Wrist Joint

The wrist is a complex articulation composed of multiple joints that work together to position the hand in space, enabling fine motor control and powerful grip. This joint complex serves as the critical link between the forearm and hand, balancing mobility with stability for functional tasks.

Quick Reference

Property	Details
Joint Type	Condyloid (radiocarpal); Plane (intercarpal, carpometacarpal)
Bones	Radius, ulna (indirectly via TFCC), 8 carpal bones (scaphoid, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate, hamate), 5 metacarpals
Degrees of Freedom	2 (flexion/extension, radial/ulnar deviation)
Key Ligaments	Radial collateral ligament, ulnar collateral ligament, palmar radiocarpal ligaments, dorsal radiocarpal ligament, intercarpal ligaments, TFCC (triangular fibrocartilage complex)
Key Structures	Carpal tunnel, Guyon's canal, extensor retinaculum, flexor retinaculum, scapholunate ligament
Stability	Static (ligamentous) > Dynamic (muscular)
Common Issues	Carpal tunnel syndrome, TFCC injury, scapholunate ligament injury, de Quervain's tenosynovitis, ganglion cysts

Anatomy

The wrist complex consists of three primary articulations that function together to provide coordinated hand movement:

Radiocarpal Joint: The primary wrist joint is a condyloid articulation between the distal radius and the proximal row of carpal bones (scaphoid, lunate, and triquetrum). The triangular fibrocartilage complex (TFCC) separates the ulna from direct carpal contact, providing ulnar-sided support and allowing smooth ulnar rotation. This configuration provides two degrees of freedom while maintaining significant stability through ligamentous support.

Intercarpal Joints: Multiple plane synovial joints exist between the carpal bones, divided into proximal and distal rows. The midcarpal joint (between the two rows) contributes significantly to overall wrist motion, particularly in the extremes of flexion/extension and radial/ulnar deviation. The scapholunate ligament is critical for maintaining proper carpal alignment and kinematics.

Carpometacarpal (CMC) Joints: Five joints connect the distal carpal row to the metacarpal bases. The 2nd and 3rd CMC joints are relatively immobile, providing a stable central column for the hand. The 4th and 5th CMC joints allow greater mobility, contributing to the cupping motion of the hand. The 1st CMC (thumb) joint is saddle-shaped and highly mobile, allowing thumb opposition.

Supporting Structures:

• Triangular Fibrocartilage Complex (TFCC): Cartilage structure connecting ulna to carpals, stabilizes the distal radioulnar joint, provides cushioning for ulnar-sided loads
• Carpal Tunnel: Fibro-osseous canal formed by carpal bones (floor/sides) and flexor retinaculum (roof), transmits 9 flexor tendons and median nerve
• Guyon's Canal: Tunnel on ulnar side of wrist transmitting ulnar nerve and artery into the hand
• Extensor Retinaculum: Fibrous band on dorsal wrist holding extensor tendons in place, organized into 6 compartments
• Scapholunate Ligament: Critical intrinsic ligament connecting scaphoid and lunate; injury leads to carpal instability

tip

The wrist achieves its range of motion through coordinated movement across multiple joints. Approximately 40% of wrist flexion/extension occurs at the radiocarpal joint, with the remaining 60% at the midcarpal joint. Disruption of normal carpal kinematics can lead to pain and instability.

Range of Motion

Normal wrist range of motion is essential for activities of daily living, with different tasks requiring varying degrees of motion. Composite wrist motion occurs across radiocarpal and midcarpal joints.

Movement	Normal ROM	Limiting Factors
Flexion	0-80°	Dorsal radiocarpal ligament, dorsal capsule, wrist extensor muscles
Extension	0-70°	Palmar radiocarpal ligaments, palmar capsule, wrist flexor muscles
Radial Deviation	0-20°	Ulnar collateral ligament, ulnar-sided soft tissues, radial styloid contact
Ulnar Deviation	0-30°	Radial collateral ligament, radial-sided soft tissues

caution

Functional wrist ROM requirements vary by activity. Most ADLs require 5° flexion to 35° extension, and 10° radial to 15° ulnar deviation. However, activities like push-ups or yoga may demand near-end range extension, making full ROM important for athletic populations.

