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This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview¶

Bony Anatomy¶

• The wrist is the anatomic region between the forearm and the hand [1].
• The wrist includes the distal radioulnar, radiocarpal, and ulnocarpal joints [1].
• The wrist includes the eight carpal bones and their proximal and distal articulations [1].
• The wrist includes the ligaments attached to the carpal bones [1].
• The proximal row of carpal bones includes the scaphoid, lunate, triquetrum, and pisiform [1].
• The distal row of carpal bones includes the trapezium, trapezoid, capitate, and hamate [1].
• The pisiform and trapezoid are the smallest carpal bones [1].
• The capitate is the largest carpal bone [1].
• The pisiform articulates with one bone (the triquetrum) [1].
• The capitate articulates with seven bones [1].
• The radiocarpal joints are formed by the articulation of the distal radius with the scaphoid and lunate [1].
• The radiocarpal joints are formed by the articulation of the distal radius with the triquetrum on the triangular fibrocartilage [1].
• The midcarpal articulations are formed by the distal concave articular surfaces of the proximal carpal row with the distal row [1].
• The distal row articulates with the metacarpals [1].
• The distal ulnar convexity articulates at the lesser sigmoid notch of the distal radius [1].
• The sigmoid notch articular surface accommodates the ulnar head through two thirds of its arc [1].
• There is about a 20-degree inclination of the distal ulna at its articulation with the radius [1].
• The ulnar styloid lies dorsal to the ulnar head and extends distally [1].

Ligaments and Soft Tissue Supports¶

• The triangular fibrocartilage attaches to the base of the ulnar styloid [1].
• The triangular fibrocartilage separates the hyaline cartilage–covered ulnar head from the styloid [1].
• The chondroligamentous supports attaching the distal radius and ulnar side of the carpus to the distal ulna are designated as the triangular fibrocartilage complex (TFCC) [1].
• The TFCC attaches to the ulnar margin of the lunate fossa of the radius [1].
• The TFCC includes the ulnar collateral ligament [1].
• The TFCC includes the dorsal and volar radioulnar ligaments [1].
• The TFCC includes the articular disc [1].
• The TFCC includes the meniscal homologue [1].
• The TFCC includes the extensor carpi ulnaris sheath [1].
• The TFCC includes the ulnolunate and ulnotriquetral ligament [1].
• Interosseous intrinsic ligaments connect the carpal bones in the proximal and distal carpal rows [1].
• Extrinsic ligaments extend from the radius and ulna distally across the carpal rows [1].
• The scapholunate interosseous ligament connects the proximal carpal row [1].
• The lunotriquetral interosseous ligament connects the proximal carpal row [1].
• Interosseous ligaments connect the trapezium to the trapezoid in the distal carpal row [1].
• Interosseous ligaments connect the trapezoid to the capitate in the distal carpal row [1].
• Interosseous ligaments connect the capitate to the hamate in the distal carpal row [1].
• The radial collateral ligament extends from the radial styloid to the scaphoid waist [1].
• The ulnar collateral ligament extends from the base of the ulnar styloid attaching to the pisiform [1].
• The transverse carpal ligament is an extrinsic or crossing ligament [1].
• The volar extrinsic or crossing ligaments include the radioscapocapitate ligament [1].
• The volar extrinsic or crossing ligaments include the radiolunotriquetral ligament [1].
• The volar extrinsic or crossing ligaments include the radioscapolunate ligament [1].
• The ulnolunate and ulnotriquetral components of the TFCC are volar extrinsic or crossing ligaments on the ulnar side [1].
• The space of Poirier is a relatively thin area on the palmar side of the carpus between the radiolunotriquetral ligament and the radioscapocapitate ligament [1].
• The space of Poirier overlies the palmar surface of the lunate [1].
• The dorsal radiocarpal ligament is an identifiable extrinsic ligament on the dorsal side [1].
• The dorsal intercarpal ligament is an identifiable extrinsic ligament on the dorsal side [1].
• The trapezoidal dorsal radiocarpal ligament attaches along the dorsal radial articular margin of the lunate fossa [1].
• The trapezoidal dorsal radiocarpal ligament extends from the Lister tubercle to the lesser sigmoid notch [1].
• The trapezoidal dorsal radiocarpal ligament spans the lunotriquetral joint [1].
• The trapezoidal dorsal radiocarpal ligament inserts on the dorsal surface of the triquetrum [1].
• There are four types of dorsal radiocarpal ligaments [1].
• The dorsal intercarpal ligament is attached to the distal, dorsal surface of the triquetrum [1].
• The dorsal intercarpal ligament passes across the midcarpal joint [1].
• The dorsal intercarpal ligament attaches to the dorsal surfaces of the scaphoid waist and the trapezoid [1].

Musculotendinous Apparatus¶

• Only the extensor tendons are accessible to visual inspection and palpation owing to the thin dorsal skin on the hand [2].
• Extensor tendons are visible with the fingers in active extension and the thumb in abduction [2].
• The abductor pollicis longus and extensor pollicis brevis tendons are seen between the radial styloid proximally and the base of the first metacarpal distally [2].
• The extensor pollicis longus tendon runs from the radial styloid to the ulnar side of the base of the first metacarpal [2].
• The extensor pollicis longus tendon is best seen with the thumb in active retropulsion [2].
• The extensor communis and proprius tendons of the fingers lie in the axis of each metacarpal to the level of the proximal phalanx [2].
• The extensor carpi radialis tendons are palpable for a short distance proximal to the bases of the second and third metacarpals with the wrist in resisted extension [2].
• The extensor carpi ulnaris tendon is palpable during resisted extension and adduction of the wrist [2].
• The extensor carpi ulnaris tendon is palpable immediately distal to the ulna styloid until the fifth metacarpal [2].
• The flexor carpi ulnaris tendon is felt in active flexion of the wrist immediately proximal to the pisiform [2].
• The flexor carpi radialis and palmaris longus tendons are palpable and visible in resisted flexion of the wrist just proximal to the distal wrist flexion crease [2].

Osseous Anatomy¶

General Wrist Structure¶

• For discussion purposes, the wrist includes the distal radioulnar, radiocarpal, and ulnocarpal joints, the eight carpal bones, their proximal and distal articulations, and attached ligaments [1].
• Wrist mobility is a sum of all the movements of an articular complex made up of the radiocarpal joint, the mid-carpal joint, the ulnocarpal joint, and the radioulnar joint [3].
• The stability of the wrist is a function of the equilibrium of the bony morphology at each joint and the passive resistance of the fibrous skeleton [3].
• The carpus does not form a single rigid bony block because the eight small bones have different degrees of movement [3].
• The distal row of carpal bones is quite rigid, while the three proximal row bones are relatively mobile [3].
• The carpus is more stable in flexion than in extension due to its anterior concavity [3].
• The carpal arch has a deep palmar concavity which resembles a rigid osseous mass sometimes incorrectly termed the "carpal block" [9].

