II BOT_Wrist Biomechanics and Applied Anatomy_Punita V. Solanki_07.08.2022.pdf

Wrist Biomechanics

1. CourseSyllabus:KeralaUniversityof
HealthSciences(KUHS)BOTProgramme
2020
CourseCode:022
Year:Second(II)BOT
Subject:206:Biomechanics,Applied
AnatomyandAppliedPhysiology
Lecture:ModuleII:TheWristandHand
Complex
Punita V. Solanki
MSc (OT), Fellow ACOT (AIOTA), ADCR (Mumbai)
Principal (BOT Programme)
Mobile:[phone] (Personal)
Email: [email protected] 2022

2. Table of Contents
Punita V. Solanki
1. The Wrist Complex (Radiocarpal and Midcarpal Joints)
2. Ligaments of Wrist Complex
3. Movements at Wrist Complex
4. Muscles Crossing Wrist Complex
5. Applied Anatomy
6. Quiz Time
7. References
August 2022

3. Punita V. Solanki
Anatomy of Wrist and Hand Joints
Anatomy of Right Wrist and Hand: Dorsal/Posterior Surface
19 Bones & 19 Joints
in the Hand
(5 CMC, 5 MCP,
5 PIP & 4 DIP)
3 of 8 Carpal
Bones + Radius +
Radio-Ulnar Disc
(TFCC)
(Wrist Complex)
CMC: Carpo-Metacarpal; MCP: Meta-Carpo-Phalangeal; PIP: Proximal Inter Phalangeal;
DIP: Distal Inter Phalangeal; D: Distal; P: Proximal; L: Lateral; M: Medial; TFCC: Triangular
Fibro-Cartilage Complex
D
P
ML
August 2022

4. Punita V. Solanki
Anatomy of Wrist and Hand Joints
Anatomy of Right Wrist and Hand: Anterior/Volar/Palmar Surface
3 Arches of Hand
Carpal Tunnel
D: Distal; P: Proximal; L: Lateral; M: Medial
D
P
LM
August 2022

5. Punita V. Solanki
Wrist Complex
D
P
ML
August 2022
The wrist complex: 2 compound joints
1. Radiocarpal joint (& inferior radio-ulnar joint in function)
1,2
2. Midcarpal joints
The wrist: biaxial joint with motions of: (2°of FoM)
a. Flexion/Extension in sagittal plane & coronal/frontal axis
b. Ulnar/Radial Deviation in coronal/frontal plane & antero-posterior
axis
D: Distal; P: Proximal; L: Lateral; M: Medial; FoM: Freedom of Motion
References: 1. Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis. 5th Edi
tion. 2011. 2. Kapandji IA. The Physiology of Joints. Volume One: The Upper Limb. 6th Edition. 2007.

6. Punita V. Solanki
Wrist Complex
D: Distal; P: Proximal; L: Lateral; M: Medial; FoM: Freedom of Motion
References: 1. Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis. 5th Edi
tion. 2011. 2. Kapandji IA. The Physiology of Joints. Volume One: The Upper Limb. 6th Edition. 2007.
D
P
ML
August 2022
c. Some degree of pronation/ supination at radio-carpal joint
(some researchers claim) (3
rd
degree of FoM)
1,2
d. Circumduction (It occurs in joints with ≥2°of FoM)
A multiplanar movement (sagittal and coronal/frontal at wrist
complex)

7. Punita V. Solanki
Wrist Complex Range of Motion
ROM: Range of Motion
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume One: The Upper Limb. 6th
Edition. 2007. 3. Radomski MV, Trombly Latham CA. Occupational Therapy for Physical
Dysfunction. 7th Edition. 2014. 4. Pendleton HM, Schultz-Krohn W. Pedretti’s Occupational
Therapy: Practice Skills for Physical Dysfunction. 8th Edition. 2018. 5. Bear-Lehman J, Abreu BC.
Evaluating the Hand: Issues in Reliability and Validity. Physical Therapy 1989; 69: 1025-1033. August 2022
S. No. Movements ROM
1
End Feel
1.Flexion 0°to 65°-85°Firm
2.Extension 0°to 60°-85°Firm or Hard
3.Ulnar Deviation0°to 20°-45°Firm or Hard
4.Radial Deviation0°to 15°-21°Firm
ROM Norms (American Academy of Orthopaedic Surgeons)
3,4
Flexion/Volar or Palmar Flexion: 0°-80°
Extension/Dorsi Flexion : 0°-70°
Ulnar Deviation/Adduction: 0°-30°Radial Deviation/Abduction: 0°-20°
A 5-degree margin of error: acceptable for goniometric measurements of
joints in the hand by an experienced examiner using standardized
protocols. ~ (Bear-Lehman, Jane and Abreu, Beatriz C; 1989)
5

8. Punita V. Solanki
Wrist Complex Range of Motion
August 2022
Flexion; Extension; Radial Deviation; Ulnar Deviation & Circumduction
Including Planes and Axes of Movements
Ref. 2. Kapandji IA. The Physiology of Joints. Volume One: The Upper Limb. 6th Edition. 2007

9. Punita V. Solanki
Wrist Complex
August 2022
Gilfordandcolleaguesproposedthatthetwo-joint
(radio-carpalandmid-carpal)ratherthansingle-joint(wrist)
systemofthewristcomplex:
1.PermitslargeROMswithlessexposedarticular
surfaceandtighterjointcapsules.
2.Haslesstendencyforstructuralpinchatextremesofranges.
3.Allowsforflattermulti-jointsurfacesthataremorecapable
ofwithstandingimposedpressures.
ROMatwristcomplexisvariableduetovariablecarpal
kinematics(motion)indifferentindividuals(duetoligament
laxity,shapeofarticularsurfacesandconstrainingeffectsof
musclescrossingthewrist)
ROM: Range of Motion
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume One: The Upper Limb. 6th
Edition. 2007.