Joint Actions

Flexion/Extension

Flexion (moving palm toward forearm):

• Prime Movers: Flexor carpi radialis, flexor carpi ulnaris
• Assistors: Palmaris longus, flexor digitorum superficialis, flexor digitorum profundus, flexor pollicis longus
• Stabilizers: Wrist extensors (eccentric control), intercarpal ligaments

Extension (moving back of hand toward forearm):

• Prime Movers: Extensor carpi radialis longus, extensor carpi radialis brevis, extensor carpi ulnaris
• Assistors: Extensor digitorum, extensor indicis, extensor digiti minimi, extensor pollicis longus
• Stabilizers: Wrist flexors (eccentric control), intercarpal ligaments

Radial/Ulnar Deviation

Radial Deviation (thumb side moves toward forearm):

• Prime Movers: Flexor carpi radialis, extensor carpi radialis longus, extensor carpi radialis brevis
• Assistors: Abductor pollicis longus, extensor pollicis brevis
• Stabilizers: Intercarpal ligaments, ulnar-sided structures

Ulnar Deviation (pinky side moves toward forearm):

• Prime Movers: Flexor carpi ulnaris, extensor carpi ulnaris
• Assistors: Extensor digiti minimi
• Stabilizers: Intercarpal ligaments, radial-sided structures

Circumduction

Circumduction (circular motion combining all movements):

• Mechanism: Sequential activation of flexors, radial deviators, extensors, and ulnar deviators
• Purpose: Demonstrates full wrist mobility, combines all planes of motion
• Stabilizers: Coordinated activation of all wrist muscles, intrinsic hand muscles for stabilization

Note: The wrist does not have true rotational capability; pronation and supination occur at the radioulnar joints in the forearm.

Muscles Acting On It

Wrist function depends on extrinsic muscles originating in the forearm that cross the wrist to insert on carpal bones, metacarpals, or phalanges. These muscles are organized into compartments and functional groups.

Muscle Group	Prime Movers	Primary Actions	Additional Functions
Wrist Flexors	Flexor carpi radialis, Flexor carpi ulnaris, Palmaris longus	Wrist flexion	FCR: radial deviation; FCU: ulnar deviation
Wrist Extensors	Extensor carpi radialis longus, Extensor carpi radialis brevis, Extensor carpi ulnaris	Wrist extension	ECRL/ECRB: radial deviation; ECU: ulnar deviation
Radial Deviators	FCR, ECRL, ECRB	Radial deviation	APL and EPB assist
Ulnar Deviators	FCU, ECU	Ulnar deviation	Work synergistically across flexion/extension
Finger Flexors	Flexor digitorum superficialis, Flexor digitorum profundus	Finger flexion	Assist wrist flexion when wrist is stabilized
Finger Extensors	Extensor digitorum, Extensor indicis, Extensor digiti minimi	Finger extension	Assist wrist extension when wrist is stabilized
Thumb Muscles	Flexor pollicis longus, Extensor pollicis longus/brevis, Abductor pollicis longus	Thumb movement	APL/EPB assist radial deviation and extension

tip

Wrist stability during grip requires co-contraction of wrist extensors and flexors. The wrist naturally extends during power grip (grabbing a hammer) to optimize finger flexor length-tension relationships. Loss of wrist extension significantly impairs grip strength.

Mobility Work

Stretches

Wrist Flexor Stretch

• Extend arm forward, palm up
• Use opposite hand to pull fingers back (extending wrist)
• Keep elbow straight for maximum stretch
• Targets: Flexor carpi radialis, flexor carpi ulnaris, palmaris longus, finger flexors
• Hold: 30 seconds, 3 reps each side

Wrist Extensor Stretch

• Extend arm forward, palm down
• Use opposite hand to pull fingers down (flexing wrist)
• Keep elbow straight
• Targets: Extensor carpi radialis longus/brevis, extensor carpi ulnaris, finger extensors
• Hold: 30 seconds, 3 reps each side

Prayer Stretch

• Place palms together in front of chest
• Lower hands toward waist while keeping palms together
• Elbows point outward
• Targets: Wrist flexors, forearm flexor mass
• Hold: 30 seconds, 2-3 reps

Reverse Prayer Stretch

• Place backs of hands together in front of chest
• Lower hands while maintaining contact
• Targets: Wrist extensors, forearm extensor mass
• Hold: 30 seconds, 2-3 reps

