Wrist and Hand
Original Editors - Rachael Lowe
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Introduction[edit | edit source]
The human hand has a complex mechanism to perform functional capabilities. Its integrity is essential for daily functions. Understanding of the normal hand characteristics requires a comprehensive analysis of sensory and mechanical features.
This 11 minute video is worthwhile viewing
- The upper limb has sacrificed locomotor function and stability for mobility, dexterity and precision.
- The hand, positioned at the end of the upper limb, is a combination of complex joints whose function is to manipulate, grip and grasp, all made possible by the opposing movement of the thumb.
- Some biologists believe that the development of the human hand lead indirectly to the development of our large and complex brain. The hand's existence promoted brain development by allowing humans to manipulate, interact with, explore, and gain information from the environment. A more complex brain permitted us in turn to make and use tools and to develop language leading to an elaborate system of shared meanings, what we know as culture.
Bony Anatomy[edit | edit source]
The hand and wrist have a total of 27 bones arranged to roll, spin and slide; allowing the hand to explore and control the environment and objects. The carpus is formed from eight small bones collectively referred to as the carpal bones. The carpal bones are bound in two groups of four bones:
- the pisiform, triquetrum, lunate and scaphoid on the upper end of the wrist
- the hamate, capitate, trapezoid and trapezium on the lower side of the hand.
Other bones of the hand are:
- the metacarpals – the five bones that comprise the middle part of the hand
- the phalanges (singular phalanx) – the 14 narrow bones that make up the fingers of each hand. Each finger has three phalanges (the distal, middle, and proximal); the thumb has two.
The hand is divided into three regions
- Proximal region of the hand is the carpus (wrist)
- The middle region the metacarpus (palm)
- The distal region the phalanges (fingers).
Image: Overview of the bones of the wrist and hand
The Carpus[edit | edit source]
- The carpus controls length-tension relationships in the multiarticular hand muscles and to allow fine adjustment of grip.
- Three of the bones in the proximal row articulate with the radius forming the radiocarpal joint and distally with the distal carpal forming the midcarpal joint.
- The four carpal bones in the distal row articulate with the bases of the five metacarpal bones forming the carpometacarpal joints.
- The joints formed between the carpal bones are known as the intercarpal joints and most are of the plane synovial type, as the bones interlock with each other the rows are sometimes referred to as two single synovial joints.
The exception to this is the capitate which has a larger range of movement.
Proximal Row[edit | edit source]
- Scaphoid – (boat like)– anterior surface palpable tubercle. Articulates proximally with radius, medially with lunate and distally with the head of the capitate. It is a common site of fracture- 70% of all carpal fractures, often injured by a fall onto an outstretched limb
- Lunate – (moon shaped) – Its palmar surface is smooth and convex and is larger than its dorsal surface. Proximally it articulates with the radius and articular disc, medially with the triquetrum, laterally with the scaphoid and distally with the head of the capitate
- Triquetrum – (three cornered) – Nestles in the space between the lunate and hamate. When the hand is adducted it enters the radiocarpal joint.
- Pisiform – (pea shaped) = a small round bone found in the tendon of flexor carpi ulnaris. It articulates with the palmar surface of the triquetrum. The anterior surface projects distally and laterally forming the medial part of the carpal tunnel.
Distal Row[edit | edit source]
- Trapezium – four sided figures with no two sides parallel – the most irregular, with a palpable tubercle and groove anterior medially. It articulates proximally with the scaphoid and medially with the trapezoid. Its articular surface is saddle-shaped and contributes to the mobility of the carpometacarpal joint of the thumb
- Trapezoid – four sided figure with two parallel sides – Articulates distally with the second metacarpal, laterally with the trapezium, proximally with the scaphoid and medially with the capitate
- Capitate - head shaped – The largest of all the carpal bones sitting centrally and articulating with the lunate and scaphoid, medially with the hamate and laterally with the trapezoid. The distal surface articulates mainly with the base of the third metacarpal but also by narrow surfaces with the bases of the second and fourth metacarpals.