Distal Radius and Ulna¶

• The distal radial articular surface has a double obliquity of 12–15 degrees in the lateral view and 15–20 degrees in the anteroposterior (AP) view [3].
• The posterior lip and the radial styloid of the distal radius have a buttressing effect [3].
• The distal radius articular surface has two concave facets, the scaphoid and lunate facets, separated by the scapholunate, or anterior-posterior, ridge [27].
• The sigmoid notch along the ulnar border of the distal radius is a shallow concavity for the articulating ulnar head at the distal radioulnar joint [27].
• The distal ulna is covered with hyaline cartilage on its dorsal, lateral, palmar, and distal surfaces [27].
• The ulnar styloid projects distally, and at its base, the fovea is the insertion for the triangular fibrocartilaginous complex (TFCC) [27].
• The ulnar head sits proximal to the distal radius and has only an indirect effect on stability of the wrist [3].
• The triangular ligament extends the distal radial articular surface to the ulnar styloid and forms the principal link between the two bones [3].

Carpal Bones¶

• The eight carpal bones include the scaphoid, lunate, triquetrum, and pisiform in the proximal row and the trapezium, trapezoid, capitate, and hamate in the distal row [1].
• The carpal bones vary in size from the smallest (pisiform and trapezoid) to the largest (capitate) [1].
• The amount of articular cartilage allowing for articulation varies from one bone by the pisiform (the triquetrum) to seven bones by the capitate [1].
• The scaphoid presents a long axis inclined by 45 degrees to the long axis of the radius [3].
• The distal pole of the scaphoid has a tubercle which lies palmarly [3].
• The lunate has a palmar tubercle [3].
• The lunate sits on the capitate and has anterior and posterior horns [3].
• A line drawn between the anterior and posterior horns of the lunate lies perpendicular to the long axis of the wrist in neutral position [3].
• The triquetrum is not in contact with the ulnar head; a fibro-cartilage disc, the triangular ligament, separates the two bones [3].
• The scaphoid and lunate articulate with the radius [3].
• The triquetrum articulates with the hamate distally, the lunate radially, and the pisiform volarly [27].
• The hamate consists of the body and the hook (hamulus) of the hamate [27].
• The head of the capitate (the proximal portion) often relies on a retrograde vascular supply [27].
• Two ridges separate the distal articular surface of the capitate into three facets for articulation with the metacarpals of the index, long, and ring fingers [27].
• The trapezoid has two distal facets, which articulate with the metacarpal of the index finger [27].
• The trapezium has a saddle-shaped articulation with the base of the thumb metacarpal [27].
• The trapezium has a palmar groove for the flexor carpi radialis (FCR), bordered laterally by a palmar tuberosity and the attachment for the transverse carpal ligament [27].
• The pisiform is a sesamoid bone within the flexor carpi ulnaris (FCU) tendon [27].
• The pisiform is the origin for the abductor digiti minimi [27].
• The lunate is broader palmarly than dorsally [27].
• The primary vascular supply of the scaphoid is a branch of the radial artery at the dorsal ridge [27].
• A group of smaller vessels enters the palmar tubercle of the scaphoid and supplies the distal 30% [27].
• The transverse carpal ligament attaches to the palmar tubercle of the scaphoid [27].
• A dorsal and a palmar vascular supply are found in 80% of wrists for the lunate; in 20% of wrists, only a palmar supply is found [27].
• The hook of the hamate serves as an attachment for the transverse carpal ligament and for the origins of the flexor digiti minimi and opponens digiti minimi [27].
• The triquetrum is stabilized to the fovea of the ulna through the ulnotriquetral ligament [27].

Carpal Articulations and Kinematics¶

• The radiocarpal joints are formed by the articulation of the distal radius with the scaphoid and lunate through their respective concave facets on the distal radius and the triquetrum on the triangular fibrocartilage [1].
• The distal concave articular surfaces of the proximal carpal row form the midcarpal articulations with the distal row [1].
• The distal row articulates with the metacarpals, allowing mobility in the thumb, stability in the index and long finger metacarpals, and increased mobility in the ring and little finger metacarpals [1].
• The center of rotation for most wrist motions is generally considered to be located in the proximate capitate [4].
• During flexion and extension, most motion occurs at the radiocarpal joint, with some occurring through the midcarpal area [4].
• Using ultrafast CT in vivo kinematic studies, the radiocarpal and midcarpal joints were found to contribute equally to wrist flexion [4].
• The midcarpal joint contributed more to wrist extension than the radiocarpal joint in ultrafast CT in vivo kinematic studies [4].
• During radial-to-ulnar deviation, the proximal carpal row rotates dorsally and the proximal row intercalates or shifts at the midcarpal and radiocarpal joints [4].
• During ulnar-to-radial deviation, the proximal carpal row tends toward palmar rotation, with most of the motion occurring in the intercarpal joints [4].
• The proximal carpal row is considered to be an intercalated segment in the forearm-to-hand connection [4].
• The scaphoid functions to stabilize the wrist [4].
• The proximal carpal row has no muscular or tendinous attachments and is an intercalary segment [27].
• With ulnar deviation, the proximal row extends relative to the forearm/distal row [27].
• With radial deviation, the proximal row flexes relative to the forearm/distal row [27].
• With axial loading through the neutral wrist, approximately 80% of forces are transmitted through the distal radius (60% scaphoid facet, 40% lunate facet) and 20% through the distal ulna [27].
• With wrist flexion, 60% of the motion is midcarpal and 40% is radiocarpal [27].
• With wrist extension, 33% of the motion is midcarpal and 66% is radiocarpal [27].
• The distance between the distal articular surface of the radius and the base of the metacarpals is constant [3].
• Rotation of the scaphoid and lunate as the wrist moves from extension to flexion has a double "cam" effect [3].
• Rotation in a sagittal plane allows the persistent adaptation of the carpal articular surface in order to present the correct diameter of curvature to the distal radius [3].
• The carpus is described as a "condyle of variable geometric form" [3].
• The carpal articular surface ("the carpal condyle") has a smaller diameter of curvature than the radius [3].
• The precarious stability of the carpal articular surface in the medial and palmar aspects depends upon ligamentous and capsular resistance [3].
• The stability of the carpal bones does not rely upon tendon insertions, with the exception of the pisiform which is a sesamoid in flexor carpi ulnaris tendon [3].
• Carpal stability is largely due to interosseous ligaments and bony configuration of these carpal bones [3].
• The scaphoid, as it cradles the capitate, also articulates distally with the trapezium and the trapezoid and so contributes to the stability of the midcarpus [9].
• The transverse arch of the distal carpal row is much more rigid than the proximal row [9].
• The keystone of the transverse arch of the distal carpal row is formed by the capitate, which moves with the fixed metacarpals [9].
• The proximal row of carpal bones is mobile because of its connections to the radius and the distal row [9].
• Each of the bones that make up the proximal row (scaphoid, lunate, and triquetrum) has its own distinct movements [9].
• Viegas emphasized the considerable variation found in the fourth carpometacarpal articulation and in the scaphotrapeziotrapezoid, capitolunate, and hamatolunate articulations [1].
• Awareness of these variations may lead to better understanding of the normal kinematics of the wrist and the various injury patterns that are encountered [1].

