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70

Anatomy and Biomechanics of


the Hand and Wrist
JOHN V. INGARI ROBERT E. ATKINSON

Hand
The human hand is the athletes tactile connection to his or
her sport. Our hands are virtually linked to every sport via a
handle, a stick, a glove, or even our bare fingers. Athletes may
be said to have good hand-eye coordination, good ballhandling skills, or even quick hands, but in each case the
relationship between the sport and the athletes hands is
obvious. Hand anatomy and biomechanics form the framework for understanding the human ability to grip, let go, cup,
spread, flex, extend, and even strike, using the most complex
anatomic tool of our bodies. The wrist, forming the linkage
between the forearm and the hand, is discussed later in this
chapter because it allows our hands to be placed in a multitude of positions and is integral in the interactions that lead
to throwing, catching, twisting, or any of the innumerable
actions that our hands can perform.

Skin
The skin of the hand is specialized to allow the complex
activities we take for granted. Complex dermatoglyphics, our
fingerprints, each unique to an individual, allow optimal
grip of smooth objects, like a baseball, much like the ribbed
sole of a running shoe allows grip to a smooth basketball
court.1 The skin on the palmar surface of the hand is tethered
by septae to the underlying tissues to minimize the natural
tendency of our skin to slide over underlying fat and fascia.
This tethering of the palmar skin improves grip as well, creating a sturdy surface for tight grasping. Even the moisture on
our fingertips is modulated to allow optimal grip.1 Compare
the skin on the dorsum of the hand (Fig. 70-1, A) which is
easily pulled and stretched, to that on the palm of our hands
(Fig. 70-1, B), which is firmly tethered to the deeper structures. The septae of Legueu and Juvara form the specialized
tethers to the deeper tissue and ligamentous structures in the
palm of the hand that limit the skin mobility on the palmar
surface, thereby optimizing grip.2 Several reproducible lines
on the palms of our hands allow flexion not just of the fingers
but controlled collapse of the skin on the palm as well. The
thenar, proximal palmar, and distal palmar creases are the
visible lines that are evident on uninjured hands (Fig. 70-2,
A). The creases on the palmar side of the fingers, namely the
palmar digital crease, proximal interphalangeal (PIP) flexion

crease, and distal interphalangeal (DIP) flexion crease, also


accommodate the specialized tethered skin on our palms and
fingers while allowing full flexion and extension (Fig. 70-2,
B). The creases of the palm and the digits also allow communication of anatomic locations on the hand. For example,
a 1cm transverse laceration at the level of the proximal
palmar crease in line with the middle finger ray communicates the exact location of a hand laceration within the palm.
Additionally, these creases often provide frames of reference
for underlying structures, which aids in planning surgical
incisions.

Nerves
Sensory nerves in the hand are the terminal branches of the
radial, ulnar, and median nerves. The nerves of the fingertip
pads that allow fine sensation are the terminal branches of the
median and ulnar nerves. Although anatomic variability
exists, the median nerve innervates the volar thumb, index,
middle, and radial half of the ring finger, whereas the ulnar
half of the ring finger and the small finger are innervated by
ulnar nerve terminal branches. The main nerve branches
within the fingers are termed proper digital nerves and are
further designated as radial or ulnar based on which half of
the finger is being described (Fig. 70-3). The radial nerve
provides sensation to the dorsum of the hand and digits, but
its terminal branches do not technically reach the tip of any
digit. Dermatomal diagrams delineate the actual areas innervated by individual nerve roots (primarily C6 to C8 in the
hand), although some individual variation exists. It is the fine
tactile sensation in the hand that allows us to feel surfaces,
easily sensing the difference between the edge of a quarter and
the edge of a nickel, for example. Normal two-point discrimination, our ability to sense two separate points of contact
on our fingertips, is generally accepted as 5mm (Fig. 70-4,
A and B).

