
innervate all muscles that cross
Anterior the palmar side of the wrist,
view Posterior view
The role of muscles further
in wrist
physiologic andmovement/
reduces effective grip force. This combination of
biomechanic events explains why a person
including the primary wrist flexors (see Figure 6-32, C and D).
The flexor carpi radialis and palmaris longus are innervated by
stability with paralyzed wrist extensor muscles has difficulty produc-
ing an effective grip, even though the finger flexor muscles
the median nerve; the flexor carpi ulnaris is innervated by the
ulnar nerve. As a reference, the primary spinal nerve roots that Brachioradialis
remain fully innervated. Trying to produce a maximal-effort supply the muscles of the upper extremity are listed in Appen-
grip when the wrist extensors are paralyzed results in an dix II, Part A. In addition, Appendix II, Parts B to D include
- Promoting a stable base for the hand
abnormal posture of finger flexion and wrist flexion (Figure additional reference items to help guide the Medial
clinicalepicondyle
assessment
Olecranon
Medial Lateral epicondyle
7-27, A). Stabilizing the wrist in greater extension enables the of the functional status of the C5 to T1 spinal nerve roots and epicondyle
finger flexor muscles to nearly triple their grip force (see several major peripheral nerves of the upper limb.
Figure 7-27, B). Manually or orthotically preventing the wrist Extensor carpi
Extensor carpi radialis longus
from flexing maintains the extrinsic finger flexors at an elon-
- Allowing an optimal length-tension
Pronator teres
SENSORY INNERVATION OF THE JOINTS ulnaris
gated length more conducive to a higher force production. Extensor carpi
Ordinarily the person depicted in Figure 7-27 wears a The radiocarpal and midcarpal joints receive sensory fibers
relationship of the flexor and extensor
radialis brevis
splint that holds the wrist in 10 to 20 degrees of extension. from the C6 and C7 spinal nerve roots carriedPalmarisinlongus
the median Extensor digitorum
If the radial nerve fails to reinnervate the wrist extensor andcarpi
radial nerves.19,26,30 (This terminal sensory branch of the
muscles of the fingers muscles, a tendon from another muscle is often surgically
Flexor radialis
radial nerve often develops a painful Flexor carpi within
neuroma ulnaris the
transferred to provide wrist extension torque. For example, wrists’ dorsal capsule.) The midcarpal joint is also innervated
the pronator teres muscle, innervated by the median nerve, by sensory nerves traveling to the C8 spinal nerve
Flexor root via the
digitorum Extensor digiti Abductor pollicis
is connected to the tendon of the extensor carpi radialis deep branch of the ulnar nerve. superficialis minimi longus (cut)
brevis. Of the three primary wrist extensors, the extensor carpi
radialis brevis is located most centrally at the wrist and has Function of the Muscles at the Wrist Extensor pollicis
the greatest moment arm for wrist extension (see Figure 7-24). Palmar carpal brevis (cut)
Theligament
wrist is controlled by a primary and a secondary set of Extensor Extensor pollicis
FUNCTION OF THE WRIST FLEXORS muscles. The tendons of thePisiform muscles within the primary set retinaculum longus
attach distally within the carpus, or the adjacent proximal end
Muscular Anatomy of the metacarpals;
Pa these muscles act essentially on the wrist Extensor
lma
The three primary wrist flexors are the flexor carpi radialis, the only. The tendons r apo of the muscles within the secondary set cross
neurosis indicis
flexor carpi ulnaris, and the palmaris longus (Figure 7-28). The the carpus as they continue distally to attach to the digits. The
palmaris longus is absent in about 10% to 15% of people.82 secondary muscles therefore act on the wrist and the hand.
Even when present, the muscle often exhibits variation in This7-28.
FIGURE chapter focuses
Anterior viewmore
of theon theforearm
right muscles of thethe
showing primary
primaryset. FIGURE 7-22. A posterior view of the right forearm showing the
shape and number of tendons. The tendon of this muscle is wristThe anatomy
flexor muscles: and kinesiology
flexor of the
carpi radialis, muscles
palmaris of theand
longus, secondary
flexor primary wrist extensors: extensor carpi radialis longus, extensor carpi
often used as a donor in tendon grafting surgery. carpiset—such
ulnaris. as
Thethe extensor
flexor pollicis
digitorum longus and
superficialis the flexor wrist
(a secondary digito- radialis brevis, and extensor carpi ulnaris. The extensor digitorum
The tendons of the three primary wrist flexor muscles are flexor)
rumand pronator teres muscles
superficialis—are are also
considered in shown.
detail in Chapter 8. The and other secondary wrist extensors are also evident.
easily identified on the anterior distal forearm, especially
during strong isometric activation. The palmar carpal ligament, Other secondary muscles capable of flexing the wrist are the
Mod. 45 not easily identified by palpation, is located proximal to the extrinsic flexors of the digits: the flexor digitorum profundus, 38
transverse carpal ligament. This structure, analogous to the flexor digitorum superficialis, and flexor pollicis longus. (The
extensor retinaculum, stabilizes the tendons of the wrist classification of these muscles as “secondary” wrist flexors
B flexors and prevents excessive bowstringing during flexion. should not imply they have a limited potential to perform this
2362_Ch08-271-304.qxd 1/31/11 6:02 PM Page 280
qMyofascial
system 280 SECTION 3 ■ Upper Extremity Joint Complexes
B Lateral
Proximal inserBon at A
Posterior view
Right arm
epicondyle
Anconeus
elbow level Anterior view
Right arm Supinator
Flexors Medial
Lateral
epicondyle
- Pronator teres Medial
epicondyle
- Flexor carpi radialis epicondyle Extensor carpi

radialis longus
Extensor carpi
- Palmaris longus Pronator teres ulnaris Extensor carpi
radialis brevis
- Flexor carpi ulnaris

Palmaris
longus
Extensor digitorum Extensors
communis
- Flexor digitorum
Flexor carpi
radialis
Flexor carpi Extensor digiti
- Extensor carpi radialis
superficialis
ulnaris
Flexor digitorum
minimi
longus
superficialis
- Extensor carpi radialis
Extensor
retinaculum
brevis
Flexor retinaculum
- Extensor digitorum
communis
Figure 8–11 A. Insertion of the flexor muscles on the medial epicondyle of the humerus. B. Insertion of the extensor muscles- on the
Extensor digi8 minimi
lateral epicondyle of the humerus.
- Extensor carpi ulnaris
Mod. 45 39
process. Both the biceps and brachioradialis insert into
the radius. CASE APPLICATION
The two extensors of the elbow are the triceps brachii
case 8–3
Muscles and
and the anconeus. The triceps brachii has three heads:
long, medial, and lateral. The long head crosses both the Tendons
glenohumeral joint at the shoulder as well as the elbow The extensor carpi radialis longus and brevis and the
joint. It arises from the infraglenoid tubercle of the scapula extensor carpi ulnaris are active in gripping, hammering,
by a flattened tendon that blends with the glenohumeral and sawing activities. Therefore, the repetitive pull of
Chapter 7 Wrist 233
Anterior (palmar)
qMyofascial system
ra
r
to
ev r
Fl l de
di
r d xo
ia
ex vi
a
na Fle
or ato
Flexor Flexor carpi
carpi Flexor
digitorum radialis
ulnaris
ul
superficialis
r
Abductor
Pis Trapezium pollicis
ifo Flexor longus
rm Flexor
qu e digitorum
(Lateral) radial
pollicis Sca
Medial (ulnar)
profundus
trum
Tri
longus p Extensor
pollicis brevis
ho
ML
id
Ca
Axis pit Extensor carpi
Hamate a te radialis longus
Extensor Extensor carpi Extensor
carpi radialis brevis pollicis
Extensor longus
ulnaris
digitorum
r
ev or
to
Ex r d
ul
ia
lD s
na
te ev
ia ten
ns ia
ad Ex
or tor
Axis
AP
R
Posterior (dorsal)
1 cm
FIGURE 7-24. A cross-sectional view looking distally through the right carpal tunnel, similar to the perspective
shown in Figure 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 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 either 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.
Mod. 45 600 40
3 r d me
ta c
ar
pal
tons)
Extensor carpi radialis brevis

ate
dius
pit
Ca
a te
s. The other six are finger and thumb muscles except those performed in supination.92 The extensorprimary wrist muscles: the extensor carpi radialis longus, the One stu
secondarily on the wrist: the extensor digito- carpi radialis longus muscle inserts into the more radialextensor carpi radialis brevis (ECRB), and the extensor to be a
munis (EDC), the extensor indicis proprius second metacarpal and, therefore, has a smaller momentcarpi ulnaris. The other six are finger and thumb muscles except
extensor digiti minimi (EDM), the extensor
232 arm for
Section II wrist extension
Upper Extremitythan does the extensor carpi radi-that may act secondarily on the wrist: the extensor digito- carpi ra
gus (EPL), the extensor pollicis brevis (EPB), alis brevis muscle. The extensor carpi radialis longus mus-rum communis (EDC), the extensor indicis proprius
7 second
ductor pollicis longus (APL). The extensor cle shows increased activity when either radial deviation or(EIP), the extensor digiti minimi (EDM), the extensor arm for
of generating significant wrist extension torque but is mainly particularly susceptible
pollicis longus (EPL),tothe
inflammation, a condition
extensor pollicis called
brevis (EPB), alis bre
involved with extension of the fingers. Other secondary wrist de Quervain’s tenosynovitis. Activities that frequently cause this
Human Movement – Biomechanics ofandthepainful
wrist and hand
and the abductor pollicis longus (APL). The extensor cle show
extensors are the extensor indicis, extensor digiti minimi, condition include repetitively pressing the trigger
extensor pollicis longus. 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 conserva-
qMyofascial Wrist Extensor Muscles
tively by phonophoresis or iontophoresis, cortisone injec-
Primary Set (Act on Wrist Only)
system • Extensor carpi radialis longus
tions, ice, wearing a hand-wrist–based thumb splint, and
modifying the activity that caused the inflammation. If con-
• Extensor carpi radialis brevis servative therapy fails to reduce the inflammation, surgical
• Extensor carpi ulnaris release of the first compartment may be indicated.
Secondary Set (Act on Wrist and Hand)
Extensors • Extensor digitorum Biomechanical Assessment of Wrist Muscles’ Action
• Extensor indicis and Torque Potential
Abductor pollicis • Extensor digiti minimi Data are available on the relative position, cross-sectional area,
longus muscle • Extensor pollicis longus Abductor pollicis
and length of the internal moment arms of most muscles that
longus muscle
Extensor pollicis 40,83
brevis muscle
cross the wrist. By knowing the approximate location of
Extensor pollicis
The proximal attachments of the primary wrist extensors the axes of rotation of the wrist, these databrevis provide
muscle a useful
are located on and near the lateral (“extensor-supinator”) epi- method for estimating the action and relative torque potential
condyle of the humerus and dorsal border of the ulna (see of the wrist muscles (Figure 7-24). Consider, for instance, the
Figures 6-2 and 6-6). Distally, the extensor carpi radialis longus extensor carpi ulnaris and the flexor carpi ulnaris. By noting
Figure 9–13 The dorsally located extensor tendons pass
and brevis attach
beneath the extensor retinaculum, where the tendons arethe location of each tendon from the axis of rotation, it is
side by side to the dorsal bases of the second Figur
APL
ECRB
ECRL
EPB
APL
Abductor pollicisand third metacarpals, respectively; thetheextensor
radial tocarpi ulnaris
side, theevident that the extensor carpi ulnaris is an extensor and ulnar
ECRB
benea
ECRL
EPB
EPL
compartmentalized. From the ulnar

