wrist complex

1. The Wrist
Complex
PRESENTED BY : USMAN FAROOQ

2. The Wrist Complex
 The wrist (carpus) consists of two compound joints:
 The radiocarpal and the
 midcarpal joints,
referred to collectively as the wrist complex

3. Wrist Complex

4.  The shoulder serves as a dynamic base of support; the
elbow allows the hand to approach or extend away
from the body; and the forearm adjusts the approach
of the hand to an object.
 The major contribution of the wrist complex seems to
be to control length-tension relationships in the multi
articular hand muscles and to allow fine adjustment of
grip.

5.  The wrist has been called the most complex joint of
the body, from both an anatomic and physiologic
perspective.
 The wrist complex as a whole is considered to be
biaxial, with motions of
 extension/flexion around a coronal axis
 ulnar deviation/radial deviation around an
anteroposterior axis.

6. Normal ranges are cited as
 Wrist flexion, 65 to 85
 extension 60 to85 ,
 radial deviation 15 to 21
 ulnar deviation 20 to 45

7. Radiocarpal Joint Structure
 The radiocarpal joint is formed by the radius and
radioulnar disk as part of the triangular fibrocartilage
complex (TFCC) proximally and by the scaphoid,
lunate, and triquetrum distally

8. Triangular fibrocartilage
complex (TFCC)
 The TFCC is essentially comprised of the
fibrocartilage disc interposed between the
medial proximal row and the distal ulna
within the medial aspect of the wrist
 The primary function of the TFCC is to
improve joint congruency and to cushion
against compressive forces
 The TFCC transmits about 20% of the axial load
from the hand to the forearm

9. Anatomy
 The Wrist
 Comprised of the distal radius and ulna,
eight carpal bones, and the bases of five
metacarpals
 The carpal bones lie in two transverse rows
 The proximal row contains (lateral to medial)
the scaphoid (navicular), lunate, triquetrum, and
pisiform
 The distal row holds the trapezium, trapezoid,
capitate, and hamate

10. Anatomy
 Mid Carpal Joints
 The midcarpal joint lies between the two
rows of carpals
 A ‘compound’ articulation because each
row has both a concave and convex
segment
 The proximal row of the carpals is convex
laterally and concave medially.
 The scaphoid, lunate, trapezium trapezoid, and
triquetrum present with a concave surface to
the distal row of carpals

11. Anatomy
 Carpal Ligaments
 The major ligaments of the wrist include the palmar
intrinsic ligaments, and the dorsal extrinsic and intrinsic
ligaments
 The extrinsic palmar ligaments provide the majority of the
wrist stability
 The intrinsic ligaments serve as rotational restraints, binding
the proximal row into a unit of rotational stability

14. Anatomy
 Radiocarpal Joint
 Formed by the large articular concave surface of the
distal end of the radius, the scaphoid and lunate of the
proximal carpal row, and the TFCC

15. Anatomy
 Antebrachial Fascia
 A dense connective tissue ‘bracelet’ that encases the
forearm and maintains the relationships of the tendons
that cross the wrist

16. Anatomy
 The Extensor Retinaculum
 This retinaculum serves to prevent the tendons
from ‘bow-stringing’ when the tendons turn a
corner at the wrist

18. Anatomy
 The extensor retinaculum compartments,
from lateral to medial, contain the
tendons of:
 Abductor pollicis longus and extensor pollicis
brevis
 Extensor carpi radialis longus and brevis
 Extensor pollicis longus
 Extensor digitorum and indicis
 Extensor digiti minimi
 Extensor carpi ulnaris

19. Anatomy
 The Flexor Retinaculum
 Transforms the carpal arch into a tunnel,
through which pass the median nerve and
some of the tendons of the hand
 Proximally, the retinaculum attaches to the
tubercle of the scaphoid and the pisiform
 Distally it attaches to the hook of the hamate, and
the tubercle of the trapezium
 In the condition known as ‘carpal tunnel
syndrome’ the median nerve is compressed in
this relatively unyielding space

20. Anatomy
 Carpal Tunnel
 Serves as a conduit for the median nerve and
nine flexor tendons
 The palmar radiocarpal ligament and the palmar
ligament complex form the floor of the canal
 The roof of the tunnel is formed by the flexor
retinaculum (transverse carpal ligament)
 The ulnar and radial borders are formed by carpal
bones (trapezium and hook of hamate
respectively)
 Within the tunnel, the median nerve divides into a
motor branch and distal sensory branches

21. Anatomy
 Tunnel of Guyon
 A depression superficial to the flexor
retinaculum, located between the hook of the
hamate and the pisiform bones
 The palmar (volar) carpal ligament, palmaris brevis
muscle, and the palmar aponeurosis form its roof
 Its floor is formed by the flexor retinaculum
(transverse carpal ligament), pisohamate ligament,
and pisometacarpal ligament
 The tunnel serves as a passage way for the
ulnar nerve and artery into the hand

22. Biomechanics
 The wrist contains several segments whose combined
movements create a total range of motion that is
greater than the sum of its individual parts

23. Biomechanics
 Pronation
 Approximately 90° of forearm pronation is available
 During pronation, the concave ulnar notch of the radius
glides around the peripheral surface of the relatively fixed
convex ulnar head
 Pronation is limited by the bony impaction between the
radius and the ulna

