Clinical Anatomy and Mechanics of The Wrist and Hand

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THE JOURNALOF ORTHOPAED~C AND SPORTS PHYSICALTHERAPY
Copyright O 1983 by The Orthopaedic and Sports Physical Therapy Sections of the
American Physical Therapy Association
Clinical Anatomy and Mechanics of the

Wrist and Hand
CAROLYN T. WADSWORTH, MS, LPT*
Hand rehabilitation is an area with the potential for providing orthopaedic physical
therapists a challenging and rewarding practice. However, success in treating the
patient with hand dysfunction is closely associated with the therapist's understand-
ing of essential anatomic and pathokinesiologic principles and the related ability to
adequately evaluate, plan, and perform treatment.
This article, the first of a two-part series, is intended to provide a working
knowledge of clinical anatomy, mechanics, and pathology of the wrist and hand.
Emphasis is placed on the structure and function of parts which commonly limit
motion, and sufficient information is provided to aid the clinician in performing a
Downloaded from www.jospt.org at on June 30, 2017. For personal use only. No other uses without permission.
differential diagnosis and developing treatment rationale. The second part of the
series will describe a practical method of evaluation and offer treatment suggestions
for specific disorders.
Copyright 1983 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
OSTEOLOGY like the phalanges; their configuration produces

more mobility at the biaxial metacarpophalan-
Twenty-seven bones (excluding sesamoids)
geal (MP) joints, but less bony stability than at
contribute to the formation of the wrist and hand
the IP joints. The first metacarpal differs in that
skeleton. These bones are commonly classified
its head is pulley-shaped, and its base is sepa-
into units known as phalanges, metacarpus, and
rate from the common joint formed by the others.
carpus according to similarities in structure and
The bones of the carpus are arranged in two
Journal of Orthopaedic & Sports Physical Therapy
function (Fig. 1).

rows, with four bones to a row. The distal row
The 14 phalanges resemble miniature long
includes the trapezium, trapezoid, capitate, and
bones, with shafts and expanded ends. The con-
hamate, and the proximal row contains the
cave proximal ends, the bases, display two shal-
scaphoid, lunate, triquetrum, and pisiform. Dis-
low depressions which fit the corresponding pul-
tinguishing features of each include the follow-
ley-shaped heads of adjacent phalanges. The
ing:
heads, with their distinct condyles, form the con-
a) Trapezium-tubercle for attachment of
vex partner of the interphalangeal (IP) joints. The
flexor retinaculum; groove for flexor carpi radi-
close congruency of these "hinge" surfaces
alis tendon; saddle-shaped facet for articulation
contributes greatly to finger joint stability. (The
with first metacarpal.
bases of the proximal phalanges 2-5 are modi-
b) Trapezoid-smallest bone in distal row.
fied to articulate with the rounded metacarpal
c) Capitate-largest and most central of car-
heads and thus possess a biconcave surface.)
pals; articulates with seven other bones; inter-
Included in the metacarpus are five bones,
carpal ligaments directed toward it.
also with elongated shafts and expanded ends.
d) Hamate-hook-like hamulus, which offers
The bases articulate with the distal row of carpal
protection for the ulnar artery and nerve, and
bones, as well as with one another, in plane
attachment of flexor retinaculum.
joints with minimal movement. The convex distal
e) Scaphoid-prominent tubercle for attach-
heads are rounded rather than pulley-shaped
ment of flexor retinaculum; bridges joint between
two rows of carpals, receiving most of the force
'Associate in the Physical Therapy Educational Programs, University
transmitted through the radius and frequently
of Iowa, Iowa City. IA 52242 fractured in falls; proximal pole without its own
206
JOSPTSpring 1983 ANATOMY AND MECHANICS OF THE WRIST AND HAND 207
blood supply in one-third of the population thus hand lengthwise and two lateral arches run
subject to avascular necrosis following a frac- transversely, one at the level of the metacarpal
ture. heads, and the other at the carpus. The arch
f) Lunate-semilunar shape; most frequently formed by the carpus also provides the floor of
dislocated carpal bone, which is of significance a bony tunnel-the carpal tunnel-for support
due to its proximity to the median nerve. and protection of the finger flexor tendons and
g) Triquetral-three-sided, with facet for artic- median nerve (Fig. 2).
ulation with pisiform. When viewed from the radial side, the anterior
h) Pisiform-pea-shaped with attachments for projections of the scaphoid and trapezium tuber-
flexor and extensor retinacula, pisohamate and cles are prominent. They contribute to formation
pisometacarpal ligaments, and tendons of flexor of the osseous portion of the carpal tunnel and
carpi ulnaris and abductor digiti minimi muscles. in addition provide a supporting base for the
The bones of the hand are so arranged that thumb in a plane which allows it to oppose the
three separate arches emerge to enhance pre- rest of the hand. Experts in accident insurance
hensile function. The longitudinal arch spans the attribute 50% of the value of the hand to the
LUNATEJ '-CAP] TATE
Fig. 1 . Hand skeleton.
. -\ --
ULNARARTERY
ULNAR NERVE FLEXOR TENDONS
HAMATE FLEXOR RETINACUL