Muscles and Tendons


The muscles and tendons of the hand are the motors and
linkages that work the joints, allowing the flexion, extension,
and opposition that occur fluidly and seemingly effortlessly
in our hands with nearly every task of everyday life. The
muscles are divided into those that are intrinsic to the hand,
807

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808

Elbow, Wrist, and Hand

FIGURE 70-1 A, The skin on the dorsum of the hand is relatively smooth and elastic, allowing the skin to be easily slid or stretched, as
seen here. B, The palmar skin is creased, fingerprinted, and tethered to the underlying tissues to allow optimal grip and tactile sensation of
objects held in the hand.

meaning they originate and terminate within the hand, and


the extrinsic muscles, which originate more proximally in the
forearm but terminate in the hand. The intrinsic muscles are
the lumbrical, the dorsal and palmar interossei, and the thenar
and hypothenar muscles. The thenar muscles are specifically
named abductor pollicis brevis, flexor pollicis brevis, and
opponens pollicis. The hypothenar muscles, similarly, are

named abductor digiti minimi, flexor digiti minimi, and


opponens digiti minimi. Four dorsal interosseous muscles
serve to abduct the digits, whereas the three palmar interosseous muscles cause adduction of the fingers. All of the interossei are innervated by the ulnar nerve. The lumbrical muscles
have been given the moniker workhorse of the extensor
mechanism.3 The lumbrical muscles course on the radial side

DIP crease

PIP crease
Distal palmar crease
Palmar digital
crease
Proximal palmar crease

Thenar crease

IP crease

FIGURE 70-2 A, The proximal palmar crease, distal palmar crease, and thenar crease are normal creases found in most hands. Occasional
variations occur. B, The creases of the thumb and digits are shown, including the palmar digital crease, the proximal interphalangeal (PIP)
crease, and the distal interphalangeal (DIP) crease. The thumb has only an interphalangeal (IP) crease as shown.

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Anatomy and Biomechanics of the Hand and Wrist

809

which flex the proximal and distal interphalangeal joints in


the fingers, respectively (Fig. 70-6, A and B). Both the flexor
digitorum superficialis and FDP tendons run through the
carpal tunnel, across the hand, and into the fingers. The
extrinsic extensor muscles of the hand will be discussed in
the wrist section, because all of these muscles cross the wrist
joints but may act either at the wrist, digits, or thumb.

Joints
The joints in the hand are primarily hinge, or ginglymus,
joints but also allow some translational and rotational
moments. This mechanism is especially true at the MCP
joints, which gives us an ability to spread our fingers, slightly
rotate them, and fine-tune our grip of both large and small
objects.
FIGURE 70-3 The common digital nerve to the middle and ring
fingers in the palm can be seen to bifurcate and give off the radial
digital nerve to the ring finger and the ulnar digital nerve to the
middle finger.

of each metacarpal, then travel via the radial lateral bands to


join in confluence with the extensor mechanism. The lumbrical muscles and their tendinous extension run palmar to the
axis of rotation at the metacarpophalangeal (MCP) joint but
dorsal to the axis of rotation at the PIP and DIP joints. Therefore when the lumbrical muscles contract, flexion occurs at
the MCP joint and extension occurs at the PIP and DIP joints
(Fig. 70-5, A and B). Interestingly, the lumbrical muscles
originate on the flexor digitorum profundus (FDP) tendon
just distal to the carpal tunnel and then insert via the radial
lateral bands into the extensor mechanism. The action of the
FDP and lumbrical muscles are antagonistic, and thus this
unique arrangement allows the contraction of one muscle to
maximally relax the other.
The extrinsic flexors in the hand are the flexor pollicis
longus, which causes flexion of the interphalangeal joint of
the thumb, and the flexor digitorum superficialis and FDP,