10. Punita V. Solanki
Contribution of Wrist Complex in Function
August 2022
1.Servesasplacementofthehandinspacetoonlyaminor
degree.Allowshandtoassumeoptimalpositionforprehension.
2.Controlslength-tensionrelationshipsinthemultiarticular
handmusclesandtoallowfineadjustmentofgrip.
3.Wristmusclesappeartobedesignedforbalanceandcontrol
ratherthanformaximizingtorqueproduction.
4.Themostcomplexjointofthebody,frombothananatomical
andphysiologicalperspective.
5.Thestructureandbiomechanicsofthewrist,aswellasof
thehand,varytremendouslyfrompersontoperson.
6.Subtlevariationsinwriststructurecanproducedifferences
inthewayagivenfunctionoccurs.
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume One: The Upper Limb. 6th
Edition. 2007.

11. Punita V. Solanki
Radio-Carpal Joint
August 2022
Radiocarpaljoint:acondyloid,biaxialjointformedbythe
radiusandradioulnardiscaspartofthetriangular
fibrocartilagecomplex(TFCC)proximallyandbythescaphoid,
lunate,andtriquetrumdistally.
Thedistalradiushasasingle,continuous,biconcavecurvature
thatislongandshallowfromsidetoside(inthefrontalplane)
andshorterandsharperantero-posteriorly(inthesagittal
plane).
Theproximaljointsurfaceiscomposedofthe
1.Lateralradialfacet,whicharticulateswiththescaphoid
2.Medialradialfacet,whicharticulateswiththelunateand
3.Triangularfibrocartilagecomplex,whicharticulates
predominantlywiththetriquetrum,althoughitalsohassome
contactwiththelunateintheneutralwrist.
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume One: The Upper Limb. 6th
Edition. 2007.

12. Punita V. Solanki
Radio-Carpal Joint
August 2022
Theradioulnardisc:acomponentofthetriangular
fibrocartilagecomplex,alsoservesaspartofthedistal
radioulnarjoint
Thecompoundproximalradiocarpaljointsurfaceisoblique
andangledslightlyvolarlyandulnarly.
Theaverageinclinationofthedistalradiusis23°.This
inclinationoccursbecausetheradiallength(height)is12mm
greaterontheradialsidethanontheulnarside.
Thedistalradiusisalsotilted11°volarlywiththeposterior
radiusslightlylongerthanthevolarradius.
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume One: The Upper Limb. 6th
Edition. 2007.

13. Punita V. Solanki
Radio-Carpal Joint
August 2022
Thetriangularfibrocartilagecomplex(TFCC)consistsofthe
radioulnardiscandthevariousfibrousattachmentsthat
providetheprimarysupportforthedistalradioulnarjoint.
Disc:isconnectedmediallyviatwodense,fibrousconnective
tissuelaminae.Theupperlaminaeincludethedorsalandvolar
radioulnarligaments,whichattachtotheulnarheadandulnar
styloid.Thelowerlaminahasconnectionstothesheathofthe
extensorcarpiulnaris(ECU)tendonandtothetriquetrum,
hamate,andthebaseofthefifthmetacarpalthroughfibers
fromtheulnarcollateralligament.
Meniscushomologisaregionofirregularconnectivetissue
thatlieswithinandispartofthelowerlamina,whichtraverses
volarlyandulnarlyfromthedorsalradiustoinsertonthe
triquetrum.
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume One: The Upper Limb. 6th
Edition. 2007.

14. Punita V. Solanki
Radio-Carpal Joint
August 2022
Alongitspath,themeniscushomologhasfibersthatinsertinto
theulnarstyloidandcontributetotheformationofthe
prestyloidrecess.Themedial(ulnar)connectivetissue
structuresmayexistinlieuofmoreextensivefibrocartilage
becauseconnectivetissueismorecompressiblethan
fibrocartilageandthusarelesslikelytolimitROM.
TFCC:functionsatthewristasanextensionofthedistalradius,
justasitdoesatthedistalradioulnarjoint.
ROM: Range of Motion; TFCC: triangular fibrocartilage complex; L: lunate; TQ: triquetrum
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume One: The Upper Limb. 6th
Edition. 2007.

15. Punita V. Solanki
Radio-Carpal Joint
August 2022
Thescaphoid,lunate,andtriquetrumcomposetheproximal
carpalrow.Theproximalcarpalrowarticulateswiththedistal
radius.
Thesebonesareinterconnectedbytwoligamentsthat,likethe
carpalsthemselves,arecoveredwithcartilageproximally.
Thesearethescapholunateinterosseousandthelunotriquetral
interosseousligaments.
Theproximalcarpalrowandligamentstogetherappeartobea
singlebiconvexcartilagecoveredjointsurfacethat,unlikea
rigidsegment,canchangeshapesomewhattoaccommodateto
thedemandsofspacebetweentheforearmandhand.
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume One: The Upper Limb. 6th
Edition. 2007.