MEDIAN NERVE
PlSlFORM TRAPEZIUM
TRIQUETRUM
LUNATE SCAPHOID
Fig. 2 . Carpal tunnel-space between concave carpus and transverse retinacular ligament, enclosing the median nerve and
flexor tendons of the fingers.
208 WADSWORTH JOSPT Vol. 4, No. 4
thumb, its importance lying in its ability to op- allows slight gliding, becoming more mobile to-
pose, and thus, grasp. wards the fifth metacarpal, making cupping of
An ulnar view reveals the anterior projections the palm possible.
of the pisiform and hamulus which form the me- The trapezio-metacarpal joint is a saddle-
dial boundary of the carpal tunnel. The area shaped articulation between the trapezium and
between the hamate and pisiform is converted first metacarpal which, with its exceptional mo-
into another fibroosseous tunnel by the pisoha- bility, is often referred to as the "key" joint of
mate ligament. This tunnel of Guyon contains the the hand. Its wide range includes pure move-
ulnar artery and nerve and may be a site of ments of flexion, extension, abduction, and ad-
compression injury. duction, and combinations of movements pro-
ducing opposition and circumduction. During ab-
ARTHROLOGY duction and adduction, the convex metacarpal
surface moves on the concave trapezium; in
Carpal Joints
flexion and extension, the concave metacarpal
The carpal bones are firmly bound together on surface moves on the convex trapezium. By def-
the dorsal and palmar surfaces by short inter- inition, motions of the thumb (for example, flex-
carpal ligaments. They are also attached to each ion) occur in a plane (frontal) perpendicular to
other individually by deeper interosseous liga- the plane (sagittal) of the same movement in the
ments. They articulate with each other iv synovial digits. The pisiform-triquetral joint is a small
joints and can be passively moved in relation to plane joint which has its own separate synovial
each other. The joint capsules and interosseous cavity; it allows only a small amount of gliding.
ligaments divide the synovial cavity into the sep- The ulno-menisco-triquetral joint is the articula-
arate joints described below (Fig. 3). tion between the ulna, disc, and triquetrum, and
The radiocarpal joint is the articulation be- should be termed a "clinical joint" because it
tween the convex proximal row of carpal bones has no capsule nor separate synovial cavity;
and the concave radius and disc. The midcarpal however it becomes functionally important by
joint lies between the proximal and distal rows of providing component gliding accompanying su-
carpals; it may be described as a "compound pination and pronation. Joint play movements
articulation" in which each row acts as a unit may be produced in all of these carpal joints in
and each has both a convex and concave artic- response to traction, gliding, and rotary forces.
ulating portion. Together, the radiocarpal and The approximate ranges of motion for the wrist
midcarpal joints produce the motions occurring are 70-80" extension, 75-85" flexion, 15-20"
at the biaxial wrist joint: flexion, extension, radial radial deviation, and 30-40" ulnar deviation.
deviation, and ulnar deviation. The common car- However, these ranges may be influenced by the
pometacarpal joint is an irregular combination of position of the finger joints (and vice versa) due
plane articulations between the distal row of to the constant length of the extrinsic finger
carpals and the bases of metacarpals 2-5. It flexor and extensor muscles. For example, wrist
CARPOMETACARPAL- TRAPEZIO-METACARPAL
(COMMON) (THUMB)
MIDCARPAL
PlSlFORM
RADIOCARPAL
ULNO-MENISCO-
TRIQUETRAL
Fig. 3. Joints of the carpus.