Metacarpophalangeal Joint of the Fingers


The bony architecture of the MCP joint allows for significant
motion, including hyperextension and flexion in the sagittal
plane, adduction/abduction in the frontal plane, and rotatory
motion of the base of the proximal phalanx (P-1) on the
metacarpal head. The cartilaginous surface of the metacarpal
head has a trapezoidal shape, being broader on the palmar
surface. MCP joint stability is dependent on surrounding collateral and accessory collateral ligaments, volar plate, capsule,
and extrinsic flexor and extensor tendons.4 The collateral and
accessory collateral ligaments provide lateral static stability.
The collateral ligaments originate dorsal to the metacarpal
head axis of motion and insert into tubercles on the sides of
the P-1. Accessory collateral ligaments have their origin
palmar to the proper collateral ligaments and insert into the
palmar base of P-1 and the volar plate.2 Because of the dorsal
metacarpal origin of the collateral ligaments and the cam
shape of the metacarpal head in the sagittal plane, the ligaments have laxity in extension but are taut in flexion.2 This
characteristic is the basis for the recommendation that most
hand injuries be splinted with the MCP joints in full flexion,
or the so-called safe position.5 The safe position for the
interphalangeal joints is in extension because of disparate

FIGURE 70-4 A, Two-point discriminators, like the ones pictured, are necessary tools to evaluate the sensory examination of the fingertips.
B, Normal two-point discrimination is 5mm or less. The patient should be able to feel the two metal prongs as two separate stimuli when
they are 5mm apart. If the patient is unable to feel two points at a spread of 15mm, the area is completely insensate.

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810

Elbow, Wrist, and Hand

FIGURE 70-5 A, The lumbrical musculotendinous unit runs palmar to the axis of rotation at the metacarpophalangeal (MCP) joint, then
courses dorsal to the axis of rotation at the proximal interphalangeal and distal interphalangeal joints. B, The lateral band of the extensor
mechanism is outlined in this surgical case. Notice that it is palmar to the axis of rotation at the MCP joint and then becomes dorsal as it
travels distally.

anatomy at the PIP and DIP joints.6 Accessory collateral ligaments, along with interosseous and lumbrical tendons,
provide additional lateral (adduction/abduction) stability. The
volar plate provides a block to hyperextension and constitutes
the third side of the anatomic box that provides static MCP
stability. The volar plate has a broad, firm distal attachment
to P-1 and a membranous loose origin from the metacarpal
neck. The laxity of the collateral ligaments in extension places
the volar plate at risk of rupture (usually proximally) with
excessive or forceful MCP hyperextension. The dorsal capsule
is relatively loose, and the extrinsic extensor tendons extend
the MCP joint through the sagittal bands attachment to the
base of P-1 and the volar plate.3
Proximal Interphalangeal Joint
The PIP joint is a highly congruous hinge joint, with stability
provided by the matching articular surfaces of the phalanges

and the combination of a thick volar plate and stout collateral


ligaments (see Fig. 70-4). The tight fit of the opposing articular contours increases stability, especially when the PIP is
under axial load.3 The collateral ligaments are thick and composed of proper and accessory components. The proper ligaments insert into the base of the middle phalanx (P-2) and
the volar plate, whereas the accessory collateral ligaments
insert only into the volar plate. The volar plate is very thick
distally where it inserts into the volar lip of P-2, whereas
proximally it thins out and has two proximal projections that
attach to P-1, called the check rein ligaments. This arrangement allows the PIP joint to flex more than 110 degrees. The
condyles of the head of P-1 are not cam shaped, and the PIP
joint does not get permanently stiff when immobilized in full
extension. On the contrary, the PIP joint has a propensity to
develop flexion contracture, with shortening of the volar
plate, when immobilized or held in a flexed position as the

Flexor digitorum
profundus (FDP)

Distal phalanx
insertion

FIGURE 70-6 A, The flexor digitorum profundus (FDP) tendon, schematically shown here in red, inserts into the palmar aspect of the
distal phalanx, causing flexion of the distal interphalangeal (DIP) joint when the muscle belly contracts. B, This surgical image depicts the
actual FDP tendon, just prior to being reattached after rupture. Reattaching the tendon surgically restores the ability to flex the DIP joint.