16. Punita V. Solanki
Radio-Carpal Joint
August 2022
Thepisiform,anatomicallypartoftheproximalrow,doesnot
participateintheradiocarpalarticulation.
Thepisiformfunctionsentirelyasasesamoidbone,
presumablytoincreasethemomentarmoftheflexorcarpi
ulnaris(FCU)tendonthatenvelopsit.
Jointincongruenceandtheangulationoftheproximaljoint
surfaceresultinagreaterrangeofflexionthanextensionandin
greaterulnardeviationthanradialdeviationfortheradiocarpal
joint.
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume One: The Upper Limb. 6th
Edition. 2007.

17. Punita V. Solanki
Radio-Carpal Joint
August 2022
Ulnarnegativevariance(UNV):shortulnaincomparison
withtheradiusatthedistalend.Itisassociatedwiththicker
TFCC.Thisresultsinabnormalforcedistributionacrossthe
radiocarpaljointwithpotentialdegenerationattheradiocarpal
joint.Avascularnecrosisofthelunate,Kienbock’sdiseasehas
beenassociatedwithUNV.
Ulnarpositivevariance(UPV):thedistalulnaislongin
relationtothedistalradius.ItisassociatedwiththinnerTFCC.
UPVcausesimpingementofTFCCbetweendistalulnaand
triquetrum.e.g.,distalradiusfracturethathealsinshortened
position.Insuchsituation,patientscomplainofpaininend
rangeofpronationandulnardeviation.
Rx:optimizingthelengthsofulnaand/orradiussurgically.
TFCC: triangular fibrocartilage complex; Rx: Treatment
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume One: The Upper Limb. 6th
Edition. 2007. A: Negative Variance; B: Positive Variance

18. Punita V. Solanki
Radio-Carpal Joint
August 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume One: The Upper Limb. 6th
Edition. 2007. A: Negative Variance; B: Positive Variance
A: Ulnar Negative Variance; B: Ulnar Positive Variance

19. Punita V. Solanki
Radio-Carpal Joint
August 2022
Whenanaxial(longitudinalcompressive)loadisappliedtothe
wrist,thescaphoidandlunatereceiveapproximately80%of
theload,whereastheTFCCreceivesapproximately20%.
TFCCstabilizesradius/ulnaduringpronation-supination
motionandgrasping.TFCCcushionscarpalbones.
Atthedistalradius,60%ofthecontactismadewiththe
scaphoidand40%withthelunate.
TFCC: triangular fibrocartilage complex
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume One: The Upper Limb. 6th
Edition. 2007.

20. Punita V. Solanki
Mid-Carpal Joint
August 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume One: The Upper Limb. 6th
Edition. 2007.
Midcarpaljoint:articulationbetweenscaphoid,lunate,and
triquetrumproximallyandthedistalcarpalrowcomposedofthe
trapezium,trapezoid,capitate,andhamate.
Itisanatomicallyseparatefromtheradiocarpaljointandhasa
fibrouscapsuleandsynovialliningthatiscontinuouswitheach
intercarpalarticulationandmaybecontinuouswithsomeofthe
carpometacarpal(CMC)joints.
Functionally,thecarpalsofthedistalrow(withtheirattached
metacarpals)moveasanalmostfixedunit.
Theunionofthedistalcarpalsalsoresultsinnearlyequaldistribution
ofloadsacrossthescaphoid-trapezium-trapezoid,thescaphoid-
capitate,thelunate-capitate,andthetriquetrum-hamatearticulations.

21. Punita V. Solanki
Mid-Carpal Joint
August 2022
FoM: Freedom of Motion
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume One: The Upper Limb. 6th
Edition. 2007.
Distalcarpalrowcontribute2°FoMtothewristcomplex,with
varyingamountsofradial/ulnardeviationandflexion/extension
creditedtothejoint.
Midcarpaljointfavorsrangeofextensionandradialdeviation.
Thefunctionalunionofthedistalcarpalswitheachotherandwith
theircontiguousmetacarpalsalsoserveasthefoundationforthe
transverseandlongitudinalarchesofthehandinadditiontoits
contributiontowristcomplexfunctions.

22. Punita V. Solanki
Radio-Carpal Joint Capsule and Ligaments
August 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume One: The Upper Limb. 6th
Edition. 2007.
Radio-carpaljointcapsule:Theradiocarpaljointisenclosedbya
strongbutsomewhatloosecapsuleandisreinforcedbycapsularand
intracapsularligaments.
Ligaments:thedorsalwristligamentsaredescribedasthin,whereas
themorenumerousvolarligamentsarethickerandstronger.The
ligamentsaregroupedasextrinsicandintrinsic.
Extrinsicligaments:arethosethatconnectthecarpalstothe
radiusorulnaproximallyortothemetacarpalsdistally.Extrinsic
ligamentsrelyoncontiguousvascularizedtissuesfornutrition.More
likelytofailasitacceptstheforcesfirst,buthavebetterpotentialfor
Healing.
Intrinsicligaments:arethosethatinterconnectthecarpals
themselvesandarealsoknownasintercarpalorinterosseous
ligaments.Arestrongerandlessstiffthanextrinsicligaments.Are
withinsynovialliningandrelyonsynovialfluidfornutrition.