JOSPTSpring 1983 ANATOMY AND MECHANICS OF THE WRIST AND HAND 209
flexion is greater with fingers extended. This ulnocarpal, dorsal radiocarpal, radial collateral,
property has important clinical ramifications and ulnar collateral ligaments.
such as a) the need for maintaining a constant b) Midcarpal joint-volar and dorsal intercar-
position of other joints when measuring any one pal and interosseous ligaments.
particular joint; b) the need for identifying hand c) Common carpometacarpal joint-volar and
position when measuring strength; c ) the need dorsal carpometacarpal, and intermetacarpal lig-
for determining when tenodesis may be desired aments.
when planning treatment, such as utilizing wrist d) Trapezio-carpometacarpal joint-lateral,
extension to enhance grasp in the C6 cord injury volar, and dorsal oblique ligaments.
or utilizing wrist flexion to enhance finger exten-
sion in spastic cerebral palsy. The thumb rotates Metacarpophalangeal (MP) Joints
90" to oppose the fingers, abducts 65-80" from
the plane of the palm, and extends 65-80' away The articulations formed by metacarpals 2-5
from the palm. and respective proximal phalanges are biaxial
The ligaments attaching the carpals are often joints. The joint capsules are reinforced (or re-
not distinct entities, like those of the shoulder, placed) dorsally by the dorsal hood apparatus
and may be hard to identify. The major ligaments and volarly by the volarplates. The distal portion
are listed below in relation to the joints they span of the volar plates is cartilagenous and firmly
(Fig. 4). fixed to the phalanx, whereas the proximal por-
a) Radiocarpal joint-volar radiocarpal, volar tion is membranous and loosely attached to the
COLLATERAL
LIGAMENTS
VOLAR PLATES
!EP TRANSVERSE
METACARPAL
LIGAMENTS
CARPO-METACARPAL
LIGAMENTS
INTERCARPAL
LIGAMENTS PISOMETACARPAL LlGP
PISOHAMATE L l G A M E N l
FLEXOR CARPI
RADIALIS T E N D O N
COLLATERAL
COLLATERAL LIGAMENT
ULNOCARPAL
RADIOCARPAL LIGAMENT
LIGAMENT
Fig. 4. Ligaments of the wrist and hand.