Column Concepts¶

• The concept of a wrist consisting of three columns was popularized by Novarro: the central (force-bearing) column, the radial column, and the ulnar (control) column [4].
• The central column includes the distal articular surface of the radius, the lunate, and the capitate [4].
• Some definitions add the proximal two thirds of the scaphoid, the trapezoid, and the articulations with the second and third metacarpal bases to the central column [4].
• The radial column includes the radius, the scaphoid, the trapezium, the trapezoid, and the thumb carpometacarpal joint [4].
• The ulnar column includes the triangular fibrocartilage (articular disc), the hamate, the triquetrum, and the articulations of the carpometacarpal joints of the ring and little fingers [4].
• Taleisnik proposed that the central column includes the entire distal row and the lunate [4].
• According to Taleisnik's concept, the scaphoid is included as the lateral column and the triquetrum as a rotary medial column [4].
• Lichtman proposed a ring concept of wrist kinematics [4].
• According to Lichtman's ring concept, the interosseous ligaments stabilize the semirigid proximal and distal carpal rows [4].
• Limited mobility occurs between the scaphotrapezial joints and the triquetrohamate joints in Lichtman's ring concept [4].
• Bone or ligament disruption of the ring creates instability deformities, with the lunate tilting either dorsally or volarly [4].
• In the vertical classification of carpal bones, only the radial (scaphoid) and central (capitate articulated with the lunate) columns articulate with the radius [9].
• In the ulnar column there is a gap between the ulna and the triquetrum [9].
• The horizontal classification of carpal bones stresses the transverse cohesion of the bones, considering two rows: proximal and distal [9].
• The proximal row is intercalated between the radius and the distal row and relates simultaneously to the articular surfaces of both the radius and the second carpal row [9].
• The vertical classification emphasizes the longitudinal coherence, essential for the transmission of muscular forces [9].

Radiographic Anatomy Metrics¶

• The A1 angle is formed by the tangent of the inferior aspect of the radius and the radial aspect of the second metacarpal [26].
• The A1 angle, indicating "radial angulation", is normally 120 degrees to 125 degrees [26].
• The A2 angle measures the ulnar deviation of the fingers and is defined by the angle formed between the tangent of the radial aspect of the second metacarpal and the axis of the proximal phalanx of the middle finger [26].
• The A2 angle becomes pathological when it exceeds 25 degrees [26].
• The ratio of L2 (height of the wrist passing through the center of the head of the capitate) to L1 (length of the third metacarpal) is normally 0.54 ± 0.03 [26].
• The L2:L1 ratio decreases with involvement of the wrist [26].
• The L3 (distance between the center of the head of the capitate and the extended axis of the ulnar epiphysis) to L1 ratio is 0.30 ± 0.03 [26].
• The L3:L1 ratio is reduced with displacement of the wrist in the frontal plane [26].
• In a strict lateral view in a neutral position, the radial axis usually extends through the lunate axis and the capitate axis [26].
• The scaphoid makes an angle of 30–60 degrees with the radial axis [26].
• The dorsal or palmar displacement of the lunate is judged at the level of the distal pole and is measured with the same 30–60 degree angle relative to the radial axis [26].
• The DISI or VISI formula signifies that the distal joint surface of the lunate is turned in extension (dorsal) or in flexion (volar) [26].
• In both DISI and VISI deformities, the scaphoid tends to become horizontal [26].

Ligaments and Joint Capsule¶

General Principles¶

• Wrist stability is a function of the equilibrium of bony morphology at each joint and the passive resistance of the fibrous skeleton [3].
• The stability of the wrist during motion depends on capsuloligamentous integrity and contact surface contours of the carpal bones [4].
• Carpal stability is largely due to interosseous ligaments and bony configuration, rather than tendon insertions, with the exception of the pisiform which is a sesamoid in the flexor carpi ulnaris tendon [3].
• The wrist is more stable in flexion than in extension due to the strength of the various capsules and ligaments [9].
• The normal inclination of the radiocarpal joint surface is inherently unstable, consisting of ulnar deviation and volar flexion, which is neutralized by a strong and complex set of anterior wrist ligaments that resist supination of the carpal bones [19].

Extrinsic Ligaments¶

• The strongest part of the joint capsule lies anteriorly to resist the tendency to anterior subluxation caused by the inclination of the distal radial articular surface [20].
• The palmar capsule is thickened to form a strap joining the anterior border of the radial articular surface to the ulnar styloid, with attachment to the anterior horn of the lunate and proximal pole of the triquetrum [20].
• The volar radiocarpal ligament arises from the radial styloid and fans out into multiple bands, including a proximal radiolunotriquetral band and a stronger, more distal band passing anterior to the scaphoid neck [20].
• The distal band of the volar radiocarpal ligament acts as a pivot for the rotation of the scaphoid and is the only ligamentous structure linking the radius to the distal carpal row [20].
• The interval between the radiolunotriquetral band and the distal volar radiocarpal band corresponds to the lunocapitate joint line and represents a weak point in the volar capsule because there is no lunocapitate ligament [20].
• The ulnar collateral ligament extends from the base of the ulnar styloid to the pisiform [1].
• The transverse carpal ligament is classified as an extrinsic or crossing ligament [1].
• The dorsal radiocarpal ligament attaches along the dorsal radial articular margin of the lunate fossa, from the Lister tubercle to the lesser sigmoid notch [1].
• The trapezoidal dorsal radiocarpal ligament spans the lunotriquetral joint and inserts on the dorsal surface of the triquetrum [1].
• The dorsal intercarpal ligament attaches to the distal, dorsal surface of the triquetrum and passes across the midcarpal joint to attach to the dorsal surfaces of the scaphoid waist and the trapezoid [1].

Triangular Fibrocartilage Complex (TFCC)¶

• The triangular fibrocartilage complex (TFCC) consists of chondroligamentous supports attaching the distal radius and ulnar side of the carpus to the distal ulna [1].
• The TFCC includes the ulnar collateral ligament, dorsal and volar radioulnar ligaments, articular disc, meniscal homologue, extensor carpi ulnaris sheath, and ulnolunate and ulnotriquetral ligaments [1].
• The triangular fibrocartilage attaches to the base of the ulnar styloid and separates the hyaline cartilage-covered ulnar head from the styloid [1].