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Anatomy and Biomechanics of the Hand and Wrist

result of an injury. PIP flexion contractures are most pronounced after trauma to the ring and small digits. Eaton
described the soft tissue constraints of the PIP joint as three
sides of a box; instability occurs when at least two sides of
this box are disrupted.4 The central slip of the extensor apparatus attaches at the dorsal epiphysis of P-2 and is frequently
avulsed in volar PIP dislocations from a hyperflexion mechanism of injury. The PIP joint is notorious for the challenges
posed by intraarticular injury and the consequences of poor
management, often leading to recalcitrant stiffness.

Distal Interphalangeal Joint


Like the PIP joint, the DIP joint acts as a hinge. It allows
flexion and extension, but its bony and ligamentous anatomy
effectively eliminates lateral motion and minimizes rotation.
Digital DIP flexion is provided through contraction of the FDP,
and DIP extension occurs via the contraction of the lateral
bands, which coalesce into a terminal extensor tendon insertion at the distal phalanx dorsal epiphysis.3 Common sportsrelated injuries involving the DIP joint are mallet finger,
which refers to an avulsion of the terminal extensor mechanism, and jersey finger, which refers to a disruption to the
FDP tendon at its insertion (Fig. 70-7, A and B). These entities
will be further discussed in Chapter 77.
Thumb
The human thumb is unique in its ability to provide circumduction and opposition to the other digits, giving the human
hand its superb functional capacity to grasp, pinch, and

Torn tendon of
flexor digitorum
profundus

811

oppose. Athletes and physicians alike are familiar with the


thumbs crucially important role in hand function through
sporting activity. Whether an athlete handles a ball, a pole, or
a stick or checks reins, the opposable thumbs function is
indispensable in the interaction of the athlete with his or her
competitive environment. Essential functions of large object
(cylindrical) grasp, key (power) pinch, and tip (precision)
pinch are dependent on normal thumb stability, mobility,
sensibility, and length. The thumb is frequently injured
because of its location out of the plane of the palm and its
involvement in the most demanding of tasks.
Because of the thumbs specific osseous makeup, with a
specialized basilar joint, along with its at-risk position,
injury patterns in the thumb are unique. For example,
the MCP joint is more exposed than the corresponding
joint in the digits, leading to a higher incidence of collateral
ligament tears in the thumb. Injuries to the thumb
require special attention, because the thumbs functions
are unique and highly dependent on ligamentous, bony,
and tendinous integrity. Further discussion of specific thumb
injuries are also covered in Chapter 77.

Wrist
The hand and wrist are intimately linked, and therefore any
study of the anatomy and biomechanics of the hand and the
wrist as a single functional unit is both appropriate and essential. Although the biomechanics of each individual articulation in the wrist are unique and separate from the biomechanics
in each of the digits, the conglomerate actions of both hand
and wrist are necessary in essentially all sports. Throwing a
baseball, for example, involves complex interactions of finger
flexion, grip, and extension, coupled with motions of wrist
extension and radial deviation, followed by wrist flexion and
ulnar deviation to achieve the goal of directed, accurate, ball
release.7 Virtually all sports, from baseball, basketball, football, swimming, and even ping-pong, depend on the complex
interactions of the hand and wrist to allow successful performance.8 This section will focus on the integral linkage of the
hand to the forearm.
The wrist in the adult athlete is amazingly complex. Understanding wrist anatomy and kinematics helps explain why this
complex arrangement of bones, ligaments, tendons, and neurovascular structures is susceptible to athletic injury. This
section will outline the anatomy, kinematics, and some pertinent physical examination findings in the wrist. Discussion of
the various specific injuries, their diagnosis, treatment options,
and authors preferred methods are presented in other chapters, with emphasis on the athlete as the patient and return
to sports as the goal.