21 0 WADSW ORTH JOSPT Vol. 4. No. 4
m e t a ~ a r p a l . 'Adhesions
~ commonly form be- common structures, their interrelationships, and
tween the membranous surfaces which fold upon disorders are discussed here.
themselves when immobilized in flexion. On their The subcutaneous tissue of the dorsum of the
palmar surface, the plates are grooved to receive hand is structurally quite different from the tissue
and pad the flexor tendons of the finger (Fig. 4). of the palm. The dorsal areolar tissue is thin and
Laterally, the joints are supported by the col- elastic to permit stretching as a fist is made. Its
lateral ligaments which are strong cords running loose attachment and preponderance of lym-
obliquely from the dorsum of the metacarpals to phatics and veins account for the fact that swell-
the ventral aspect of the base of the phalanges ing is manifested predominantly on the dorsal
(Fig. 4). They become taut in flexion, thereby surface, although the source of the problem of-
restricting MP joint abduction and adduction in ten lies elsewhere in the hand.= In the palm,
this position. Contractures of these ligaments is many strong fibrous fasiculi connect the skin
a key factor contributing to loss of MP joint tightly to the adjacent palmar aponeurosis, per-
flexion. In order to prevent their shortening dur- mitting relatively little sliding of the skin and
ing immobilization, the fingers should be splinted enhancing secure grasp.
with the MP joints in 70-90" flexion.' The meta- The palmar aponeurosis, just deep to the sub-
carpal heads are connected to one another by cutaneous tissue, is composed of dense fibrous
superficial and deep transverse metacarpal lig- tissue. It is continuous with the palmaris longus
aments which offer indirect support for the joints. tendon and fascia covering the thenar and hy-
Movement increases progressivel'y from the pothenar muscles and extends distally into the
second to the fifth MP joint, but is generally transverse metacarpal ligaments and flexor ten-
approximated to range from 90" flexion to 25" don sheaths. It provides protection for the ulnar
extension, and 20" abduction to 0" adduction. artery and nerves and digital vessels and nerves,
The articulation of the first metacarpal and and may transmit a weak flexion force from the
phalanx is a hinge joint. Bony stability is inherent palmaris longus into the fingers (Fig. 5). Nodule
in its configuration, and to this is added volar formation or scarring in this structure produces
and collateral ligamentous support (Fig. 4). Flex- the clinical entity known as Dupuytren's contrac-
ion occurs to 50". Traction, gliding, and rotatory ture, which may eventually result in flexion con-
joint play movements are also possible in all of tractures of the digits.
the MP joints. The flexor retinaculum (transverse carpal lig-
ament), deep to the palmar aponeurosis, spans
lnterphalangeal (IP) Joints the area between the pisiform, hamate, scaph-
oid, and trapezium. It forms the "roof" of the
The articulations between adjacent phalanges
carpal tunnel which transmits some of the ten-
are termed hinge joints because the pulley-like
dons, vessels, and nerves of the hand. The ret-
surfaces allow motion in only one plane. The
inaculum offers attachment for the thenar and
volar and collateral ligaments are similar to those
hypothenar muscles, helps maintain the trans-
of the MP joints, but are not as important to
verse carpal arch, prevents bowstringing of the
stability (Fig. 4). The collaterals differ in that they
extrinsic flexor tendons, and protects the median
are most taut at 25" of flexion. This position,
nerve (Fig. 5). The median nerve is subject to
therefore, is ideal for splinting the fingers in
compression in this relatively unyielding space,
order to prevent IP joint contractures (contrac-
a condition known as carpal tunnel syndrome.
ture results in loss of IP joint extension). Flexion
Muscles acting upon the hand are referred to
at the proximal interphalangeal (PIP) joints ap-
as extrinsic when their origin lies outside the
proximates 1 10, at the distal interphalangeal
hand, and intrinsic when originating within the
(DIP) joints 90, and at the thumb interphalan-
hand. The extrinsic and intrinsic muscles are
geal joint 90". Traction, gliding, and joint play
differentiated in Table 1. A thorough review of
movements are also possible at the IP joints.
muscle origins, insertions, and actions is rec-
MECHANICS ommended, but due to comprehensive coverage
e l ~ e w h e r e , ~ ,is
" not included in this text. Se-
The physical therapist is frequently called lected kinesiologic concepts related to hand
upon to treat disorders of the hand stemming function and impairment are described in the
from soft tissue pathology. Some of the more following paragraphs.
JOSPTSpring 1983 ANATOMY AND MECHANICS OF THE WRIST AND HAND
FLEXOR DlGlTORUM
PROFUNDUS
FLEXOR DlGlTORUM
SUBLlMlS
FIBROUS
DIGITAL SHEATHS
FLEXOR RETINACULUM
APONEUROSIS ULNAR NERVE
MEDIAN NERVE
Fig. 5. Volar soft tissue relationships in the wrist and hand.
TABLE 1 operation of the hand is notably enhanced by