23. Punita V. Solanki
Radio-Carpal & Mid-Carpal Joint Ligaments
August 2022
TFCC: triangular fibrocartilage complex
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume One: The Upper Limb. 6th
Edition. 2007.

24. Punita V. Solanki
Radio-Carpal & Mid-Carpal Joint Ligaments
August 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis. 5th Edi
tion. 2011. 2. Kapandji IA. The Physiology of Joints. Volume One: The Upper Limb. 6th
Edition. 2007.
Extrinsic Ligaments
1,2
Anterior/Volar Carpal Ligaments
I. Volar Radio-carpal ligaments
1. Radial collateral (A and P bands)*
2. Anterior/Volar
a. Superficial
b. Deep
i.Radioscaphocapitate
ii.Radiolunate & radiotriquetral
iii.Radioscaphoid-lunate
II. Volar Ulno-carpal ligaments
1. Ulnar collateral (A and P bands)*
2. Triangular fibrocartilage complex
3. Meniscus homolog
4. Ulnolunate
Posterior/Dorsal Carpal Ligaments
Dorsal Radio-carpal ligaments
(Radiolunate & radiotriquetral)
Intrinsic (Mid-Carpal)
Ligaments
1
1. Short
a.Volar
b.Dorsal
c.Interosseous
2. Intermediate
a.Lunotriquetral
b.Scapholunate
c.Scaphotrapezium
3. Long
a.Volar intercarpal (v-ligament,
deltoid)
b. Dorsal intercarpal
*Radial collateral: A: Anterior band and
P: Posterior band
*Ulnar collateral: A: Anterior Stylo-
Pisiform band and P: Posterior Stylo-
Triquetral band

25. Punita V. Solanki
Mid-Carpal Joint Ligaments
August 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis. 5th Edi
tion. 2011. 2. Kapandji IA. The Physiology of Joints. Volume One: The Upper Limb. 6th
Edition. 2007.
Intrinsic (Mid-Carpal) Ligaments
2
Volar/Anterior
1. Radio-capitate ligament
2. Lunato-capitate ligament
3. Triquetro-capitate ligament
4. Scapho-trapezial ligament
5. Triquetro-hamate ligament
6. Piso-hamate and Piso-metacarpal ligaments
Dorsal/Posterior
1.Triquetro-hamateligament
2.Scapho-trapezoidligament
3.Transverseposteriorproximalband(posterioraspectofthetriquetrum
tothatofthescaphoidasitrelaysthroughtheposteriorhornofthelunate
andsendsfiberstotheradialcollateralligamentandtheposterior
radiotriquetralligament).
4.Transverseposteriordistalband(stretchingobliquely,laterallyand
slightlydistallyfromtheposterioraspectofthetriquetrumtothatofthe
trapezoidandtothatofthetrapeziumalongtheposteriorsurfaceofthe
capitate).

26. Punita V. Solanki
Radio-Carpal & Mid-Carpal Joint Ligaments
August 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume One: The Upper Limb. 6th
Edition. 2007.
1.Volarwristligaments:stretched/tautwithwristextension.
2.Radioscapholunateligament:actsasaconduitfor
neurovascularitytothescapholunatejoint.
3.Scapholunateinterosseousligament:keyfactorinmaintaining
scaphoidandtherebywriststability.Asitislargelyavascular,hence
maybesusceptibletodegenerativechange.
4.Lunotriquetralinterosseousligament:keyfactorinmaintaining
stabilitybetweenthelunateandtriquetrum.
5.Dorsalwristligaments:taut/stretchedwithwristflexion.Thetwo
dorsalligamentstogetherformahorizontalVthatcontributestoradio
carpalstability,notablystabilizingthescaphoidduringwristROM.
6.Medial(ulnar)collateralligament:stretchedwithradialdeviation
/abduction.
7.Lateral(radial)collateralligament:stretchedwithulnar
deviation/adduction.

27. Punita V. Solanki
Movements of Radio-Carpal & Mid-Carpal Joints
August 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume One: The Upper Limb. 6th
Edition. 2007.
MovementsofRadiocarpalandMidcarpaljointsarecausedby:
1.Activemuscularforces
2.Passiveligamentousforces
3.Jointreactionforces
Theproximalcarpalrowfunctionsasanintercalatedsegment
betweenthedistalradius/triangularfibrocartilagecomplexandthe
relativelyimmobiledistalrow.
Whencompressiveforcesareappliedacrossanintercalatedsegment,
themiddlesegmenttendstocollapseandmoveintheopposite
directionfromthesegmentsabove(radius)andbelow(distalcarpal
row).
Theheadofthecapitate,frequentlyreferredtoasthe“keystone”of
thewrist,mayserveasthelocationofthecoronalaxisforwrist
extension/flexionandtheA-Paxisforradial/ulnardeviationaswellas
providingtherigidcenterofthefixedcarpalarch.