EIP
EDC
EDM
Abductor pollicis
EPL
longus tendon attaches to theabductor
dorsal base of the fifth metacarpal. deviator and the flexor carpi ulnaris is a flexor and ulnar devia- comp
EIP
EDC
pollicis longus (APL) and extensor pollicis brevis
ECU
EDM
longus tendon abduc
Extensor pollicis
The tendons of the muscles that cross the dorsal and
(EPB) muscles share a compartment; the extensor carpi radi- tor. Because both muscles have similar cross-sectional areas,
(EPB)
dorsal-radial side
brevis tendon alis of the (ECRB)
brevis wrist areand
secured in place
the extensor by the
carpi exten-
radialis longus they likely produce comparable levels of maximal force. In
Extensor pollicis
alis br
brevis tendon
sor retinaculum(ECRL) muscles
(Figure 7-23). share a the
Ulnarly, compartment; the extensor pollicis
extensor retinaculum order to estimate the relative torque production of the two (ECR
Anatomical
snuffbox wraps around longus (EPL) process
the styloid muscle has of athe
compartment of its own;
ulna to attach pal- the four
muscles, however, each muscle’s cross-sectional area must be
Anatomical longu
tendonsofofthe
marly to the tendon theflexor
extensor digitorum
carpi ulnaris,communis (EDC) muscle
pisiform bone, multiplied by each muscle’s specific moment arm snuffbox
length. The tendo
share a compartment with the extensor indicis proprius (EIP) share
and pisometacarpal ligament. Radially, the retinaculum extensor carpi ulnaris therefore is considered a more potent
muscle; the extensor digiti minimi (EDM) muscle has its muscl
attaches to theown styloid process of the radius and the radial
compartment; and the extensor carpi ulnaris (ECU)
ulnar deviator than an extensor; the flexor carpi ulnaris is
Extensor indicis own c
collateral
tendon ligament. The extensor retinaculum
muscle has its own compartment. prevents the considered both a potent flexor and a potent ulnarExtensor indicis
deviator.
tendon muscl
underlying tendons from “bowstringing” up and away from
the radiocarpal joint during active movements of the wrist. Wrist Extensor Activity while Making a Fist
Mod. 45 41
Between the extensor retinaculum and the underlying The main function of the wrist extensors is to position and
bones are six fibro-osseus compartments that house the tendons stabilize the wrist during activities involving active flexion of
along with their synovial sheaths.32 Clinicians frequently refer the fingers. Of particular importance is the role of the wrist
to these compartments by Roman numerals I to VI (see Figure extensor muscles in making a fist or producing a strong grip.
7-23). Each compartment houses a specific set of tendons. To demonstrate this, rapidly tighten and release the fist and
Tenosynovitis frequently occurs within one or more of these note the strong synchronous activity from the wrist extensors.
ap
Hamate ita Posterior (dorsal)radialis longus
adial
t e
Me
1 cm
Extensor Extensor carpi Extensor
carpi radialis brevis pollicis
Extensor
FIGURE 7-24. A cross-sectional view looking distally through the right carpal
ulnaris longus tunnel, similar to the perspective
digitorum
r
ev or
to
Ex r d
ul
ia
lD s
most muscles that cross the wrist at the level of the head of the capitate. The area within the red boxes on the
na
te ev
ia ten
n s ia
ad Ex
or tor
Axis
AP
production. The small black dot within each red box indicates the position of the muscle’s tendon. The wrist’s
R
medial-lateral (ML) axis of rotation (dark gray) and anterior-posterior
the head of the capitate bone. Each
distance
Posterior (dorsal) (AP) axis of rotation (red) intersect within
muscle’s moment arm for a particular action is equal to the perpendicular
1 cm
FIGURE 7-24. between either axis
A cross-sectional andlooking
view the position
distallyof the muscle’s
through the righttendon. The length
carpal tunnel, of each
similar to themoment arm (expressed
perspective
qMyofascial system most muscles that cross the wrist at the level of the head of the capitate. The area within the red boxes on the
production. The small black dot within each red box indicates the position of600 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
Extensors the head 3ofrdthe
mecapitate bone. Each muscle’s moment arm for a particular action is equal to the perpendicular
distance betweentaeither
c axis and the position of the muscle’s tendon. The length of each moment arm (expressed
ar
pal
Muscle stability/synergy
Compressive force (newtons)

ate
Radius
pit
Ca
a te
600
400
Lun
Flexor digitorum profundus
3 r d me Flexor digitorum superficialis
ta c
ar
pa
Compressive force (newtons)

l
ate
Radius
pit
Ca
a te
Lun
400
FIGURE 7-25. Muscle mechanics involved with the production of a
Flexor digitorum profundus 200
strong grip. Contraction of the extrinsic Flexor digfinger flexors (flexor digito-
itorum superficialis
rum superficialis and profundus) flexes the fingers but also creates
a simultaneous wrist flexion torque. Activation of the wrist extensors,
such as the extensor carpi radialis brevis, is necessary to block the
wrist7-25.
FIGURE flexion tendency
Muscle causedinvolved
mechanics by the with
activated finger flexor
the production of amuscles. 200
In this manner the wrist extensors maintain the
strong grip. Contraction of the extrinsic finger flexors (flexor digito- optimal length of
rum superficialis and profundus) flexes the fingers but also createsmoment
the finger flexors to effectively flex the fingers. The internal 0
arms for thewrist
a simultaneous extensor
flexioncarpi radialis
torque. brevisofand
Activation the extrinsic
wrist extensors,finger flexors 90 60 30 0 30 60 90
areasshown
such in dark
the extensor bold
carpi lines.brevis,
radialis The small circle to
is necessary within blockthe
thecapitate Wrist angle (degrees)
marks
wrist thetendency
flexion medial-lateral
caused axis
by theof activated
rotation finger
at theflexorwrist.muscles.
In this manner the wrist extensors maintain the optimal length of FIGURE 7-26. The compression forces produced by a maximal-effort
the finger flexors to effectively flex the fingers. The internal moment grip
0 are shown for three different wrist positions (for three subjects).
of for
arms these musclescarpi
the extensor for wrist
radialisflexion is evident
brevis and extrinsicin Figure
finger 7-24. The
flexors Maximal
90 grip
60 force 30occurs0at about
30 30 degrees
60 of
90extension. (With
arewrist
shown extensor
in dark muscles
bold lines.must
The counterbalance
small circle within thethesignificant
capitate wrist permission fromWrist Inman VT, Ralston
angle (degrees) HJ, Todd F: Human walking,
Mod. 45 flexion
marks torque produced
the medial-lateral by the atfinger
axis of rotation flexor muscles (Figure
the wrist. Baltimore, 1981, Williams & Wilkins.) 42
FIGURE 7-26. The compression forces produced by a maximal-effort
7-25). As a strong grip is applied to an object, the wrist extensors grip are shown for three different wrist positions (for three subjects).
of typically holdfor
these muscles thewrist
wrist in about
flexion 30 toin35Figure
is evident degrees7-24.ofThe
extension
Maximalstrength
grip forceisoccurs
caused by a combination
at about of two factors.
30 degrees of extension. (With First, and
wrist
andextensor
aboutmuscles
5 degreesmustofcounterbalance
ulnar deviation. the 56
significant wrist opti-
This position permissionlikely
fromforemost,
Inman VT,the finger
Ralston HJ,flexors
Todd F:cannot generate adequate
Human walking,
flexion
mizestorque produced by therelationship
the length-tension finger flexorofmuscles (Figure finger
the extrinsic Baltimore, 1981,because
force Williamsthey
& Wilkins.)
are functioning at an extremely shortened
7-25). As a strong
flexors, therebygrip is applied to
facilitating an object,
maximal thestrength
grip wrist extensors
(Figure 7-26). length respective to their length-tension curve. Second, the
typically hold the wrist in about 30 to 35 degrees
As evident in Figure 7-26, grip strength of extension strengthoverstretched
is significantly is caused by a combination of two
finger extensors, factors. First,
particularly theand
extensor digi-
56
A
Palmar view
task. Actually, based on the muscles’ cross-sectional areas and
wrist flexor moment arms [see Figure 7-24], the wrist flexion CHAPTER 9 ■ The Wrist and Hand Complex 317
torque potential of extrinsic flexors of the digits may exceed that
of the primary wrist flexors.) With the wrist in a neutral posi- A

tion, the abductor pollicis longus and extensor pollicis brevis
have a small moment arm for wrist flexion (see Figure 7-24).
Flexor carpi Transverse

arpal ligament
qMyofascial
c
radialis tendon Pisometacarpal ligament
Wrist Flexor Muscles Palmaris longus
Flexor pollicis tendon
Primary Set (Act on Wrist Only) Pisohamate ligament
system • Flexor carpi radialis
longus tendon Ulnar nerve
• Flexor carpi ulnaris Median nerve

Flexor carpi
ulnaris
Flexor carpitendons
• Palmaris longus radialis tendon Palmaris longus
Flexor carpi ulnaris
Flexor carpi radialis

Flexor retinaculum and Flexor
Flexor pollicisdigitorum tendon
Secondary Set (Act on Wrist and Hand)
Palmaris longus
transverse carpal ligament superficialis
longus tendon tendons Ulnar nerve
Flexors • Flexor digitorum profundus Median nerve

Flexor carpi
• Flexor digitorum superficialis ulnaris tendons
• Flexor pollicis longus Flexor retinaculum and Flexor digitorum
• Abductor pollicis longus transverse carpal ligament superficialis tendons
• Extensor pollicis brevis

FIGURE 7-29. The palmar aspect of the right wrist showing the distal
B attachments
Volar of the primary wrist flexor muscles. Note that the
tendon of the flexor carpi radialis courses through a sheath located
The proximal attachments of the primary wrist flexors are within the superficial fibers of the Volar
Palmaris transverse carpal ligament. Most
B Transverse
located on and near the medial (“flexor-pronator”) epicondyle of the
longus distal attachment
carpal ligament of the palmaris longus has been removed
Median
of the humerus and dorsal border of the ulna (see Figures
Flexor pollicis 6-2nerve
with the palmar aponeurosis. Palmaris
Ulnar artery Transverse longus
and 6-6). Technically, the tendon of the flexor carpi longus radialis andMedian
nerve carpal ligament
does not cross the wrist through the carpal tunnel; rather, the
Flexor carpi Functional Considerations
Flexor pollicis
longus
nerve Ulnar artery
and nerve
Figure 9–12 A. The tendons and nerves radialis
tendon passes in a separate
of the primary and secondary wrist flexors
tunnel formed by a groove in the Based on
Flexor moment
carpi arm and cross-sectional
Four stacked tendons
of the flexor digitorum
area (see Figure
Figure 9–12 A. The tendons and nerves radialis
trapezium
lie on the volar and fascia
aspect of thefrom
wrist.the adjacent transverse
All but of the primary andcarpal liga-
secondary 7-24), the flexor carpi ulnaris produces
wrist flexors superficialisthe greatest wrist flexion
Four stacked tendons
of the flexor digitorum
ment (Figure
the palmaris longus7-29).
tendon,The tendon
the ulnar nerve,of thelieflexor carpi
on the volar aspectradialis torque potential of the three primary wrist flexor muscles.
of the wrist. All but superficialis
the palmaris longusTp tendon, the ulnar nerve,
attaches distally
and the flexor to themuscle
carpi ulnaris palmar pass base
be- of the second
and the and
flexor carpi some-
ulnaris muscle pass During
be- active wrist Tp flexion, the flexor
Flexor carpi carpi radialis and flexor
neath the flexor retinaculum. B.
times the third metacarpal. The palmarisOn cross- longus
neath the flexorhas a distal
retinaculum. B. On cross-carpi ulnaris act together H
as synergists
ulnaris
Flexor carpi
whileH simultaneously ulnaris
section, the relationship of the tendons and section, the relationship of the tendons and
attachment primarily to the
nerves to the transverse carpal ligament is thick aponeurosis
nerves to theof the
transverse palm.
carpal Tz
ligament opposing
is each other’s radial
Tz and ulnar deviation ability.
The tendonThe
more evident. offlexor
the pollicis
flexorlonguscarpiis ulnarismore courses
evident. Thedistally to longus is As indicated
flexor pollicis C in Table 7-1, data indicate C that the wrist flexor
encased in its own tendon sheath (or radial
attach
encased to the
in its own pisiform
tendon sheathbone(orand,radialin a plane superficial to the
bursa), whereas the four deep tendons of muscles produce about 70% greater isometric torque than the
bursa), whereas
transverse the four
carpal deep tendons
ligament, intoofthe pisohamate and pisometa-
the flexor digitorum profundus and the wrist
four extensor muscles—12.2 Nm tendons
Four side-by-side versus of 7.1 Nm, respec-
the flexor digitorum profundus and the four more superficial stacked tendonsFour of theside-by-side
17 tendons of the flexor digitorum profundus
carpal ligaments
more superficial stackedand the base
tendons of the of the fifth metacarpal
flexor bone.arethe
digitorum superficialis tively.
flexor
wrapped digitorumThe greater total cross-sectional area of the wrist
profundus
Mod. 45 flexor digitorum superficialis are wrapped by folds in the ulnar bursa. Dorsal 43
by folds in the ulnar bursa. Dorsal
The flexor carpi ulnaris muscle envelops the pisiform, a function.4 The flexor carpi ulnaris muscle is able to exert the
sesamoid bone that increases the moment arm of the flexor greatest tension of all the wrist muscles, giving it particular
The flexor carpi ulnaris muscle envelops the pisiform,
carpi a
ulnaris muscle function.
for flexion.4 The flexorcarpi
The flexor carpiulnaris
ulnaris muscle is able
functional to exert
relevance, the with activities requiring
especially
muscle can
sesamoid bone that increases the moment arm of the flexoract on the hamate
greatestandtension
fifth metacarpal
of all indirectly
the wrist high ulnar
muscles, deviation
giving it forces such as chopping wood.4
particular
carpi ulnaris muscle for flexion. The flexor through the pisiform’s ligaments,35 effectively producing
carpi ulnaris functional relevance, especially with The flexor digitorum superficialis and flexor digitorum
activities requiring
flexion and ulnar deviation of the wrist complex. The flexor profundus muscles are predominantly flexors of the fingers,
muscle can act on the hamate and fifth metacarpal indirectly high ulnar deviation forces such as chopping wood.
4
the other joint or joints crossed by the multijoint muscles.
For example, elbow flexion with the forearm in pronation
is accomplished primarily with the brachialis, not with the
biceps brachii.
Single-joint and multijoint muscles may also work to-
gether in such a way that the single-joint muscle can assist in
the movement of joints that it does not cross.65 For example, Figure 3–28 An example of the two-joint function of the
the simple movement of standing up from a chair requires hamstring muscles in transferring force of the single-joint knee
qMyofascial system
knee and hip extension. The hip extension is accomplished by extensors to extend the hip.
Tenodesis acBon
Figure 3–29 Passive insufficiency. A. The finger exten-

