The Wrist Joint

The wrist joint (also known as the radiocarpal joint) is a synovial joint in the upper
limb, marking the area of transition between the forearm and the hand.

In this article, we shall look at the structures of the wrist joint, the movements of
the joint, and the relevant clinical syndromes.

Structures of the Wrist Joint

Articulating Surfaces
The wrist joint is formedby:

Distally The proximal row of the carpal bones (except the pisiform).

Proximally The distal end of the radius, and the articular disk (see below).

The ulna is not part of the wrist joint itarticulates with the radius, just proximal
to the wrist joint, at the distal radioulnar joint. It is prevented from articulating
with the carpal bones by a fibrocartilaginous ligament, called the articular disk,
which lies over the superior surface of the ulna.

Together, the carpal bones form a convex surface, which articulates with the
concave surface of the radius and articular disk.
Fig 1.0 Articular surfaces of the wrist joint.

Joint Capsule
Like any synovial joint, the capsule is dual layered. The fibrous outer layer attaches
to the radius, ulna and the proximal row of the carpal bones. The internal layer is
comprised of a synovial membrane, secreting synovial fluid which lubricates the
joint.

Ligaments
There are four ligaments of note in the wrist joint, one for each side of the joint

Palmar radiocarpal It is found on the palmar (anterior) side of the hand. It

passes from the radius to both rows of carpal bones. Its function, apart from
increasing stability, is to ensure that the hand follows the forearm during
supination.
Dorsal radiocarpal It is found on the dorsum (posterior) side of the hand. It
passes from the radius to both rows of carpal bones. It contributes to the
stability of the wrist, but also ensures that the hand follows the forearm
during pronation.
Ulnar collateral Runs from the ulnar styloid process to the triquetrum and
pisiform. Works in union with the other collateral ligament to prevent
excessive lateral joint displacement.
 Radial collateral Runs from the radial styloid process to the scaphoid and
trapezium. Works in union with the other collateral ligament to prevent
excessive lateral joint displacement.

Fig 1.1 Palmar view of the ligaments of the wrist joint.

Neurovascular Supply
The wrist joint receives blood from branches of the dorsal and palmar carpal
arches, which are derived from the ulnar and radial arteries (for more information,
see Blood Supply to the Upper Limb)

Innervation to the wrist is delivered by branches of three nerves:

Median nerve Anterior interosseous branch.

Radial nerve Posterior interosseous branch.
Ulnar nerve deep and dorsal branches.

Movements of the Wrist Joint

The wrist is an ellipsoid type synovial joint, allowing for movement along two axes.
This means that flexion, extension, adduction and abduction can all occur at the
wrist joint.

All the movements of the wrist are performed by the muscles of the forearm.

Flexion Produced mainly by the flexor carpi ulnaris, flexor carpi radialis, with
assistance from the flexor digitorum superficialis.
Extension Produced mainly by the extensor carpi radialis longus and brevis, and
extensor carpi ulnaris, with assistance from the extensor digitorum.

Adduction Produced by the extensor carpi ulnaris and flexor carpi ulnaris

Abduction Produced by the abductor pollicis longus, flexor carpi radialis,

extensor carpi radialis longus and brevis.

By Gilo1969 (Own work) [CC-BY-SA-3.0], via Wikimedia Commons

Fig 1.2 Radiograph of a scaphoid fracture.

In the event of a blow to the wrist (e.g falling on an outstretched hand), the
scaphoid takes most of the force. A fractured scaphoidis more common in the
younger population.
The scaphoid has a unique blood supply, which runsdistal to proximal. A fracture
of the scaphoid can disrupt the blood supply to theproximalportion this is an
emergency. Failure to revascularise the scaphoid can lead to avascular necrosis,
and future arthritis for the patient.

The main clinical sign of a scaphoid fracture is tenderness in the anatomical

snuffbox.

Anterior Dislocation of the Lunate

This can occur by falling on a dorsiflexed wrist. The lunate is forced anteriorly, and
compresses the carpal tunnel, causing the symptoms of carpal tunnel syndrome.