- Hamate – hooked – This is wedge shaped with a curved palpable hook projecting from the palmar surface near the base of the fifth metacarpal.
The following pneumonic makes it easy to remember the position of each bone, naming the carpal bones in a circle, starting with the proximal row from the scaphoid towards the pinky (small finger) and then the distal row starting from the hamate towards the thumb:
- So Long To Pinky, Here Comes The Thumb
- Straight Line To Pinky, Here Comes The Thumb
The Carpal Tunnel – formed by the anterior concave space formed by the pisiform and hamate – on the ulnar side and the scaphoid and trapezium – on the radial side, with a roof-like covering of the flexor retinaculum (strong fibrous bands of connective tissue). The long flexor tendons of the digits and thumb and the median nerve pass through the carpal tunnel
The Metacarpus[edit | edit source]
The metacarpus, the palm of the hand, which is made up of five bones – the metacarpals. The bones are numbered laterally, from the thumb, 1 – 5. Each bone is long with a proximal quadrilateral base, a shaft (body) and a distal rounded head. The base of the first metacarpal is saddle-shaped and articulates with the trapezium. The base of the second metacarpal articulates with the trapezium, trapezoid and capitate. The base of the third metacarpal articulates with the capitate. The bases of the fourth and fifth metacarpal articulate with the hamate. The bases of the second to fifth metacarpals also articulate with each other.
The heads of the metacarpals, commonly known as knuckles, are smooth and rounded and extend onto the palmar surface – these become visible when the fist is clenched. The head of the first metacarpal is wider than the others, having two sesamoid bones, usually found in the short tendons crossing the joint, which articulate with the palmar part of the joint surface. The heads fit into a concavity on the base of the proximal phalanx at the metacarpophlangeal joints.
The Phalanges[edit | edit source]
The phalanges, the fingers, consist of 14 long bones. Apart from the thumb (the pollex) each phalanx has three bones, the distal, middle and proximal phalanx – the thumb has only two distal and proximal. As with the metacarpals, the phalanges are numbered 1-5 starting at the thumb. The proximal phalanx is large and is concave for articulation with the head of the metacarpal. The shaft is curved along its length being convex dorsally. It is convex from side to side on its dorsal surface and flat on the palmar surface. The distal end, the head, is smaller and convex to articulate with the next bone in sequence. In order from the thumb, digits are also known as the index finger, middle finger, ring finger and little finger.
Joints of the Wrist and Hand[edit | edit source]
The wrist has two degrees of freedom, although some say three degrees of freedom because they include the movements of pronation and supination, which occur at the the radioulnar joint. The radioulnar joint is often referred to as a joint of the forearm but it is this articulation that gives the wrist more freedom of movement. The true joints of the wrist and hand are listed in the table below.
|Joint||Proximal articulation||Distal Articulation||Type||Movement|
|Radiocarpal joint||Radius and articular disc/ concave||Scaphoid, lunate, triquetrum / – convex||Ellipsoid||Flexion-extension; Abduction-adduction|
|Midcarpal joint||Scaphoid. Lunate, Triquetrum||Trapezium, Trapezoid, Capitate, Hamate||Gliding||Flexion-extension; Abduction-adduction|
|Carpometacarpal joint (thumb)||trapezium||1st metacarpal||Saddle||Flexion-extension; Abduction-adduction; circumduction; opposition|
|Carpometacarpal joint (fingers)||trapezoid, trapezium
|Metacarpophalangeal joints||Metacarpals||phalangeal||Ellipsoidal||Flexion, extension, abduction, adduction, circumduction|
|Interphalangeal||Proximal phalangeal||Distal phalangeal||Hinge||Flexion (lots) Extension (minimal)|
Ligaments of the Wrist and Hand[edit | edit source]
Important ligaments of the hand are:
- Collateral ligaments – strong ligaments on either side of the finger and thumb joints, which prevent sideways movement of the joint
- Volar plate – a ligament that connects the proximal phalanx to the middle phalanx on the palm side of the joint. As the joint in the finger is straightened, this ligament tightens to keep the PIP joint from bending backward.