sors become passively insufficient as they are lengthened
over the wrist and fingers during wrist flexion. The passive
tension that is developed causes extension of the fingers
(tenodesis). B. The finger flexors become passively insuffi-
cient as they are lengthened over the wrist and fingers
during wrist extension. The passive tension developed in A B
the finger flexors causes the fingers to flex.
Mod. 45 44
The axis of rotation is through the capitate with the internal moment
longus muscles flexor
andforbrevis, is required during these activities to prevent a rela-
arms shown the
tivelyextensor carpicarpi
ineffective radialis
position
radialis,
brevis
of combined
abductor
(ECRB) and the
wrist
pollicis
andflexor
finger
slight extension for optimal grasp of the hammer.
longus, and(FCR)
carpi radialis flexor pollicis
only.
flexion. longus
The flexor (review
pollicis longus Figure
is not7-24).
shown.InAPL, the Muscles capable of ulnar deviation of the wrist are the extensor
neutral
abductorwrist
pollicisposition,
longus; ECRL the extensor carpi radialis
and B, extensor longuslongus
carpi radialis and carpi ulnaris, flexor carpi ulnaris, flexor digitorum profundus and
L and B
ed abductor EPL andlongus
and brevis;pollicis B, extensorpossess pollicis
the longus
largestand brevis. of cross-
product ECR
superficalis, and extensor digitorum (see Figure 7-24). Because of
APL dB
1, TABLE 7-1. Magnitude and Wrist Joint Position of Peak L an
sectional area and moment
Isometric Torquearm for radial
Produced by Healthy deviation
Males torque. moment arm EP length, however, the muscles most capable of this
Figure 7-30
The extensor pollicis shows the radial deviator
brevis has the greatest moment muscles contracting
arm of action, by far, are the extensor carpi ulnaris and flexor carpi radia-
Wrist
during use of
all radial deviators; a hammer.
Musclehowever, All these
Mean because muscles pass
of a relatively laterally small to lis. Figure 7-31 shows this strong pair of ulnar deviator muscles
Peak
the wrist’s anterior-posterior
cross-sectional area,
Groupthis muscle’s Torqueaxis(Nm)of rotation.
torque AngleThe
Jointproduction of Peakaction
is rela-
Torque of contracting as a nail is struck with a hammer. Both the flexor and
the extensor
tively small.carpiThe radialis
abductor
Flexors
longus
pollicis
12.2 (3.7)
and the
longus flexor
and carpi
extensor
40 degrees of flexion
radialis,
pol- extensor
236 carpi ulnaris
Section II Upper contract
Extremitysynergistically to perform the ulnar
shown
licis withprovide
brevis momentExtensors arms, 7.1illustrates
important stabilityaFrom
(2.1) finethe
to 30example
radial
degrees of two
side
of flexion of
to deviation
flexor muscles but as also stabilize
a group the wrist
can account in aofslightly
for much this dis- extended posi-
muscles cooperating as synergists for one motion but as FIGURE 7-30. It The muscles that perform radial deviation offlexors
the wrist between the
qMyofascial system
the wrist, augmenting that produced passively by the radial tion.
qMyofascial system
Because of the strong functional association
70 degrees of extension parity. 29
is noteworthy that the extrinsic finger
are(flexors
shown preparing tosuperficialis
strike a nail with aprofundus)
hammer. The image in the
re antagonists
collateral for another.
ligament. Radial
As shown The 11.0net effect
(2.0)
in Table of 7-1, this
themuscular
0 degrees (neutral)
radial deviator coop- flexor
backgroundand digitorum
isextensor
a mirror carpi
reflection
and
ulnaris
of the muscles,
palmar
account
surfaceinjury
of the
for
to either muscle EPB
wrist.
deviators about two thirds of the total cross-sectional area of the wrist
is eration produces
muscles generate a
Ulnar
radially
about 15% deviated
greater
9.5 (2.2)
wrist,
isometric well stabilized
torque
0 degrees (neutral) than in can
The incapacitate
axis of the
40 rotation is through overall
the kinetics
capitate with
flexors. Activities such as lifting or pulling heavy objects the of ulnar
internal moment deviation. For APL
is slight extension for optimal grasp of the hammer. arms shown for the extensor carpi radialis brevis (ECRB) and the flexor
the ulnar deviator muscles—11.0 Nm versus 9.5 Nm,
deviators example,
normally demand rheumatoid
carpi radialis (FCR)
strength arthritis
only. The flexor
in both theoften
pollicis longus iscauses inflammation
wrist flexor and finger
not shown. APL, and
FCR
he Muscles capable
respectively. 17 of ulnar deviation of the wrist are the extensor painflexor musculature. Strong coactivation of the wrist extensor
abductor in the
pollicis extensor
longus; ECRL carpiandulnaris
B, extensor tendon near
carpi radialis its
longus distal attach-
muscles is required during these activities to prevent a rela-
d Radial
carpi deviators
ulnaris, flexor carpi
Data from ulnaris,
Delp SL, Grierson AE,flexor
Buchanandigitorum profundus
TS: Maximum isometric and
moments generated
by the wrist muscles in flexion-extension and radial-ulnar deviation, J Biomech 29:1371,
and brevis;
ment. EPL and B,atextensor
tively Attempts
ineffective position active pollicis longus
of ulnar
combined
and brevis.with minimal to no
deviation
wrist and finger
s- superficalis, and1996. extensor digitorum (see Figure 7-24). Because of activation
flexion. in the painful extensor carpi ulnaris cause the action
Figure 7-30 shows the radial deviator muscles contracting
e. moment arm length, however,
Standard deviations the muscles most capable of this
in parentheses. of the flexor
during use of acarpi hammer. ulnaris to gomuscles
All these unopposed. The resulting
pass laterally to ECR
flexed
L and B
of Radial
action, byDeviators
far, are the of
Conversions: theNm/ft-lb.
extensor
1.36 Wrist
carpi ulnaris and flexor carpi radia- posture
the TABLEof
wrist’s theMagnitude
wrist is and
anterior-posterior
7-1. thereby
axis of notPosition
Wrist Joint suitable
rotation. The for an effective grasp.
action
of Peak of A PL L an
dB
EP
ll • Extensor
lis. Figure 7-31 carpi
showsradialis
this stronglonguspair of ulnar deviator muscles the extensor
IsometriccarpiTorque radialis
Stability/ muscle synergy Produced longus and theMales
by Healthy flexor carpi radialis,
a- •
contracting as a nail is struckbrevis
Extensor carpi
FUNCTION radialis
OF THEwithRADIAL AND ULNAR
a hammer. BothDEVIATORS
the flexor and shown Wristwith moment arms, illustrates a fine example of two
l- • Extensor pollicis
extensor carpi ulnaris longus
Muscles capable of producing radial deviation of the
contract synergistically to perform ulnarare
the wrist
Ulnar
musclesMuscle
antagonists
Deviators
cooperating
Group for another.
Mean as ofsynergists
Peak the Wrist
The netJoint effect
for one motion but as
of this muscular
Torquecoop-
of • Extensor
deviation but alsopollicis brevis
stabilize
the extensor theradialis
carpi wrist brevis
in a slightly
and longus, extended
extensor posi-
pollicis
• Extensor carpi ulnaris Angle
Torque (Nm)
eration produces a radially deviated wrist, well stabilized in
of Peak
al
• Flexor carpi
tion.• Because longusradialis
and brevis,
functional association betweenpollicis
flexor carpi radialis, abductor slight•Flexors
Flexor carpi
extension ulnarisgrasp
12.2 (3.7)
for optimal
40 degrees of flexion
of the hammer.
Abductorof the strong
pollicis
longus, andlongus
flexor pollicis longus (review Figure 7-24). In the
the •Extensors
MusclesFlexor 7.1 (2.1) profundus
digitorum
capable
From 30 degrees
of ulnar deviation70ofdegrees theand wrist
of flexion to Chapter 7 Wrist
superficialis
are the extensor FIGURE 7-30. The 237
or flexor and extensor
• Flexor pollicis carpi
neutrallongus ulnaris muscles, injury to either
wrist position, the extensor carpi radialis longus and muscle carpi•Radial
Extensor
ulnaris, digitorum
flexor11.0 carpi ulnaris, flexor
of extension muscles that perform radial deviation of the wrist
(2.0) 0 degrees (neutral)profundus and are shown preparing to strike a nail with a hammer. The image in the
digitorum
n can incapacitate the overall
abductor kinetics
pollicis longus of the
possess ulnarlargestdeviation.
product of For cross- superficalis,
deviatorsand extensor digitorum (see Figure 7-24). Because of background is a mirror reflection of the palmar surface of the wrist.
m, example, rheumatoid sectional arthritis
area and moment often causesarm for inflammation
radial deviation torque. and moment Ulnar arm length, 9.5 however,
(2.2) the0 degrees most capable of this The axis of rotation is through the capitate with the internal moment
muscles(neutral)
pain in the extensor The extensorcarpipollicis
ulnarisbrevis has the
tendon neargreatest moment
its distal arm of
attach- by far, are the extensor carpi ulnaris and flexor carpi radia- arms
action,deviators shown for the extensor carpi radialis brevis (ECRB) and the flexor
carpi radialis (FCR) only. The flexor pollicis longus is not shown. APL,
all radial deviators; however, because of a relatively small lis. Figure 7-31 shows this strong pair of ulnar deviator muscles abductor pollicis longus; ECRL and B, extensor carpi radialis longus
ment. Attempts at active ulnar
cross-sectional area, thisdeviation
muscle’s with torqueminimal
productiontois no rela- contracting
Data from DelpasSL,a Grierson
nail is AE, struck with
Buchanan TS:aMaximum
hammer. Both
isometric the flexor
moments and and brevis; EPL and B, extensor pollicis longus and brevis.
generated
Ulnar deviators
activation in the painful
tively small. extensor
The abductorcarpi ulnaris
pollicis cause
longus andthe action
extensor pol- extensor carpi
by the wrist
FCU
ulnaris
muscles contract synergistically
in flexion-extension to perform
and radial-ulnar deviation, J Biomech the ulnar
29:1371,
of the flexor carpi licis ulnaris to go important
brevis provide unopposed. Thetoresulting
stability the radialflexedside of deviation
1996. but also stabilize the wrist in a slightly extended posi-
Standard deviations in parentheses.
Figure 7-30 shows the radial deviator muscles contracting
the wrist, augmenting during use of a hammer. All these muscles pass laterally to
posture of the wrist is thereby not that produced
suitable for an passively
effective
collateral ligament. As shown in Table 7-1, the radial deviator
by the radial
grasp. tion. Because of the
Conversions: 1.36 Nm/ft-lb.
strong functional association between the
flexor and extensor carpi ulnaris muscles, injury to either muscle the wrist’s anterior-posterior axis of rotation. The action of
muscles generate about 15% greater isometric torque than ECU
can incapacitate the overall kinetics of ulnar deviation. For the extensor carpi radialis longus and the flexor carpi radialis,
the ulnar
Ulnar Deviators deviator muscles—11.0 Nm versus 9.5 Nm,
of the FUNCTION
example, OF THE RADIAL
rheumatoid arthritis AND ULNAR
often causes inflammation and shown with moment arms, illustrates a fine example of two
DEVIATORS
17 Wrist muscles cooperating as synergists for one motion but as
respectively. pain in the extensor carpi ulnaris tendon near its distal attach-
• Extensor carpi ulnaris Muscles capable of producing radial deviation of the wrist are
ment. Attempts at active ulnar deviation
the extensor carpi radialis brevis and longus, extensor pollicis with minimal to no
antagonists for another. The net effect of this muscular coop-
eration produces a radially deviated wrist, well stabilized in
• Flexor carpi ulnaris activation
longus and in the painful
brevis, extensor
flexor carpicarpi ulnaris
radialis, cause the
abductor action slight extension for optimal grasp of the hammer.
pollicis
• Flexor digitorum profundus and superficialis
Radial Deviators of the Wrist
of longus,
the7-31.
FIGURE flexorThecarpi
and flexor
muscles ulnaris
pollicis
that to longus
performgoulnar
unopposed.
(review are
deviation The
Figureshownresulting
7-24). In flexed
as a nail the
is struck with Muscles
a hammer.capable
The of ulnar deviation of the wrist are the extensor
• Extensor digitorum
• Extensor carpi radialis longus
posture
image in theof
neutral the wrist
background
wrist is is
position, thereby
a mirror
the not ofsuitable
reflection
extensor carpi for
the palmar an effective
surface
radialis of the wrist.grasp.
longus and The axis of rotation is shown
through the capitate with internal moment arms shown for the flexor carpi ulnaris (FCU) and the extensor
carpi ulnaris, flexor carpi ulnaris, flexor digitorum profundus and
carpiabductor pollicis longus possess the largest product of cross-
ulnaris (ECU). superficalis, and extensor digitorum (see Figure 7-24). Because of
Mod. 45 • Extensor carpi radialis brevis sectional area andofmoment arm for radial deviation torque. moment arm length, however, the muscles most capable of 45 this
• Extensor pollicis longus Ulnar Deviators the Wrist
The extensor pollicis brevis has the greatest moment arm of action, by far, are the extensor carpi ulnaris and flexor carpi radia-
• Extensor pollicis brevis all• radial
Extensor carpi ulnaris
• Flexor deviators; however, because of a of relatively small lis. Figure 7-31 shows
The design the wrist is also strongly associated with the this strong pair of ulnar deviator muscles
• Flexor carpi radialis SYNOPSIS carpiarea,
cross-sectional ulnaris
this muscle’skinematics of pronation is
torque production andrela-
supination of the forearm.
contracting Ele-is struck with a hammer. Both the flexor and
as a nail
• Abductor pollicis longus • Flexor
tively digitorum
small. profundus
The abductor and
pollicis superficialis
ments of this
longus anddesign are present
extensor pol- on both sides carpi
extensor of theulnaris
wrist. contract synergistically to perform the ulnar
• Flexor pollicis longus • Extensor
The wrist consists of two primary
licis digitorum
articulations:
brevis provide
the radiocar-
important
Radially, the radiocarpal joint restricts axial rotation between
stability to the radial side of deviation but also stabilize the wrist in a slightly extended posi-
B pal and the midcarpal joints. The radiocarpal joint joins the the carpus and the radius. By restricting this motion, the hand
the bones
distal end of the radius with wrist,ofaugmenting
the proximal that produced
carpus; passively
is obligated by the
to follow radial
the path of the tion. Because
pronating of the strong functional association between the
and supinat-
the midcarpal joint unitescollateral ligament.
the proximal As shown
and distal rows of in Table 7-1, As
ing radius. thetheradial
wristdeviator flexor radially,
limits axial rotation and extensor
it selec-carpi ulnaris muscles, injury to either muscle
carpal bones. Forces produced
musclesby active muscle
generate and subse-
about tively permits
15% greater isometricthis torque
motion ulnarly.
than Thecan largeincapacitate
ulnocarpal spacethe overall kinetics of ulnar deviation. For
quently stretched ligaments guide the arthrokinematics across and associated soft tissues loosely bind the ulnar side of the
qPalmar arch
Function
- Optimized hand shape for gripping an object