Muscles which act upon the hand: extrinsic versus intrinsic its large number of muscles. The design of the
Extrinsic muscles Intrinsic muscles extrinsics, the muscle bellies of which are lo-
Extensor carpi radialis Lurnbricals cated in the forearm but taper into tendons prox-
longus and brevis imal to the wrist, allows the action of many mus-
Extensor c a r ~ulnaris
i Dorsal and palmar cles without inordinate bulkiness. The extrinsic
interossei muscle tendons en route to the fingers cross the
Flexor carpi radialis Adductor pollicis
wrist and serve to enhance its stability by forcing
Flexor carpi ulnaris Flexor pollicis brevis
Palrnaris longus Abductor pollicis brevis the hand proximally into the concave radial sur-
Extensor pollicis longus Opponens pollicis face during cocontraction (Fig. 5). The muscles
and brevis acting upon the wrist itself also contribute to
Abductor pollicis longus Flexor digiti rninirni
wrist stability by achieving a balance of flexor
Extensor indicis Abductor digiti rninirni
Extensor digiti rninirni Opponens digiti rninimi
and extensor forces through their attachment to
Extensor digitorurn Palrnaris brevis corresponding surfaces of the stable metacarpal
cornrnunis bases.4
Flexor digitorurn sublirnis The extrinsic flexor muscle tendons of the
Flexor digitorum profundus
fingers pass into the hand deep to the flexor
Flexor pollicis longus
retinaculum. Flexor digitorum sublimis, which
21 2 WADSWORTH JOSPT Vol. 4. No. 4
primarily flexes the PIP joint, and secondarily primary repair of two severed tendons lying
assists MP joint flexion, divides into tendons within this rigid fibroosseous space.
which are capable of relatively independent ac- The dorsal extensor tendons are retained at
tion at each finger. The flexor digitorum profun- the wrist by the extensor retinaculum, but are
dus, which solely flexes the DIP joints and assists separated from it as well as the underlying bones
in flexion of the PIP and MP joints, also supplies by tendon sheaths. Toward the distal ends of the
tendons for each finger, but unlike sublimis, the metacarpals, the four tendons of extensor digi-
tendons cannot operate independently. There- torum communis (EDC) are interconnected by
fore, if one wishes to isolate the function of these juncturae tendinae, limiting their independent
two muscles in flexion of the PIP joint, the fin- motion (Fig. 6). Extension of the ring finger MP
g e r ( ~to
) the side(s) of the finger being tested are joint is hindered by flexion of the middle and little
passively held in extension to pull the profundus fingers because the juncturae tendinae pull the
distally which "inactivates" it and allows the ring finger extensor distally, rendering it lax.
sublimis to act alone at the PIP joint.3 Conversely, extension of the ring. finger exerts
The flexor tendons are tethered to the fingers an extensor force upon its neighbors, such that
by fibrous sheaths between the distal palmar they can be actively extended even if the middle
crease and the PIP joint. This area is referred to and little extensor tendons are severed proximal
as "no man's land" because of the difficulty of to the j u n c t ~ r a e . ~

PAN
Fig. 6. Dorsal hood apparatus, extensor tendons, and ligaments of fingers.