- Radial and ulnar collateral ligaments – a pair of ligaments which bind the bones of the wrist and provide stability
- Volar radiocarpal ligaments – a complex web of ligaments that support the palm side of the wrist
- Dorsal radiocarpal ligaments – ligaments that support the back of the wrist
- Ulnocarpal and radioulnar ligaments – two sets of ligaments that provide the main support for the wrist.
The stability of the wrist is provided by ligaments (see table); on the palmar aspect is the flexor retinaculum which together with the carpal bones forms a canal – the carpal tunnel - which nerves, muscles and blood vessels run through, it is this area that is involved in carpal tunnel syndrome.
|Posterior radiocarpal ligament||runs diagonally across the posterior aspect of the wrist from the distal end of the radius to the triquetral and hamate carpal bones (on the ulnar side of the wrist||limits flexion of the wrist|
|Anterior radiocarpal ligament||runs from the anterior aspect of the distal end of the radius to the scaphoid, lunate and capitate bones of the wrist||Limits extension of the wrist|
|Radial collateral ligament||from the styloid process of radius to the scaphoid bone||limits adduction of wrist (frontal plane)|
|Ulnar collateral ligament||from the styloid process of the ulna to the triquetral||limits abduction (front plane)|
|Anterior, posterior and interosseous carpal ligaments||Between the carpal bones||holds carpal bones together - reinforced by the shape and interlocking structure of the bones|
|Transverse carpal ligament||flexor retinaculum||The roof of the carpal tunnel which the median nerve and flexor tendons pass through|
Movements of the Wrist and Hand[edit | edit source]
Thirty-four muscles act on the hand.
- Intrinsic muscles of the hand contain the origin and insertions within the carpal and metacarpal bones.
- Muscles originating in the forearm are the extrinsic muscles of the hand.
- The intrinsic muscles of the hand provide the fine motor movements while the extrinsic muscles permit strength.
A common rule of thumb is that any muscle tendon that crosses a joint will act on that joint. For example, muscles of the forearm that cross the carpometacarpal joint will produce flexion or extension at the wrist joint. 
|Flexion||Flexor carpi radialis||0-80||Medial Epicondyle of humerus||2nd and 3rd metacarpals||Median nerve (C6,7)||Radiocarpal Jt|
|Flexor carpi ulnaris||Medial epicondyle of humerus and sup.post. border of ulna||Pisiform, hamate and base 5th metacarpal||Ulnar nerve (C7,8)|
|Palmaris longus||Medial epicondyle of humerus||Flexor reinaculum and palmar aponeurosis||Median nerve (C8)|
|Flexor digitorum superficialis||Medial epicondyle of humerus, coronoid process of
ulna, and a ridge along lateral margin of anterior surface of radius
|Middle phalanges of each finger||Median nerve (C7,8 T1)|
|Flexor digitorum profundus||Anterior medial surface of body of ulna||Base of distal phalanx of thumb||Median nerve (C7,8, T1)
Ulnar nerve (C8, T1)
|Flexor pollicis longus||Anterior surface of radius and interosseous membrane||Base of distal phalanx of thumb||Median nerve (C8, T1)|
|Extension||Extensor carpi radialis longus||0-70||Lateral supracondylar ridge of humerus||2nd metacarpal||Radial nerve (C6,7)||Radiocarpal Jt|
|Extensor carpi radialis brevis||Lateral epicondyle of humerus||Distal and middle phalanges of each finger||Radial nerve (C6,7)|
|Extensor carpi ulnaris||Lateral epicondyle of humerus and posterior border of ulna||5th metacarpal||Radial nerve (C7,8)|
|Extensor digitorum||Lateral epicondyle of humerus||Distal and middle phalanges of each finger||Radial nerve (C7,8)|
|Extensor indicis||Posterior surface of ulna||Tendon of extensor digitorum of index finger||Radial nerve (C7, 8)|