24. Biomechanics
 Supination
 Approximately 85-90° of forearm supination is available
 Supination is limited by the interosseous membrane, and
the bony impaction between the ulnar notch of the radius,
and the ulnar styloid process

25. Biomechanics
 Wrist flexion and extension
 The movements of flexion and extension of the wrist are
shared among the radiocarpal articulation, and the
intercarpal articulation, in varying proportions

26. Biomechanics
 Wrist flexion and extension
 During wrist flexion, most of the motion
occurs in the midcarpal joint (60% or 40°
versus 40% or 30° at the radiocarpal joint), and
is associated with slight ulnar deviation and
supination of the forearm
 During wrist extension, most of the motion
occurs at the radiocarpal joint (66.5% or 40°
versus 33.5% or 20° at the midcarpal joint),
and is associated with slight radial deviation
and pronation of the forearm

27. Biomechanics
 Radial Deviation
 Radial deviation occurs primarily between the proximal
and distal rows of the carpal bones
 The motion of radial deviation is limited by impact of the
scaphoid onto the radial styloid, and ulnar collateral
ligament

28. Biomechanics
 Ulnar deviation
 Ulnar deviation occurs primarily at the radiocarpal joint
 Ulnar deviation is limited by the radial collateral ligament

29. Clinical Examination
of the
Wrist Joint

31. HISTORY
 Age
 Chief complaint
 Occupation
 Previous injury
 Previous surgery
 What exacerbates
 What improves
 Frequency
 Duration

32. HISTORY
 4 principle
mechanisms of injury
 Throwing
 Weight bearing
 Twisting
 Impact

33. PHYSICAL EXAM
 Inspection
 Palpation
 Range of Motion
 Neurologic Exam
 Special Tests

34. Ganglion
 Cystic structure that
arises from synovial
sheath
 Discrete mass
 Dull ache
 Dorsal or Volar aspect

35. RANGE OF MOTION
 Active range of motion
 Passive range of motion if unable to actively move joint
 Bliateral comparison
 To determine degrees of restriction

36. RANGE OF MOTION
Wrist
 Flexion
 Extension
 Radial deviation
 Ulnar deviation
 Ulnar deviation is
greater than radial

37. PALPATION of Wrist Dorsum
 Radial Styloid
 Scaphoid
 1st MC/Trapezium jt
 Lunate
 Lister’s Tubercle
 Ulnar Styloid
 TFCC
 Triquetrum
 Pisiform
 Hook of Hamate
 Guyon’s Tunnel

38. Radial Styloid palpation
Scaphoid Bone palpation
Radial styloid

39. Scaphoid Fracture
 Most commonly fractured carpal bone
 70-80% of all carpal bone injuries
 8% of all sports related fractures
 1 in 100 college football players
 Most susceptible to injury
 Bridges proximal and distal rows of the carpal bones
 Load to the dorsiflexed wrist as in fall onto outstretched hand

40. Scaphoid Fracture
 Painful, swollen wrist after a fall
 Tenderness in snuffbox
 High frequency of nonunion and avascular necrosis
 Initial x-rays often unremarkable

41. 1st MC/Trapezium joint palpation

42. Lunate Bone palpation

43. Scapholunate Dissociation
 Diagnosis often missed
 Pain, swelling, and decreased ROM
 Pressure over scaphoid tuberosity elicits pain
 Greatest pain over dorsal scapholunate area,
accentuated with dorsiflexion
 X-ray shows widening of scapholunate joint space by
at least 3 mm

44. Ulnar Styloid palpation
Lister’s Tubercle palpation
Ulnar styloid

45. Triangular Fibro-Cartilage Complex
palpation (TFCC)

46. Triangular Fibrocartilage Complex
Injuries
 Thickened pad of connective tissue that functions as a cushion
for the ulnar carpus as well as a sling support for the lunate and
triquetrum
 Injury from compression between lunate and head of ulna
 Breaking fall with hand
 Rotational forces-racket and throwing sports

47. Triangular Fibrocartilage Complex
Injuries
 Ulnar sided wrist pain,
swelling, loss of grip
strength
 “Click” with ulnar
deviation
 Point tenderness
distal to ulnar styloid
 TFCC load test

48. Carpal Tunnel
 Deep to palmaris
longus
 Contains median
nerve and finger
flexor tendons
 Most common
overuse injury of
the wrist

49. Carpal Tunnel Syndrome
 Entrapment of the median nerve
 Phalen’s and Tinel’s Test
 2 point discrimination
 Symptoms
 Aching in hand and arm
 Nocturnal or AM paresthesias
 “Shaking” to obtain relief

50. Carpal Tunnel Tests
 Neurologic exam
 Median nerve
sensation and motor
 Phalen’s Test:
both wrists maximally
flexed for 1 minute
 Tinel’s Test

51. NEUROLOGIC EXAM
 Muscular assessment using grading system
 Sensation testing
 Bilateral comparison

52. NEUROLOGIC EXAM
Muscle Testing
 WRIST
EXT C6
FLEX C7
 FINGERS
EXT C7
FLEX C8
ABD T1
ADD T1

53. Sensation Testing
Dorsal hand Radial hand