Structure and Function of the Wrist (chapter Outline Osteoiogy Distal Radius and Una Carpal Bones Arthrology soint Structure Ligaments of the Wrist Kinomaties ((Obiectives + Identify the bones and primary bony features relevant to the wrist complex + Desoribe the supporting structures of the wrist. + Cite the normal ranges of motion for wrist flexion and extension and radial and ulnar deviation. + Degorilfe the planes of motion and axes of rotation for the Joints of the wrist. + Olte the proximal and distal attachments and innervation of the primazy muscles of the wrist. avascular necrosis Key Terms cavjalitetoel the wrist contains eight small bones that are located L between thecistal end ofthe radius and the hand (Figure 6-1), Although slight, the passive movements that occur ‘within the carpal hones help alsorb forces that cross between, the hand and the férearm, as when eravrlins on all four limbs, or when bédting weight through the hands when using cetlitches or walker, ‘The wrist has two major articulations: (1) the radioearpal joint, and @) the midcarpal joint. As a functional pair, these joints allow the wrist to adequately position the hand for ‘optimal fanetion. 4122 Muscle and Joint Interaction Innervation of the Wrist Muscles Function of the Wrist Muscles Summary Study Questions Additional Readings + Justify the primary actions of the muscles of the wrist. + Describe how compressive forces are transferred from the hhand through the wrist + Explain the function of the wrist extensor muscles when rasping «+ List the structures that travel within the carpal tunnel, + Explain the synergistic action between the muscles of the vist when flexion-extension and radial and ulnar deviation are performed. lateral epicondylitis palmar ‘carpal tunnel syndrome dorsal ‘The wrist can flex and extend and move in a side-to-side fashion known as radia! and ulnar deviation. In addition to these important movements, the wrist must serve as a stable platform for thehand. A painful or weak wristtypically cannot provide an adequate base for the muscles to operate the hand. ‘Making firm grip, fpr example, is not possible with paralysis of the wrist extensor muscles. As will be presented in this chapter, the kinesiology of the wrist is heavily linked to the kinesiology of the hand. . ‘Several new terms in this chapter describe surfaces of the wrist and hand. Palmar is synonymous with the anteriorMidearcal joint Figure 6-1 The bones are maior aroulations of tho wrt. Note as (he ulnocarpal space, ust deal tothe una. From Neumarn DA Krestbgy ofthe misculskcletal system: foundations for physical ‘ehabiation,e0 2, St Louis, 2010, Mast. gure 7-1) ‘aspect of the wrist and hand; dorsal refers to the posterior aspect of the wrist or hand. Thesetermsare used interchande sly throughout this chapter and the next chapter on the hand Osteology ‘Ten bones are involved in the kinesiology of the wrist: distal ‘radius, distal ulna, and cight carpal bones. Distal Radius and Uina ‘The distal radius and vlna (Figure 6-2) articulate with the ‘proximal row of earpal bones. The distal forearm is bordered Jsterally by the radial stploid process and medially by the winar styloid process, The radial tubercle, also called Lister's tubercle, {sa.small, palpable projection on the dorsal aspect ofthe distal radius. This ridge of bone helps gulde the direction of the ‘tencions of several wrist and thumb extensor muscles. Carpal Bones ‘From a radial (lateral) to ulnar direction, the proximal row of ‘carpal bones includes the seaphoid, lunate, riquetrum, and HAPTER 6 Structure and Function of the Wrist 123 Dorsal view racials bros ‘Groove for extensor ‘onp radial Drews Brachiorasials: igure 6-2 The dorsal aspect of te bones ofthe it wrt, Tho ‘muscs distal attachments ao shawn n zy, The dashes Ines ow tte proximal attachment ofthe dorsal capeuls ofthe writ From. Neumann DA: Knesioiogy ef the muscuoskest sytem: foundations for physica reheoltation, ed 2, St Lowe, 2010, Mosby, Figue 7-2) pisiform. The distal row includes the trapezium, trapezoid, capitate, and hamate (see Figures 6-2 and 6-8). The bones ‘within the proximal rew are loosely joined. In contrast, strong ligaments tightly bind the bones of the distal row. The natural stability of the distal row provides an important rigid base for articulations with the metacarpal bones. © Consider this... Carpal Bones: A Few Highlights ‘Scaphoid ‘The scaphoid is located in the direct pathway ofthe forces that naturally cross the wrist, For this reason, fracture of the scephoid ocours more frequently than fracture of ary other carpal bone. Healing is frequently rindered because biood supply to the fractured component of bone 's often poor Lunate Its interesting to rote that no muscles and only a few. ligaments ar attached to the lunate, The lunate therefor ls Toosely anicuiated and is the mast frequently dislocated ccarpal bone, As with the scaphoid, the blood supply to the Junate is ofen compromised after trauma, eesuitng in avascular necrosis.724 CHAPTER 6 Structure and Function of the Wrist Palmar view Flexor camp ‘nas Hamate wan nok Pisiorm. Abductor polis longue Trapezium Tubercles Groove fr extensor ples brevis ‘and abductor polos longus Figure 6-8 The patmar aspect of ino bones ofthe right st. Tho muscles proxtralatachments are shown red, and dist attachments ia “Te dashed nce chow tha proximal atta ‘ofthe palmar capsule ofthe wrist. From Neumann CA: Kinesiology of the musculoskeletal ‘system: fourdiaions