Wrist Anatomy and Biomechanics

B
FIGURE 70-7 A jersey finger occurs when the flexor digitorum
profundus tendon is disrupted or torn from its attachment to the
distal phalanx (A). There is resultant loss of the normal flexion
cascade of the digits, and the involved finger remains extended at
rest (B).

The bony anatomy of the wrist, or carpus, comprises eight


carpal bones and their articulations with one another, as well
as with the radius, ulna, and metacarpals (Fig. 70-8). The
scaphoid, lunate, triquetrum, hamate, capitate, trapezoid, trapezium, and pisiform create a uniquely mobile, interconnected bony network that allows motion in a limitless number
of planes. For example, the motion involved in throwing a
dart exemplifies the combination of the wrist moving from
relative extension and radial deviation to a position of flexion

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Elbow, Wrist, and Hand

FIGURE 70-8 A, A posteroanterior radiograph of the carpus, with each of the carpal bones identified. C, Capitate; H, hamate; L, lunate;
P, pisiform; S, scaphoid; Td, trapezoid; Tq, triquetrum; Tz, trapezium. B, Artists rendition of the dorsal view of the carpus. C, A threedimensional computerized tomogram depicting a volar view of the carpus. Notice how the hook of the hamate projects palmarly.

and ulnar deviation in a fluid, almost effortless action.8-10 The


simplistic motion of the dart throw belies the complexity of
muscle action, tendon excursions, and carpal bone movements that is occurring in the wrist, simultaneous with grip
and release in the hand. Most of this natural motion occurs
not through the radiocarpal joint but rather through the midcarpal joint, which obviously has implications not only for
the initial understanding of injury, but also for methods of
rehabilitation after nonoperative and operative treatment of
various injuries.
The basic carpal anatomy and kinematics have been
likened to an oval ring,6,11 a proximal and distal row,12-14 and
three columns,15 as well as combinations of these descriptions. Each of the carpal bones has a ligamentous attachment
to the adjacent bone within its row. These attachments are the
intrinsic intercarpal ligaments, such as the scapholunate ligament and lunotriquetral ligament joining the adjacent bones
in the proximal row. The scapholunate ligament is stouter on
the dorsal aspect, whereas the lunotriquetral ligament is
stouter on the palmar aspect. The extrinsic ligaments, conversely, provide connection between the carpals and the
radius and ulna proximally, as well as to the metacarpals
distally. Extrinsic ligaments include the radiocarpal ligaments
and the carpometacarpal ligaments. The radiocarpal ligaments
are more stout on the palmar aspect than on the dorsal aspect
and are usually best seen during wrist arthroscopy from
within the joint.16 Viewed arthroscopically, the radialmost
volar extrinsic ligament is the radioscaphocapitate ligament.
Progressing in the ulnar direction, next is the long radiolunate
ligament, followed by the radioscapholunate (RSL) ligament.
The RSL ligament is directly in line with the articulation
between the scaphoid and the lunate when viewed arthroscopically and is otherwise known as the ligament of Testut. It is
primarily a vascular structure, contributing little structural
support. Immediately ulnar to the RSL ligament is the short
radiolunate ligament. Continuing further in the ulnar direction is the ulnolunate ligament, followed by the ulnotriquetral
ligament. The two primary dorsal extrinsic radiocarpal ligaments are the dorsal radiotriquetral (radiocarpal) ligament

and the dorsal intercarpal ligament. All extrinsic wrist ligaments are thickenings of the joint capsule, which underscores
the complexity of providing stability while allowing free,
unhindered movement of the wrist. Pathology involving any
of these ligaments, whether intrinsic or extrinsic, may lead to
pain, limitation of motion, and eventually carpal arthritis and
collapse.15