28. Punita V. Solanki
Movements of Radio-Carpal & Mid-Carpal Joints
August 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume One: The Upper Limb. 6th
Edition. 2007.
Flexion -Extension of the Wrist Complex
Sequence of events proposed by Conwell are:
1.Withwristinfullflexion,activeextensionisinitiatedatthedistalcarpal
rowandmetacarpalsbywristextensors.Thedistalcarpals(capitate,
hamate,trapezium,andtrapezoid)glideontherelativelyfixedproximal
bones(scaphoid,lunate,andtriquetrum),inthesamedirectionasthe
motionofthehand.Whenthewristcomplexreachesneutral(thelongaxis
ofthethirdmetacarpalinlinewiththelongaxisoftheforearm),the
ligamentsspanningthecapitateandscaphoiddrawthecapitateand
scaphoidtogetherintoaclose-packedposition.
2.Continuedextensorforcemovesthecombinedunitofthedistalcarpal
rowandthescaphoidontherelativelyfixedlunateandtriquetrum.At
approximately45°ofextensionofthewristcomplex,thescapholunate
interosseousligamentbringsthescaphoidandlunateintoclose-packed
position.Allthecarpalsuniteandcausesthemtofunctionasasingleunit.
3.Wristextensioncompletes:asproximalcarpalsmoveonradiusand
TFCC.Allligamentsbecometautonfullextensionandthewristcomplexis
inclosed-packedposition.Reversesequenceoccursforextension-flexion.

29. Punita V. Solanki
Movements of Radio-Carpal & Mid-Carpal Joints
August 2022
TFCC: Triangular Fibro Cartilage Complex
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume One: The Upper Limb. 6th
Edition. 2007.
Flexion -Extension of the Wrist Complex
Sequence of events proposed by Conwell:
A. As wrist extension is
initiated from full flexion,
(1)the distal carpal row
moves on the proximal
carpal row;
(2) the scaphoid and distal
row move on the lunate/
triquetrum; and
(3) the carpals move as a
unit on the radius and
TFCC to achieve full wrist
extension (B). C,
capitate; L, lunate; S,
scaphoid.

30. Punita V. Solanki
Movements of Radio-Carpal & Mid-Carpal Joints
August 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume One: The Upper Limb. 6th
Edition. 2007.
Radial-Ulnar Deviation of the Wrist Complex
1.Inradialdeviation,thecarpalsslideulnarlyontheradius.Thecarpal
motionnotonlyproducesreciprocaldeviationoftheproximalanddistal
carpalswithradialdeviation,butsimultaneousflexionoftheproximal
carpalsandextensionofthedistalcarpals.(withobservationsof
accompanyingpronation/supinationcomponents)
2.Theoppositemotionsoftheproximalanddistalcarpalsoccurwithulnar
deviation
3.Ligamentouslaxityleadstolessbindingofthescaphoidtothedistal
carpalrowand,therefore,moreout-of-planemotionforthescaphoid.
4.Infullradialdeviation,boththeradiocarpalandmidcarpaljointsarein
close-packedposition.
5.Therangesofwristcomplexradialandulnardeviationaregreatest
whenthewristisinneutralflexion/extension.
6.Infullwristextension(closed-packedposition)andfullwristflexion
(loose-packedposition)verylittleradialandulnardeviationarepossible.

31. Punita V. Solanki
Movements of Radio-Carpal & Mid-Carpal Joints
August 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume One: The Upper Limb. 6th
Edition. 2007.
Radial-Ulnar Deviation of the Wrist Complex
With radial
deviation of the
wrist
(A) the flexion of
the scaphoid makes
the scaphoid
appear shorter
than when the
scaphoid extends
during ulnar
deviation
(B) C, capitate;
L, lunate;
S, scaphoid.

32. Punita V. Solanki
Functional Position of Wrist Complex
August 2022
ADL: Activities of Daily Living
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume One: The Upper Limb. 6th
Edition. 2007.
Functional Position of Wrist Complex
2
The position of the wrist when the hand is best adapted for its
function of prehension is:
1. Slight extension/dorsi flexion of wrist to 40°-45°
2. Slight ulnar deviation/adduction of wrist to 15°
•Most of the ADL are accomplished between the wrist positions of 10°
Flexion to 35°Extension.
•Greatest arc of motion up to 63°Extension is employed during
rising from a chair whilst weight bearing over the hand.

33. Punita V. Solanki
Functional ROM of Wrist Complex
August 2022
ROM: Range of Motion
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume One: The Upper Limb. 6th
Edition. 2007.
Functional Range of Motion of Wrist Complex
1
1. A series of hand activities necessary for independence requires a
functional wrist motion of 10°flexion/volar or palmar flexion and
35°of extension/dorsi flexion
2. Wrist extension and ulnar deviation are most important for
wrist activities and provide a stable base that allows for maximum
hand function distally.
3. When deciding on the position of splinting and fusion for the wrist,
the surgeon commonly chooses an optimal functional position of
approximately 20°of extension and neutral or 5°-10°of ulnar
deviation. In this position, the long digital flexors can generate
maximal force in prehension activities.