Intrinsic Ligaments¶

• The scapholunate and lunotriquetral interosseous ligaments connect the bones of the proximal carpal row [1].
• Intrinsic ligaments connect the trapezium to the trapezoid, the trapezoid to the capitate, and the capitate to the hamate in the distal carpal row [1].
• The interosseous ligaments stabilize the semirigid proximal and distal carpal rows in Lichtman’s ring concept of wrist kinematics [4].

Pathology and Clinical Correlates¶

• Uncontrolled joint synovitis stretches essential anterior wrist ligaments, eventually eroding cartilage and bone, resulting in a progressive shift of the carpus ulnarward and volarward [19].
• The progressive ulnarward and volarward shift of the carpus leaves the ulna dorsally dislocated and creates a dorsal wrist step-off due to subluxed carpus [19].
• Bone or ligament disruption of the carpal ring creates instability deformities, with the lunate tilting either dorsally or volarly [4].
• Arthroscopic evaluation is indicated for the assessment of acute ligamentous injuries, including scapholunate, lunotriquetral, and TFCC injuries [21].
• Arthroscopic therapeutic procedures include debridement of ligament tears and reconstruction of scapholunate and lunotriquetral ligaments with tendon grafts [21].

Muscles and Tendons¶

Anatomy and Palpation¶

• Only extensor tendons are accessible to visual inspection and palpation due to thin dorsal skin on the hand [2].
• Extensor tendons are visible with fingers in active extension and the thumb in abduction [2].
• The abductor pollicis longus and extensor pollicis brevis tendons are located between the radial styloid proximally and the base of the first metacarpal distally [2].
• The extensor pollicis longus is best visualized with the thumb in active retropulsion [2].
• The extensor carpi ulnaris tendon is palpable immediately distal to the ulna styloid until the fifth metacarpal during resisted extension and adduction of the wrist [2].
• The flexor carpi ulnaris is palpable immediately proximal to the pisiform in active flexion of the wrist [2].
• The flexor carpi radialis and palmaris longus tendons are palpable and visible just proximal to the distal wrist flexion crease in resisted flexion of the wrist [2].

Wrist Extension Mechanics¶

• Wrist extension is dependent on the extensor carpi radialis longus (ECRL), extensor carpi radialis brevis (ECRB), and extensor carpi ulnaris (ECU) [12].
• The ECRL inserts on the base of the second metacarpal and extends the wrist while drawing it into radial deviation [12].
• The ECRB inserts on the radial part of the base of the third metacarpal and is the primary wrist extensor with a slight action of radial deviation [12].
• The ECU inserts on the base of the fifth metacarpal and crosses the wrist at the level of the ulna [12].
• The ECU tendon rotates around the ulnar head, situated on the ulnar side of the styloid process in pronation and on the radial side in a dorsal position closer to the radius in supination [12].
• The ECU acts as an extensor of the wrist in supination and primarily causes ulnar deviation of the wrist in pronation [12].
• In pronation, the ECU works in synergy with the flexor carpi ulnaris to prevent radial deviation [12].
• The ECRL originates at the supracondylar ridge of the humerus about 4–5 cm proximal to the epicondyle [12].
• The thickest part of the ECRL muscle is proximal to the elbow joint [12].
• The ECRL plays a role in elbow flexion and loses part of its wrist action when the elbow is flexed [12].
• The ECRB originates on the epicondyle and is not affected by the position of the elbow [12].
• All action of the ECRB is on the wrist [12].
• The ECRL and ECRB tendons are congruent along most of their length in the forearm and often have tendinous connections [12].
• Distal to the retinaculum, the ECRL and ECRB tendons diverge so that the center of the ECRL tendon is about 1.5 cm lateral to the center of the ECRB [12].
• The two ECR tendons comprise about 10 per cent of the muscle mass of the forearm [12].
• The two ECR tendons comprise 76 per cent of the muscle mass of the extensors of the wrist [12].
• The muscle mass of the ECRB is 88 per cent when compared with that of the ECRL [12].
• The moment arm for wrist extension is 16.30 mm for the ECRB [12].
• The moment arm for wrist extension is 12.50 mm for the ECRL [12].
• The ECRL has longer muscular fibers, mostly at the level of the elbow [12].
• In the ECRL, the moment arm for elbow flexion and radial deviation is more important than that for wrist extension [12].
• The ECRL becomes a wrist extensor only after radial deviation is balanced against the ulnar forces of the ECU [12].
• The ECU has a moment of extension of 6.3 mm in supination [12].
• The moment of extension for the ECU becomes zero when the wrist is in complete pronation [12].
• The ECRB is the most effective extensor of the wrist due to having the greatest tension and the most favorable moment arm [12].
• The axis of common wrist movements is oblique between the ECRL and ECRB, which produce extension and radial deviation, and the flexor carpi ulnaris, which produces flexion and ulnar deviation [12].
• The ECU is the antagonist of the extensor pollicis longus, with contraction being synergistic [12].
• Tension of the ECU is felt when the thumb is abducted [12].

Functional Consequences of Loss¶

• Loss of active wrist extension results in a permanent wrist drop that makes gripping with the hand very difficult [12].
• Radial palsy involves only a very small sensory deficit on the dorsal aspect of the hand while palmar surface sensibility remains uninvolved [12].
• Loss of active wrist extension robs normal palmar sensibility of its functional capacity [12].
• Loss of active wrist movement has serious repercussions on the action of the extrinsic muscles in the hand [12].
• Flexor action in the thumb and fingers is normally reinforced by extension of the wrist [12].
• Palsy of the wrist extensors involves a great loss of grip strength [12].
• Neither the flexors nor the extensors of the fingers are long enough to allow maximal movements at the wrist and the fingers simultaneously [12].
• Complete flexion of the fingers is possible only if the wrist is in a specific position, as explained by the restraining action of long antagonistic muscles [12].

