Stanbridge - T4 - TMT - W7 (Part 1/2) - Wrist

Wrist Anatomy

• The wrist consists of the capitate, hamate, pisiform, triquetrum, lunate, radioulnar disc, and ulna.
• The Capitate, Hamate, pisiform, triquetrum, lunate, Trapezoid, trapezium, scaphoid, radius, and ulna form ligamentous connections in the wrist.
• The ligaments in the wrist consist of the ulnar collateral ligaments, ulnocarpal ligaments, radial collateral ligaments, and the palmar/dorsal radiocarpal ligaments that connect the radius to the carpal bones.

Bones of the Forearm

• The bones of the forearm are interconnected via the superior radioulnar joint.
• The radius and ulna form elements of the wrist structure.
• The annular ligament and oblique cord aid in connecting the radius and ulna.
• The quadrate ligament, interosseus membrane, and anterior radioulnar ligament provide points of connection.
• The structure includes the radial head and notch, the ulnar notch, the ulnar and radial styloid processes, and the articular disc.

Goniometry of the Wrist

• Wrist Flexion normal range is 0-80 degrees.
• The patient's position when measuring wrist flexion: sitting with the shoulder abducted to 90 degrees and the elbow flexed to 90 degrees, with the arm and forearm supported by a table and the wrist free and palm facing the ground.
• The therapist should be seated to the side of the patient when measuring wrist flexion.
• When measuring wrist flexion, stabilize the radius and ulna, and avoid finger flexion as well as radial and ulnar deviation.
• To measure wrist flexion: place the fulcrum over the lateral aspect of the wrist over the triquetrum, the stationary arm along the lateral midline of the ulna (olecranon and ulnar styloid process), and the movable arm along the lateral midline of the 5th metacarpal.
• The normal end feel of wrist flexion is capsular/firm.
• Wrist Extension normal range is 0-70 degrees.
• The patient's position when measuring wrist extension: sitting with the shoulder abducted to 90 degrees and the elbow flexed to 90 degrees, with the arm and forearm supported by a table and the wrist free and palm facing the ground.
• The therapist should be seated to the side of the patient when measuring wrist extension.
• Stabilize the radius and the ulna; avoid radial and ulnar deviation and finger extension.
• To measure wrist extension: place the fulcrum over the lateral aspect of the wrist over the triquetrum, the stationary arm along the lateral midline of the ulna (olecranon and ulnar styloid process), and the movable arm along the lateral midline of the 5th metacarpal.
• The end feel of wrist extension is capsular/firm.
• Wrist radial deviation normal range is 0-20 degrees.
• The patient's position when measuring wrist radial deviation: sitting with the shoulder abducted to 90 degrees, elbow flexed to 90, with the arm forearm and hand supported by a table.
• The therapist should be seated or standing in front of the patient.
• Stabilize the radius and ulna to avoid supination or pronation; taking care to avoid wrist flexion and extension and hand rotation.
• To measure wrist radial deviation: place the fulcrum on the dorsal wrist over the capitate, the stationary arm along the dorsal midline of the forearm (lateral epicondyle), and the movable arm along the dorsal midline of the 3rd metacarpal (not phalanx).
• The normal end feel of wrist radial deviation is capsular/firm, this may be bony.
• Wrist ulnar deviation normal range is 0-30 degrees.
• The patient's position when measuring ulnar deviation: sitting, shoulder abducted 90, elbow 90 flexion, arm and forearm and hand supported by a table.
• The therapist should be seated or standing in front of the patient.
• Stabilization of the radius and the ulna should be performed by the therapist; wrist flexion, extension, and rotation are to be avoided.
• To measure wrist ulnar deviation: place the fulcrum over the dorsal wrist over the capitate, the stationary arm aligned with the dorsal midline of the forearm (lateral epicondyle), and the movable arm aligned with the dorsal midline of the 3rd metacarpal (not phalanx!).
• The normal end feel of wrist ulnar deviation is capsular/firm.