|Extensor digiti minimi||Lateral epicondyle of humerus||Tendon of extensor digitorum on 5th phalanx||Radial nerve (C7,8)|
|Extensor pollicis longus||Posterior surface of middle of radius and ulna and interosseous membrane||1st metacarpal||Radial nerve (C7,8)|
|Extensor pollicis brevis||Posterior surface of middle of radius||Base of proximal phalanx of thumb||Radial nerve (C7,8)|
|Radial deviation||Flexor carpi radialias||30||Medial Epicondyle of humerus||2nd and 3rd metacarpals||Median nerve (C6,7)||Radiocarpal Jt|
|Ulnar deviation||Flexor carpi ulnaris||20||Medial epicondyle of humerus and sup.post. border of ulna||Pisiform, hamate and base 5th metacarpal||Ulnar nerve (C7,8)||Radiocarpal Jt|
|Supinator||60||Lateral epicondyle of humerus and ridge near radial notch of ulna||Lateral surface of proximal one-third of radius||Radial nerve (C5,6)||Sup. and inf.radioulnar jt|
|Biceps brachii||Long head - supraglenoid tubercle; Short head - coracoid process of scapula||Radial tuberosity and bicipital aponeurosis||Musculocutaneous nerve (C5,6)|
|Brachioradialis||Medial and lateral borders of distal end of humerus||Superior to styloid process of radius||Radial Nerve (C5,6)|
|Pronator teres||40||Medial epicondyle of humerus and coronoid process of ulna||Midlateral surface of radius||Median nerve (C6,7)||Sup.and inf.radioulnar jt|
|Pronator quadratus||Distal portion of shaft of ulna||Distal portion of shaft of radius||Median nerve (C8, T1)|
|Brachioradialis||Medial and lateral borders of distal end of humerus||Superior to styloid process of radius||Radial nerve (C5,6)|
Grip[edit | edit source]
Types of grasp. Two types of grasp are differentiated according to the position and mobility of thumb, CMC, and MP joints.
- POWER grasp (The terms grasp, grip, and prehension are interchangeable.) (The adductor pollicis stabilizes an object against the palm; the hand's position is static.)
- Cylindrical grip (fist grasp is a small diameter cylindrical grasp)
- Spherical grip
- Hook grip (MP extended with flattening of transverse arch; the person may or may include the thumb in this grasp)
- Lateral prehension (this can be a power grip if the thumb is adducted, a precision grip if the thumb is abducted).
- PRECISION (Muscles are active that abduct or oppose the thumb; the hand's position is dynamic.)
- Palmar prehension (pulp to pulp), includes 'chuck' or tripod grips
- Bip-to-tip (with FDP active to maintain DIP flex)
- Lateral prehension (pad-to-side; key grip)
Arches of the Hand[edit | edit source]
The hand, when in at rest, forms a hollow at the palm, with the fingers flexed and the thumb in slight opposition. There are three distinct arches, longitudinal, oblique and transverse, that are formed by the bones, ligaments and tendons these are of vital importance when gripping and manipulating objects.
Longitudinal Arches (Brown)[edit | edit source]
These are known as the carpometacarpophalangeal arches run from the wrist to each digit. The arches are concave with the keystone laying level with the metacarpophalangeal joint; muscular imbalance at this point can decrease the concavity of the arch. The most important of these arches are the ones of the index finger and middles finger which are used when gripping objects, especially the arch formed to the index finger which we use when holding and using objects such as a pen.
Oblique Arch (Red)
These arches runs from the base of the hypothenar eminence to the head of the second metacarpal. It lies in parallel the palmar crease 'life-line' and is evident when holding tools or a tennis racquet.
Transverse Arches (Light green and Dark Green)
This arches lays across the palm and is maintained by the retinaculum. It runs from the wrist where its shape is maintained by the retinaculum and therefore more rigid, distally to the metacarpal heads where it is much shallower and more flexible.