JOSPTSpring 1983 ANATOMY AND MECHANICS OF THE WRIST AND HAND 21 3
As the EDC tendons cross the region of the continuation of both extrinsic and intrinsic ten-
MP joints, their main connection to the proximal dons are prevented from dislocating dorsally by
phalanx is through the sagittal bands (dossier), the transverse retinacular ligaments which link
which pass palmarward to attach to the volar them to the volar plates of the PIP joints (Fig. 6).
plate (Fig. 6). The primary function of the sagittal Stretching or laxity of these ligaments allows
bands is to transmit the extension force of the bowstringing of the bands which transmits ex-
EDC, thus extending the MP joint, but they also cessive extension force to the PIP joint from the
serve to prevent bowstringing of the extensor intrinsics. This abnormal tension-combined
tendon d o r ~ a l l y . ~ When
- ~ , ' ~ hyperextension of with a volar plate rupture or the joint laxity char-
the MP joint is allowed, the force and excursion acteristic of rheumatoid arthritis-contributes to
of the EDC will be transmitted to the proximal hyperextension deformity of the PIP joint. Ter-
phalanx rather than the interphalangeal joints. In minal phalangeal flexion frequently results from
this situation, IP joint extension is only possible the taut profundus tendon in the presence of
'.
through the intrinsic^.^, " Thus a test to differ- weakened DIP joint extension. This deformity is
entiate function of the extrinsic and intrinsic ex- referred to as "swan neck" (Fig. 7h8
tensors would involve maintaining full active ex- The oblique retinacular ligament (Landsmeer's
tension of the MP joints and then attempting IP ligament) also contributes to interdependence of
joint extension, an action that would only be interphalangeal joint movement. It is attached
possible if the intrinsics were operating. between the PIP volar plate, where it is volar to
Between the MP and PIP joints the EDC ten- the joint axis, and the terminal tendon, where it
dons divide into three parts, the central slip is dorsal to the DIP joint axis (Fig. 6). When the
which inserts into the base of the middle phalanx, PIP joint is extended it exerts a passive extensor
and two lateral bands (Fig. 6). These lateral force on the DIP joint, and when the PIP joint
bands eventually rejoin into a terminal tendon flexes, it allows the DIP joint to flex. In the normal
which inserts into the base of the distal phalanx. hand the function of the oblique retinacular lig-
Rupture of this insertion produces a mallet fin- ament is essentially nil. However, if it becomes
ger. Fibers from the lumbricals and interossei contracted after burns or trauma it produces a
join the EDC tendons over the proximal phalanx, tenodesis effect (when the PIP joint is extended,
contributing to the dorsal hood apparatus. The the DIP joint will be brought into fixed extension
tendons of the intrinsics pass volar to the MP by this ligament).'
joint axis, thus exerting a flexion force on these When the PIP joint is flexed, the conjoined
joints, whereas both the intrinsic and extrinsic lateral bands slip volarly, decreasing the excur-
tendons pass dorsal to the PIP and DIP joint sion required for full DIP joint flexion. If the PIP
axes upon which they exert an extension force. joint is fully flexed passively, the extensor mech-
Thus, labeling the dorsal hood as extensor hood anism is held distally by the central slip and thus
is inappropriate because it also serves as a flexor check-reined. The lateral bands become com-
of the MP. pletely lax, thus permitting only weak and limited
The conjoined lateral bands formed by the distal joint extension.235If, on the other hand,
LATERAL BANDS\
CENTRAL SLIP EXTENSOR
DlGlTORUM
COMMUNIS
INTEROSSEOUS
PROFUNDUS TENDON MUSCLE
TRANSVERSE LUM'BRICAL
RETINACULAR MUSCLE
LIGAMENT
Fig. 7 . Swan neck deformity, demonstrating laxity of the transverse retinacular ligament.
WADSWORTH JOSPT Vol. 4, No. 4
LATERAL BANDS
\
EXTENSOR
DlGlTORUM
COMMUNIS
OBLIQUE 'INTEROSSEOL
RETINACULAR
LIGAMENT T
LUMBRICAL
MUSCLE
TRANSVERSE MUSCLE
RETINACULAR
LIGAMENT
Fig. 8. Boutonniere deformity, demonstrating rupture of the central slip
the central slip is ruptured from its insertion, the ling the digits, considerable substitution, and the
extensor mechanism is pulled proximally render- sometimes varying nerve supplies of these mus-
ing the lateral bands taut. The joint is pulled into cles. Following is a general summary of the major
flexion by the unopposed flexor digitorum sub- nerves and their corresponding loss of function
limis, and the lateral bands which now lie volar following injury.
to the PIP joint axis function as flexors. The force The median nerve in its passage along the
of the intrinsic muscles and EDC are transmitted forearm supplies the following muscles: pronator
directly to the distal phalanx, extending it, and teres, flexor carpi radialis, palmaris longus,
producing a "boutonniere deformity" (Fig. flexor digitorum sublimis, flexoq pollicis longus,
8).8-10When evaluating the DIP joint in cases of pronator quadratus, and flexor digitorum profun-
PIP joint contracture, these interrelationships dus (to index, middle, and sometimes ring fin-
must be considered. gers). It then passes under the flexor retinaculum
The lumbrical muscles originate from the and enters the palm, splitting into a sensory
flexor digitorum profundus tendons and insert branch and a motor branch which supplies the
into the dorsal apparatus. During contraction, following: abductor pollicis brevis, opponens pol-
they pull the profundus tendons distally, thus licis, flexor pollicis brevis, and first and second
possessing the unique ability to relax their own lumbricals. Impairment resulting from median
antagonist.' In instances of lumbrical spasm or nerve paralysis includes inability to oppose or
contracture, as in rheumatoid arthritis, attempts flex the IP joint of the thumb and inability to flex
to flex the fingers via the profundus result in the first two fingers, resulting in a "benediction
transmission of force through the lumbricals into attitude." Loss of the above functions severely
the extensor apparatus, contributing to exten- hinders the ability to perform precision maneu-
sion rather than flexion. This may result in a ver~.~
"lumbrical plus deformity," i.e., MP joint flexion The ulnar nerve supplies the following muscles
and IP joint extension. The lumbrical muscles in the forearm: flexor carpi ulnaris and flexor
serve as a primary organ of feedback in the digitorum profundus (to little and sometimes ring
hand. They are ideally suited to link position and fingers). In the hand it innervates the following:
movement of the hand and finger joints due to flexor digiti minimi, abductor digiti minimi, op-
their location as well as abundance of annulos- ponens digiti minimi, adductor pollicis, palmaris
pinal (AS) endings. brevis, third and fourth lumbricals, and the inter-
ossei. Paralysis of the ulnar nerve produces loss
NEUROLOGY of thumb adduction (lateral pinch), weakness in
Motor Innervation power grip,6 and difficulties in finger spreading
and coordinated activities such as piano playing.
Clinical evaluation of neurological damage is An ulnar claw hand deformity, i.e., "intrinsic
made difficult by the numerous muscles control- minus" with MP joint extension and IP joint flex-
JOSPT Spring 1983 ANATOMY AND MECHANICS OF THE WRIST AND HAND 21 5
ion, often results. This deformity is more severe

