The Wrist Complex

Vanita A Pathare
PG-1

Objectives
To understand the anatomy of wrist joint.
To understand the kinetics and kinematics of wrist joint
To understand the pathomechanics of wrist joint

Function
Symbol of power
It control the length tension relationship in multiarticular hand
muscle to allow fine adjustment of grip.

Wrist complex
The wrist (carpus) consists of two compound joints1) Radiocarpal joint
2) Midcarpal joint

 Wrist complex- Biaxial

Extension/ flexion- frontal axis , saggital plane
Ulnar deviation/radial deviation- anteroposterior axis , frontal
plane.
Some degree of pronation/ supination at radiocarpal joint.

 Gilford & colleagues proposed that the two joint, rather then
single joint, system of wrist complex
Premittes larger ROM with less exposed articular surface &
tighter joint capsule.
Less tendency for structural pinch
Allows for flatter multijoint surfaces

Radiocarpal joint
1. Radiocarpal joint
.Proximally-Radius and Radioulnar disk as part of triangular
fibrocartilage complex (TFCC)
.Distally- scaphoid, lunate, and triquetrum.

 Proximal joint1. The lateral radial facet ------- scaphoid

2. The medial radial facet ------- lunate; &
3. The Radio ulnar disc (TFCC) ------ triquetrum & lunate
.

Pisiform bone------ increases the moment arm of FCU do no

participate in articulation

 Radio carpal joint surface- oblique, angled slightly volarly and

ulnarly.
Angle of inclination of distal radius 23 degree (frontal plane)
Inclination occurs because the radius length (height) is 12 mm
greater on radial side than on the ulnar side.
Distal radius-tilted 11 degree volarly with posterior radius
slightly longer than volar radius ----incongruency-----F>E,
UD>RD.

 TFCC -> triangular fibrocartilagenous complex

It includes articular disc with its fibrous attachment which
provide support to distal radio ulnar joint.
The disc is connected medially via. Two dense fibrous
connective tissue.
Upper lamina- dorsal and volar radioulnar ligaments-ulnar head
and ulnar styloid.
Lower lamina- sheath of extensor carpi ulnaris(ECU) tendon and
the triquetrum, hamate, and base of 5th metacarpal through fibers
from ulnar collateral ligament.

 Originates from firm attachments on medial border of distal radius

& inserts into base of ulna styloid.
It separates the radiocarpal from the distal radioulnar joint.
Thickness---roughly 5mm at ulnar side & 2mm thick at radial side.
Vascular anatomy- only the peripheral 15-20% of TFCC has a blood
supply.
The TFCC stabilizes the bones in wrist, acts as shock absorption &
enables smooth movements.

 Meniscus homolog is region of irregular connective tissue that

lies within and is part of lower lamina.
Along its path meniscus homolog has fibres that insert into ulnar
styloid and contribute to the formation of prestyloid recess.

 Scaphoid, lunate, and triquetrum- proximal carpal row.

Articulates-distal radius.
Interconnected- 2 ligaments1. Scapholunate interosseous ligament
2. Lunotriquetral interosseous ligament
. The curvature of the distal radicarpal joint surface is sharper than
proximal joint surface- sagittal and coronal planes- incongruent.
. Contact between proximal and distal radiocarpal surface- 20%
. The radio carpal joint is incongurent. So joint incongurence and
angulation of proximal joint surface result in F>E, UD> RD

 Length of ulna in relation to radius

Ulnar negative variance- short ulna then radius at their distal end
Ulnar positive variance- distal ulna is long then distal radius
With ulnar +ve variance----impingement of TFCC b/w ulna & tq
Long ulna may be present with distal radius fracture.
Short ulna result in abnormal distribution of force---AVN of lunate
(kienbocks)

In axial loading:
80% load---(Scaphoid 60% & lunate 40%)
20% TFCC

Midcarpal joint structure

Proximally- scaphoid, lunate and triquetrum
Distally- trapezium, trapezoid, capitate and hamate
The midcarpal joint surfaces are complex, with reciprocally
concave-convex configuration.

 Carpals of distal row- moves in fixed unit

Capitate and hamate- strongly bound together-small amount of
play among them.
Distal carpal row- 2 degree of freedom-radial/ ulnar deviation
and flexion/extension.
Articular surfaces of midcarpal joint- range of extension over
flexion & radial deviation over ulnar deviation.