34. Punita V. Solanki
Muscles of the Wrist Complex
August 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume One: The Upper Limb. 6th
Edition. 2007.
1.Primaryroleofthemusclesofthewristcomplexistoprovidea
stablebaseforthehandwhilepermittingpositionaladjustmentsthat
allowforanoptimallength-tensionrelationshipinthelongfinger
muscles.
2.Arangeof20°to25°ofwristextensionwith5°to7°ofulnar
deviationistheoptimalrangetomaximizegripstrengthoutput.
3.Theworkcapacity(abilityofamuscletogenerateforceperunitof
cross-section)ofthewristflexorsismorethantwicethatofthe
extensors.

35. Punita V. Solanki
Muscles of the Wrist Complex
August 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume One: The Upper Limb. 6th
Edition. 2007.
Anterior/Volar Wrist Muscles
Six muscles cross the volar aspect of the wrist
Prime Movers
1. Palmaris longus (PL) (Flexor)
2. Flexor carpi radialis (FCR) (Flexor and radial deviator)
3. Flexor carpi ulnaris (FCU) (Flexor and ulnar deviator)
Secondary Movers
4. Flexor digitorum superficialis (FDS)
5. Flexor digitorum profundus (FDP)
6. Flexor pollicis longus (FPL)
Figure A. The tendons and nerves of the
primary and secondary wrist flexors lie
on the volar aspect of the wrist. All, except
the palmaris longus tendon, the ulnar
nerve, and the flexor carpi ulnaris muscle
pass beneath the flexor retinaculum.

36. Punita V. Solanki
Muscles of the Wrist Complex
August 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume One: The Upper Limb. 6th
Edition. 2007.
Anterior/Volar Wrist Muscles
Atthewrist:allofthevolarwristmusclespassbeneaththeflexor
retinaculumalongwiththemediannerveexceptthepalmarislongus
(PL)andtheflexorcarpiulnaris(FCU)muscles.
Flexorretinaculumpreventsbowstringingofthelongflexortendons,
therebycontributingtomaintaininganappropriatelength-tension
relationship.
Flexor retinaculum has a proximal portion and a distal portion,
with the distal portion more commonly known as the transverse
carpal ligament (TCL).
The palmaris longus muscle and tendon are absent unilaterally or
bilaterally in approximately 14% of people without any apparent
strength or functional deficit. Given its apparent redundancy
with other muscles, the palmaris longus tendon (when present) may
be “sacrificed” for surgical reconstruction of other structures.

37. Punita V. Solanki
Muscles of the Wrist Complex
August 2022
FDS: Flexor Digitorum Superficialis; FDP: Flexor Digitorum Profundus; FPL: Flexor Pollicis
Longus
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume One: The Upper Limb. 6th
Edition. 2007.
Anterior/Volar Wrist Muscles
1.Flexorcarpiulnarismuscleismoreeffectiveinitsulnardeviation
functionthanistheflexorcarpiradialismuscleisinitsradialdeviation
function.
2.Theflexorcarpiulnarismuscleisabletoexertthegreatesttension
ofallthewristmuscles,givingitparticularfunctionalrelevance,
especiallywithactivitiesrequiringhighulnardeviationforcessuchas
choppingwood.
3.FDSandFDPmusclesarepredominantlyflexorsofthefingers,
andtheFPLmuscleispredominantlytheflexorofthethumb.
Asmulti-jointmuscles,theircapacitytoproduceaneffectivewrist
flexionforcedependsonsynergisticstabilizationbytheextensor
musclesofthemoredistaljointsthatthesemusclescrosstoprevent
excessiveshorteningofthemusclesovermultiplejoints(Active
Insufficiency)

38. Punita V. Solanki
Muscles of the Wrist Complex
August 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume One: The Upper Limb. 6th
Edition. 2007.
Posterior/Dorsal Wrist Muscles
Nine muscles cross the dorsal aspect of the wrist
Prime Movers
1.Extensorcarpiradialislongus(ECRL)(ExtensorandRadialDeviator)
2.Extensorcarpiradialisbrevis(ECRB)(ExtensorandRadialDeviator)
3.Extensorcarpiulnaris(ECU)(ExtensorandUlnarDeviator)
SecondaryMovers
1.Extensordigitorumcommunis(EDC)
2.Extensorindicisproprius(EIP)
3.Extensordigitiminimi(EDM)
4.Extensorpollicislongus(EPL)
5.Extensorpollicisbrevis(EPB)
6.Abductorpollicislongus(APL)

39. Punita V. Solanki
Muscles of the Wrist Complex
August 2022
ECRL: Extensor Carpi Radialis Longus; ECRB: Extensor Carpi Radialis Brevis
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume One: The Upper Limb. 6th
Edition. 2007.
Posterior/Dorsal Wrist Muscles
1. The tendons of all nine muscles pass under the extensor retinaculum,
which is divided into six distinct tunnels by septa. As the tendons
pass deep to the retinaculum, each tendon is encased within its own
tendon sheath to prevent friction between the tendons and the
retinaculum.
2. The septa of the retinaculum through which the tendons pass are
attached to the dorsal carpal ligaments and help maintain stability of
the extensor tendons on the dorsum, as well as allowing those muscles
to contribute to wrist extension and preventing bowstringing
of the tendons with active contraction.
3. ECRL and ECRB muscles together make up the predominant part of
the wrist extensor mass. ECRB shows more activity during extension.