in lesions distal to innervation of flexor digitorum
profundus.
The motor supply of the radial nerve is con-
fined to the forearm where branches are given
to the following: extensor carpi radialis longus
and brevis, extensor carpi ulnaris, supinator,
extensor digitorum communis, abductor pollicis,
extensor pollicis longus and brevis, extensor
indicis, and extensor digiti minimi. Radial nerve
paralysis prevents extension of the wrist and MP
joints of the fingers. Since wrist extension pro-
vides synergistic and stabilizing functions, this
loss can significantly hamper hand function. The
ability to extend and abduct the thumb is also
lost.
Sensory Innervation
The hand is sometimes referred to as a

"sensory organ" because 25% of all the Paci-
nian (touch) corpuscles in the body are located
therein. The motor system is absolutely depend-
ent upon the constant feedback it receives from

the sensory receptors. Branches of the three
major peripheral nerves carry sensation from the
hand in the following manner.
a) Median-lateral portion of palm and thenar
VOLAR DORSAL
surface; volar part of thumb, index, and middle
fingers, and lateral half of ring finger, extending Fig. 9. a) Delineation of the peripheral cutaneous sensation
over the dorsum of the terminal phalanges; in- supplied by the radial (R), median (M), and ulnar (U) nerves.
b) Delineation of sensation derived from cervical root levels
nervation is purest at tip of index finger.
C6, C7, and C8.

b) Ulnar-ulnar side of hand, medial half of
ring finger, and little finger (both dorsal and
palmar surfaces); innervation is purest at tip of ANGIOLOGY
little finger. Arterial'
c ) Radial-dorsum of hand, lateral to fourth
metacarpal, and dorsal surfaces of thumb and The hand receives its blood from the radial
first 2% digits to DIP joints; innervation is purest and ulnar arteries. The radial artery courses
at the dorsal web space between thumb and along the lateral side of the forearm to the wrist,
index finger. where its pulse is palpable just lateral to the
Sensory changes produced by cervical root flexor carpi radialis tendon. After giving off the
pressure are frequently experienced in the dis- superficial palmar branch it winds laterally
tal-most areas of the dermatomes, thus involving around the dorsum of the wrist and enters the
the hand. When evaluating the hand, knowledge palm between the first and second metacarpals
of the dermatomal distribution assists in differ- where it forms the deep palmar arch by uniting
entiating between nerve root and peripheral with the deep branch of the ulnar artery. The
nerve lesions. Root level representation includes radial artery gives off a superficial palmar branch
C6 to the thenar area and thumb, C7 to the proximal to the scaphoid which anastomoses
midpalm and dorsal areas and index, middle, with the corresponding ulnar branch forming the
and ring fingers, and C8 to the hypothenar area superficial palmar arch. This arch is larger and
and little finger (Fig. 9).' Because of the similar more significant than the deep arch.
patterns of C8 and ulnar nerve sensory distri- The ulnar artery crosses the wrist medially,
bution, additional motor tests may be necessary where it is superficial to the flexor retinaculum.
for making a differential diagnosis. Just distal to the pisiform it divides into a super-
21 6 WADSWORTH JOSPT Vol. 4, No. 4
ficial branch, which continues across the palm