for physi! habitation, ed 2, St Lous, 2010, Mosby, Figue 7-2) Triquetrum ‘The triquetrum is named after ts triangular appesrance. Pisiform Strictly speaking, the piso is not a true carpal bore. Rather its a sesamoid bone that develops within the tendon ofthe flexor carpi unaris. Technical, therefore, the wrist has seven carpal bones; this matches the arrangement cf seven tarsal bones of the ankle ‘Trapezium ‘The distal, saddle-shaped surface of the trapezium articulates withthe base ofthe fist metacarpal. The reeutting ccarpometacarpal joint fs a highty specialized articulation allowing @ wide range of motion of the thumb. Trapezoid ‘This bone is tighity wedged between the trapezium and the capitate, serving as a stable base for the secand metacerpal Capitate ‘The capitate isthe largest of all carpal bones, occupying a ‘central locaton within the wrist. The axis of rotation forall Jurist mation passes through this bone. Hamate ‘The hamate (rom Latin, meaning “hook’) is named after its prominent hook-tke process on ts palmar suriace, Carpal Tunnel ‘The transverse carpal ligament bridges the palmar side of the carpal bones, helping to form the earpal tunnel (Figure 6-4). ‘The carpel tunnel serves as a passayeway that helps protect the median nerve and the tendons of the extrinsio flexor inuseles of the digits, Clinical insight Carpal Tunnel Syndrome All the tendons that flex the digits travel with the median Nerve andi pass through the tightly packed carpal tunnel (soe Figure 6-4). Aso traveling within the carpal tunnel are several ‘synovial membranes thal help reduce fiction between tendons and surrounding structures. Hand! activites that equire prolonged and often extreme wrist positions can initate these tendons and synavial sheaths. Bacause of the smal Sze of the carpal tunnel, sweling of the synovial ‘membranes can inorease pressure on the median nerve Carpal tunnel syndrome, which is characterized by pain or paresthesia tingling), or both, over the sensory distrution of the mectan nerve, may result, In more extreme cases, ‘muscular weakness and ztrophy may occur i the intrinsic, ‘muscles around the thumb,CHAPTER 6 Structure and Function of the Wrist nar now. Flexor aighorum nar ¢ynovial sheath Flexor capl radials ‘Racial synovial shoath Flexor polis longus {6-4 The transverse carpal gament is shown asthe oof ofthe carpal tunel, Observe the synovial sheaths (lve) curoundg the tendons fexcr diglorum supers, fexor dgttrum protoundus, and exo poles longus. Note tat the median nerve i loceted nice the tur 35 the Un name is located outside of the tun (From Neumann DA: Knssiclogy’of the musculaskaetlcystem: foundations fr physica tion, 2d 2, St Louls, 2070, Mos, Figure €-25,) hrology Structure is illustrated in Figure 6-1, the wrist is a double-jointed sm, consisting of the racioearpal and midearpal joints. smaller intercarpal joints also exist between carpal 5. Compaved with the larse ranges of motion permitted the radiocarpal and midearpal joints, motion at the many stercarpal joints is relatively small. Major Joints of the Wrist _ + Raciccarpal joint * Midearpal joint Radiocarpal Joint ‘The proximal part of the radiocarpal joint consists of the concave surface of the radius and the adjacent articular dise (Pigure 6-5). The distal part ofthe joint consists primarily of the convex articular surfaces of the scaphoid and the lunate, “Approximately 80% of the force that erosses the wrist passes ‘between the scaphoid and the lunate, and then to the radius. ‘The large, expanded distal enc of the radius is well designed *soaccept this foree. Unfortunately, however, for many persons, fall onto an outstretched hand fractures the distal end of the ‘radius, as well as the seaphoid. Persons with weakened bones ue to osteoporosis are particularly susceptible wo these fractures, Distal ‘acioulnar jain Aioular 52 Prostylod nar colateral ligament Figure 6-5 A tronial plane crass section through the ight wrist anc distal forearm shawing the shapo of tho bones and cennective tissues. “The margins ofthe redigearpa and midoarcal ons ae highighted is ‘ed. (Mode fom Neumann DA: Kinesiology ofthe musculoskeletal “stam: founcebons fer physical rehabitaton, ed 2, St Louis, 2070, Mosby, Faure 7-7)126 cuapren 6 Structure and Function of the Wrist, ‘The ulnar-located carpal bones and the distal ulna are less likely to fracture from such » fall because they are not in the direct path of weight bearing Furthermore, a relatively wide space exists between the distal ulna and the ulnar carpal bones, This space, formally known as the ulnocarpal space (see Figure 6-1), helps buffer the forces that cross the wrist. ‘Midcarpal Joint ‘The midcarpal joint separates the proximal and distal rows of carpal bones (see Figure 6-5). Although this joint involves several urticulations, the most prominent is formed between the head of the eapitate anc the socket formed by the distal ‘surfaces of the seaphoid and lunate. Note that the scaphoid and the lunate bones are important members of the main two articulations of the wrist. Ligaments of the Wrist ‘The joints of the wrist are enclosed within a fibrous capsule, ‘Tho capsules thickened by extrinsic and intrinsic ligaments, Extrinsic ligaments have their proximal attachments outside ‘the earpal hones but attach distally within the cargal bones. Intrinsic ligaments, in contrast, have both their proximal and distal attachments located within the earpal bones. Table 6-1 lists the main attachments and primary