Neurovascular Anatomy¶

Arterial Supply¶

• The hand is supplied through two main arteries: the radial and the ulnar [14].
• Under normal circumstances, the radial and ulnar arteries are responsible for virtually the entire arterial supply of the hand [14].
• The interosseous arteries, especially the anterior interosseous artery, arise from the common interosseous branch of the ulnar artery [14].
• The interosseous arteries may assume a vital role if either of the main forearm arteries is injured [14].
• In 8–9 per cent of cases, the anterior interosseous artery gives off an artery that accompanies the median nerve, known as the median artery [14].
• The median artery usually anastomoses with the superficial palmar arch [14].
• The deep palmar arch is formed by the terminal part of the radial artery and its anastomosis with the deep branch of the ulnar artery [14].
• The deep palmar arch lies anterior to the upper extremity of the metacarpal shafts [14].
• The deep palmar arch is seldom fully developed, and the deep ulnar branch is often negligible [14].
• The dominance of the radial artery is readily demonstrable by the selective vascular compression test [14].
• The deep palmar arch gives rise to the interosseous (or metacarpal) arteries [14].
• The interosseous artery of the first interspace ramifies into the ulnar palmar collateral, the radial palmar collateral (princeps pollicis), and the radial collateral artery of the index finger [14].
• The superficial palmar arch is formed from the anastomosis of the terminal branch of the ulnar artery with the superficial palmar branch of the radial artery [14].
• On an arteriogram, the superficial palmar arch lies under the deep palmar arch and has a smaller caliber [14].
• The superficial palmar arch is fully developed in only 13–19 per cent of cases [14].
• In 60 per cent of cases, the superficial palmar arch is formed from the ulnar artery alone [14].
• In 32 per cent of cases, the superficial palmar arch is formed from the superficial palmar branch of the radial artery [14].
• In 8 per cent of cases, the superficial palmar arch results from the anastomosis of the median with the ulnar artery [14].
• The superficial palmar arch gives off four collaterals known as the palmar digital arteries [14].
• The palmar digital arteries are, from the ulnar to the radial side, the first, second, third, and fourth digital arteries [14].
• A fifth digital artery is often present, is of small caliber, and anastomoses with the first palmar interosseous artery [14].
• The dorsal carpal arch, when present, is formed by the union of homologous branches from the radial and ulnar arteries [14].
• The interosseous dorsal arteries of the second, third, and fourth interspaces, as well as the medial collateral of the little finger, are formed from the dorsal carpal arch [14].
• Each dorsal interosseous artery splits into two dorsal collateral branches that terminate on the lateral aspects of adjacent fingers [14].
• The dorsal carpal arch can function as a collateral channel between the radial artery and the deep palmar arch [14].
• The dorsal carpal arch often receives a significant contribution from the radial artery [14].
• The palmar carpal arch is much less commonly found and seldom forms a recognizable arcade [14].
• The palmar carpal arch frequently consists of a loose collateral network known as the palmar carpal plexus [14].
• The palmar carpal plexus usually connects the anterior interosseous artery with the radial and ulnar arteries [14].
• The superficial palmar arch lies slightly proximal to the proximal transverse palmar crease in the midline [14].
• The deep palmar arch is approximately 2 cm proximal to the superficial palmar arch [14].

Radial Nerve¶

• The radial nerve is a continuation of the posterior cord [24].
• The roots of the radial nerve emerge at the C6, C7, C8, and T1 levels [24].
• The radial nerve lies at first behind the axillary artery [24].
• The radial nerve runs distally in the arm by winding around the posterior aspect of the humerus from medial to lateral [24].
• The radial nerve continues in the lateral bicipital groove in the cubital fossa [24].
• As it reaches the humeroradial joint line, the radial nerve divides into two terminal branches [24].
• The anterior sensory branch of the radial nerve runs into the forearm under the brachioradialis lateral to the radial artery [24].
• The posterior motor branch of the radial nerve is the posterior interosseous nerve [24].
• The posterior interosseous nerve penetrates the supinator muscle by passing under the arcade of Frohse [24].
• The arcade of Frohse is fibrous in about one-third of cases and may compress the nerve [24].
• The posterior interosseous nerve winds around the neck of the radius between the two heads of the supinator [24].
• In 25 per cent of cases, the posterior interosseous nerve lies flush against the periosteum for about 3 cm (bare area) when the forearm is supinated [24].
• The posterior interosseous nerve is more vulnerable at the level of the bare area [24].
• The posterior interosseous nerve emerges from the supinator in the posterior compartment of the forearm [24].
• The radial nerve supplies all the extensors of the elbow, the wrist, and the fingers [24].
• The sensory territory of the radial nerve is relatively limited to the lateral half of the dorsum of the hand [24].
• The autonomous zone of the radial nerve is restricted to the dorsal aspect of the first interosseous space [24].
• Sensory nerve palsy of the radial nerve is functionally insignificant [24].
• Sectioning of the small sensory branches of the radial nerve at the wrist can give rise to painful neuromas [24].
• In the arm, the anterior (superficial) and posterior (interosseous) divisions of the radial nerve can be traced as funiculi for 7.2–9.0 cm above their point of division [24].
• The single funiculus of the posterior interosseous nerve branches 35 mm distal to its origin, giving a branch to the supinator [24].

Ulnar Nerve¶

• The deep branch of the ulnar nerve can be exposed from its origin as a branch of the main trunk at the wrist to its midpalmar part [6].
• The course of the deep branch of the ulnar nerve can be exposed from the pisiform to the midpalm [6].
• The deep branch of the ulnar nerve can be identified and followed where it passes through the transverse fibers of the adductor pollicis [6].
• The motor component of the ulnar nerve can be dissected from the trunk well into the distal forearm [6].
• The ulnar bursa lines the carpal tunnel and can be freed from the ulnar side of the carpus [6].
• The proximal end of the ulnar nerve can be displaced into the carpal tunnel [6].
• The proximal end of the ulnar nerve can be brought to the midpalm by flexing the wrist [6].
• Branches to the hypothenar muscles may remain intact and can be saved during mobilization of the ulnar nerve bundles [6].
• Recovery of ulnar nerve function can be tested by noting voluntary activity of the first dorsal interosseous muscle [6].

Tendon Anatomy and Landmarks¶

• The extensor tendons are visible with the fingers in active extension and the thumb in abduction [2].
• The abductor pollicis longus and extensor pollicis brevis tendons can be seen between the radial styloid proximally and the base of the first metacarpal distally [2].
• The extensor carpi radialis tendons are only palpable for a short distance proximal to the bases of the second and third metacarpals with the wrist in resisted extension [2].
• The extensor carpi ulnaris tendon is palpable during resisted extension and adduction of the wrist, immediately distal to the ulna styloid until the fifth metacarpal [2].
• On the palmar aspect, the flexor carpi ulnaris is felt in active flexion of the wrist immediately proximal to the pisiform [2].

Vascular and Neural Relations in Volar Wrist Pathology¶

• The majority of volar ganglions occur either directly over the distal edge of the radius or slightly more distally over the scaphoid tubercle [10].
• Volar ganglions arising from the radiocarpal joint occur under the volar wrist crease between the flexor carpi radialis and abductor pollicis longus tendons [10].
• The main cyst of a volar ganglion may be intertwined with bifurcating branches of the radial artery [10].
• Volar ganglions can extend under the thenar muscles, along the flexor carpi radialis tendon, into the carpal canal, and under the first extensor compartment adjacent to the dorsal branch of the radial artery [10].
• The radial artery is frequently intimately attached to the wall of a volar ganglion and may even be completely encircled by it [10].
• Unexpected branches of the radial sensory or lateral antebrachial cutaneous nerves may be injured during volar ganglion excision and lead to troublesome neuromas [10].
• Extensions of the routine incision into the carpal canal must avoid injury to the palmar cutaneous branch of the median nerve [10].