Chapter 8 Hand 24
- Increases the contact area
Longitudinal
- Improves stability arch
Distal
transverse arch
- Increases sensory feedback
Proximal
Ca
transverse arch
pit
Keystone
ate
FIGURE 8-8. The natural concavity of the palm of the hand is supported by three integrated arch systems: one
longitudinal and two transverse.
Mod. 45 46
2362_Ch09-305-353.qxd 1/29/11 4:29 PM Page 321
Human Movement – BiomechanicsC Hof

A P Tthe
E R 9 wrist andandhand
The Wrist Hand Complex ■ 321
qPalmar archExploration 9-2:

Continuing
C
Carpal Tunnel Syndrome
When the median nerve becomes compressed within
Proximalthetransverse
carpal tunnel, a neuropathy known as carpal tunnel
arch
- Archsyndrome
formed by(CTS) may develop.
the concavity of theCobb
carpalandbones
colleagues
proposed that the proximal edge of the transverse carpal
ligament is the most common site for wrist flexion-
induced median nerve compression.104 The tunnel is nar- B
Distal transverse arch at the level of the hook of the hamate,

rowest, however,
- Heads of the 1st,nerve
where median compression
4th and 5th fingersis unlikely
around to be
theaffected
by changes in wrist position. 104 When the transverse
morecarpal
fixedligament
2nd andis 3rd fingers
cut to release median nerve compres-
sion, the carpal arch may widen somewhat, but investiga- A
tors found that the arch would maintain its dorsovolar
stiffnessarch
Longitudinal as long as the stronger transverse intercarpal
ligaments were intact.105
- Crosses the length of the fingers from proximal to
distal
Carpometacarpal Joint Range of Motion
The range of carpometacarpal motion of the second Figure 9–17 The palmar arch system assists with functional
through fifth metacarpals is observable most readily at the grasp. The proximal transverse arch (A) is fixed, while the distal
metacarpal heads, and shows increasing mobility from the transverse arch (B) and longitudinal arch (C) are mobile.
radial to the ulnar side of the hand.57,106 The second
Mod. 45 through fourth carpometacarpal joints are plane synovial 47
digits to conform optimally to the shape of the object
joints with one degree of freedom: flexion/extension. Al-
being held.110 This maximizes the amount of surface
though structured to permit flexion/extension, the second
contact, enhancing stability as well as increasing sensory
and third carpometacarpal joints are essentially immobile
feedback.
and may be considered to have “zero degrees of free-
Muscles that cross the carpometacarpal joints will con-
dom.”40,98 The fourth carpometacarpal joint has perceptible
occupies a central location within the wrist, making articular many muscles located within the hand and the palmaris
contact with seven surrounding bones when considering the longus, a wrist flexor muscle.
metacarpals (see Figure 7-3, A). The word capitate is derived The transverse carpal ligament converts the palmar con-
from the Latin root meaning head, which describes the shape cavity made by the carpal bones into a carpal tunnel. The 2362_Ch09-305-353.qxd 1/29/11 4:29 PM Page 322
of the bone’s prominent proximal surface. The large head tunnel serves as a passageway for the median nerve and the
articulates with the deep concavity provided by the scaphoid tendons of extrinsic flexor muscles of the digits. Furthermore,
and lunate. The capitate is well stabilized between the hamate the transverse carpal ligament restrains the enclosed tendons
and trapezoid by short but strong ligaments. from “bowstringing” anteriorly and out of the carpal tunnel,
The capitate’s distal surface is rigidly joined to the base of the most notably during grasping actions performed with a par-
third and, to a lesser extent, the second and fourth metacarpal
bones. This rigid articulation allows the capitate and the third
tially flexed wrist.
322 SECTION 3 ■ Upper Extremity Joint Complexes
metacarpal to function as a single column, providing significant
longitudinal stability to the entire wrist and hand. The axis of cong
qPalmar arch
rotation for all wrist motions passes through the capitate. lang
vide
TRAPEZIUM plate
the
The trapezium has an asymmetric shape. The proximal surface meta
is slightly concave for articulation with the scaphoid. Of par- prox
Passive
ticular importancesupport structures
is the distal saddle-shaped surface, which to th
P1
articulates with the base of the first metacarpal. The first car- Hamate (Fig
pometacarpal joint is a highly specialized saddle-type articula- with hook Transverse Tubercle on fibro
ligamen
tion-allowing
Transverse
a wide rangecarpal
of motionligament
to the human thumb. carpal t trapezium
sule
Pisiform
A slender and sharp tubercle projects from the palmar Groove for
face
surface of the trapezium. This tubercle, along with the palmar flexor carpi
radialis artic
tubercle of the scaphoid, provides attachment for the lateral Triquetrum
meta
Scaphoid tubercle
side of the transverse carpal ligament (see Figure 7-5). Imme- Lunate
Capitate amo
diately medial to the palmar tubercle is a distinct groove for Action line of the
Scaphoid opponens digiti minimi The
the tendon of the flexor carpi radialis.
MC with
met
TRAPEZOID TQ H TZ forc
FIGURE 7-5. A view through the carpal tunnel of the right wrist with C TP
The Active
trapezoid support structures
is a small bone wedged tightly between the all contents removed. The transverse carpal ligament is shown as the P Transverse meta
B L S carpal ligament ible
capitate and the trapezium. The trapezoid, like the trapezium, roof of the tunnel.
to gl
head
- Flexor carpi ulnaris vent
poph
In
- Intrinsic muscles of the hand (those that insert into the transverse Figure 9–18 The opponens digiti minimi is the only muscle mal
carpal ligament) that acts exclusively on a carpometacarpal joint. As indicated by its sules
blen
action line, it is effective at flexion of the fifth metacarpal joint and
rotation of the metacarpal joint around its long axis. The opponens tran
digiti minimi muscle’s attachment to the transverse carpal ligament teth
may also contribute to supporting the proximal palmar arch. gers
ligam
Mod. 45 48 head
Metacarpophalangeal Joints of the Fingers tran
com
Each of the four metacarpophalangeal joints of the fingers is
The
composed of the convex metacarpal head proximally and the
four
concave base of the first phalanx distally (see Fig. 9–14). The
metacarpophalangeal joint is condyloid with two degrees of
freedom: flexion/extension and abduction/adduction. The Col
large metacarpal head has 180° of articular surface in the
movement of the thumb serves as the basis for the naming of intermetacarpal
the fourth and fifth metatarsals.) The bases of the second metacarpal ena
the muscles that act on the thumb (e.g., the opponens pollicis, through fifth metacarpals haveligaments
small facets for attachments
extensor pollicis longus, and adductor pollicis). to one another through intermetacarpal joints. These joints help
sha
stabilize the bases of the secondPalmar
through fifth metacarpals, tact
carpometacarpal joints. Anterior
Carpometacarpal Joints thereby reinforcing the carpometacarpal oblique thu
ligaments (cut)
All CMC joints of the fingers are surrounded by articular ligament siti
The carpometacarpal (CMC) joints of the hand form the capsules and strengthened by multiple dorsal, palmar, and
articulation between the distal row of carpal bones and the interosseous ligaments.70 The dorsal ligaments are particularly
Cap
Ca
bases of the five metacarpal bones. These joints are positioned well developed (Figure 8-11). pit a t
e
Palmar tubercle
at the very proximal region of the hand. on trapezium
The
Joint Structure and Kinematics
Figure 8-10 shows a mechanical illustration of the relative loo
mobility at the CMC joints. The joints of the second and The CMC joints of FIGURE
the second8-12.
and The
thirdpalmar side
digits are of thetoright hand showing the articu-
difficult cap
third digits are rigidly joined to the distal carpus, forming a lar surfaces of the second through
classify, ranging from planar to complex saddle joints (Figure the fifth carpometacarpal joints.
qOsteokinema+cs
stable central pillar throughout the hand. In contrast, the 101
The capsule and palmar carpometacarpal
8-12). Their jagged interlocking articular surfaces, coupled ligaments of digits 2 to
and
more peripheral CMC joints form mobile radial and ulnar with strong ligaments, permit very
5 have been cut. little movement. As men-
borders, which are capable of folding around the hand’s tioned earlier, stability at these joints forms the central pillar the
central pillar. The function of the CMC joints allows the of the hand. The inherent stability of these radial-central dist
concavity of the palm to fit around many objects. This metacarpals also provides a very firm attachment for several ran
Carpometacarpal joints
feature is one of the most impressive functions of the human key muscles, including the extensor carpi radialis longus and
hand. Cylindric objects, for example, can fit snugly into the brevis, the flexor carpi radialis, and the adductor pollicis.
foc
palm, with the index and middle digits positioned to rein- The slightly convex bases of the fourth and fifth metacarpals elem
articulate with a slightly concave articular surface formed by the the
hamate. These two ulnar CMC joints contribute a subtle but mo
3rd important element of mobility to the hand. As depicted in Figure duc
2nd
4th M 8-10, the fourth and fifth CMC joints allow the ulnar border of
e
the hand to fold toward the center of the hand, thereby deepen- atta
t
5th a ing the palmar concavity. This mobility—often referred to as a win
c
a “cupping” motion—occurs primarily by flexion and “internal” tion
r rotation of the ulnar metacarpals toward the middle digit. Mea- all
p 1st
surements of maximal passive mobility on cadaver hands have
a
l shown that, on average, the fourth CMC joint flexes and extends
of
about 20 degrees and rotates internally about 27 degrees.21 The war
fifth CMC joint (when tested with the fourth CMC joint firmly to
Thumb (first)
constrained) flexes and extends about 28 degrees and rotates tion
carpometacarpal internally 22 degrees. The range of flexion and extension of the of t
Fourth and fifth joint fifth CMC joint increases to an average of 44 degrees when the
carpometacarpal closely positioned fourth CMC joint is unconstrained and free
joints
to move. This research demonstrates the strong mechanical link Sad
between the kinematics of the fourth and fifth CMC joints. This The
FIGUREwhen
point should be considered 8-13.evaluating
Mobility andoftreating
the ulnar (fourth and fifth) carpometacar-
limita-
FIGURE 8-10. Palmar view of the right hand showing a highly the
pal joints of the
tions of motion in this region of the hand. left hand. White line indicates the relaxed position
mechanical depiction of the mobility across the five carpometacar-
of the distal allowed
metacarpals; join
pal joints. The peripheral joints—the first, fourth, and fifth—are much The greater relative mobility at the red
ulnarline
CMC indicates their position after the
B more mobile than the central two joints. joints is evidenced fist
by theis clenched.
movement of the fourth and fifth and
arti
Mod. 45 49 pal
metacarpal heads while clenching a fist (Figure 8-13). The fro
increased mobility of the fourth and fifth CMC joints ete
improves the effectiveness of grasp, as well as enhancing the con
functional interaction with the opposable thumb. The irregu- the
lar and varied shapes of these CMC joint surfaces prohibit the
standard roll-and-slide arthrokinematic descriptions. rec
FIGURE 8-8. The natural concavity of the palm of the hand is supported by three integrated arch systems: one
longitudinal and two transverse.