functions of the four primary extrinsic ligaments: radial colleteral, ulnar collateral, dorsal radiocarpal, and palmar radioearpal. Three of the four primary extrinsic ligaments are indicated by red dots in Figure 6-6, A and B, and are summarized along with their individual funetions in Table 6-1. The detailed anatomy of the intrinsic ligaments is eyonc¢ the scope ofthe text, AS a group. however, the intrinsic ligaments (1) interconnect various (tante 6-1 Ligaments of the wast Ligament Function Comments Dorsal radiocarpal Resists extremes Attachos between the ligament of flexion radius and the dorsal side of the carpal bo Radial colateral Rassts extremes Strengthened by ligament of uinar ‘muscles auch as the deviation ‘abductor policis longus and the extensor pollicis . Drovis Palmar radiocarpal Resists extremes Thickest ligament of the ligament of wrist waist; consists of extension throe parts Uar colateral Resists extremes Part of the ulnocarpal ligament of rackal ‘complex; helps deviation stablize the distal radioulnar joint carpal bones; (2) help transfer forces between the hand and the forearm; and (8) maintain the natural shapes of radiocar- pal and midearpal joints, thereby minimizing joint stress during movement. © Consider this... Ulnocarpal Complex A complex set of connective tissues, Known as the uocarpal complex, exists near the uinar border of the wrist (see Figure 6-6, 8), (This group of tissues is often referred 10 as the thanguler flrocartlage complex, or TFC}. The Ulnocarpal complex includes the articular cisc (described in CChaptor § as an important component of the distal radioulnar join), the ulnar collateral igament, and the palmar Ulnocarpal igament. This set of tisues fils most ofthe Unocarpal epace between the distal ulna and the carpal bones (se¢ Figure 6-1). The uinocarpal space alows the carpal bones to follow the pivoting radius during pronation {and supination ofthe foreairn, without interference from the ist end of the ulna, Tears in the articular giso, the central ‘component of the Linacarpal complex, may rest in Inetabilty and pain of the wrist and tha distal radioulnar joint. Wrist Instability Compression forces naturally cross the wrist every time an overlying musele contracts or weight is placed through the hand. Normally, the wrist remains stable when compressed, even under substantial forces, Resistance from healthy liga ments, muscles, and tendons and the fit of the articulations add an important element of stability to the wrist, However, damage from a large force such as a fall or, in more extreme cases, degeneration associated with theumatoid arthritis can significantly destabilize this region. Consider that the loosely articulated proximal row of carpal bones is located between two rigid structures: the radius and the distal row of earpal bones. Ligaments weak- ened by injury or disease often lead to instability ofthe wrist and even collapse. When compressed strong'y from both ends (eq, froma fall), the proximal row of carpal bones is prone to collapse in azigzag fashion, much likederailed ears ofa freight train (Figure 6-7), An unstable wrist can become painful and isoften disabling Even a moderately unstable wrist can disrupt the natural arthrokinematics, eventually leading to severe pain and overall weakening caused by atrophy of the surrounding muscles. A painful and weak wrist typically fails to provide a stable platform for the hand. In severe cases, surgery is rrequited, often combined with physical therapy: Components ‘of physical therapy typically include strengthening, efforts to relieve pain, education on ways to protect the wrist, and splinting.Radloseaphotunate. Palmar Rasiolunate raciocsrs! | radiosc i fecara| | Raclescapnocaptar adil cotateral igament ‘Trangverse carpal Tigament (out) Shot palmar igaments ot dial ow B CHAPTER 6 Structure and Function of the Wrist 127 adda coatoral ligament Seaphotapedal Atcuar die Palmar uinocarpl Igament Triangular Unrarcotaioat | fbrocariiage ligament nee Palmar intescarpal ligament Transverse carpal ligament (out) 16-6 The primary axtrnsteKgaments of he night wrist are rghightad by red dts. Adetonal camera ae ited but not hhightos. Dorsal view B, Palmar vw, The raneverss carpal igament has been cut and related to show the undervng igaments. (Modif from mann DA: Kinesiology of tts mscuoskesta systam: foundations fr physical iphabillaton, ed 2, St Louis, 2002, Mosby, Fgures 7-9 and 7-10)Pee 128 cHAPrER 6 Structure and Function of the Wrist Figure 6-7 4 hight dagrammatic depiction of a “rgzag" cotanso of the wit sscordary 10a lange compression force aft afl. Note that ‘only selected bones representing the major ats of the wrist are stonn. Fram Neumann DA: Knesilogy of ho mascuosoltal syst: foundations for physical rab, ed 2, St Lous, 2010, Mosoy Figure 7-18) Kinematics Osteokinematics Osteakinematics of the wrist involves flexion and extension ‘and ulnar end radial deviation. Except for minimal accessory ‘motions, the wrist does not spin in a cireular motion relative toa fixed radius, The bony fit and ligaments of the radiocarpal joint naturally block this twisting motion, As studied in Chapter 5, pronation and supination involve rotation of the forearm, with the hand and wrist “following” the path of the radius, ‘The axis of rotation for wrist movement pierces the head of the capitate (Figure 6-8). The axis runs in a medial-lateral direction for flexion and extonsion, and in an anterior- posterior dizection for radial