Capsule and ligaments

Enclosed by- strong but somewhat loose capsule &

reinforced by capsular and intracapsular ligament

Most ligaments that cross the radiocarpal joint also

contribute to stability at midcarpal joint.

Similarly, muscles of the radiocarpal joint also function at

the midcarpal joint.

The FCU is the only muscle that crosses he radiocarpal

joint- bones of proximal carpal row.

Ligaments
Function
1. Articular stability
2. To guide and check motion between and among the carpals.

Ligaments
Extrensic

 Ligaments
Volar ligaments
Dorsal ligaments

 Volar carpal ligaments and dorsal carpal ligaments.

Volar carpal ligament-> volar extrinsic and volar intrinsic
ligament.
Volar extrinsic-> radiocarpal and ulnocarpal ligament.
Volar radiocarpal- 3 bands-> radioscaphocapitate (radiocapitate),
radiolunate ( radiolunotriquetral) & radioscapholunate ligaments.
Radial collateral ligament- extension of volar radiocarpal ligament
and capsule

 Ulnocarpal ligament complex- TFCC, ulnolunate ligament & ulnar

collateral ligament.
Volar intrinsic ligament1. Scapholunate interosseous ligament- scaphoid stability- stability
of much of wrist
2. Lunotriquetral interosseous ligament- stability between lunate
and triquetrum.

 Dorsal carpal ligaments

1. Dorsal radiocarpal ligament- converges on triquetrum from distal
radius- attaches to lunate and lunotriquetral interosseous ligament.
2. Dorsal intercarpal ligament-horizontally from triquetrum to lunate,
scaphoid and trapezium.
.

Both together form a horizontal V -> radiocarpal stability->

scaphoid stabilization during wrist ROM.

Muscles of wrist complex

Volar wrist musculature
6 muscles have tendon crossing volar ascept of wrist-wrist
flexion
1. Palmaris longus (PL)
2. Flexor carpi radialis (FCR)
3. Flexor carpi ulnaris (FCU)
4. Flexor digitorium superficialis (FDs)
5. Flexor digitorum profundus (FDP)
6. Flexor policis longus (FDP)
. First 3 primary wrist muscle & last 3 flexors of digitssecondary action of wrist.

Function of Wrist Complex:

Movements
1.Motion are unique combination of
Active muscular
Passive ligamentous
Joint reaction forces
2. No muscular force are applied directly on articular bones of
proximal row, only the FCU muscle applies its force via
pisiform to the move distal bone.

Functions

1.

Movements of the radiocarpal and midcarpal joint.

Flexion/ Extension

o. Scaphoid- greater motion, lunate- least

o. Primary movement at proximal c. row following seq. occur
As wrist extension is initiated from full wrist flexion.
o. 1.The distal carpal row( tr, tz, c, h) with its MCP glide over fixed proximal
carpal row(s, l,t) during active extension in same direction as the motion of hand.
o. When wrist complex reaches to neutral i.e long axis of 3 MCP in line with long
axis of forearm, the ligament spanning the capitate and scaphoid draw both
together into closed pack position.

2.Continued ext. force now move combined unit of dist. C row &
scaphoid on lunate & triquetrum
At 45 degree of extensionthe scapholunate interosseous lig. Bring
scaphoid & lunate into closed packed position this unite all
carpals and move as a fixed unit
3. the carpal moves as the unit on distal radius & TFCC at full ext--all lig taut in close pack position
4.wrist motion from full wrist extension occur in reverse sequence.

Radial n ulnar deviation

Complex movement
The proximal carpal row display unique reciprocal motion with
RD/UD
In RD carpal slide ulnarly on radius
The carpal motion not only produce deviation of proximal and
distal carpal radially, but simultaneously flexion of proximal
carpal & extension of distal carpal.
The opposite motion of proximal & distal carpal occur during
ulnar deviation

 During RD/UD the distal carpal once again move as a relatively

fixed unit, although the magnitude of motion b/w the bones of
proximal row may differ.
Studies have shown that magnitude of scaphoid flexion during
RD( extension during UD) was related to ligamentous laxity.
( female > male)
In full RD both radiocarpal & midcarpal joints are in closed pack
position.
Functional position: 10 flexion, 35 extension
Fusion is done in 20 ext, 10 UD