40. Punita V. Solanki
Muscles of the Wrist Complex
August 2022
ECRL: Extensor Carpi Radialis Longus; ECRB: Extensor Carpi Radialis Brevis; ECU: Extensor
Carpi Ulnaris
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume One: The Upper Limb. 6th
Edition. 2007.
Posterior/Dorsal Wrist Muscles
4. ECRB muscle is active during all grasp-and-release hand
activities, except those performed in supination.
5. ECRL muscle inserts into the more radial second metacarpal and,
therefore, has a smaller moment arm for wrist extension than does the
ECRB muscle.
6. ECRL muscle shows increased activity when either radial deviation
or support against ulnar deviation is required or when forceful finger
flexion motions are performed.
7. The ongoing activity of the ECRB muscle makes it vulnerable to
overuse and is more likely than the quieter ECRL muscle to be
Inflamed in lateral epicondylitis.

41. Punita V. Solanki
Muscles of the Wrist Complex
August 2022
ECRL: Extensor Carpi Radialis Longus; ECRB: Extensor Carpi Radialis Brevis; ECU: Extensor
Carpi Ulnaris; EIP: Extensor Indicis Proprius; EDM: Extensor Digiti Minimi; EDC: Extensor
Digitorum Communis; EPL: Extensor Pollicis Longus; APL: Abductor Pollicis Longus;
EPB: Extensor Pollicis Brevis
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume One: The Upper Limb. 6th
Edition. 2007.
Posterior/Dorsal Wrist Muscles
8. When the forearm is pronated it causes a reduction in the moment
arm of the ECU muscle, making it less effective as a wrist extensor.
9. EIP and EDM muscles are capable of extending the wrist, but
wrist extension is credited more to the EDC muscle.
10. EDC muscle is a finger extensor muscle but functions also as a
wrist extensor. (without radial or ulnar deviation)
11. When EDC muscle is active at wrist, the ECRB activity is seen to be
less.
12. Three extrinsic thumb muscles (EPL, APL & EPB) cross the wrist
and serve a minor role in wrist extension and radial deviation.

42. Punita V. Solanki
Muscles of the Wrist Complex
August 2022
ECRL: Extensor Carpi Radialis Longus; ECRB: Extensor Carpi Radialis Brevis; ECU: Extensor
Carpi Ulnaris; EIP: Extensor Indicis Proprius; EDM: Extensor Digiti Minimi; EDC: Extensor
Digitorum Communis; EPL: Extensor Pollicis Longus; APL: Abductor Pollicis Longus;
EPB: Extensor Pollicis Brevis
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume One: The Upper Limb. 6th
Edition. 2007.
Posterior/Dorsal Wrist Muscles
PassiveInsufficiency
Passiveinsufficiency.A.Thefingerextensorsbecomepassively
insufficientastheyarelengthenedoverthewristandfingersduring
wristflexion.Thepassivetensionthatisdevelopedcausesextensionof
thefingers(tenodesis).B.Thefingerflexorsbecomepassively
Insufficientastheyarelengthenedoverthewristandfingersduring
wristextension.Thepassivetensiondevelopedinthefingerflexors
causesthefingerstoflex.

43. Punita V. Solanki
Wrist Complex Instability
August 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume One: The Upper Limb. 6th
Edition. 2007.
IntercalatedSegmentalInstability
Injurytooneormoreoftheligamentsattachedtothescaphoidand
lunatemaydiminishorremovethesynergisticstabilizationofthe
lunateandscaphoid.Thezigzagpatternofmovementofthethree
segments(thescaphoid,thelunate/triquetrum,andthedistalcarpal
row)followingligamentinjuryisknownasintercalatedsegmental
instability.
DorsalIntercalatedSegmentalInstability
Whenthelunateassumesanextendedposture,thepresentation
isreferredtoasdorsalintercalatedsegmentalinstability(DISI)
ScapholunateAdvancedCollapse(SLACwrist)
Theprogressivedegenerativeproblemfromanuntreateddorsal
Intercalatedsegmentalinstability

44. Punita V. Solanki
Wrist Complex Instability
August 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume One: The Upper Limb. 6th
Edition. 2007.
VolarIntercalatedSegmentalInstability(VISI)
Itistheulnarperilunateinstabilitythatoccurswhenthelunateisno
longerlinkedwiththetriquetrum,thelunateandscaphoidtogether
fallintoflexion,andthetriquetrumanddistalcarpalrowextend.
ClinicalImplication
Theproblemsofvolarintercalatedsegmentalinstabilityanddorsal
intercalatedsegmentalinstabilityillustratetheimportanceofproximal
carpalrowstabilizationtowristfunctionandofmaintenanceofthe
scaphoidasthebridgebetweenthedistalcarpalrowandthe
twootherbonesoftheproximalcarpalrow.

45. Punita V. Solanki
Wrist Complex Trauma
August 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume One: The Upper Limb. 6th
Edition. 2007.
Thewrististhejointmostlikelytobetraumatized
e.g.,fallingontheoutstretchedhand(FOOSH)whenitisabductedand
extended.Forcedabductionischeckedbytwofactors:
1.theresistanceoftheligamentsattachedtothetriquetrum
2.theradialstyloidprocess.
Dependingonthepositionofthescaphoidrelativetotheproximal
articularsurfaceofthewristjoint,eitherthedistalepiphysisofthe
radiusisfracturedwithdetachmentofasegment,orthescaphoidis
fracturedinitsmid-portionasithitstheradialstyloidprocess.