Pronator/Supinator Stretch

• Hold light weight (1-2 lbs) with arm bent at 90°
• Slowly rotate palm up (supination) and palm down (pronation)
• Move through full available range
• Targets: Pronator teres, supinator, radioulnar joints
• Reps: 10-15 each direction

Mobilizations

Wrist CARs (Controlled Articular Rotations)

• Make a fist with tension
• Slowly move through maximum flexion, extension, radial deviation, ulnar deviation
• Create full circles in both directions
• Purpose: Full ROM assessment and maintenance, motor control
• Sets: 5 rotations each direction per wrist

Carpal Bone Mobilization

• Use opposite thumb to mobilize individual carpal bones
• Apply gentle pressure and circular motions
• Target scaphoid, lunate, and other carpals
• Purpose: Improve intercarpal joint mobility, reduce stiffness
• Duration: 1-2 minutes per wrist

Wrist Circles on Floor

• Position on hands and knees (quadruped)
• Shift weight forward and make circles with upper body
• Keep palms flat on floor
• Purpose: Load-bearing extension mobility, wrist strengthening
• Sets: 10 circles each direction

Fist to Open Hand

• Make tight fist, then fully extend and spread fingers
• Move slowly and deliberately through full range
• Purpose: Tendon gliding, forearm muscle activation
• Reps: 15-20 repetitions, 2-3 sets

Wrist Rocks

• Start in quadruped with hands flat
• Rock forward (increasing wrist extension) and backward (decreasing load)
• Progress to shifting side to side
• Purpose: Progressive loading of wrist extension
• Duration: 1-2 minutes

caution

For desk workers, wrist position during typing is critical. Keyboard should allow neutral wrist posture (slight extension, no deviation). Avoid resting wrists on sharp desk edges. Take regular breaks to move through full wrist ROM to prevent stiffness and overuse injuries.

Common Issues

Carpal Tunnel Syndrome

Description: Compression of the median nerve as it travels through the carpal tunnel, causing numbness, tingling, and pain in the thumb, index, middle, and radial half of the ring finger.

Common Causes:

• Repetitive hand/wrist motions (typing, assembly work)
• Prolonged or sustained wrist flexion/extension
• Pregnancy (fluid retention)
• Diabetes, thyroid disorders, rheumatoid arthritis
• Anatomical variations (smaller carpal tunnel)

Signs/Symptoms:

• Numbness and tingling in median nerve distribution
• Nocturnal symptoms (waking with hand numbness)
• Weakness in thumb opposition and grip
• Positive Phalen's test, Tinel's sign at wrist
• Symptoms often relieved by shaking hands

Management Approach:

• Wrist splinting (neutral position, especially at night)
• Activity modification and ergonomic adjustments
• Nerve gliding exercises (median nerve flossing)
• Anti-inflammatory measures
• Corticosteroid injection for symptom relief
• Surgical carpal tunnel release for severe or refractory cases

TFCC Injury

Description: Tear or degeneration of the triangular fibrocartilage complex on the ulnar side of the wrist, affecting stability and causing pain with loading and rotation.

Common Causes:

• Fall on outstretched hand (FOOSH injury)
• Repetitive loading with forearm rotation (racquet sports, gymnastics)
• Ulnar impaction (positive ulnar variance)
• Age-related degeneration
• Distal radius fractures affecting TFCC integrity

Signs/Symptoms:

• Ulnar-sided wrist pain
• Pain with forearm rotation (especially pronation/supination with ulnar deviation)
• Clicking or popping sensation
• Weakness with gripping
• Tenderness over ulnar wrist
• Positive TFCC compression test, ulnar grind test

Management Approach:

• Initial rest and immobilization (3-6 weeks for acute tears)
• Activity modification (avoid provocative positions)
• Strengthening of forearm and wrist stabilizers
• Taping or splinting for support
• Corticosteroid injection for inflammation
• Surgical repair or debridement for complete tears or failed conservative management

De Quervain's Tenosynovitis

Description: Inflammation of the tendons in the first dorsal compartment of the wrist (abductor pollicis longus and extensor pollicis brevis), causing pain along the radial wrist and thumb.