Pathomechanics of Wrist Joint

Wrist Instability
Dorsal intercalated segmental instabiity (DISI)
Injury to one or more ligaments attached to scaphoid and lunatediminish or remove the synergistic stabilization of the lunate and
scaphoid.
The flexed distal carpals glide dorsally on the lunate and triquetrumaccentuating extension of the lunate and triquetrum.
This zigzag pattern of the 3 segments ( the scaphoid, the lunate/
triquetrum & the distal carpal row)- know as intercalated segmental
instability
Lunate assumes an extended posture- DISI

VISI
Volar intercalated segmental instability (VISI)
Caused- ligamentous union of lunate and triquetrum is disrupted
through injury.
Usaually- lunate & triquetrum tend to move towards extesionscaphoid flex.
When lunate is no longer linked with triquetrum- lunate and
scaphoid fall into flexion- triquetrum and distal carpal row extends.
This ulnar perilunate instability- VISI

SLAC
Scapholunate advanced collapse ( SLAC wirst)
With subluxation of scaphoid- increase contact pressure in
smaller area.
With sufficient ligamentous laxity-capitate sublux dorsally off
the extended lunate- migrate into gap between flexed scaphoid
and extended lunate.
Progressive degeneration problem from untreated DISI SLAC
wrist.

Kienbocks Disease
KD( or lunatomalacia) is an
idiopathic AVN of carpal lunate
which may lead to collapse of the
bone & arthritis in advanced stages
Ulnar ve variant wrist is common
association
Pain, tenderness, swelling, clunk
with deviation, dec. ROM, weak
grip.

TFCC
Triangular Fibrocartilage Complex (TFCC) Injury

Etiology
Occurs through forced hyperextension, falling on outstretched hand
Violent twist or torque of the wrist
Often associated w/ sprain of UCL

Signs and Symptoms

Pain along ulnar side of wrist, difficulty w/ wrist extension,
possible clicking
Swelling is possible, not much initially
Athlete may not report injury immediately

Tenosynovitis
Tenosynovitis

Etiology
Cause of repetitive wrist accelerations and decelerations
Repetitive overuse of wrist tendons and sheaths

Signs and Symptoms

Pain w/ use or pain in passive stretching
Tenderness and swelling over tendon

Carpal Tunnel Syndrome

Carpal Tunnel Syndrome

Etiology
Compression of median nerve due to inflammation of
tendons and sheaths of carpal tunnel
Result of repeated wrist flexion or direct trauma to anterior
aspect of wrist

Signs and Symptoms

Sensory and motor deficits (tingling, numbness and
paresthesia); weakness in thumb

Colles Fracture
Dorsally displaced fracture of the distal radius generally occuring 2-3
cm proximal to the radiocarpal joint.
Most common #, seen mainly in middle aged and elderly women.
FOOSH most likely cause.

Clinical Evaluation: Pain and swelling in wrist, often gross

deformity in wrist.

Lunate Dislocation
Dislocation of Lunate Bone

Etiology
Forceful hyperextension or fall on outstretched hand

Signs and Symptoms

Pain, swelling, and difficulty executing wrist and finger
flexion
Numbness/paralysis of flexor muscles due to pressure on
median nerve

Scaphoid #
Scaphoid Fracture

Etiology
Caused by force on outstretched hand, compressing

scaphoid between radius and second row of carpal bones

Often fails to heal due to poor blood supply

Signs and Symptoms

Swelling, severe pain in anatomical snuff box
Presents like wrist sprain
Pain w/ radial flexion

Hamate #
Etiology
Occurs as a result of a fall or more commonly from contact while
athlete is holding an implement

Signs and Symptoms

Wrist pain and weakness, along w/ point tenderness
Pull of muscular attachment can cause non-union

Wrist Ganglion
Wrist Ganglion
Etiology
Synovial cyst (herniation of joint capsule or synovial sheath of
tendon)
Generally appears following wrist strain
Signs and Symptoms
Appear on back of wrist generally
Occasional pain w/ lump at site
Pain increases w/ use
May feel soft, rubbery or very hard

Perilunate Injury
Perilunate Injuries
Load applied to hand forcing the wrist into extension and ulnar
deviation
Severe ligament injury necessary to tear the distal row from the lunate
to produce perilunate dislocation
Dorsal displacement of the carpus may be seen
Significant swelling common
Evaluate for compartment syndrome
If lunate is dislocated, median nerve symptoms may be present

References
Joint structure and function -Cynthia Norkins
Kinesiology: the mechanics & pathomechanics of human
movement---- Carol A. Oatis