and ulnar deviation. The firm articulation between the capitate and the base of the third ‘metacarpal hone causes rotation of the capitate to direct the overall path of the entire hanc. Sagittal Plane: Flexion and Extension (On average, from a neutral (O-degree) position, the wrist flexes approximately 70 to 80 degrees and extends approxi- ‘mately 60 to 65 degrees, fora total of approximately 190 to 145 dogrees (Figure 6-9, 4) Total loxion normally exceeds exten sion by approximately 15 degrees. Extension is normally limited by tension in the thicker palmar radiocarpal liga- ments, as well as by contact of the carpal bones with the slightly elongated dorsal side of the distal radius. Figure 6-8 The mestt-seral (year) and antero-posterior Le) ‘266 of rotation fr wat movement are shown percing the base of the ‘captate bone, (From Neurann DA Kineaoloay of the musculaskoatal system: foundations for physical rehatiaton, ed 2, 81 Lous, 2010, Moy, Feu 7-13) @ consider this... The “Position of Function” pf the Wrist Many common dally sctivties require about 45 degrees of sagittal plane mation: from 5 to 10 degrees of flexion to 30 10 35 dagreas of exteneon, These same dally actvtios also require approximately 25 degrees of frontal plane motion; from 15 degrees of unar deviation to 10 degrees of radia ovation, Medical management of a severely painful or Unstable wrist sometimes requires surgical fusion, To minimize the functional impairment caused by this procedure, the wrist may be fused! in an average positon of function: ‘approximately 10 to 15 degrees of extension and 10 degrees of ulnar deviation,bs ore Figure 6-9 cctookineratics ot Fiction excoeds rad deviate us, 2010, Mosby, Figue 7-12. Frontal Plane: Radial and Ulnar Deviation On average, from a neutral (0-lesree) position, the wrist, Slows approximately 30 to 35 degrees of ulnar deviation lsd approximately 15 to 20 degrees of radial deviation, f of about 45 to 55 degrecs of motion (Figure 6-9, B). jaimum ulnar deviation is normally twice that of radial viation, mostly because of the void crested by the ulnocar- space. Radial deviation is blocked by contact between styloid process of the radius and the radial side of the arpal bones. Arthrokinematies Wrist movements occur simultaneously at both the radio- arpal and midcarpal joints. The upcoming diseussion on scthrokinematics facuses on the dynamie relationship between these two joints. Central Column of the Wrist ‘The essential kinematics of the wrist can be well appreciated by obsorving motion oecurring through the central column of the wrist—the series of articulations, or links, among the radius, lunate, capitate, and thitd metacarpal bone Figure 6-10, middie). Although this central column does not include allbones of the wrist, it does provide excellent insight into an, otherwise complexmovement. Within this cokumn, theradio- sarpal joint is represented by the articulation between the radius and the lunate, and the midearpal joint is represented, by the articulation between the lunate and the capitate. The carpometacarpal joint indicated in Figure 6-10 (middle) is a relatively rigid articulation between the capitate and the base of the thicd metacarpal; this allows movement of the hand to follow" the third metacarpal hone. Apres 6 Structure and Function of the Wrist 129 (0 wot. A, Flexion and extension. B, Unar and racial dovtion. Noto that Soxion exceeds extension, and nar ram Neumann DA Kinesiclogy of he musculoskeletal systam: radatens for physical rehabitalion, a 2 Extension and Flexion ‘The arthrokinematies of wrist extension is based on simmulta- neous convex-on-coneave rotations at both radiocazpal and ‘midearpal joints (Figure 6-10, lg). As would be expected by tho convex-concave rules of arthrokinematics (see Chapter 1), Kinematics oceurs as «roll and slide in opposite directions. What complicates matters, however, is that these kinematics ‘occur simultaneously at two joints: radiocargal and midea pal These compound arthrokinematies are illustrated in Figure 6-10 (left) by the red and white “roll-and-slide” arrows, Full wrist extonsion olongates (stretches) the palmar ra- diocarpal ligaments, the palmar capsule, and the wrist and finger flexor muscles, This helps to stabilize the wrist in an ‘oxtentdod position, which is useful when one isbearing weight through the upper extremity ‘The arthrokinematics of wrist flexion is similar to that deseribed for extension, but it oceurs in a reverse fashion (Figure 6-10, right). Ulnar and Radial Doviation of the Wrist Similar to flexion and extension, ulnar and radial deviation can be studied by observing selected bones that represent both the radiocarpal and midoarpal joints (Figure 6-11, ‘middle). The motions of ulnar and radial deviation also occur through simultaneous coavex-on-coneave rotations at both the radiocarpal joint and the midearpal joint. The arthrokin ematios for ulnar deviation Isshown in Figure 6-11 (left). Note that the roll and slide occurs in apposite directions, at both joints, Radial devintion at the wrist occurs through similar arthrokinematies, as has just been described for ulnar devia- tion (Figure 6-11, right); however, the amount ofradial devia tion is far less than the amount of ulnar deviation, The radial130 cuaprer 6 Structure and Function of the Wrist Figure 6-10 A mechanical moce! ofthe central column of the fight wrist showing te artwokineratics of exon and extension, Te wrist in the center is shown at ret, na naural