Biomechanics and Function¶

Osseous Anatomy and Joint Structure¶

• The wrist is the anatomic region between the forearm and the hand, including the distal radioulnar, radiocarpal, and ulnocarpal joints, the eight carpal bones, their articulations, and attached ligaments [1].
• The proximal carpal row consists of the scaphoid, lunate, triquetrum, and pisiform [1].
• The distal carpal row consists of the trapezium, trapezoid, capitate, and hamate [1].
• The pisiform and trapezoid are the smallest carpal bones, while the capitate is the largest [1].
• The capitate articulates with seven other carpal bones, whereas the pisiform articulates with only one (the triquetrum) [1].
• The radiocarpal joint is formed by the articulation of the distal radius with the scaphoid and lunate via concave facets, and the triquetrum on the triangular fibrocartilage [1].
• The midcarpal articulation is formed by the distal concave articular surfaces of the proximal carpal row articulating with the distal row [1].
• The distal radial articular surface has a double obliquity of 12–15 degrees in the lateral view and 15–20 degrees in the anteroposterior view [3].
• The posterior lip and radial styloid of the distal radius provide a buttressing effect [3].
• The carpal articular surface has a smaller diameter of curvature than the radius [3].
• The carpus is more stable in flexion than extension due to its anterior concavity [3].
• The distal row of the carpus is quite rigid, while the three proximal row bones are relatively mobile [3].
• The lunate sits on the capitate and has anterior and posterior horns, with a line drawn between these horns lying perpendicular to the long axis of the wrist in neutral position [3].
• The triquetrum is not in contact with the ulnar head; a fibro-cartilage disc separates the two bones [3].

Ligamentous Anatomy¶

• The triangular fibrocartilage complex (TFCC) attaches to the ulnar margin of the lunate fossa of the radius and includes the ulnar collateral ligament, dorsal and volar radioulnar ligaments, articular disc, meniscal homologue, extensor carpi ulnaris sheath, and ulnolunate and ulnotriquetral ligaments [1].
• Interosseous intrinsic ligaments connect the carpal bones in the proximal and distal rows [1].
• The scapholunate and lunotriquetral interosseous ligaments connect the proximal carpal row [1].
• The space of Poirier is a relatively thin area on the palmar side of the carpus, located between the radiolunotriquetral ligament and the radioscapocapitate ligament, overlying the palmar surface of the lunate [1].
• The dorsal intercarpal ligament attaches to the distal, dorsal surface of the triquetrum and passes across the midcarpal joint to attach to the dorsal surfaces of the scaphoid waist and trapezoid [1].

Kinematics and Motion¶

• Wrist mobility is a sum of movements from the radiocarpal, mid-carpal, ulnocarpal, and radioulnar joints [3].
• In vivo kinematic studies using ultrafast CT found that the radiocarpal and midcarpal joints contribute equally to wrist flexion [4].
• The midcarpal joint contributes more to wrist extension than the radiocarpal joint [4].
• During radial-to-ulnar deviation, the proximal carpal row rotates dorsally and intercalates or shifts at the midcarpal and radiocarpal joints [4].
• During ulnar-to-radial deviation, the proximal carpal row tends toward palmar rotation, with most motion occurring in the intercarpal joints [4].
• The proximal carpal row functions as an intercalated segment in the forearm-to-hand connection, with the scaphoid functioning to stabilize the wrist [4].
• The wrist can be considered a two-joint system linking the hand to the forearm around the highly mobile bones of the proximal carpal row [7].
• The two principal articulations of the wrist are the radiocarpal and midcarpal joints, situated proximal and distal to the mobile proximal carpal row [7].
• Global motions of the hand in relation to the fixed forearm include flexion/extension and radioulnar deviation, as well as coupled oblique deviation [7].
• In most individuals, the proximal carpal row rotates predominantly around the flexion-extension axis during radioulnar deviation [7].
• All bones of each carpal row rotate in the same plane during any direction of global wrist motion [7].
• In all but pure flexion/extension of the uninjured wrist, the proximal and distal rows move in divergent directions [7].
• Division of either of the proximal row’s interosseous ligaments in isolation does not result in a postural deformity of the lunate [7].
• Similar collapse deformities of proximal row alignment (VISI or DISI) can occur with or without disruption of an interosseous ligament [7].
• The dart-thrower’s path of radial extension to ulnar flexion defines the transition between flexion and extension of the scaphoid and lunate [7].
• During the dart-thrower’s motion, proximal row motion approaches zero and occurs almost exclusively through the midcarpal joint [7].

Biomechanical Models and Stability¶

• Wrist stability during motion depends on capsuloligamentous integrity and contact surface contours of the carpal bones [4].
• The concept of a wrist consisting of three columns was popularized by Navarro: the central (force-bearing) column, the radial column, and the ulnar (control) column [4].
• In Navarro's model, the central column includes the distal articular surface of the radius, the lunate, and the capitate [4].
• In Navarro's model, the radial column includes the radius, scaphoid, trapezium, trapezoid, and thumb carpometacarpal joint [4].
• In Navarro's model, the ulnar column includes the triangular fibrocartilage (articular disc), hamate, triquetrum, and ring and little finger carpometacarpal articulations [4].
• Taleisnik proposed that the central column includes the entire distal row and the lunate, with the scaphoid as the lateral column and the triquetrum as a rotary medial column [4].
• Lichtman proposed a ring concept of wrist kinematics where interosseous ligaments stabilize semirigid proximal and distal carpal rows [4].
• In Lichtman's ring concept, limited mobility occurs between the scaphotrapezial joints and the triquetrohamate joints [4].
• Bryce (1896) proposed that carpal bones are arranged into two rows moving as rigid functional units about two transverse joints [7].
• Navarro (1935) proposed that the central column controls flexion-extension, the lateral column controls load transfer, and the medial column controls pronosupination [7].
• Gilford et al. (1943) defined the central column as a "link joint" that "crumples" when the scaphoid is fractured or dissociated from the lunate [7].
• Landsmeer (1961) described the "intercalated bone" as a single segment responding to mechanical signals from neighboring phalanges and musculotendinous units [7].
• Linscheid et al. (1972) defined the "intercalated segment" as the lunate and triquetrum, which move synchronously throughout wrist motion [7].
• Linscheid et al. (1972) defined dorsal intercalated segment instability (DISI) and volar intercalated segment instability (VISI) as predominant postures of dissociative carpal instability following ligament disruption [7].
• Taleisnik (1978) modified the columnar theory to include the entire distal row with the lunate as the force-bearing central column, excluding the pisiform from the model [7].
• Weber (1980) proposed three columns: a load-bearing column, a metacolumn, and a thumb column, emphasizing the helicoidal joint between the triquetrum and hamate [7].
• Lichtman et al. (1981) proposed that the carpus functions as an oval ring formed by four interdependent elements connected by ligamentous links [7].
• Craigen and Stanley (1995) identified two predominant patterns of motion during radioulnar deviation: a row pattern (frontal plane rotation) and a column pattern (sagittal plane rotation) [7].
• Crisco et al. (2005, 2011) described the dart-thrower’s motion as occurring along the mechanical axis of the wrist [7].
• Sandow et al. (2014) proposed that the lunate, capitate, hamate, trapezium, and trapezoid function as a "stable central column" controlled by the scaphoid in a two-gear, four-bar linkage system [7].