Common Causes:

• Repetitive thumb and wrist motions
• New mothers (lifting baby with thumb extended)
• Occupations requiring repetitive pinching or gripping
• Direct trauma to radial wrist
• Inflammatory conditions

Signs/Symptoms:

• Sharp pain along radial wrist and thumb base
• Pain with thumb movement, especially abduction
• Swelling over radial styloid
• Positive Finkelstein's test (ulnar deviation with thumb in palm)
• Tenderness over first dorsal compartment
• Difficulty with pinching and grasping

Management Approach:

• Thumb spica splinting (immobilize thumb and wrist)
• Activity modification (avoid repetitive thumb motions)
• Ice and anti-inflammatory measures
• Corticosteroid injection into tendon sheath (high success rate)
• Tendon gliding exercises once acute inflammation settles
• Surgical release of first dorsal compartment for refractory cases

Scapholunate Ligament Injury

Description: Tear of the scapholunate interosseous ligament, leading to carpal instability and abnormal wrist kinematics. This is the most common and significant ligamentous wrist injury.

Common Causes:

• Fall on outstretched hand with wrist extended and ulnarly deviated
• High-impact trauma
• Chronic wrist loading (gymnastics, manual labor)
• Repetitive stress

Signs/Symptoms:

• Dorsal wrist pain, typically over scapholunate interval
• Weakness with gripping
• Painful clicking or clunking with motion
• Positive Watson's (scaphoid shift) test
• Swelling and tenderness dorsally
• Progressive arthritis if untreated (SLAC wrist - scapholunate advanced collapse)

Management Approach:

• Acute injuries may benefit from immobilization or pinning
• Strengthening of dynamic wrist stabilizers
• Activity modification
• Surgical repair for acute complete tears (within 6-8 weeks)
• Reconstruction or salvage procedures for chronic instability
• Long-term outcomes variable; early treatment improves prognosis

Ganglion Cysts

Description: Fluid-filled sacs that develop along tendons or joints, most commonly on the dorsal wrist (60-70% of cases) arising from the scapholunate ligament area.

Common Causes:

• Joint or tendon irritation
• Previous wrist injury
• Repetitive wrist stress
• Often idiopathic (unknown cause)

Signs/Symptoms:

• Visible or palpable lump, typically dorsal wrist
• Size may fluctuate
• Usually painless, but can cause discomfort with wrist motion
• May compress nearby nerves causing numbness
• Transluminates with light

Management Approach:

• Observation for asymptomatic cysts (many resolve spontaneously)
• Activity modification if symptomatic
• Aspiration (50-85% recurrence rate)
• Surgical excision for symptomatic cysts or failed aspiration
• Reassurance that cysts are benign

tip

Wrist pain that persists beyond 2-3 weeks or significantly impacts function warrants professional evaluation. Many wrist injuries appear minor initially but can lead to chronic instability or arthritis if not properly managed. Early diagnosis and appropriate treatment improve long-term outcomes.

Related Joints

The wrist functions as part of an integrated upper extremity kinetic chain, with its health and function dependent on adjacent joints and structures.

Distal Radioulnar Joint (DRUJ)

• Connection: Shares ligamentous support (TFCC), allows forearm pronation/supination
• Impact: DRUJ instability affects wrist loading patterns and TFCC integrity
• Key Consideration: Forearm rotation must be assessed when evaluating wrist pain

Elbow

• Connection: Shared musculature (wrist flexors/extensors originate at elbow)
• Impact: Lateral epicondylitis (tennis elbow) and medial epicondylitis affect wrist extensor/flexor function
• Key Consideration: Elbow position affects wrist muscle length-tension relationships

Hand (MCP and IP Joints)

• Connection: Direct functional link; extrinsic hand muscles cross the wrist
• Impact: Finger position affects wrist torque demands; grip requires wrist stabilization
• Key Consideration: Tenodesis effect - passive finger extension with wrist flexion, passive finger flexion with wrist extension

Shoulder

• Connection: Part of upper extremity kinetic chain for throwing, reaching, lifting
• Impact: Shoulder dysfunction can increase compensatory wrist stress
• Key Consideration: Overhead activities require coordinated shoulder-elbow-wrist mechanics

Cervical Spine

• Connection: Neural supply to wrist/hand originates C6-T1
• Impact: Cervical radiculopathy can mimic wrist pathology or cause referred pain
• Key Consideration: Screen neck with peripheral wrist complaints, especially if neurological symptoms present

tip

Wrist pain may originate from or be influenced by proximal structures. Evaluate the entire upper extremity, not just the wrist in isolation. Cervical radiculopathy (C6-C7), elbow tendinopathy, and DRUJ instability commonly contribute to wrist symptoms.

Sources

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