Forearm and
Originated by Prof. Andy Cheng
Ms. Joy Lau
Department of Rehabilitation Sciences
The Hong Kong Polytechnic University
Objectives
• To identify the gross structures of the wrist & hand
• To understand the general arrangement of the bones
• To recognize the function of the hand
Functions of Hand
• Prehensile movement
• Sensation
• Expression
• Communication
• Body image
• Cosmesis
Functions of Hand
Prehensile movement
• object is grasped, held
• precision vs power
Power grip Precision grip
Non-prehensile movement
• no grasping or seizing
• objects manipulated by pushing
or lifting motions of the hand as
a whole
Forearm & Hand Bones
Distal forearm
• Radius
Wrist
• Carpus (8 carpal bones, in two rows)
Hand
• Metacarpus
• Proximal phalanx
• Middle phalanx
• Distal phalanx
(Themes, 2016)
Total 27 bones
Moore et al. (2018) Fig. 3.9 (8th ed.)
Flexor retinaculum
(transverse carpal
ligament) converts it into
carpal tunnel.
Carpal groove
Palmar surface
Concave
Dorsal surface
Convex
All carpal bones bound by ligaments to form a compact
mass.
• Metacarpal shaft
• Concave longitudinally on palmar surface.
• Metacarpal II, III,IV, V
• Lie side by side.
• Metacarpal I
• Lies on a more anterior plane.
• Rotated medially on its long axis through 90o .
Hand Joints
• Radiocarpal joint between the radius and
carpal bones
• Intercarpal and midcarpal joint between the carpal
bones
• Carpometacarpal joint between the carpal bones
and metacarpal bones
• Intermetacarpal joint between metacarpal bones
• Metacarpophalangeal joint between the
metacarpal bones
• Interphalangeal joint between the phalanges of
the fingers
(Themes, 2019)
Radiocarpal Joint
• Wrist joint
• a condyloid (ellipsoid) type of
synovial joint
• The distal end of the radius and the
articular disc of the distal radioulnar
joint articulate with the proximal row
of carpal bones (except pisiform)
• The ulna does not participate in the
wrist joint
Moore et al. (2018) Fig. 3.107 (8th ed.)
Intercarpal (IC) Joints
• Plane type of synovial joint
• Joints between the carpal bones of the
proximal row
• Joints between the carpal bones of the
distal row
• The midcarpal joint
a complex joint between the proximal
and distal rows of carpal bones
• The pisotriquetral joint
formed from the articulation of the
pisiform with the palmar surface of the
triquetrum
Moore et al. (2018) Fig. 3.107 (8th ed.)
Carpometacarpal (CMC) Joint
• Plane type of synovial joint
(except of the thumb, which is a
saddle type of synovial joint)
• The distal surfaces of the carpals of
the distal row articulate with
the carpal surfaces of the bases of
the metacarpals at the CMC joints
• CMC joint of the thumb is
between the trapezium and the
base of the 1st metacarpal
Moore et al. (2018) Fig. 3.107 (8th ed.)
Intermetacarpal (IM) Joint
• Plane type of synovial
joint
• Adjacent metacarpals
articulate with each other
• Between the radial and
ulnar aspects of the bases of
the metacarpals
Moore et al. (2018) Fig. 3.107 (8th ed.)
Metacarpophalangeal Joint (MCP) &
Interphalangeal Joint (IP)
MCP joint
• Condyloid type of synovial joint
• The heads of the metacarpals
articulate with the bases of the
proximal phalanges
MCP
IP joint MCP MCP
• Hinge type of synovial joint MCP MCP Metacarpophalangeal
• The heads of the phalanges
articulate with the bases of more PIP
distally located phalanges
DIP
Interphalangeal
Q1. Which of the following is NOT an
articulating surface of the wrist joint?
a) Distal end of radius
b) Distal end of ulna
c) Scaphoid
d) Lunate
Q2. Which of the following is NOT a correct
description of intercarpal joint?