Common Sites of Injury¶

Distal Radius and Styloid¶

• Fractures of the distal radius are among the most common fractures seen in the emergency department [17].
• Patients of advanced age with osteoporosis have an increased fracture risk during low-energy falls [17].
• Fracture patterns of the distal radius vary depending on the mechanism of injury [17].
• Nondisplaced distal radius fractures are associated with occasional extensor pollicis longus rupture, usually about 4 to 6 weeks after injury [17].
• Fractures of the radial styloid may be associated with scapholunate ligament injuries because the intra-articular fracture line extends into the joint at that level [17].
• Intra-articular displacement or diastasis greater than 2 mm in radial styloid fractures is an indication for surgery [17].

Carpal Bones and Ligaments¶

• The scapholunate interval starts to dissociate in rheumatoid arthritis, continuing to disintegrate the internal carpal architecture [16].
• Volar intercalated segment instability (VISI) occurs following ligament disruption of the proximal carpal row [7].
• Dorsal intercalated segment instability (DISI) occurs following ligament disruption of the proximal carpal row [7].
• The central column of the wrist (radius-lunate-capitate) is mechanically arranged as a "link joint," which "crumples" when the scaphoid is either fractured or dissociated from the lunate by scapholunate ligament injury [7].
• The scaphoid represents the lateral column in the modified columnar theory of wrist kinematics [7].
• The lunate and triquetrum are defined as the "intercalated segment" which moves synchronously throughout wrist motion [7].

Distal Radioulnar Joint (DRUJ)¶

• The distal radioulnar joint is assessed following stabilization of the radius in distal radius fractures [17].
• Only frank dislocation with forearm rotation merits surgery to stabilize the distal radioulnar joint [17].
• The presence of a displaced fracture at the base of the ulnar styloid is not in itself an indication for surgical fixation [17].
• The triangular fibrocartilage complex (TFCC) attaches to the ulnar margin of the lunate fossa of the radius and includes the ulnar collateral ligament, dorsal and volar radioulnar ligaments, articular disc, meniscal homologue, extensor carpi ulnaris sheath, and ulnolunate and ulnotriquetral ligament [1].

Rheumatoid Arthritis Involvement¶

• The wrist is one of the main targets of rheumatoid arthritis that may deteriorate rapidly despite current medical management strategies [16].
• Cumulative incidences of wrist involvement in rheumatoid arthritis are over 70% and 95%, 3 and 11 years after the onset of the disease, respectively [16].
• The classic pattern of deformity and destruction in rheumatoid arthritis involves the radiocarpal and radioulnar joints with destabilization of the carpus caused by attenuation of the extrinsic wrist ligaments [16].
• The result of rheumatoid wrist destruction is ulnar-palmar translocation and wrist supination [16].
• Three main pathophysiological factors play the greatest role in the process of rheumatoid wrist deformation: cartilage destruction, synovial expansion, and ligamentous laxity [16].
• Bony erosion in rheumatoid arthritis arises due to synovial expansion, particularly at the site of vascular penetration into the bone such as the radial origin of the Testut ligament [16].
• Flexion of the scaphoid through the weakening of the scapholunate ligament with subsequent collapse of the radial column is described in rheumatoid arthritis [16].
• Volar flexion of the lunate relative to the scaphoid was reported in 100 early-to-midstage rheumatoid arthritis wrists, caused by intrinsic ligament laxity, mainly of the scapholunate ligament [16].
• At later stages of rheumatoid arthritis, the capitate tends to flex dorsally due to midcarpal instability as a result of extrinsic ligament weakening [16].

Diagnostic Assessment¶

• Palpation for areas of maximal tenderness is one of the most useful tools in the diagnosis of wrist pathology, especially in patients with chronic dysfunctions [18].
• In acute dislocations, tenderness is seldom elicited at specific points but rather in a diffuse manner due to extensive soft tissue damage [18].
• A careful assessment of neural and vascular status is imperative, with particular attention being paid to the median and ulnar nerves, which may be injured by direct contusion, compression from displaced bones, or swelling within the carpal canal [18].
• The triangular fibrocartilage complex must be carefully examined, and the distal radioulnar joint must be assessed for instability in neutral, supination, and pronation [18].
• Ulnar impaction and ulnar styloid impingement must be assessed in pronation and supination [18].
• Nondissociative instability of the carpus is assessed with Lichtman’s midcarpal shift test and the associated "catch up clunk" [18].
• Louis’ CLIP maneuver is used to assess midcarpal instability [18].
• Patients without positive provocative sign on examination seldom yield positive findings at wrist arthroscopy [5].
• Arthroscopic findings need to correlate with clinical examination [5].

Surgical Anatomy¶

Volar Wrist Ganglion Anatomy¶

• Volar wrist ganglions are the second most common ganglion of the hand and wrist, accounting for 18% to 20% of cases [10].
• The majority of volar wrist ganglions occur directly over the distal edge of the radius or slightly more distally over the scaphoid tubercle [10].
• Ganglions arising from the distal edge of the radius originate from the capsular and ligamentous fibers of the radiocarpal joint [10].
• Radiocarpal volar ganglions are located under the volar wrist crease between the flexor carpi radialis and abductor pollicis longus tendons [10].
• The main cyst of a radiocarpal volar ganglion may be intertwined with bifurcating branches of the radial artery [10].
• A second type of volar ganglion arises from the capsule of the scaphotrapezial joint [10].
• Volar wrist ganglions can be multiloculated, extending under the thenar muscles, along the flexor carpi radialis tendon, into the carpal canal, and under the first extensor compartment adjacent to the dorsal branch of the radial artery [10].
• The radial artery is frequently intimately attached to the wall of a volar wrist ganglion and may be completely encircled by it [10].
• Ganglia arising from the interval between the radioscaphocapitate (RSC) and long radiolunate (LRL) ligaments are located at the more lateral aspect of the distal radius [22].
• Ganglia arising from the interval between the long radiolunate (LRL) and short radiolunate (SRL) ligaments are located at a more central position of the distal radius [22].