poston, The roland-sicearhrckinerats is shovm in red forthe eciocerpal jo, and h gray forthe miccarpel faint During wist extension fo), ths dorsal radacarca igaments Secome slackened and the palmar aciocarpalijrnents taut. Reverse ‘athvokinemates occurs dung wis! exon ght. (Fram Neumann DA Kineiclogy of tho muscuoskaletl system: foundations for physical ‘arabian, ed 2, St Lous, 2010, Mosby, Pgs 7-18) sides of the neazby carpal bones quickly abut against the styloid process of the radius, thereby limiting the extent of radial deviation across the wrist. Muscle and Joint Interaction Innervation of the Wrist Muscles ‘The radial nerve courses down the posterior aspect of the forearmand suppliesall the muscles that extend the wrist and ‘the digits, Tho median and ulnar nerves travel down the ante- rior aspect ofthe forearm and innervate all ofthe wrist flexor muscles. The paths of these nerves can be reviewed in the previous chapter (see Figures 5-21, 5-22, and $-29). Function of the Wrist Muscles ‘Wrist muscles ean be classified into (2) a primary set that attaches to the wrist or nearby regions, and (2) a secondary set that bypasses the wrist and attaches more distally to the digits. The secondary set of muscles is also referred to as the extrinsic muscles to the hand, the detailed anatomy of which is described in Chapter 7 Bynecessity all muscles ofthe wrist cross the axes of rota tion located at the capitate bone and therefore produce move- zment at the wrist. The two axes of rotation that earrespond to the two planes of motion at the wrist are shown in Figure 6-8, Flexion and extension occur about the medial-lateral axis of rotation; radial and ulnar deviation occurs about an anterior- posterior axis of rotation. The specific action of each wrist ‘muscle is determined by the location of its tendon relative to ‘cach axis of rotation. For example, the extensor carp| ulnaris isa wrist extensor because it passes posterior to the medial- lateral axis of the wrist. As is described later, the extensor ‘carpi ulnaris is also an ulnar deviator of the wrist because it passes ulnar (or medial) to the anterior-posterior axis of the ‘wrist. Figure 6-12 shows a cross-sectional view of the right ‘wrist indicating the position (and therefore the function) of the tendons of the wrist and hand muscles relative to the medial-lateral and anterior-posterior axes of rotation. Note that the cross-sectional image shown in this figure is at the level ofthe capitate,cuaprer @ Structure and Function of the Wrist 131 Palmar view ‘Figure 6-11 Radiographs and a macherial mode of tho right wrist showwng the artrokinemstis of unar and racial devation. The wrist inthe Centar s shaw t rest, In 2 neutal postion The rol-and-side arttrckinemaic is shown in re forthe radiccarpel joint, and in wiht forthe ‘miccarpal jot. C, Capa: , namate L, luna; S, seaphal T,tlquetram. rom Neumann DA: Kinesiology of the musculoskeletal sytem: ‘eundations fr physical rebatikanion, ed 2, St Lous, 2010, Mosby. Faure 7-18. Athrkinais is based on obeontions mas Fm cineradograoty ‘conducted at Marquette University, Miwaukee, Wisconsin, in 1969) reppe (eso1e7) Postorior (dorsal) Figure 6-12 Cross-sectonal ew looking stall through the right carpal tunnel tthe velo hs capitate. Note that this figs depcis the hen In a tly supinateg, pam-up postion. The ares within the red boxes on the grid is propor to the cross-sectional area of each muscle and therelo is nccaive ofthe musde's mexinal force preduction. The small biack dot within each red box indcates the positon of the tenon of the ‘muselerelatve To the aves, 2nd therefore can be used 1 determine the intemal mement arms ef each muscle. rem Neumann DA: Kinesiology of the musculoskeletal aster: foundations for physica rohabilitio, ed 2, St Louis, 2010, Mosby, Hau 7-24.)132 cuapren 6 Structure and Function of the Wrist Posterior view Extensor carp vunarie Exonsor cig Extensor retinaculum Exionsor indice Lateral epicondye Extensor cap radalis longus Extensor carpi radalis breve Exiensor digitorum Extensor plicis Figure 6-13 Postrcr vow ofthe right forearm nigightng the muscles within the primary set of wis extensors: extensor carpi racialis ongus, ‘etenscr cap acs revs, and extensor carp ulnae, Mery ofthe muscios ofthe socondary st of wrist extensors ar also shown. From Neumann DA: Kinesioogy of the musculoskeletal system: foundations fr physica rehatiltation, ed 2, St Louis, 2010, Mosby, Figue 7-22), Wrist Extensors Anatomy. ‘The primary set of wrist extensorsincludes the extensor carpi radialis longus, extensor carpi radialis brevis, and extensor carpi ulnaris (Figure 6-13), The secondary set of wrist exten sors are the extensor digitorum, extensor indicis, extensor digiti minimi, and extensor pollicis longus—muscles that are studied in greater detail in Chapter 7 Wrist Extensors Primary Set (Act on Wrist Only) '* Extensor carpi radials longus * Extonsor carpl radials brevis * Extensor carpi unaris ‘Secondary Set (Act on Wrist and Hand) ® Exlensor digitorum + Extensor indcis| » * Extonsor digit minim + Extensor pollicis fongus:Extensor carp Benson ‘acai longus capt ulnar Extensor carp radials brows Exencor retnai Extensor Carpi Radialis Brevis Proximal Attachment: Lateral eiondyle of hurenas—conmn extensor tendon Distal tachment; Base of Ue thi metacarpal—drsal aspect Innervation: Radial neve ations: ' Wistexenson ‘= Radial dovaion CHAPTER 6 Structure and Function of the Wrist 133, ‘Comments: DORSAL VIEW Pua at | extensor carol