46. Punita V. Solanki
HomeWork (Peer Group Teaching)
August 2022
1.Nervesupplytothewristcomplex
2.Bloodsupplytothewristandbonesofthewristcomplex
3.Listallactivitiesofdailyliving(ADL)requiringfunctionalpositionof
thewrist

47. Quiz Time
Punita V. Solanki
Say True or False
❑Circumductionispossibleonlyinthosejointswiththreedegreesof
freedomofmotion.
Answer:False
❑Therearetwodegreesoffreedomofmotionatwristcomplex
Answer:True
❑Thereare3planesand3axesofjointmotion
Answer:True
❑Aspecialfingergoniometerhasdial’scalibrationfrom0°to120°
Answer:True
❑Innormaljointmotions,therearethreetypesofend-feels:soft,firm
&hard
Answer:True
August 2022

48. Quiz Time
Punita V. Solanki
Say True or False
❑Flexion,ExtensionandHyper-Extensionoccursinsagittalplane
throughmedio-lateralaxis
Answer:True
❑AbductionandAdductionoccursinfrontalplanethroughantero-
posterioraxis
Answer:True
❑Rotationoccursintransverseplanethroughlongitudinalaxis
Answer:True
❑Rangeofmotionassessmentbygoniometerorrulerisanobjective
methodofassessment
Answer:True
❑Emptyend-feel&boggyend-feelarecomeacrossedonlyinpatients
Answer:True
August 2022

49. Quiz Time
Punita V. Solanki
SelecttheBest Option (Multiple Choice Question)
1. Circumduction is characteristic of all of the following
joints except
a. Wrist
b. Shoulder
c. Metacarpophalangeal
d. Interphalangeal
Answer Key: d
2. A series of hand activities necessary for independence
requires a functional wrist motion of
a. 10º Flexion and 35º Extension
b. 20º Flexion and 20º Extension
c. 10º Flexion and 20º Extension
d. 20º Flexion and 35º Extension
Answer Key:a
August 2022

50. Quiz Time
Punita V. Solanki
Select the Best Option (Multiple Choice Question)
3. When the finger flexors are paralyzed wrist extension causes
finger flexion as the flexors are shorter than the extensors. This
is known as
a. Accessory Insertion
b. Tendon Action/Tenodesis Effect
c. Direct Substitution of Favorably Placed Muscles
d. Rebound Phenomenon
Answer Key: b
4. In ulnarnegativevariance
a. Ulna is shorterthanradius
b. Radius is shorter than ulna
c.Bothulnaandradius are equal in length
d.Noneoftheabove
Answer Key: a
August 2022

51. Quiz Time
Punita V. Solanki
Select the Best Option (Multiple Choice Question)
5. When an axial (longitudinal compressive) load is applied to
the wrist, TFCC
a.Receives approximately 20% of the load
b.Stabilizes radius/ulna during pronation-supination motion
and grasping
c.Cushions carpal bones
d.AlloftheAbove.
AnswerKey:d
6. Medial (ulnar) collateral ligament is stretched with wrist
a. Radial deviation/abduction
b. Ulnar deviation/adduction
c.Flexion/volarorpalmarflexion
d. Extension/dorsi flexion
AnswerKey: a
August 2022

52. Quiz Time
Punita V. Solanki
Select the Best Option (Multiple Choice Question)
7. The keystone of the wrist is the head of
a. Scaphoid
b. Lunate
c. Capitate
d. Hamate
Answer Key: c
8. Following movements are most important for wrist activities
and provide a stable base that allows for maximum hand
function distally:
a. Wrist extension and radial deviation
b. Wrist extension and ulnar deviation
c. Wrist flexion and radial deviation
d. Wrist flexion and ulnar deviation
Answer Key: b
August 2022

53. Recommended Reading & References
Punita V. Solanki
1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive
Analysis. 5
th
Edition. 2011. [Section 3. Upper Extremity Joint Complexes.
Chapter 9. The Wrist and Hand Complex. Pages: 305-353.]
2. Kapandji IA. The Physiology of Joints. Volume One: The Upper Limb. 6
th
Edition. 2007. [Chapter 4. The Wrist. Pages: 146-196.]
3. Radomski MV, Trombly Latham CA. Occupational Therapy for Physical
Dysfunction. 7
th
Edition. 2014. Lippincott Williams & Wilkins, a Wolters
Kluwer Business. [Section II. Chapter 7: Assessing Abilities and Capacities:
Range of Motion, Strength, and Endurance. Pages: 144-241.]
4. Pendleton HM, Schultz-KrohnW. Pedretti’s Occupational Therapy:
Practice Skills for Physical Dysfunction. 8
th
Edition. 2018. Elsevier.
[Part IV: Chapter 21. Joint Range of Motion. & Chapter 22. Evaluation of
Muscle Strength.]
5. Bear-Lehman J, Abreu BC. Evaluating the Hand: Issues in Reliability
and Validity. Physical Therapy 1989; 69: 1025-1033. PMID: 2685841
DOI: 10.1093/ptj/69.12.1025
August 2022

54. August 2022