a) joints between the carpal bones of the proximal row
b) joints between the carpal bones of the distal row
c) a complex joint between the proximal and distal rows of
carpal bones
d) it includes condyloid type of synovial joint
Joint Capsule and Ligament
Wrist joint
• Joint capsule is attached to the distal
ends of the radius and ulna and the
proximal row of carpals (scaphoid,
lunate, and triquetrum)
• Doral and palmar radiocarpal
ligaments
• radius to the two rows of carpals
• Ulnar collateral ligament
• ulnar styloid process and
triquetrum
• Radial collateral ligament
• radial styloid process and scaphoid Anterior (palmar ) view
Moore et al. (2018) Fig. 3.108 (8th ed.)
Joint Capsule and Ligament
Intercarpal joint
• Joint capsule surrounds
the intercarpal joints,
which helps unite the
carpals
• Doral and palmar and
interosseous intercarpal
ligaments
clinicalgate.com/wrist-2/
Joint Capsule and Ligament
Carpometacarpal joint and
Intermetacarpal joint
• The medial four carpometacarpal joints and three
intermetacarpal joints are enclosed by a common joint
capsule on the palmar and dorsal surfaces
• Palmar and dorsal carpometacarpal ligament
Connect carpal and metacarpal bones
Anterior (palmar ) view
• Superficial and deep transverse metacarpal ligaments
Connect the palmar surfaces of the heads of the Base of metacarpal
second to fifth metacarpal bones bone
• Three intermetacarpal ligaments
Dorsal and palmar intermetacarpal ligaments connect the
dorsal and palmar surfaces of the bases of the second to
fifth metacarpal bones
Interosseous intermetacarpal ligaments connect
adjacent surfaces of metacarpal bones
Posterior (dorsal) view Clinicalgate.com/hand-3
Joint Capsule and Ligament
Metacarpophalangeal joint and
Interphalangeal joint
• A joint capsule encloses each metacarpophalangeal
joint and interphalangeal joint
• Strengthened by medial and lateral collateral
ligaments
• Each has two parts:
• Cord-like parts that pass distally from the heads of the
metacarpals and phalanges to the bases of the phalanges
• Fan-like parts that pass anteriorly to attach to thick, densely
fibrocartilaginous plate or the palmar ligaments (plates)
Lateral view
Moore et al. (2018) Fig. 3.110 (8th ed.)
Forearm Muscles
Anterior compartment
Flexor muscles (3 layers)
• A superficial layer consists of four muscles
pronator teres,
flexor carpi radialis
palmaris longus
flexor carpi ulnaris
• An intermediate layer consists of one muscle
only
flexor digitorum superficials
• A deep layer consists of three muscles Superficial layer
flexor digitorum profundus
flexor pollicis longus
pronator quadratus Deep layer
Intermediate layer Moore et al. (2018) Fig. 3.59 (8th ed.)
Forearm Muscles
Posterior compartment
Extensor muscles (2 layers)
• A superficial layer consists of six muscles
brachioradialis
extensor carpi radialis longus
extensor carpi radialis brevis
extensor digitorum
Superficial layer
extensor digiti minimi
extensor carpi ulnaris
• A deep layer consists of five muscles
Supinator
Extensor indicis
Abductor pollicis longus
Outcropping
Extensor pollicis longus muscles
Extensor pollicis brevis
Deep layer
Moore et al. (2018) Fig. 3.60 (8th ed.)
Hand Muscles
Intrinsic muscles
• smaller muscles located
within the hand itself
Five compartments:
• thenar compartment Superficial layer
• adductor compartment
• hypothenar compartment
• central compartment
• interosseous compartment
(Intrinsic Muscles of Hand, n.d.)
Hand Muscles
Abductor Digiti Flexor Pollicis
Minimi Brevis
Flexor Digiti Minimi
Opponens
Pollicis
Opponens Digiti
Minimi
Thenar
compartment
Abductor
Pollicis Brevis
Clinically oriented anatomy p. 775 fig 6.77b
Hand Muscles
Central compartment Interosseous compartment
Lumbricals
Moore et al. (2018) Fig. 3.78 (8th ed.)