redalis brows 1 Extensor capi radials longus ‘he etensr carpi radials longus and bres tach stay tothe bases of he second aed tie metacatpals,respectety. Not coincidently, nese twin metecarpas ae igi tached to the dst set of carpal tones. This esting stably helps \ransfer wrist enor frees across th entre ‘exjons ofthe was cain134 cHApr=n 6 Structure and Function of the Wrist Extensor Carpi Radialis Longus Proximal tachment: Lateral epconle of humeris—oarnon extensor tendon Distal tachment: Base ofthe second metacarpal—dorsl aspect Inervation: Radia nee Actions: Wist extension + asa evi ‘comments: “Te evtonsor carp rads longus i a mare effete adel devator ofthe ws than is parte, ‘he exensr capris bres. The lng rail ‘rit extensor eaceods i this function because of is farther ditenee from the ate poster avs ‘of rotation (hough te capt. noes words, ‘he ang ral wst extensor has eater leverane for redial dvi han the shrt radia wit ‘ters. Functional Consideration: Wrist Extensor Activity While Making a Grasp ‘The main funetion of the wrist extensors is to position and stabilize the wrist for activities involving the fingers, espe- cially while making strong grasp or fist. The eommon muscle belly of the wrist extensors can be felt contracting on the dorsal side of the proximal forearm during rapid tightening and releasing of the fist. Contraction of the wrist extensors is, necessary to prevent the wrist from collapsing into flexion because of the strong flexion pall ofthe extrinsic finger flexor muscles, namely, the flexor digitorum profundus and flexor digitorum superficialis (Figure 6-14). Because these two strong finger flexors cross palmar (anterior) to the wrist, they generate a strong flexion torque at the wrist while they are flexing the fingers, The wrist extensor muscles, therefore, ‘must eontract every time a grasp is made; if not, the wrist col- lapses into unwanted flexion. Combining full wrist flexion ‘with active flexion of the fingers results in a very ineffective ‘erasp—something that can be verified on yourself, Normally, the wrist extensor muscles hold the wrist in about 30 to 35 degrees of extension while one is making a grasp—a position that maintains the finger flexors at a length that is conducive to producing a strong force Extensor Carpi Ulnaris Proximal tachment: Lael econ of numerus—comman extensor ‘enon and posterior borer of he mide one thc of he ule Distal tachment: Base ofthe fth etacapal—dorsalasect Innervation: oda nerve ‘Actions ist etension © ‘Umar deiton ‘Comments: During active Wrst extension, the extensor carp nari hs he important ob of nealing the racial deviton ection of two muscles: he extensor carn adalslrgus and bres. Once netaled, the wrist can ba extended, if desired, nthe pure sagital plane, With a ruptured tendon of the earsor carp unas, fr example, ist extension is sl possible, but ony when combined with ad ‘evaton, igure 6-14. An duration showing the importance ofthe wrist fextenscr muscles ding a srong grasp. Actvaton ofthe wrist ‘extensors, such a8 the extensor capl radials bri, is necessary to rule out the st eon tordncy cautod by the activated ger axors {texae digtorum supericais ard profundus In tis mann, the wrist ‘exteneors are eble to rata the optimal length ofthe tnger fas to ‘factively ex the Engees, The ntl moment arms for the extansor carp racials brews an ingerHexors ate shown in dk bold Ines. [From Neurana Di: Kinesobay ofthe mucculsksloa system: foundations for physcalrshabitation, ed 2, St Loui, 2010, Mosby, Figure 7-25}Clinical insight What Is “Tennis Elbow"? Acthtes that require a repetitive forceful raso such as, hammering or playing tennis may overwork the wrist ‘extensors, especially the extensor carpi radials brevis. A condition known as lateral epicondylitis, or iennis elbow ‘occurs from stress and resultant inflarnmation of the proximal aitachment of the wrist extensors, Recently, the term lateral epicondaigia—the sutix-algia meaning “pain”—is used in the medica’ iterature to suggest that this painful condition may nol alvays involve infarreration} The small common insertion point of the wrist extensors concentrates alaroe foros on a small area near the bony ridge of the lateral epicondyle (Figure 6-15). The large stress created at this small point is Ikely volved in the pathology of this paintul ‘synarome, Giinicaly, this condition is often treated by controling inflammation, integrating propar stretching and strengthening regimens, and Imiting tna muscular activation ofthis group, ‘Qveruse of this group may be effectively prevented by wearing a brace that limits excessive wrist motion or a cut that wraps around the baly of the muscles involved Extensor carpi Co radials brevis Extensor dgtorum Exensor carpi ulnar Figure 6-15 image depicting itera eploondylis of thet arm, A person with paralyzed wrist extensor muscles usually 2 great deal of difficulty making a grip, even when the er flexor muscles possess normal strength, Figure 6-16 sa person with a damaged radial nerve attempting to otuce a maximum grip force on a hand-held dynamometer. auuse the wrist extensors are paralyzed, attempts at pro- Jing a grip resull in a posture of combined finger flexion ad wrist flexion. This unstable and awkward position is cmaprer @ Structure and Function of the Wrist 135 actively inefficient for the finger flexors. Until strength is retumed to the wrist extensor muscles, a wrist extension splint is usually required to brace the wrist into slight exten- sion. Once