as the superficial palmar arch, and a deep
branch, which anastomoses with the radial artery REFERENCES

completing the deep arch.
From the deep palmar arch arise the palmar
1. Cailliet R: Hand Pain and Impairment, Ed 2. Philadelphia: FA
metacarpal arteries, which join the palmar digital Davis Co. 1975
arteries from the superficial arch. They extend 2. Harris C, Rutledge GL: The functional anatomy of the extensor
into the fingers as digital arteries. mechanism of the finger. J Bone Joint Surg 54A(4):713-726,
1972
3. Hoppenfeld S: Physical Examination of the Spine and Extremi-
Venous ties. New York: Appleton-Century-Crofts, 1976
4. Kapandji IA: The Physiology of the Joints. Vol 1. Baltimore:
The hand is drained by a plexus of superficial Williams 8 Wilkins Co, 1970
5. Lampe EW: Surgical anatomy of the hand. ClBA Clin Symp, 9,
and deep veins, of which the superficial is most 1957
significant. 6. Landsmeer JM: Power grip and precision handling. Ann Rheum
The superficial system is best developed over Dis 22:164-170. 1962
7. Moore KL: Clinically Oriented Anatomy. Baltimore: Williams 8
the dorsal surface of the hand and becomes Wilkins, 1980
increasingly prominent with age. At the level of 8. Smith RJ: Balance and kinetics of the fingers under normal and
the wrist, this system converges into the cephalic pathological conditions. Clin Orthop 104:92-111, 1974
9. Souter WA: The problem of Boutonniere deformity. Clin Orthop
vein laterally, and the basilic vein medially, which 104:116-131, 1974
'
ascend superficially up the forearm. 10. Swezey RL: Dynamic factors in deformity of the rheumatoid
The deep veins of the hand travel in pairs with hand. Bull Rheum Dis 22. 649-656. 1971-72
11. Warwick R. Williams PC (eds): Gray's Anatomy. 35th British Ed.
the arteries (vena comitantes). They ascend from
Philadelphia: WB Saunders Co, 1973
the digits to the palmar arches to the radial and 12. Weeks P. Wray C: Management of Acute Hand Injuries. St. Louis:
ulnar arteries. CV Mosby Co, 1973

Clinical Anatomy and Mechanics of The Wrist and Hand

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Clinical Anatomy and Mechanics of the

OSTEOLOGY like the phalanges; their configuration produces

function (Fig. 1).

LUNATEJ '-CAP] TATE

Fig. 1 . Hand skeleton.

ULNAR NERVE FLEXOR TENDONS

HAMATE FLEXOR RETINACUL

Fig. 3. Joints of the carpus.

Fig. 4. Ligaments of the wrist and hand.

APONEUROSIS ULNAR NERVE

Fig. 5. Volar soft tissue relationships in the wrist and hand.

TABLE 1 operation of the hand is notably enhanced by

as "no man's land" because of the difficulty of to the j u n c t ~ r a e . ~

Fig. 6. Dorsal hood apparatus, extensor tendons, and ligaments of fingers.

ion, often results. This deformity is more severe

The hand is sometimes referred to as a

ent upon the constant feedback it receives from

C6, C7, and C8.

ficial branch, which continues across the palm

branch, which anastomoses with the radial artery REFERENCES

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