qOsteokinematics
Carpometacarpal joint of the thumb

- Saddle joint
- Flexion/ extension
- Abduction/ adduction
- Opposition A B C D
Metacarpophalangeal joints of the fingers

- Condyloid joint
- Flexion/ extension
- Abduction/ adduction
Interphalangeal joints of the fingers

- Hinged joint E F G H I
- Flexion/ extension FIGURE 8-9. The system for naming the movements within the hand. A to D, Finger motion. E to I, Thumb
motion. (A, Finger flexion; B, finger extension; C, finger abduction; D, finger adduction; E, thumb flexion;
Mod. 45 F, thumb extension; G, thumb abduction; H, thumb adduction; and I, thumb opposition.) 50
ARTHROLOGY
As depicted in Figure 8-8, all three arches of the hand are Before progressing to the study of the structure and fu
mechanically interlinked. Both transverse arches are joined of the joints, the terminology that describes the mo
carpa groove on the articular surface of the trapezium guides the 8-18, B shows the detail of the kinematics of this complex
ligamelnt such as the
oblique anterior
ligament.15,51
Table
Radial collateral metacarpal
ligament into slight
lateral rotation. Full8-2extension
shows a During
ment. flexion–medial
During abduction,rotation,
the basethe
of base of this metacarpa
the thumb metacarpa
summary
Abductor pollicisstretches
longus ligaments situated on the ulnar side of the abduc-
of the kinematics for flexion-extension and joint, slightly
a path 115 medially, led by the groove on
in a palmar direction across the surfacethe surface
of theoftrape
the
tion-adduction
such as the anterior
Flexor carpi radialis at theoblique
CMC joint of theTable
ligament. thumb. 8-2 shows a zium. Muscle force, especially from the opponens
During flexion–medial rotation, the base of this metacarpa po
summary
Extensor carpi radialis longus of the kinematics for flexion-extension and abduc- helps guide and rotate the metacarpal to the medial
slightly medially, led by the groove on the surface of the side
Opposition of the Thumb Carpometacarpal Joint articular
115 surface of the trapezium. The partially abducted
FIGURE 8-14. Palmar and lateral views of the ligaments of the carpometacarpal at
tion-adduction the
joint of CMC
the right joint
thumb.of the thumb. zium. Muscle force, especially from the opponens po
The ability to deliberately and precisely oppose the thumb joint guide
helps increases
andpassive
rotate tension in most to
the metacarpal connective
the medialtissues
side a
TABLE 8-1. Ligaments of the Carpometacarpal Joint of the Thumb*
to the tips
Opposition of the
of the Thumbother fingers is perhaps
Carpometacarpal Jointthe ultimate expres- ated with
articular the CMC
surface of the joint. Increased
trapezium. tension in
The partially the stre
abducted
Name Human Movement – Biomechanics of the wrist and hand
Proximal Attachment Distal Attachment
sion of functional
The ability to deliberately health of
Most Taut Positions
this
and precisely digit—and
oppose the
to the tips of the other fingers is perhaps the ultimate expres-of
the entire hand. This complex motion is a
arguably
thumbof
composite
posterior
joint
rotation
oblique
increases
(spin) of
ligament,
passive
the
tensionfor
thumb
in instance,
metacarpal.
promotes
most connective
115
ated with the CMC joint. Increased tension in the stre
the m
tissues a
Anterior oblique† Palmar tubercle on trapezium Palmar base of thumb metacarpal
sion of functionalAbduction,health extension,
of thisanddigit—and
opposition
arguably of posterior oblique ligament, for instance, promotes the m
Ulnar collateral Transverse carpal ligament Palmar-ulnar base of thumb Abduction, extension, and opposition
the entire hand. This complex motion is a composite of rotation (spin) of the thumb metacarpal.115
qArthrokinema+cs
First intermetacarpal Dorsal-radial side of base of
metacarpal
Palmar-ulnar base of thumb Abduction and opposition
second metacarpal metacarpal with ulnar collateral
Posterior oblique Posterior surface of trapezium Palmar-ulnar base of thumb Abduction and opposition
metacarpal
Radial collateral Radial surface of trapezium Dorsal surface of thumb All movements to varying degrees
Carpometacarpal joint of the thumb metacarpal except extension
3 3
r r
d d
*Ligament names are based on attachment to trapezium surfaces, not the thumb metacarpal.
†
Often described as having superficial and deep (“beak”) fibers. m m
Flexion/ extension 3e
rt
Medial
rotation
e
3
rt
da a
d
Palmar view Figure 8-15). The longitudinal diameter
c along the articular c
surface of the metacarpal is convex ma in a palmar-to-dorsal
ION ma
er EX Medial er
direction; its transverse diametertpis concave FL in a medial-to- pt
1st
aa rotation a
m lateral direction. cl cl
e a a
Intermetacarpal t ION
a Kinematics
r EX SLIDE r E Lateral rotation
FapLerzoi
Ra ligamenat dial collateral

ligament p p S
apezoid L
X
a Tr
R O ID
Tr
d ia l
LL degrees a
c
d
The motions at the CMC joint occur io e t
primarily RO
in two
TE
a
l en l E
ob ter
liga liqu
r
An
NS
of freedom. Abduction and adduction occur generally in
p
collateral
LL
nt
a
obl rior
liga ique
SLIDE E
l
me
e
IO
the sagittal plane, and flexion Cand
apitatextension occur generally Capitate Lateral rotation
Ant
e apezoi
R ligament
S
m
v ave
apezoid LI
N
X
C ra LL Tr
Tr
r
ziu
in the frontal plane. The axis of rotation for each plane
d
io e t
RO peO DEd
T
pe TraR
TE
m
C F o ziu
c
e al
ob ter
en ral
e
liga liqu
l C a t
on
i
An
R la
of movement passes through the convex member of the
NS
a
t
C
col am
e
LL
e nt
x
obl rior
p C o nv e x
liga ique
Capsule with radial id id li g
articulation.38
me
x
IO
Capitate ho Capitate ho
Ant
i c collateral ligament Scap Scap
m
o
A B
N
t a
Opposition and reposition of the thumb are ra mechanically
ziu
r
T
peziu
m
a v Trape
e al
en ral
e d
c derived from the two primary planes of motion at the CMC Ra lat
i
t
t
e a col am
r joint. The kinematics of opposition pand ho reposition are dis-
id
h oid
li g
p Anterior oblique ca
Stwo Scap
Scaphoi d i ligament A
cussed after the description of the primary motions. B
r
a Palmar tubercle FIGURE 8-17. The arthrokinematics of flexion and extension at the carpometacarpal joint of the thumb. A, Flexion
d on trapezium Abduction and Adduction at the Thumb
is associated Carpometacarpal
with a slight medialJoint
rotation, causing elongation in the radial collateral ligament. The anterior oblique
i
a
In the position of adduction
ligament is slack. B, Extension isthumb
of the CMC joint, the associated with slight lateral rotation, causing elongation of the anterior oblique
l lies within the plane of the hand. Maximum abduction, in
i FIGURE 8-17.The
ligament. The arthrokinematics
axis of flexion
of rotation is depicted as aand extension
small at the carpometacarpal
circle through joint of
the trapezium. Note thethe A, Flexion
thumb.between
analogy the
s contrast, positions the thumb metacarpal about 45 degrees
arthrokinematics
is associated
anterior to the plane of the palm. withFull ofabduction
extension
a slight and
medialopens athe
cowboy
rotation, falling
causing sidewaysinon
elongation thethe horse’s
radial saddle:
collateral As the cowboy
ligament. falls sideways
The anterior oblique
(toward
web space of the ligament
thumb, isextension),
slack.a B,
forming wide points
Extensiononiscurvature
concave his chest and
associated rearslight
with end both
lateral“roll and slide”
rotation, in the
causing same lateral
elongation of thedirection.
anterior oblique
FIGURE 8-15. The carpometacarpal joint of the right thumb is useful for graspingligament. The axis of rotation is depicted as a small circle through the trapezium. Note the analogy between the
large objects.
exposed to show its saddle-shaped appearance. The longitudinal TheTABLE arthrokinematics
arthrokinematics
8-2. Factors of Associated
abductionof extension
and
with and a cowboy
adduction
Kinematics falling
are of the sideways
Primary on the horse’s
Motions of the saddle: As the cowboy
Carpometacarpal fallsofsideways
Joint the Thumb*
diameters
Mod. 45are shown in purple, and the transverse diameters in green. based on the convex(toward extension),
articular surface ofpoints on his
the thumb chest and rear end both “roll and slide” in the same lateral direction.
metacar- 51
Motion Osteokinematics Joint Geometry Arthrokinematics
TABLE 8-2. Factors
Abduction Associated
and adduction with plane
Sagittal Kinematics
movement of the PrimaryConvex
around Motions of the Carpometacarpal
(longitudinal) Joint ofpalmar
Abduction: the Thumb*
roll and do
Motion a medial-lateral
Osteokinematics axis of rotation diameter
Joint Geometryof metacarpal slide
Arthrokinematics
through the metacarpal moving on a concave Adduction: dorsal roll and pal
Abduction and adduction Sagittal plane movement around surface
Convex of the trapezium
(longitudinal) slide
Abduction: palmar roll and do
Flexion and extension a medial-lateral
Frontal axis of rotation
plane movement around diameter(transverse)
Concave of metacarpal slide medial roll and slide
diameter Flexion:
carpa
ligamelnt
Radial collateral ligament
Abductor pollicis longus
Extensor carpi radialis longus
FIGURE 8-14. Palmar and lateral views of the ligaments of the carpometacarpal joint of the right thumb.
TABLE 8-1. Ligaments of the Carpometacarpal Joint of the Thumb*