Extensor Tendons of the Wrist and Hand


Any thorough discussion of wrist anatomy needs to include
the extensor tendons as they cross the wrist. The six dorsal
compartments of the wrist are arranged in numeric order from
radial to ulnar, and each compartment houses one or more
wrist, hand, or digital extensor (Fig. 70-9). Beginning radially,
the first dorsal compartment houses the tendons of the abductor pollicis longus (APL) and the extensor pollicis brevis. The
APL inserts on the base of the thumb metacarpal and abducts
the thumb ray. The extensor pollicis brevis, a more diminutive
tendon that lies dorsal to the APL, is attached to the base of
the proximal phalanx of the thumb, and its action is extension
of the thumb MCP joint. The second dorsal compartment
comprises two tendons, the extensor carpi radialis longus and
the extensor carpi radialis brevis. These wrist extensors and
insert dorsally at the bases of the index and middle finger
metacarpals, respectively. The third dorsal compartment has
only a single tendon, the extensor pollicis longus. The tendon
turns 40 degrees radially as it courses around the ulnar aspect
of Listers tubercle and then runs obliquely across the carpus,
inserting into the dorsum of the base of the distal phalanx of
the thumb. Its primary action is to extend the interphalangeal
joint of the thumb (Fig. 70-10). The fourth dorsal compartment houses the tendons of the extensor digitorum communis
and extensor indicis proprius. These tendons, via the central
slips of the extensor mechanism, insert onto the dorsal aspect
of the base of the middle phalanx of the index through small
fingers. Although their primary function is MCP extension
through the sagittal bands, they also participate via a complex
mechanism in the extension of the interphalangeal joints

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Anatomy and Biomechanics of the Hand and Wrist

FIGURE 70-9 The extensor compartments of the wrist are depicted


here in an artists rendering. The compartments are from radial to
ulnar: 1, Abductor pollicis longus and extensor pollicis brevis;
2, extensor carpi radialis longus and extensor carpi radialis brevis;
3, extensor pollicis longus; 4, extensor digitorum communis and
extensor indicis proprius; 5, extensor digiti minimi; and 6, extensor
carpi ulnaris.

813

FIGURE 70-11 The extensor indicis proprius allows independent


extension of the index finger even when the other digits are maximally flexed.

small finger metacarpal, allows wrist extension and ulnar


deviation simultaneously.

Wrist Flexors
along with the lumbrical and interosseous muscles. The
extensor indicis proprius allows independent extension of the
index finger, even when the remaining digits are held in
flexion (Fig. 70-11). The fifth dorsal compartment, which
overlies the distal radioulnar joint, contains the tendon of the
extensor digiti minimi. This tendon allows independent
extension of the small finger via its insertion onto the dorsal
aspect of the middle phalanx of small finger. The sixth dorsal
compartment, coursing intimately upon the dorsal ulnar
aspect of the ulnar head, comprises the tendon of the extensor
carpi ulnaris. This tendon, via its insertion at the base of the

Three primary wrist flexors cross the wrist, with their respective muscle bellies lying further proximal in the forearm. They
are the flexor carpi radialis (FCR), palmaris longus (PL), and
flexor carpi ulnaris (FCU). These three, in particular the FCR
and FCU, are the primary wrist flexors of the human wrist.
The FCR courses adjacent to the scaphotrapezial articulation
and inserts at the base of the second metacarpal. The FCU
blends into the sesamoid pisiform at the volar ulnar wrist.
Interestingly, 13% to 15% of normal adults do not have a PL,
although the actual number varies depending on the population studied.7 The PL is often used as a tendon autograft in
upper extremity reconstructive procedures to replace tendinous deficits or augment ligamentous stability.

Vascular Anatomy

FIGURE 70-10 The extensor pollicis longus tendon, seen coursing


obliquely across the dorsal wrist and hand, extends the interphalangeal joint of the thumb.