Dorsal Wrist Anatomy and Compartments¶

• The dorsal wrist approach involves identifying the interval between the first and second dorsal compartments to incise the dorsal carpal ligament [11].
• The extensor carpi radialis longus tendon inserts on the base of the second metacarpal [11].
• The dorsal branch of the radial artery connects to the dorsal carpal arch [11].
• The extensor retinaculum covers the extensor tendons, with the extensor pollicis longus exiting the third dorsal retinaculum compartment [25].
• The dorsal wrist capsule is bounded by the dorsal intercarpal ligament and the dorsal radiotriquetral ligament [25].
• The extensor carpi ulnaris tendon sheath attaches to the base of the fifth metacarpal [8].
• The extensor pollicis longus tendon is at risk of injury during dorsal synovectomy due to its location relative to the retinacular flap [8].

Radiocarpal and Intercarpal Joint Anatomy¶

• The radiocarpal joint includes the distal radius, scaphoid, lunate, and triquetrum [13].
• The intercarpal joints include the scaphotrapezial joint and the articulations between the proximal and distal carpal rows [10, 13].
• The dorsal radiocarpal ligament attaches to the rim of the radius and can be raised as an ulnar-based flap while leaving fibers attached to the hamate and triquetrum [13].
• The Lister tubercle is located on the dorsoradial quadrant of the distal radius [13].
• The capitate articulates with the third metacarpal [13].
• The hamate articulates with the fourth metacarpal [13].
• The fourth carpometacarpal (CMC) joint is mobile [13, 15].
• The second carpometacarpal (CMC) joint is a site for screw fixation in wrist arthroplasty [13, 15].

Nerve and Vascular Anatomy¶

• The superficial branch of the radial nerve is located on the midlateral aspect of the forearm and must be mobilized during dorsal wrist approaches [11].
• Sensory branches of the radial and ulnar nerves are located in the dorsal transverse incision area 5 to 10 mm distal to the radiocarpal joint [25].
• The palmar cutaneous branch of the median nerve is at risk during incision extension into the carpal canal for volar ganglion excision [10].
• The radial sensory nerve and lateral antebrachial cutaneous nerves may be injured during volar wrist ganglion excision [10].
• The Allen test is used to assess the patency of the radial and ulnar arteries preoperatively [10].
• The radial artery is a critical structure to preserve, particularly in patients with a radial-dominant circulation [10].

Arthroscopic Portal Anatomy¶

• The 3-4 portal is used for inspection of the ulnocarpal joint before creating an ulnar wrist portal [5].
• The 1-2 portal is typically used for scope entry and the 3-4 portal for working in the "1234" technique for right-handed surgeons operating on the right wrist [22].
• The 6U portal is used as the outflow portal in arthroscopic volar wrist ganglionotomy [22].
• Portal incisions are made in the skin, with transverse incisions healing better than longitudinal incisions [5].

References¶

[1] Campbell S Operative Orthopaedics 4 Volume Set. NERVE INJURIES AT THE LEVEL OF THE HAND AND WRIST > ANATOMY.

[2] Exam Of The Hand Wrist 2Ed. 2.3 EXAMINATION OF THE MUSCULOTENDINOUS APPARATUS.

[3] Exam Of The Hand Wrist 2Ed. 1.2 SKELETON OF THE WRIST.

[4] Campbell S Operative Orthopaedics 4 Volume Set. NERVE INJURIES AT THE LEVEL OF THE HAND AND WRIST > BIOMECHANICS AND KINEMATICS.

[5] Green S Operative Hand Surgery. AUTHOR'S PREFERRED METHOD OF TREATMENT: ARTHROSCOPIC PARTIAL WRIST FUSION > Diagnostic Wrist Arthroscopy.

[6] Campbell S Operative Orthopaedics 4 Volume Set. NERVE INJURIES AT THE LEVEL OF THE HAND AND WRIST > REPAIR OF THE DEEP BRANCH OF THE ULNAR NERVE.

[7] Green S Operative Hand Surgery. WRIST BIOMECHANICS > Carpal Kinematics.

[8] Campbell S Operative Orthopaedics 4 Volume Set. THUMB CARPODNETACARPAL ARTHRODESIS WITH KIRSCHNER WIRE OR BLADE-PLATE FIXATION > SYNOVITIS OF THE WRIST > DORSAL SYNOVECTOMY.

[9] Exam Of The Hand Wrist 2Ed. The arches of the hand > The transverse arches.

[10] Green S Operative Hand Surgery. BOX 59.1 Ganglions of the Hand and Wrist > Operative Treatment > Volar Wrist Ganglion.

[11] Campbell S Operative Orthopaedics 4 Volume Set. ANATOMIC RECONSTRUCTION OF THE DISTAL RADIOULNAR LIGAMENTS > ARTHRODESIS OF THE WRIST.

[12] Exam Of The Hand Wrist 2Ed. Extension of the wrist > Muscles of wrist extension.

[13] Green S Operative Hand Surgery. Preoperative Evaluation: Total Wrist Arthroplasty > Surgical Technique (Universal II and Freedom) (Video 12.2).

[14] Exam Of The Hand Wrist 2Ed. Arterial supply of the hand.

[15] Green S Operative Hand Surgery. Total Wrist Arthroplasty > Pearls and Technical Points.

[16] Green S Operative Hand Surgery. WRIST INVOLVEMENT IN RA.

[17] Aaos Comprehensive Orthopaedic Review 3. Wrist Fractures and Dislocations, Carpal Dissociation, and Distal Radius Fractures > III. Fractures of the Distal Radius.

[18] Green S Operative Hand Surgery. Diagnosis and Treatment > Assessment of the Symptomatic Wrist.

[19] Tachdjian S Pediatric Orthopaedics From The Texas Scottish Rite Hospital For Children E Book. Wrist Involvement.

[20] Exam Of The Hand Wrist 2Ed. The fibrous skeleton > The fibrous joint capsule and extrinsic capsular ligaments.

[21] Green S Operative Hand Surgery. AUTHOR'S PREFERRED METHOD OF TREATMENT: ARTHROSCOPIC PARTIAL WRIST FUSION > SURGICAL TECHNIQUE FOR DIAGNOSTIC ARTHROSCOPY > Setup.

[22] Green S Operative Hand Surgery. AUTHOR'S PREFERRED METHOD OF TREATMENT: ARTHROSCOPIC PARTIAL WRIST FUSION > Volar Wrist Ganglion.

[24] Exam Of The Hand Wrist 2Ed. Techniques of investigation of the arterial supply by J P Melki > Radial nerve > Functional anatomy (Figure 4.3).

[25] Campbell S Operative Orthopaedics 4 Volume Set. NERVE INJURIES AT THE LEVEL OF THE HAND AND WRIST > OPEN REDUCTION AND INTERNAL FIXATION OF ACUTE DISPLACED FRACTURES OF THE SCAPHOID—DORSAL APPROACH.

[26] Exam Of The Hand Wrist 2Ed. Examination > Radiographic assessment (see pages 226–35).

[27] Aaos Comprehensive Orthopaedic Review 3. Anatomy of the Hand and Wrist > VII. The Wrist.