Name Human Movement – Biomechanics of the wrist and hand
Proximal Attachment Distal Attachment Most Taut Positions
Anterior oblique† Palmar tubercle on trapezium Palmar base of thumb metacarpal Abduction, extension, and opposition
Ulnar collateral Transverse carpal ligament Palmar-ulnar base of thumb Abduction, extension, and opposition
pal moving on the fixe
qArthrokinematics
First intermetacarpal Dorsal-radial side of base of
metacarpal
Palmar-ulnar base of thumb Abduction and opposition
the trapezium (review
second metacarpal metacarpal with ulnar collateral 2 pal
Posterior oblique Posterior surface of trapezium Palmar-ulnar base of thumb Abduction and opposition n convex articular surface the
metacarpal d
Radial collateral Radial surface of trapezium Dorsal surface of thumb All movements to varying degrees Stretched
slides dorsally n
2
on the co
con
adducto m d
Carpometacarpal joint of the thumb metacarpal except extension r po llicis e Stretched a
dducto
8-16). Fullm
abduction at
slide
a
t r poll
tor icis pollicis
e 8-16
muscle and
t
*Ligament names are based on attachment to trapezium surfaces, not the thumb metacarpal. c a tor p
†
Often described as having superficial and deep (“beak”) fibers. a arthrokinematics
c add
of arth
Abduction/ adduction r a
Figure 8-15). The longitudinal diameter along the articular p those pdescribed for thos
r
abd
N
Palmar view a a
O
surface of the metacarpal is convex in a palmar-to-dorsal LL LL l
TI
l
TI
IML IML
RO
UC
direction; its transverse diameter is concave in a medial-to-
and Extension Flex
RO
UC
1st
lateral direction. AOL Flexion AOL at t
ABD
E
m ID Acti
ABD
E
Intermetacarpal t
e
S LID zoid
Actively
SL pe zoid
performing flex the
a Kinematics pe
Tra
m
ligament Tr a p e z i u
the thumb
a te
is associatedof th
c
Tra
m
The motions at the CMC joint occur primarily in two degrees Tr a p e z i u
a
it
ate
Cap
r
of freedom. Abduction and adduction occur generally in apof the metacarpal. Duri ally
p
a
Sc
it
hoid
l
Cap
the sagittal plane, and flexion and extension occur generally rota
ally (i.e., toward the third
v ave
C ap
Sc
F o in the frontal plane. The axis of rotation for each plane hoid
C
axia
c
l C Abductor pollicis
on
of movement passes through the convex member of the longusrotates laterally (i.e., away
a C
e
e o
x
C o nv e x
p
i x Capsule with radial
articulation.38 nail
axial rotation is apparen
c collateral ligament
o Abductor pollicis
t
a r
a
v
e
Opposition and reposition of the thumb are mechanically
longus
rota
t
e
c
a
r
derived from the two primary planes of motion at the CMC
joint. The kinematics of opposition and reposition are dis-
nail of the thumb betwe
cann
p Anterior oblique
ligament cussed after the description of the two primary motions. FIGURE 8-16. The arthrokinematics of abduction rotation of the is not considere
carpometa- I
d i
Scaphoi
carpal joint of the thumb. Full abduction stretches the anterior oblique add
r
a Palmar tubercle
on trapezium Abduction and Adduction at the Thumb Carpometacarpal Joint ligament (AOL), the intermetacarpal ligament (IML), and the adduc-
cannot be executed inde
met
d
i
a
In the positionFIGURE 8-16. The arthrokinematics of abduction of the carpometa-
of adduction of the CMC joint, the thumb tor pollicis muscle. The axis of rotation is depicted In
as the
a anatomic
small circle at posi T
lies within the plane of the hand. Maximum abduction, in the base of the metacarpal. The muscle primarily responsible for the
l
i carpal joint of the thumb. Full
contrast, positions the thumb metacarpal about 45 degreesabduction stretches the anterior oblique additional 10 to 15 deg
join
s
active rolling of the articular surface of the thumb metacarpal is the
anterior to theligament (AOL),
plane of the theabduction
palm. Full opens the ligament (IML), and the adduc-
intermetacarpal metacarpal flexes across carp
web space of the thumb, forming a wide concave curvature abductor pollicis longus. Note the analogy between the arthrokinemat- trap
tor pollicis muscle. The axis of rotation
useful for grasping large objects.
is abduction
ics of depictedand as aa small fallingatforward on The
cowboycircle arthrokinematic
the horse’s saddle:
FIGURE 8-15. The carpometacarpal joint of the right thumb is surf
exposed to show its saddle-shaped appearance. The longitudinal the base of
The arthrokinematics the metacarpal.
of abduction The are
and adduction muscle primarily
as the cowboy falls responsible
forward (towardfor the
abduction), joint a point areonbased
his cheston the
dire
diameters
Mod. 45are shown in purple, and the transverse diameters in green. activearticular
based on the convex rollingsurface
of the articular
of the surface “rolls”
thumb metacar- of theanteriorly,
thumbbut a point on is
metacarpal histhe
rear end “slides” posteriorly. 52
carpal moving across th
abductor pollicis longus. Note the analogy between the arthrokinemat- trapezium (review Figu
ics of abduction and a cowboy falling forward SonP the E Chorse’s
I A L saddle:
F O C U S 8-1
surface of the metacarp
as the cowboy falls forward (toward abduction), a point on his chest
“rolls” anteriorly, but a point on his rear end “slides” posteriorly. direction (Figure 8-17, A
Osteoarthritis of the Carpometacarpal Joint of the Thumb: a Co
FIN
Gen
Th
tiv
hea
sur
Human Movement – Biomechanics of the wrist and hand 2 1 the
and
tio
qArthrokinema+cs
ove
A MC
of
Carpometacarpal joint of the thumb is a
tiss
Chapter 8 Hand 255 ap
OpposiBon pla
Reposition of the CMC joint returns the metacarpal from
Posterio
att
full opposition back to the anatomic position. This motionobliqu r
ligam
e Cr
involves arthrokinematics of both adduction and extension– liga
ent
lateral rotation of the thumb metacarpal.
of
Metacarpophalangeal Joints pal
Opponens pollicis
sor
FINGERS alo
2
General Features and Ligaments
1
The metacarpophalangeal (MCP) joints of the fingers are rela-
B
tively large, ovoid articulations formed between the convex
heads of the metacarpals and theFlexion/medial
shallow concave rotation
proximal
surfaces of the proximal phalanges (Figure 8-19). Motion atAbduction
2 1 the MCP joint occurs predominantly in two planes: flexion
FIGURE 8-18. The arthrokinematics of opposition of the carpometa-
and extension in the sagittal plane, and abduction and adduc-
carpal
tion in the joint
frontal of the thumb. A, Two phases of opposition are shown:
plane.
(1) abduction
Mechanical stability at andthe(2)MCP
flexionjointwith medialtorotation
is critical the B, The detailed
kinematics ofofthe
overall biomechanics thetwo phases
hand. As of opposition:
discussed thethe
earlier, posterior oblique liga-
A MCP jointsment is shown
serve taut; that
as keystones the opponens
support thepollicis
mobile is shown contracting (red).
arches
of the hand. In the healthy hand, stability at the MCP joints
Mod. 45
is achieved by an elaborate set of interconnecting connective 53
As evidenced
tissues. Embedded within theby the change
capsule of each MCPin orientation
joint are of the thumb-
nail, and
a pair of radial full ulnar
opposition
collateralincorporates
ligaments and one 45 to 60 degrees of medial
palmar
rotation
plate (Figure 8-20).ofEach collateral 13
the thumb. The CMC
ligament has itsjoint of the thumb accounts
proximal
Posterio
attachmentforonmost
the posterior
but nottubercle
all of of therotation.
this metacarpalLesser
head. amounts of axial
obliqu r
Crossing the MCP joint in an oblique palmar direction, the
ligam
e
rotation occur in the form of accessory motions at the MCP
ligament forms two distinct parts. The more dorsal cord part
ent
and IPis joints.

of the ligament thick andThe trapezium
strong, also medially
attaching distally to the rotates slightly
an
x
Chapter 8 Hand 257
Collateral
The arthrokinematics at the MCP joint are based on the Palmar plate ligaments
concave articular surface of the phalanx moving against the
Head
convex metacarpal head. Figure 8-24, A shows the arthrokine-
matics of active flexion, driven by one of the extrinsic flexor
muscles: the flexor digitorum profundus. Flexion stretches
and therefore increases the passive tension in both the dorsal
Collateral ligament Cord
Accessory
M
e
Posterior
tubercle
t
capsule and the collateral ligaments. In the healthy state this a
passive tension helps guide the joint’s natural arthrokinemat- c
qArthrokinematics
ics.7 For example, as depicted in Figure 8-24, A, the increased
a
r
p
tension in the stretched dorsal capsule (depicted by the thin a
l
elongated arrow) prevents the joint from unnaturally “hinging”
outward on its dorsal side. The tension helps maintain firm
ut contact between the articular surfaces as the proximal phalanx
FIGURE 8-22. The accessory motions of axial rotation at the meta- FIGURE 8-23. A dorsal view of the metacarpophalangeal joint o
mar Metacarpophalangeal
slides joints
and rolls in a palmar direction. The ofincreased
the fingers
tension
carpophalangeal joints are evident across several fingers during a to expose the shape of the articular surfaces. The longitudinal dia
ire in the dorsal capsule and collateral ligaments stabilizes the
grasp of a large, round object. of the joint is shown in green; the transverse diameter in purp
ve joint in flexion, which is useful during grasp.
ure Flexion/ extension Radial Extensor
tal Dorsal view Dorsal collateral digitorum
ne. capsule ligament
Pr
ox
im
al
Metacarpal
ph
ala
nx
FL E
EXT
OL Intrinsic muscle
R
SL L
XIO
A1 pulley
EN
I DE Palmar plate (taut)
Palmar plate IO
S
N
Collateral N Radial collateral ligament
x
Palmar plate ligaments
an
A2 pulley
hal
Head
al p
xim
Flexor digitorum
Cord
Collateral ligament Posterior profundus
Pro
Accessory
M tubercle
e A B
t
a FIGURE 8-24. Lateral view of the arthrokinematics of active flexion and extension at the metacarpophalangeal
c
a (MCP) joint. A, Flexion is shown during activation of the flexor digitorum profundus muscle. The tendon of
r
p
this muscle is shown coursing through the A1 and A2 pulleys (specifically named pulleys within the fibrous
a digital sheaths). Flexion draws both the dorsal capsule and radial collateral ligament relatively taut. The arthro-
l
kinematics are shown as a roll and slide in similar directions. B, Extension is shown controlled by coactivation
of the extensor digitorum and one of the intrinsic muscles of the finger. The extended position draws the
ta- FIGURE 8-23. A dorsal view of the metacarpophalangeal joint opened palmar plate taut while simultaneously creating relative slack in the radial collateral ligament. Taut or stretched
a to expose the shape of the articular surfaces. The longitudinal diameter tissues are shown as thin elongated arrows; slack structures are shown as wavy arrows. The axis of rotation for
of the joint
Mod. 45 is shown in green; the transverse diameter in purple. this motion is in the medial-lateral direction, shown piercing the head of the metacarpal. 54
Extensor
digitorum
E
Chapter 8 Hand 257 inc
the
The arthrokinematics at the MCP joint are based on the of
concave articular surface of the phalanx moving against the 258 Section II Upper Extremity
pro
convex metacarpal head. Figure 8-24, A shows the arthrokine-
matics of active flexion, driven by one of the extrinsic flexor me
increases
muscles: the flexor digitorum profundus. Flexion stretches
and therefore increases the passive tension in both the dorsal
surr
thereby
ma
of about
capsule and the collateral ligaments. In the healthy state this proximal
passive tension helps guide the joint’s natural arthrokinemat- metacarp
qArthrokinema+cs
ics.7 For example, as depicted in Figure 8-24, A, the increased surfaceTHb
tension in the stretched dorsal capsule (depicted by the thin I ON maximal
elongated arrow) prevents the joint from unnaturally “hinging” CT Ge
U
outward on its dorsal side. The tension helps maintain firm D
THUMBTh
AB
ut contact between the articular surfaces as the proximal phalanx
mar Metacarpophalangeal
slides joints
and rolls in a palmar direction. The ofincreased
the fingers
tension IO
N be
CT E Uln GeneralcoF
ire in the dorsal capsule and collateral ligaments stabilizes the D
U I D collatear
SL LL ligam r The MC
thu
AB
ve joint in flexion, which is useful during grasp. e
al n t
O
ure AbducBon/ adducBon between
R
I D
E Uln
collatear concaveof
tal SL
l ateral
Dorsal view LL ligam r
thumbfin
o amentoll ment
(F
dial adial
e
al n t
ne. O
Pr
of theAc
gaR
M
ox
li
RaateraR
im
fingers.sigM
al
c
ph
DI1 ActiveFo an
ala
lig
l l
nx
significan
c
For allon
DI1
pr
fro
only one
Collateral
Palmar plate ligaments frontalofpl
Head
of the Th
thu
The arthr
gea
Cord geal joint
Collateral ligament
Accessory
M
Posterior
tubercle
ext
extension
about ab
e
t 60
a
c Active
a
r
p
FIGURE 8-25.8-25.
FIGURE TheThearthrokinematics
arthrokinematics ofofactive
activeabduction
abduction the meta- veryare
at meta-
at the are li
a carpophalangeal joint. Abduction is shown powered
carpophalangeal joint. Abduction is shown powered by the first by the first This limi
Th
l
dorsal interosseus muscle (DI1). At full abduction, the ulnar collat-
dorsaleral
interosseus muscle (DI ). At full abduction, the ulnar collat- abduct or
ab
ligament is taut and the 1radial collateral ligament is slack. Note
ta- FIGURE 8-23. A dorsal view of the metacarpophalangeal joint opened
eral ligament is taut
that the axis and the
of rotation forradial collateral
this motion is in ligament is slack. Notethe thum
an anterior-posterior the
and bony
a to expose the shape of the articular surfaces. The longitudinal diameter that the axis of
direction, rotation
through for this
the head motion
of the is in an anterior-posteriorfor restric
metacarpal. an
of the joint
Mod. 45 is shown in green; the transverse diameter in purple. direction, through the head of the metacarpal. for
55gitudinal
Figure 8-24, B illustrates active extension of the MCP joint, Althou
git
Extensor driven8-24,
Figure through a coordinated
B illustrates activecoactivation
extension of of the
the extensor
MCP joint,joint prov
digitorum
digitorum and one of the intrinsic muscles (to be further collateral
driven through
described latera coordinated
in this chapter). coactivation of the extensor
The arthrokinematics of injury joi
fro
digitorum and one of the intrinsic muscles (to
extension are similar to those illustrated for flexion except be further co
plified by
described
that thelater in this
roll and chapter).
slide of The phalanx
the proximal arthrokinematics
occur in a ofhandleinj an
E
Human Movement – Biomechanics of260the wrist and hand