The vascular supply to the wrist and hand is from a rich


network of anastomosing vessels that originate primarily from
the radial artery, ulnar artery, and interosseous arteries (Fig.
70-12). Gelbermans classic cadaveric studies17,18 delineated
three dorsal arches and three palmar arches that are longitudinally fed by the radial artery laterally and the ulnar artery
medially.17 These arches, along with several recurrent branches,
form a rich network of vessels supplying the carpus and hand.
On the palmar side, the most distal arch is the superficial
palmar arch, formed by the main continuation of the ulnar
artery with an anastomosis to the radial artery in most hands.
The deep palmar arch is located more proximal and is formed
by the anastomosis of the radial artery and the deep branch
of the ulnar artery. The superficial palmar arch courses immediately distal to the distal edge of the transverse carpal

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814

Elbow, Wrist, and Hand

or a baseball bat, and virtually move in any and all directions


during sporting activity. The actions of the hand and wrist are
intimately coordinated, as ball release, mainly a finger function, follows closely after the wrist is snapped from a dorsal
and radial cocked position into a palmar and ulnar followthrough position. Any injury to the hand or wrist may lead
to a loss of function, as well as pain, impairing participation
in virtually all athletic endeavors. This chapter has touched
on the anatomy and biomechanics of the wrist and hand to
provide the reader with a basic understanding of the underpinnings of their structure and function, as well as some
general history, physical, and radiologic evaluation tools that
are such a vital part of what we do as physicians every day.
For a complete list of references, go to expertconsult.com.
Suggested Readings
FIGURE 70-12 Vascular anatomy of the carpus. The proximal and
distal palmar arches are part of a rich anastomotic blood supply of
the wrist. Bottom arrow, Radiocarpal arch; middle arrow, deep
palmar arch; top arrow, superficial palmar arch.

ligament. Gelberman etal.17,18 also described the arterial


anatomy of the carpal bones themselves, and specifically
noted that single vessels supply the scaphoid, capitate, and
87% of lunates examined, which explains why those three
bones are at risk for vascular compromise with fractures or
other trauma. The vascular anatomy of the wrist and the
carpal bones most at risk for osteonecrosis have been reexamined by Botte etal.,19 confirming Gelbermans original work.

Summary
The hand and wrist comprise a complex array of tendons,
muscles, nerves, arteries, and bones that all come together,
not just anatomically, but functionally, to allow the athlete to
effortlessly throw a baseball or a dart, swing a tennis racket

Citation: Garcia-Elias M: Carpal Instabilities and Dislocations. In Green


DPH, RN, Pederson WC, editors: Greens Operative Hand Surgery, vol 1,
ed 5, New York, 2005, Elsevier.
Level of Evidence: I
Summary: This comprehensive textbook chapter delineates the anatomy
and biomechanics of the carpus along with pathologic injury to the wrist
and is the single most important current compilation of existing works
regarding wrist biomechanics and associated pathology.
Citation: Wolfe SW, Crisco JJ, Orr CM, et al: The dart-throwing motion of
the wrist: is it unique to humans? J Hand Surg Am 31:14291437, 2006.
Level of Evidence: V
Summary: The standard motion from dorsoradial to palmar-ulnar in the
dart-throw motion is examined in this thoughtful summary. The evolution of the dart-throw motion is discussed.
Citation: Pappas AM, Morgan WJ, Schulz LA, et al: Wrist kinematics during
pitching. A preliminary report. Am J Sports Med 23:312315, 1995.
Level of Evidence: V
Summary: An in-depth evaluation of the biomechanics of wrist motion
during baseball pitching is described. Unique baseball throwing motions
and carpal biomechanics are discussed.
Citation: Smith RJ: Intrinsic muscles of the fingers: function, dysfunction
and surgical reconstruction. AAOS Instr Course Lect 200220, 1975.
Level of Evidence: I
Summary: This Instructional Course lecture by Richard Smith is considered
a classic work in the anatomy and biomechanics of the hand. No anatomic
study of the hand or wrist is complete without referencing Smiths brilliant
evaluations of the intrinsic muscles of the hand.

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Anatomy and Biomechanics of the Hand and Wrist

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