This manifests clinically as paraesthesia in the sensory distribution of the median

nerve and weakness of thenar muscles. The lunate can also undergo avascular
necrosis, so immediate clinicalattention to the fracture is needed.

Colles Fracture
The Colles fracture is the most commonfractureinvolving the wrist, caused by
falling onto an outstretched hand.

The radius fractures, with the distal fragment being displaced posteriorly. The
ulnar styloid process can also be damaged, and is avulsed in the majority of cases.

This clinical condition produces what is known as the dinner fork deformity.
The Carpal Tunnel

The carpal tunnel is a narrow passageway found on the anterior portion of the
wrist. It serves as the entrance to the palm for several tendons and the median
nerve.

In this article, we will look at the borders and contents of the carpal tunnel and its
clinical significance.

Borders
The carpal tunnel is formed by two layers: a deep carpal arch and a superficial
flexor retinaculum. The deep carpal arch forms a concave surface, which is
converted into a tunnel by the overlying flexor retinaculum.

Carpal Arch
Concave on the palmar side, forming the base and sides of the carpal tunnel.
Formed laterally by the scaphoid and trapezium tubercles
Formed medially by the hook of the hamate and the pisiform

Flexor Retinaculum
Thick connective tissue which forms the roof of the carpal tunnel.
Turns the carpal arch into the carpal tunnel by bridging the space between
the medial and lateral parts of the arch.
Originates on the lateral side and inserts on the medial side of the carpal
arch.

To find where the carpal tunnel begins on yourself, locate your distal wrist crease,
which aligns with the entrance of the carpal tunnel.
Fig 1 Transverse section of the carpal tunnel.

Contents
The carpal tunnel contains a total of 9 tendons, surrounded by synovial sheaths,
and the median nerve. The palmar cutaneous branch of the median nerve is given
off prior to the carpal tunnel, travelling superficially to the flexor retinaculum.

Tendons
The tendon of flexor pollicis longus
Four tendons of flexor digitorum profundus
Four tendons of flexor digitorum superficialis

The 8 tendons of the flexor digitorum profundus and flexor digitorum superficialis
are surrounded by a single synovial sheath.The tendon of flexor pollicis longus is
surrounded by its own synovial sheath. These sheaths allow free movement of the
tendons.

Sometimes you may hear that the carpal tunnel contains another tendon, the flexor
carpi radialis tendon, but this is located within the flexor retinaculum and not
within the carpal tunnel itself!
Fig 2 The muscular and tendinous components of the carpal tunnel

Median Nerve
Once it passes through the carpal tunnel, the median nerve divides into 2 branches:
the recurrentbranch and palmardigitalnerves.

The palmar digital nerves give sensory innervation to the palmar skin and dorsal
nail beds of the lateralthreeand a half digits.They also provide motor innervation
to the lateral two lumbricals. The recurrent branch supplies the thenar muscle
group.

For a more detailed look at the median nerve, take a look here.

Compression of the median nerve within the carpal tunnel can cause carpal tunnel
syndrome (CTS).It is the most common mononeuropathy and can be caused by
thickened ligaments and tendon sheaths. Its aetiology is, however, most often
idiopathic. If left untreated, CTS can cause weakness and atrophy of the thenar
muscles.
Clinical features include numbness, tingling and pain in the distribution of the
median nerve. The pain will usually radiate to the forearm. Symptoms are often
associated with waking the patient from their sleep and being worse in the
mornings.

Tests for CTS can be performed during physical examination:

Tapping the nerve in the carpal tunnel to elicit pain in median nerve
distribution (Tinels Sign)
Holding the wrist in flexion for 60 seconds to elicit numbness/pain in median
nerve distribution (Phalensmanoeuvre)

Treatment involves the use of a splint,holding the wrist in dorsiflexion overnight

to relieve symptoms. If this is unsuccessful,corticosteroid injections into the
carpal tunnel can be used. In severe case, surgical decompression of the carpal
tunnel may be required.

Fig 3 Thenar muscle wasting, secondary to carpal tunnel syndrome.