Functional Position of the Hand[edit | edit source]
When therapists immobilize a patient's hand, they often position it this way. During a period of immobilization, the resting lengths of the hand's ligaments and muscles change. This hand position provides the best balance of resting length and force production so the hand can function when the patient mobilizes it again.
- Extended 20 degrees
- Ulnarly deviated 10 degrees
Digits 2 through 5
- MP joints flexed 45degrees
- PIP joints flexed 30-45 degrees
- DIP joints flexed 10-20 degrees
- 1st CMC jt partially abducted and opposed
- MP joint flexed 10 degrees
- IP joint flexed 5 degrees
Clinical Examination[edit | edit source]
- Wrist & Hand Examination
- Special Tests
- Outcome Measures
Conditions[edit | edit source]
- Carpel Tunnel Syndrome
- Cyclists Palsy
- De Quervains
- Wrist Sprain
- Carpal Instability
- Colles Fracture
- Smiths Fracture
- Scaphoid Fracture
- Wrist & Hand Osteoarthritis
- Rheumatoid Arthritis
- Complex Regional Pain Syndrome
- Triangular Fibrocartilage Complex Injuries
- Gamekeeper’s Thumb
- Skier's Thumb
- Lunate Instability
- Hamate Fracture
- Ape Hand
- Benediction Hand
- Claw Hand
- Dupuytren’s Contracture
- Metacarpal Fractures
- Extensor Mechanism Injuries
- Flexor Tendon Injuries
- Ulnocarpal Impaction Syndrome
- Lunotriquetral Ligament dissociation/tears
Procedures[edit | edit source]
References[edit | edit source]
- Tanrıkulu S., Bekmez Ş., Üzümcügil A., Leblebicioğlu G. (2014) Anatomy and Biomechanics of the Wrist and Hand. In: Doral M., Karlsson J. (eds) Sports Injuries. Springer, Berlin, Heidelberg Available from:https://link.springer.com/referenceworkentry/10.1007/978-3-642-36801-1_49-1#citeas (last accessed 14.3.2020)
- Randale Sechrest Hand Anatomy Animated Tutorial Available from:https://www.youtube.com/watch?v=zyl6eoU-3Rg&app=desktop (last accessed 30.3.2020)
- Palastanga N, Soames R. Anatomy and Human Movement: Structure and Function. 6th Ed. London: Churchill Livingstone, 2012.
- Biomechanics of the hand Gwenda Sharp OTR and Dave Thompson PT Available from: ☀https://ouhsc.edu/bserdac/dthompso/web/namics/hand.htm (last accessed 14.3.2020)
- Maitland, G.D. Maitland's Peripheral Manipulations. 3rd Edition Edinburg: Elsevier Butterworth-Heinemann, 1999.
- Physical Examination of the Spine and Extremities. Hoppenfield, S. New York: Appleton-Century-Crofts, 1976.
- Overview of the bones of the wrist and hand image - © Kenhub https://www.kenhub.com/en/study/hand-bones-and-ligaments
- Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis. 5th Ed. Philadelphia: F A Davis Company, 2011
- Principles of Anatomy & Physiology. Tortora GJ, Derrickson B. 13th Ed. NJ: John Wiley & Sons, Inc, 2012.
- Cael C. Functional Anatomy: Musculoskeletal Anatomy, Kinesiology, an Palpation for Manual Therapists. Lippincott Williams & Wilkins, 2009.
- Kapandji I.A. The Physiology of the Joints: Volume 1, The Upper Limb. 5th Ed. London: Churchill Livingstone, 1982.
- Dawson-Amoah K, Varacallo M. Anatomy, Shoulder and Upper Limb, Hand Intrinsic Muscles. InStatPearls [Internet] 2019 Mar 27. StatPearls Publishing. Available from:https://www.statpearls.com/kb/viewarticle/22523/?utm_source=TrendMD&utm_campaign=StatPearls_TrendMD_0&utm_medium=cpc (last accessed 14.3.2020)