braced in extension (even applied manually, as shown in Figure 6-16, 2), the finger flexor muscles are more effective at gripping. Wrist Flexors Anatomy ‘The primary set of wrist flexors includes the flexor earpl radi- alis, fexor earpi ulnaris, and, when present and fully farmed, palmaris longus (Figure 6-17). The tendons of these muscles are ensily identiled on the anterior distal wrist (Figure 6-18), especially during strong isometric activation, ‘The secondary set of wrist flexor muscles includes the extrinsic flexors to the digits (Le, the flexor digitorum profun- dus, flexor digitorum superficialis, and flexor pollicis longus). Wrist Flexors Primary Set (Act on Wrist Only) ‘+ Flexor carpi radiais ‘+ Flexor carpi vinaris ‘+ Pamats longus ‘Secondary Set (Act on Wrist and Hand) ‘Flexor cigitorum profundus + Flexor digitorum superficial «+ Flexor poles longus Figure 6-16 A, Aporson wih paresis ofthe Hight wrist extensor mmuscies after ral natu icy 1 performing & maximal elon grip using 8 dynamometer, Despite normally nnented finger flexor muscles, maximal gp srength measires only about 10 lb. B, With the wrist stablizd n naval poston (oy the Indiouals other hand), gt strength fs nes tiled. (From Neumann DA: Kinesiology ofthe rmusoJoskelatal system: foundations for physical reabiltatio, ed 2, St Lous, 2010, Mosby, Figure 7-274Pini 186 cHAPTER 6 Structure and Function of the Wrist Anterior view Mesialepicondyl Pronator teres Palmaris longus Flexor carp radials: Floxor carpi ulnais Floxorcigiorum Superioalls Figure 6-17 Anta view of th right forearm highlighting the ruses wthin the prmany set of wrist fxr: Hexor car rade, palmar Ins, and fexor carp ural, The flexor datorum sunerfeats, a russe ofthe seconciary Set of wrist fxr, Is also shown. The pronatr teres muscle is shown but does not fix the wrist (From Neumann DA: Kinesiology ofthe musculoskeletal system: foundations for physica renaoitation, ed 2, St.Louis, 2010, Mosby, Fguro 7-28) Palmar view Figure 6-18 The psinar aspect ofthe right wat rontrg the dtl etachmonts ofthe thos important wrist flexor msl. Nate tha the tendon of he flexor carp racials courses through a sheath located within he superficial bers of the transverse carpal igament. Most of the cata fattachment ofthe pals longus fas Deen removed wh the palm” aponeuross. From Neuman DA: Kinesiology of te musculoskeletal syste: foundations or physiealrehabitation, ed 2, St Louis, 2010, Mosby, Figure 7-29.)Flexor carpi ‘asia Paimaris Tengu | Medi! rime sora Flexor Carpi Radialis Proximal Attachment Distal Attachment: Sonorvaton: Actons: ‘Comments: eda eiconyle of humerus—cormmon fexor tendon ‘Base ofthe second mtacarpl—pamar aspect Madan neve + rt lasion adalat ‘Noe thatthe tendon ofthe fro carl rads oes at reside inthe carpal tunnel. How does tis tendon, therfore, gt ta is cst atactment on ‘he pa side ofthe ue ofthe second melacaspat? As is shoom in igure 6-17, the tendon ofthis muscle courses in special grow loco win th tarsveso carpal lemon Flexor Carpi UInaris Proximal Attachment: Medial epicond of humerus—cormon fexor tendon and ster: border of the mide one ti of he una Base ofthe ith metacarpal and pisrm—palrar opect Urar nave ‘Wit leon * Una deveton CHAPTER © Structure and Function of the Wrist Flexor earph racials 137 Palmar view ‘he dstal tando of the flor carp vrs contains 2 palpable sesamod bone know asthe pista Simla othe patel in he quien muscle at the nee, the sesmold Dae atthe vst improves the leverage of he flexor carpi ulnrs during the ‘combined action of wrist fexion and ulnar devon Palmaris Longus Proximal tachment: cil pone of rutus—conmon fxr Distal Atachmont: Innervation: ‘Action Comments: tendon “Transverse carpal igarent and paar aponeuross Medion nerve ist fen ‘The palmaris longs is sal, thin muscla that can floc he ist bu is more ote cited fr is bly to tense the paimar fc of the had. tis Intersting to note tat stout 109% of te populaon es nt possess this muscle in ne or bot hands When presents tencon& generally vse inthe mide ofthe par surfae ofthe wrist as one strongly flees the wrist while also carping the pal,138 cuapren s Structure and Function of the Wrist Functional Consideration: Synergistic Actions of the Wrist Muscles ‘Strong activation of all three wrist flexors is usually required while making a power grip, such as when lifting or pulling heavy objects. In this ease, isometric activation of the wrist | flexor muscles helps stabilize the wrist, especially against strong activation of the wrist extensor muscles, The palais Tongus also helps to stabilize the proximal attachment of ‘many of the intrinsie muscles of the hand. Inaddition to flexing the wrist, the flexor carpi radislis isa adial deviator, and the flexor carpi ulnaris is an ulnar devia- tor. Simultaneous activity of both muscles is required to flex the wrist in the pure sagittal plane. Clinical insight Medial Epicondylitis Medial onicondiyiiis, often referred to as “golfers elbow,” is condition suiting from initation or infrrenation of the wrist ‘fexor muscles that originate fom the medial picondivia of the humerus. Several muscles, incuding the flexor carpi radials, fexcr carp ulnafs, exor digitorum sipericias, and Ppalmaris iongus, all coalesce into a tendinous sheath known as the common fixor tendon, which arses from the mackal ‘epicondyle of the humerus. Although many potential causes ‘of medial epicondiyis are known, itis most often considered fan overuse syndrome that typically develops from