Dors
qArthrokinematics caps
a
l
L
E ID
ule l
Dors
ROL
ID SL
Distal phalanx a
caps
L
ule
ROL
SL
Distal phalanx phalanx
Proximal
Metacarpophalangeal and interphalangeal joints of the thumb
Proximal phalanx SLIDE
ion II Upper Extremity SRLO L
IDEL
Flexion/ extension
capsuDleorsal
Dorsal
Dorsal view R OLL
Dors
capsule
caps
a Distal phalanx
E
L
ID
ule
ROL
SL
Distal phalanx Palmar plate Distal interphalangeal joint
l
pa
Interphalangeal joints
lr
ac
paa
Proximal phalanx Cord
ect
Collateral
Flexor pollicis
ar
ligament Accessory m a
of the fingers SLIDE
R OLL
Middle phalanx Flexorbrevis
pollicis
brevis
1sme
t
t t
Base 1s
capsule
Dorsal
Tr Tra
p
peeziu
a
Flexion/ extension Proximal ziu m
l
m
pa
interphalangeal
ar
c a
exor pollicis et joint
brevis tm
1s Palmar plate
Flexor
Flexorpollicis
Tr
pe Check-rein ligament Head pollicis

a
ziu
m
Cord longus
longus
Collateral ligament
Accessory
xor pollicis
longus FIGURE
FIGURE8-28.
8-28.TheThearthrokinematics
arthrokinematics of of active
activeflexion
flexionareare depicted
depicted forfor
Pro x i mal
pha l anx thethe metacarpophalangeal and
metacarpophalangeal and interphalangeal
interphalangeal joints
jointsofofthethe
thumb.
thumb.
e arthrokinematics of active flexion are depicted for
halangeal and interphalangeal joints of the thumb.
Flexionis isshown
Flexion shownpowered
powered byby the
the flexor
flexor pollicis
pollicislongus
longusand and flexor
flexor
n powered by the flexor pollicis longus and flexor pollicis brevis. The axis of rotation for flexion and extension
pollicis brevis. The axis of rotation for flexion and extension at at these
these FIG
he axis of rotation for flexion and extension at these
FIGURE 8-29. A dorsal view of the proximal interphalangeal and joints is in the anterior-posterior direction, through the
joints is in the anterior-posterior direction, through the convex dis convex
anterior-posterior direction, through the convex
distal interphalangeal joints opened to expose the shape of the member of the joints. Taut or stretched tissues are shown as thin
joints. Taut or stretched tissues are shown as thin
articular surfaces. member of the joints. Taut or stretched tissues are shown as thin art
.
Mod. 45 elongated arrows. 56
elongated arrows.
rs as a tongue-in-groove articulation similar to Kinematics
pentry to join planks of wood (Figure 8-29). The The PIP joints flex to about 100 to 120 degrees. The DIP joints the joint appears as a tongue-in-groove articulation similar to Kin
ximal phalanx has two rounded condyles sepa- allow less flexion, to about 70 to 90 degrees. As with the MCP thethat
joint
usedappears as a tongue-in-groove
in carpentry articulation
to join planks of wood similar
(Figure 8-29). The to Th
ow central groove. The opposing surface of the joints, flexion at the PIP and DIP joints is greater in the more
x has two shallow concave facets separated by a ulnar digits. Minimal hyperextension is usually allowed at the that used
head of in
thecarpentry
proximal to join planks
phalanx has twoofrounded
wood (Figure 8-29).
condyles The
sepa- all
he tongue-in-groove articulation helps guide the PIP joints. The DIP joints, however, normally allow up to about head ofby
rated thea proximal phalanx
shallow central has The
groove. twoopposing
roundedsurface
condyles sepa-
of the joi
Opponens pollicis
Hypothenar eminence Abductor digiti minimi
Flexor digiti minimi
Opponens digiti minimi
Palmaris brevis
Other Adductor pollicis (two heads)
Lumbricals (four)
FIGURE 8-32. An anterior view of the right forearm highlighting the Interossei (four palmar and
action of the flexor digitorum superficialis muscle. Note the cut four dorsal)
proximal ends of the wrist flexors and pronator teres muscles.
Human Movement – Biomechanics of the wrist and handChapter 8

muscles, in contrast, have both their proximal and distal
attachments within the hand. As a summary and reference, Hand 263
the detailed anatomy and nerve supply of the muscles of the
hand are included in Appendix II, Part E. Palmar view
Palmar view
qMyofascial system
Most active movements of the hand, such as opening and
closing the fingers, require precise cooperation between the
Pronator teres
TABLE 8-3. Extrinsic and Intrinsic Muscles to the Hand
extrinsic and the intrinsic muscles of the hand and the muscles
(cut) Muscles
of the wrist. This topic is addressed in detail later in this chapter. Medial Chapter
epicondyle
8 Hand 263
EXTRINSIC FLEXORS OF THE DIGITS Lateral epicondyle (cut) Extrinsic Muscles
Palmar view
TABLE
Flexor digitorum 8-3. Extrinsic and Intrinsic MusclesFlexors
to the Hand
of the digits Flexor digitorum superficialis
Anatomy and Joint Action of the Extrinsic Flexors of the Digits superficialis (cut) Palmaris longus
The extrinsic flexor muscles of the digits are the
Pronator teres
flexor digi-
(cut)
(cut) Muscles Flexor digitorum profundus
torum superficialis, flexor digitorum profundus, andcarpi
Flexor flexor
radialis Flexor carpi ulnaris Flexor pollicis longus
pollicisLateral
longusepicondyle
(Figures 8-32 and 8-33). These (cut)muscles have Extrinsic Muscles
(cut)
extensive proximal attachments from the medial epicondyle Extensors of the fingers
Flexors of the digits Flexor digitorumFlexor digitorum superficialis
Flexor pollicis
Extensor digitorum
Palmaris longus
of the humerus and regions of the forearm. Pronator teres
(cut) longus profundus
Flexor digitorum profundus Extensor indicis
The muscle belly of the flexor digitorum superficialis(cut)
is located Flexor digitorum superficialis Extensor digiti minimi
Flexor carpi ulnaris Flexor pollicis longus
in the anterior forearm, just deep to the three wrist flexors and
(cut)
the pronator teres muscle (see Figure 8-32). Its four tendons Pronator
Extensors of the fingers Extensors of the thumb
Extensor digitorum Extensor pollicis longus
crossPronator
the wrist and enter the palmar aspect of the hand. At the
teres quadratus Extensor indicis Extensor pollicis brevis
level of the (cut)
proximal phalanx, each tendonFlexor digitorum to superficialis Flexor digitorum profundus Extensor digiti minimi
Flexor splits
pollicis allow
Abductor pollicis longus
passage of the tendon of the flexor digitorum profundus
longus Extensors of the thumb Extensor pollicis longus
(Figure 8-34, middle and index finger). The two split parts of Intrinsic
eachFlexor
tendon partially reunite, crossFlexor
the PIP joint, profundus
digitorum and attach Lumbricals
Extensor pollicis brevis Muscles
pollicis Abductor pollicis longus
on the sides of the palmar aspect of the middle phalanx.
longus Thenar eminence Abductor pollicis brevis
The primary action of the flexor digitorum superficialis is Intrinsic Muscles Flexor digitorum Flexor pollicis brevis
to flex the PIP joints. This muscle, however, flexes all the Thenar eminence superficialis (cut)
Abductor pollicis brevis
joints it crosses. In general, with the exception of the small Opponens pollicis
Flexor pollicis brevis
finger, each tendon can be controlled relatively indepen-
Opponens pollicisHypothenar eminence Abductor digiti minimi
dently of the other. This independence of function is espe-
cially evident at the index finger. FIGURE 8-33. AnHypothenar
anterior view ofeminence Abductor
the right forearm highlighting the digiti minimi
The muscle belly of the flexor digitorum profundus is located action of the flexor digitorum profundus and the flexor Flexor
pollicisdigiti minimi Opponens digiti minimi
in the deepest muscular plane of the forearm, deep to the longus muscles. The lumbrical muscles are shown attaching Opponens
to the digiti minimi Palmaris brevis
flexor digitorum superficialis muscle (see Figure 8-33). Once in tendons of the flexor digitorum profundus. Note the cutPalmarisproximal brevis B
the digit, each tendon passes through the split tendon of the and distal ends of the flexor digitorum superficialis. Other Adductor pollicis (two heads)
Other Adductor pollicis (two heads)
Lumbricals (four)
Lumbricals (four)
FIGURE 8-32. An anterior view FIGURE 8-32.
of the right An highlighting
forearm anterior view
the of the right forearm highlighting the
Interossei (four palmar and Interossei (four palmar and
action of the flexor digitorumaction of the
superficialis flexorNote
muscle. digitorum
the cut superficialis muscle. Note the cut four dorsal) four dorsal)
proximal
proximal ends of the wrist flexors ends teres
and pronator of the wrist flexors and pronator teres muscles.
muscles.
muscles,
Mod. 45 in contrast, have muscles,
both their proximal and distal 57
in contrast, have both their proximal and distal
attachments within the hand. As a summary and reference,
the detailed anatomy and nerve attachments
supply of the within
musclestheofhand.
the As a summary and reference,
hand are included in Appendix the II,
detailed
Part E. anatomy and nerve supply of the muscles Palmarof the
view
Most active movements of hand are included in Appendix II, Part E.
the hand, such as opening and Palmar view
closing the fingers, require precise
Mostcooperation between theof the hand, such as opening and
active movements
extrinsic and the intrinsic muscles of the hand and the muscles
closing the fingers, require precise cooperation between the
of the wrist. This topic is addressed in detail later in this chapter. Medial
Palmar view
Human Movement – Biomechanics of the wrist and handChapter 8 Flexor digitorum

profundus (cut)
Hand 263
Palmar view
qMúsculos A5
C3
Flexor digitorum
superficialis (cut) Pronator teres
TABLE 8-3. Extrinsic and Intrinsic Muscles to the Hand
A4 (cut) Muscles
C2 Flexor carpi radialis
Lateral
A3 epicondyle Deep transverse (cut) Extrinsic Muscles
Fibrous digital
sheath C1 metacarpal ligament
Palmaris longus Flexors of the digits Flexor digitorum superficialis
A2
(cut) Flexor digitorum profundus
Digital synovial
sheath A1 F Flexorlongus
Flexor pollicis carpi ulnaris Flexor pollicis longus
l
ep (cut) Extensors of the fingers Extensor digitorum
xr
o
Extensor indicis
o
Palmar plate Pronator teres r f
u Radial synovial sheath
(cut) dn
d
iu
Flexor digitorum superficialis Extensor digiti minimi
gs
i Oblique ligament Fibrous digital
Lumbricals
r
o
t
Annular ligament sheath Extensors of the thumb Extensor pollicis longus
u
m
Flexor Adductor
digitorum profundus
pollicis
Extensor pollicis brevis
Opponens digiti minimi Flexor pollicis
Hypothenar ln Abductor pollicis longus
s y sh
Un
muscles Flexor digiti minimi longuso v ar Flexor pollicis