Functional Wrist Ranges

• Eating with a fork, spoon, or cup requires 7 degrees of flexion, 21 degrees of extension, 2 degrees of radial deviation, and 19 degrees of ulnar deviation.
• Opening and closing a jar requires 35 degrees of flexion, 6 degrees of extension, 12 degrees of radial deviation, and 36 degrees of ulnar deviation.
• Reaching the hand to the top of the head requires 21 degrees of flexion and 16 degrees of ulnar deviation.
• Reaching the hand to the sacrum requires 20 degrees of flexion and 48 of Ulnar deviation
• Reaching the from hand to foot requires 30 degrees of flexion, 36 of extension, 10 degrees of radial deviation and 32 degrees of ulnar deviation

Manual Muscle Testing (MMT)

• There is a primary substitution during MMT of the wrist, that occurs during wrist extension with activation of finger extensors, and activation of finger flexors with wrist flexion.
• Four motions of the wrist include flexion, extension, radial deviation, and ulnar deviation.
• MMT grades range from 0-5; zero, trace, poor minus, poor, poor plus, fair minus, fair, fair plus, good minus, good, good plus, normal.
• A zero on the MMT requires there to be no palpable muscle contraction
• A trace during MMT requires there to be a palpable muscle contraction, or tendon prominence, with no joint movement.
• A poor minus during MMT, requires there to be partial muscle ROM across gravity.
• A poor grade signifies complete ROM of the muscle being tested, across gravity.
• A poor plus means there is complete ROM across gravity with against slight resistance, requiring limited ROM against gravity.
• A fair minus requires there to be a gradual release from the test.
• A fair grade means that the muscle holds the test position against gravity.
• A fair plus means that the muscle is able to hold test position against gravity with slight pressure.
• A good minus indicates that the muscle holds the test position against gravity with slight to moderate pressure.
• A good grade means that the muscle is able to hold the test position against gravity with moderate pressure.
• A good plus signifies that the muscle holds the test position against gravity with moderate to strong pressure.
• A normal grade on the MMT, signifies that the muscle holds test position against gravity with strong pressure.

Capsular Pattern

• The capsular pattern for the wrist are equal for flexion and extension.

Wrist Flexors

• Flexor Carpi Radialis

  • It originates on the medial epicondyle of the humerus and inserts on the base of the second and third metacarpals.
  • Testing position against gravity: Sitting or Supine, less than full supination
  • Stabilization: forearm supported by table or examiner
  • Movement: wrist flexion radial side
  • Resistance: at thenar eminence, into extension toward ulnar side
  • Weakness: unable to flex wrist, allows ulnar deviation and possibly reduced pronation strength
  • Be mindful of the profundus and superficialis substituting if fingers are flexed with wrist flexion (more than relaxed); palmaris longus action also cannot be ruled out
  • Testing position across gravity: seated with forearm midprone
  • Stabilization: forearm supported by table or examiner
  • Movement: wrist flexion radial side
  • Resistance: at thenar eminence, into extension toward ulnar side
  • Weakness: unable to flex wrist, allows ulnar deviation and possibly reduced pronation strength

• Flexor Carpi Ulnaris

  • It originates on the medial epicondyle of the humerus, olecranon and the posterior surface of the ulna, inserting on the pisiform and hamate bones.
  • Testing position against gravity: Sitting/supine full forearm supination
  • Stabilization: table or examiner supports elbow
  • Movement: Flexion of the wrist on the ulnar side
  • Resistance: at hypothenar eminence into extension toward the radial side
  • Weakness: difficulty with wrist flexion and may radially deviate
  • Watch for substitution of profundus and superficialis if fingers are flexed with wrist flexion (more than relaxed)
  • Testing position across gravity: seated with forearm in about neutral
  • Stabilization: table or examiner supports elbow
  • Movement: Flexion of the wrist on the ulnar side
  • Resistance: at hypothenar eminence into extension toward the radial side
  • Weakness: difficulty with wrist flexion and may radially deviate
  • Normal range for dorsiflexion of the wrist is about 60 degrees.