repeated activation of the wrist flexor muscles. Rock climbers are particularly susceptible to mesial epeeondytis because of the ‘requent and strong gripping forces required within the muscles needed to support one's body weight. Teatment of this disorder often ficludes controling inflammation via ret, Ice, of ultrasound, and using « counterforos brace or “elbow strap" to help reduce friction over the medial eploondyle. In the subacute phase, progressive soft tssue mobilization and strengthening aro often empioyad to help recondition tha wrist flasor muscles. Radial and Ulnar Deviators Muscles belonging to the primary set of radial deviators are ‘the extensor carpi radialis longus and the extensor carpi radi- alis brevis (see earlier discussionon wristextensors). Muscles inthe secondary set are the extensor pollicis lngus, extensor pollicis brevis, flexor carpi raclialls, abductor pollicis longus, ‘und flexor pollicisongus, Musclesin both sets radially deviate the wrist because their tendons pass radial (or lateral) to the “anterior posterior axls of rotation at the wrist. The extensor pollicis brevishas the greates! moment armofall radial devia tors; however, because of its small cross-sectional area, this imuscle's torque production is likely small, The abductor pol licis longus and the extensor pollicis brevis, in conjunction with the radial collateral ligament, provide important stabil- ity to the radial side of the wrist. ‘The two muscles within the primary set of ulnar deviators are the extensor carpi ulnatis and the flexor carpi ulnaris, Radial Deviators of the Wrist Primary Set (Act on Wrist Only) ‘Extensor carp racials longus + Extensor carpi raciats brevis Secondary Set (Act on Wrist and Hand) + Extensor policis longus + Extensor pollicis brevis «Flexor carpi raciais ‘+ Abcuctor polis longus ‘+ Flexor policis longus Ulnar Deviators of the Wrist Primary Set (Act on Wrist Only) + Extensor carpi ulnatis ‘+ Flexor carpi uinaris Functional Consideration: The Radial and Ulnar Deviators’ Functions in Grasping and Controlling ‘Objects in the Hand ‘The radial and ulnar deviator muscles are frequently used for activities that involve the grasp and control of objects held within the hand. Consider the demands placed on these ‘muscles while using a tennis racquet, casting. fishing rod, or pushing oneself in a wheelchair. Consider also hammering = nailinto apiece of wood. Figure 6-19 shows the radial deviator ‘museles contracting to prepare to strike a nail with a hammer. All the muscles shown pass lateral to the wrists anterior~ posterior axis of rotation. ‘The action of the extensor carpi radialis longus and the flexor carpi radialis (shown with ‘moment arms) illustrates fine example of wo muscles 600p~ erating as synergists for one action, and acting as agonists or “antagonists in another. By opposing each others flexion and extension actions, the two muscles stabilize the wrist in an extended position necessary to grasp the hammer Figure 6-20 shows both ulnar deviator muscles contract- Ingo strike the nail with the hammer, Both the flexor and the ‘extensor carpi ulnaris contract synergistically to perform the ulnar deviation but also stabilize the wrist in a slightly ‘extonded position, Because of the strong functional associa tion between thetlexor and the extensor carpiulnarismuscles injury to either muscle can disrupt the overall muscular action of ulnar deviation. For example, rheumatoid arthritis ‘often causes inflammation and pain in the extensor care ‘ulnaris tendon. Attempts at active ulnar deviation with minimal tono activation in this painful extensor muscleallov: the flexion action of the flexor carpi ulnaris to go uncheckes ‘The resulting flexed posture ofthe wrist is not suitable for ax effective grasp.CHAPTER 6 Structure and Function of the Wrist 138 OTECA UIS i ot ‘Figure 6-19 tustration of selected muscles performing racial ceviation ofthe writ n preparation fer rng a nal witha hemmer. Image in the [beckoround is @ minor relecion ofthe palmar surface of he wrist. The eis of rotation & through the capitate, wth intemal moment arts shown for the extensor carp rads brevis and the lor carp aca (FR) only. APL, Abductorpalicis longus; ECR. and, exensor carl radalls hngus an revs; PB, extansor polis brevis; PL sna 8, extensor polis longus and bres. Fram Neuinarn DA: Kinesiology ofthe musculoskeletal ‘system: foundations for physical ehabitaten, ed 2, St Lous, 200. Mast, Figure 7-00, Figure 6-20 tustraton o selected muscls performing uray daviaton of he wast while stg nal th a hammer mage nthe background ie 2 mirorrellection ofthe pats surace ofthe wrist, The is of cation Is through the capitate, ve intemal momert arms show for the Nexcr carp Jina’ (FCU) and the extensor carp unas ECL. (Fram Neumann OA: Kinslelogy ofthe muscucskaetal system: foundations fer ghysical ‘ehebitation, ed 2, St Lous, 2010, Mosby Fawe 7-21) Summary ‘The primary muscles ofthe wrist effetively stabilize and The wrist joint is aotully composed of two separate joints: mobilizethe wrist for avarietyof different functions; however, ‘the radiocarpal joint and the mideacpaljoint, though only2 most often these muscles are responsible for positioning the degrees of freedom are allowed atthe west, asimpleflexion/ hand, As presented in Chapter? the muscles of the wrist work fextensionorradial/alnar deviation motion requires motionat ineoncestwiththe muscles oftheband to optimize the overall both joints, function of the upper extremity.