ea ial
Abductor digiti minimi th brevis Intrinsic Muscles
Abductor pollicis Thenar muscles
brevis Thenar eminence Abductor pollicis brevis
Palmaris brevis (cut)
Opponens pollicis Flexor pollicis brevis
Opponens pollicis
Transverse carpal ligament
Hypothenar eminence Abductor digiti minimi
Opponens digiti minimi
Palmaris brevis
FIGURE 8-34. A palmar view illustrates several important structures of the hand. Note the small finger showing
the fibrous digital sheath and ulnar synovial sheath encasing the extrinsic flexor tendons. The ring finger has Other Adductor pollicis (two heads)
the fibrous digital sheath removed, thereby highlighting the digital synovial sheath (blue) and the annular (A1 Lumbricals (four)
to A5) and cruciate (C1 to C3) pulleys. The middle finger shows the pulleys removed to expose the distal attach- Interossei (four palmar and
FIGURE 8-32. An anterior view of the right forearm highlighting the
ments of the flexor digitorum superficialis and profundus. The index finger has a portion of flexor digitorum
superficialis tendon removed,action
thereby of the flexor
exposing digitorum
the deeper tendon of superficialis muscle.profundus
the flexor digitorum Note the andcut
four dorsal)
attached lumbrical. The thumb proximal ends
highlights the of the
oblique and wrist
annularflexors
pulleys,and
alongpronator teressynovial
with the radial muscles.
sheath
surrounding the tendon of the flexor pollicis longus. (The thenar and hypothenar muscles are also drawn.)
Mod. 45 muscles, in contrast, have both their proximal and distal 58
attachments
digitorum superficialis. Each profundus within distally
tendon then the hand.
to the As a summary
palmar and ofreference,
side of the base the distal phalanx of
nues distally to attach to the palmarthe
sidedetailed
of the base of
anatomy theand
thumb.
nerveThesupply
flexor pollicis
of thelongus is theof
muscles sole
theflexor at the
stal phalanx. The flexor digitorum profundus is the sole IP joint of the thumb, and it also exerts a substantial flexion
hand are included in
of the DIP joint, but, like the superficialis, can assist in
Appendix II, Part E.
torque at the MCP and CMC joints of the thumb. If not
Palmar view
g every joint it crosses. Most active movements
opposed, of
thethe
flexorhand, such
pollicis as also
longus opening andwrist.
flexes the
closing the
e flexor digitorum profundus to the index finger can befingers, require
All three of the aforementioned extrinsic the
precise cooperation between flexors of the
leagues found continuity between the ulnar bursa an
sheaths. The fibrous retinacular structures (proximal flexor don sheath of the little finger in only 30% of 60
retinaculum, transverse carpal ligament, and extensor reti- mens.130 The ulnar bursa is typically not continuous w
naculum) tether the long flexor tendons to the hand; the digital tendon sheaths for the index, middle, and ring fi
bursae and tendon sheaths facilitate friction-free excursion Rather, for these fingers, the ulnar bursa ends just di
of the tendons on the fibrous retinacula. The retinacula pre- the proximal palmar crease, and the digital tendon s
vent bowstringing of the tendons that would result in loss of begin at the middle or distal palmar creases.11 The
qMyofascial system
Flexor digitorum superficialis
and
Flexor digitorum profunds
A B
Figure 9–27 A. The so-called “pistol grip” of the hammer allows the flexor digitorum superficialis
and flexor digitorum profundus muscles to work more forcefully at the ring and little fingers because
the range of motion in the more mobile metacarpophalangeal and interphalangeal joints in these
fingers is restricted by the shape of the object. The shape also encourages wrist ulnar deviation that
further enhances force production in the long finger flexors. B. When force is not needed, the shape
of an object is often tapered to accommodate to the greater range of the ring and little fingers, allow-
ing the long finger flexors to close the fingers fully around the object.
Mod. 45 59
VI Distal only IP extension and MP adduction*
long distance. IP extension
Although a low force potential in and MP flexion*
a muscle is often small or partially formed and therefore is ign
generally suggests a limited role in controlling movement, this most biomechanical analysis. In theory, this muscle
Second Finger
is not always the case. Muscles have other important kinesio- tioned to help flex the MCP joint of the thumb, bring
logic functions besides producing force. The first lumbrical, for first metacarpal toward the midline of the hand.
DI Proximal and distal MP abduction
instance, and a very rich source of MP
IP extension
possesses flexion
muscle and IP extension The four dorsal interossei fill the dorsal sides of the
spindles—sen-
DI Proximal and distal sory organs
MP abduction andthat closely monitor changesMP
IP extension in flexion
the length of extension
and IP the seous spaces (see Figure 8-39). In contrast to the palma
muscle. The average spindle density of the first lumbrical is ossei, the dorsal muscles typically have a bipennate
Thirdapproximately
Finger three times greater than that of the interosseus As a general rule, the dorsal interossei have distal attac
DI HumanProximal
Movementand distal – Biomechanics of the wrist and hand muscles within the hand and eight times greater than that of
MP abduction
the bicepsand IP extension
brachii MP flexion
muscle.81 This large density and IPspin-
of muscle
to the oblique fibers of the dorsal hood, as well as
extensionsides of the bases of the proximal phalanges. Som
VI Distal only dles in and
IP extension the lumbricals
MP adduction*suggests an important role in providing
IP extension and MP flexion*attachments may blend with more palmar aspects of th
sensory feedback during complex movements.86,99 By also verse fibers of the dorsal hood and the palmar plate
qMyofascial system Fourth Finger to the tendons of the flexor digitorum profundus,
attaching first dorsal interosseus (formerly abductor indicis) is the
perhaps the lumbricals are in position to help coordinate the and most accessible for clinical inspection. With th
DI Proximal only MP abduction MP flexion
interactions between the intrinsic and extrinsic muscles. finger well stabilized, the first dorsal interosseus can as
VI Distal only IP extension and MP adduction* IP extension and MP flexion*
Distal interphalangeal Proximal interphalangeal Metacarpophalangeal Extensor digitorum
Lumbricals and interossei
*Occurs indirectly by continued action. joint joint joint tendon (cut)
DI, dorsal interossei; IP, interphalangeal; MP, metacarpophalangeal; VI, volar interossei.
Palmar interosseus
Lumbrical
Dorsal interosseus
Td.
A 1st metacarpal
um
ezi
Trap
B
Figure 9–37 A. Activity of the lumbrical and interossei mus-

cles without any extrinsic finger flexors or extensors produces the
“intrinsic plus” position of the hand. B. Activity of the extrinsic FIGURE 8-48. The combined actions of the lumbricals and interossei are shown as flexors at the metacarpopha-
finger flexors and extensors without any activity of intrinsic fin- langeal joint and extensors at the interphalangeal joints. The lumbrical is shown with the greatest moment arm
ger muscles produces the “intrinsic minus” position of the hand. for flexion at the metacarpophalangeal joint. The medial-lateral axis of rotation at each joint is shown as a small
Figurecircle.
9–38MomentThe arms
saddle-shaped
are depictedportion
as thick of thelines,
black trapezium is at each axis of rotation. Td, trapezoid bone.
originating
concave in the sagittal plane (abduction/adduction) and convex in
the frontal plane (flexion/extension). The spherical portion found
Mod. 45 60
near the anterior radial tubercle is convex in all directions. The
base of the first metacarpal joint has a shape reciprocal to that of
Structure of the Thumb the trapezium.
Carpometacarpal Joint of the Thumb
The carpometacarpal (or trapeziometacarpal [TM]) joint
of the thumb is the articulation between the trapezium and First Carpometacarpal Joint Structure
2362_Ch09-305-353.qxd 1/29/11 4:29 PM Page 349

qFunc+onal posi+on of the hand
CHAPTER 9 ■ The Wrist and Hand Complex 349
these (20º)
- Wrist extension needs and is the position from which optimal function
is most likely to occur. It is not necessarily the position in
which a hand should be immobilized. Position for immobi-
- Wrist ulnar lization
devia8on (10º)on the disability.
depends
The functional position is (1) wrist complex in slight ex-
- Metacarpophalangeal
tension (20°)flexion (45º)
and slight ulnar deviation (10˚) and (2) fingers
moderately flexed at the metacarpophalangeal joints (45°)
- and proximal interphalangeal
Proximal interphalangeal flexion (30º) joints (30°) and slightly flexed
at the distal interphalangeal joints (Fig. 9–46). The wrist
1
position optimizes the power of the finger flexors so that
- Distal interphalangeal
hand closureflexion
can be(ligeira)
accomplished with the least possible
effort. It is also the position in which all wrist muscles
are under equal tension. With similar considerations for the
position of the joints of the digits, the functional position
provides the best opportunity for the disabled hand to inter-
act with the brain that controls it.
Figure 9–46 Functional position of the hand: wrist extension
SUMMARY and ulnar deviation with moderate flexion of the metacarpopha-
langeal and interphalangeal joints of the finger and thumb.
Despite the many articulations that make up the hand and
Mod. 45
wrist complex, the bony and ligamentous components of 61
these joints have less potential for problems than the mus-
culotendinous structures that cross and act on other joints.
extremities does not require the complexity and delicate
The motor control of and sensory feedback from the wrist
balance of muscular control that can so profoundly affect
and hand alone occupy more space topographically on the
functional performance in the hand.
primary motor and sensory cortices of the brain than does
cis brevis muscle with firm opposition to the little finger.70
The change in balance of muscle activity with firm opposi- Prehension activities of the hand involve the grasping or
tion and with increasingly ulnar opposition can be accounted taking hold of an object between any two surfaces in the
for by the increased need for abduction and metacarpal rota- hand; the thumb participates in most but not all prehension
tion. Increased pressure in opposition additionally appears to tasks. There are numerous ways that objects of varying sizes
bring in activity of the adductor pollicis muscle. The adduc- and shapes may be grasped, with strategies also varying
tor pollicis muscle stabilizes the thumb against the opposed among individuals. Consequently, the nomenclature related

finger. In firm opposition to the index and middle fingers,
adductor pollicis activity exceeds the very minimal activity
to these functional patterns also varies.180 In spite of
nomenclature differences, a broad classification system for
of the abductor pollicis brevis muscle. With a more ulnarly grasp has evolved that will permit general observations
located position, the increased need for abduction results in about the coordinated muscular function necessary to pro-
qFunctional position of simultaneous activity of the abductor and adductor.70 Activ-
ity of the extrinsic thumb musculature in grasp appears to be
duce or maintain common forms of grasp.
Prehension can be categorized as either power grip
the hand partially a function of helping to position the metacarpopha- (full hand prehension) (Fig. 9–42A) or precision handling
langeal and interphalangeal joints. The main function of the (finger-thumb prehension) (Fig. 9–42B).181 Each of these
Grip
Power grip
- Total contact with the object,
which is moved in space
Precision handling
- Fingers and thumb dynamically
manipulate an object
B
Figure 9–42 Prehension generally consists of either (A) power grip, in which the object makes full contact with the palm
Mod. 45 and is moved through space, or (B) precision handling, in which the thumb and fingers dynamically manipulate the object.
62

qFunc+onal posi+on of
the hand
A B C
Grip
Power grip
versus
Precision handling
D E F G
H I J
FIGURE 8-55. A normal hand is shown performing common types of prehension functions. A, Power grip.
B, Precision grip to hold an egg. C, Precision grip to throw a baseball. D to F, Modifications of the precision
Mod. 45 grip by altering the concavity of the distal transverse arch. G, Power key pinch. H, Tip-to-tip prehension pinch.63
I, Pulp-to-pulp prehension pinch. J, Hook grip.
JOINT DEFORMITIES TYPICALLY CAUSED Zigzag Deformity of the Thumb

BY RHEUMATOID ARTHRITIS
qNeural system
- Musculocutaneous
- Median
- Ulnar
- Radial
Mod. 45 64
qNeural system
Extensor digitorum
versus
Lumbricals and interossei
Mod. 45 65
qNeural system
Mod. 45 66
qNeural system
Neurodynamics
Mod. 45 67
Human Movement – Bibliography
§ Levangie, P. K & Norkin, C. C. (2005). Joint structure and function: a

comprehensive analysis (4th ed.). Philadelphia: F. A. Davis Company.
§ Neumann, D. A. (2017). Kinesiology of the musculoskeletal system (3rd ed.).

Missouri: Elsevier.
Mod. 45 68
Thank you for your a7en8on!!
Mod. 45 69

6 Biomechanics of The Elbow and Forearm, Wrist and Hand - Compressed

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6 Biomechanics of The Elbow and Forearm, Wrist and Hand - Compressed

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Biomechanics of the elbow and

Humero-ulnar and humeroradial joints

- The forearm rota8on occurs around an axis of rota8on that extends

Mod. 45 FIGURE 6-16. Range of motion at the elbow. 2 A, A

from 5 degrees beyond neutral extension through 1

Elbow flexion (degrees)

convexity of the capitulum (Figure 6-19). During active flexion,

the radial fovea is pulled firmly against the capitulum by con-

Normal “Valgus Angle” of the

Normal cubitus valgus

- 10º a 15º in females

Oblique cord Annular ligament

Radius Ulna Radius Ulna

sive external rotation of the forearm with subsequent KINEMATICS

Periarticular connective tissues

Medial collateral ligament

Most elbow flexors, and essentially all primary supinator

and pronator muscles, have their distal attachment on the

Human Movement – Biomechanics of the elbow and forearm

qInterosseous membrane Trochlear notch

Function Radiocarpal joint Ulnocarpal space 4

FIGURE 6-21. A compression force through the hand is transmitted

by two black arrows), thereby transferring a significant part of the

of the hand without anJoints

friction against the radial head durin nation

qInterosseous membrane tion. The external surface of the hand l

ments from the elbow capsule, the during

fibrous ligament that arises just belofr also

What happens when the interosseous membrane is damaged?

Proximal and distal radio-ulnar joints 0° (Neutral)

Mod. 45 FIGURE 6-27. Range of motion at the forearm13 comp

Glass Fork Chair Door Pitcher Knife Tele- News-

eralized instability of the distal radio-ulnar joint, making pro-

20 190 Section II Upper Extremity

20 Chapter 6 Elbow and Forearm 191

TABLE 6-2. Structures That Can Restrict Supination

de rotation. Restrictions in passive range of motion can occur

of the radius and associated increased joint compression of the

qMyofascial system Chapter 6 Elbow and Forearm 199

Transverse ligament Chapter 6 Elbow and Forearm 203

Medial Triceps brachii Triceps brachii

qMyofascial system Chapter 6 Elbow and Forearm 199

200 Section II Upper Extremity

Human Movement – Biomechanics of the elbow and forearm

What is the acBon

Hamill_ch05_137-186.qxd 11/5/07 6:02 PM Page 160

Biceps | Stability/ muscle synergy

The PRONATOR TERES (+++), as well as the flexors

Electromyographic Analysis of Elbow Extension

s of force of most pronator and supinator muscles of

FIGURE 6-47. Vigorous contraction is

Figure 8–27 Supination of the right forearm. A. In the

supination in all positions of the elbow or forearm. It

Human Movement – Biomechanics of the elbow and forearm

qMyofascial system Note! Triceps is an important synergist by

to as the “screw home” mechanism of the elbow.45 arm

SYNOPSIS Essentially all muscles acting on the elbow and forearm

Kinematics of Wrist Motion

Human Movement – Biomechanics of the wrist and hand

qOsteokinematics the wrist—is a combination of the aforementioned move-

Kinematics of Wrist Motion

Kinematics of Wrist Motion