Wrist Extensors

• Extensor Carpi Radialis Longus and Brevis

  • Extensor Carpi Radialis Longus originates on the lateral supracondylar ridge of the humerus, and the Brevis originates on the lateral epicondyle of the humerus.

  • The longus inserts on the dorsal aspect of the base of the second metacarpal, with the brevis inserting on the dorsal aspect of the base of the third metacarpal

  • Testing position against gravity: Seated with elbow flexed to about 30, slightly less than full pronation

  • Stabilization: forearm supported by table

  • Movement: Wrist extension toward radial side (passive finger flexion)

  • Resistance: on Dorsal MC 2&3 towards flexion on the ulnar side

  • Weakness: difficulty with wrist extension and allows ulnar deviation

  • Testing position gravity reduced: seated with forearm in about neutral, elbow flexed to about 30

  • Stabilization: forearm supported by table

  • Movement: Wrist extension toward radial side (passive finger flexion)

  • Resistance: on Dorsal MC 2 & 3 toward flexion on the ulnar side

  • Weakness: difficulty with wrist extension and allows ulnar deviation

• Extensor Carpi Radialis Brevis

  • Testing position against gravity: sitting, elbow fully flexed (by pt. leaning forward), slightly less than full forearm pronation

  • Stabilization: forearm by the table

  • Movement: wrist extension, toward radial side

  • Resistance: on dorsal hand at MC 2 & 3 towards wrist flexion on the ulnar side

  • Weakness: difficulty with wrist extension

  • Watch for substitution of extensor digitorum, extensor indicis, and extensor digiti minimi if fingers extend with wrist extension

  • Testing position gravity reduced: seated elbow fully flexed (by pt. leaning forward), forearm about neutral

  • Stabilization: forearm by the table

  • Movement: wrist extension, toward radial side

  • Resistance: on dorsal hand at MC 2 & 3 toward wrist flexion on the ulnar side

  • Weakness: difficulty with wrist extension

Wrist Ulnar Deviators

• Extensor Carpi Ulnaris

  • Originates on the lateral epicondyle of the humerus and the posterior border of the ulna, inserting on the dorsal aspect of the base of the fifth metacarpal

  • Testing Position Against Gravity: sitting/supine, forearm full pronation

  • Stabilization: by table/examiner

  • Movement: Wrist extension toward Ulna

  • Resistance: Dorsal side at 5th MC into wrist flexion in radial direction

  • Weakness: unable to extend and may Radially deviate wrist.

  • Substitution of fingers that are passively flexed when wrist is extended is likely.

    • If patient's fingers actively extend with wrist extension, the finger extensors (digitorum, indicis, and digiti minimi) are likely attempting to substitute.

  • Testing position across gravity: seated with forearm about neutral

  • Stabilization: by table or PTA

  • Movement: Wrist extension toward ulna

  • Resistance: dorsal side at 5th MC into wrist flexion towards radial direction

  • Weakness: unable to extend and may RD

  • Prime Mover Radial Deviators: Extensor carpi radialis longus, Flexor carpi radialis, Abductor pollicis longus

  • Assistance Radial Deviators: Extensor digitorum, Extensor carpi radialis brevis, Extensor pollicis longus, Extensor pollicis brevis

Wrist Dermatomes and Documentation

• Dermatomes show which spinal nerve innervates a specific area of the skin
  • A dermatome is an area of skin that is mainly supplied by a single spinal nerve
  • When testing a dermatome it is good practice to note the following:
    • Type of sensory test performed
    • Where the test was performed (dermatomes)
  • Document the patient's response, noting any areas of hypoaesthesia, hyperaesthesia, dysaesthesia or normal response
  • Always grade their sensory level as such:
    • Intact, poor, fair, good.
      • 0 signifiesAbsent
      • 1 signifies Impaired
      • 2 signifies Intact
      • NT signifies Test Not Performed

Overview of the anatomy of the wrist and forearm, including bones, ligaments, and joints. The wrist is composed of carpal bones and ligaments that connect the radius to the carpal bones. The forearm contains the radius and ulna, which are interconnected through various ligaments and joints.