Q3. How many layer(s) of forearm muscles in
the anterior compartment ?
a) 1
b) 2
c) 3
d) 4
Arteries of the Hand
Clinically oriented anatomy p. 759 fig 6.67
Deep Veins of Hand
Superficial palmar venous arch
• receives oxygen-depleted blood from the common
palmar digital veins within the fingers
• blood drains through the arch and up the ulnar vein
Deep palmar venous arch
• receives oxygen-depleted blood from the palmar
metacarpal veins
• blood drains through the arch and up the radial vein
Moore et al. (2018) Fig. 3.68 (8th ed.)
Superficial Veins of Hand
Doral venous network
• Formed by the union of the
dorsal metacarpal veins
• Drains into the cephalic and
basilica veins
Anterior view
Dorsum of hand
Moore et al. (2018) Fig. 3.55 (8 th ed.)
Moore et al. (2018) Fig. 3.15 (8th ed.)
Cutaneous Nerve distribution of Hand
Ulnar nerve
• medial 11Ú2 digits and
palmar/dorsal aspect of hand
Radial nerve
• lateral half of dorsum of hand and
dorsal aspect of lateral 31Ú2 digits,
excluding their nail beds
Median nerve
• palmar aspect of lateral 31Ú2
digits, including their nail
beds Dorsal view Palmar view
Important Structures of Hand A.D.A.M.
Palmar Aponeurosis
• Triangular
• a strong, well-defined part of the deep
fascia of the palm
• The apex is continuous with the flexor
retinaculum
• forms four longitudinal digital bands and attach
distally to the bases of the proximal phalanges
and become continuous with the fibrous digital
sheaths
Moore et al. (2018) Fig. 3.74 (8th ed.)
Important Structures of Hand A.D.A.M.
Fibrous Digital Sheath
• one of the two membranes of
a tendon sheath which
covers a tendon
• the strong ligamentous
tunnels containing the
flexor tendons
• anular and cruciform parts
(pulleys) are the thickened Moore et al. (2018) Fig. 3.74 (8th ed).)
reinforcements
• prevents bowstringing of
the flexor tendons
Moore et al. (2018) Fig. 3.81 (8th ed).)
Important Structures of Hand A.D.A.M.
Synovial Sheath
• the inner membrane
which covers a tendon
• produces synovial fluid,
which keeps the tendon Tendon
lubricated
Tendon
• reduces friction between Sheath
the tendon and their
surrounding structure
Quizlet.com/145849147/6-hand-flash-cards/
A.D.A.M.
Important Structures of Hand
Flexor retinaculum
• also called transverse carpal ligament or
anterior annular ligament
• strong fibrous band
• attaches pisiform, hamate, scaphoid &
trapezium bones
• turns carpal groove into carpal tunnel
Flexor retinaculum
Important Structures of Hand
A.D.A.M.
Extensor retinaculum
• also called dorsal carpal ligament or
posterior annular ligament
4 ----> ED, EI
• strong fibrous band (fascia)
• attaches laterally to the lateral
margin of the radius & triquetral 5 ----> EDM
and pisiform bone medially
2 ----> ECRL, ECRB 6 ----> ECU
• holds six 6 synovial sheaths
(tunnel) for the passage of 12 3 --- EPL
tendons of 9 extensor muscles in
place 1 ----> ABL, EPB
Extensor retinaculum
Important Structures of Hand A.D.A.M.
Extensor Expansion
• also called extensor hood or dorsal expansion
• triangular tendinous aponeurosis
• warps around the dorsum from the head of
metacarpal to proximal phalanx
• extensor digitorum expands into three bands:
two lateral bands
one median band
• holds the extensor tendons in place
• allows lumbricals and interossei to effect
extension at the proximal and distal
interphalangeal joints
(Figure 1. Musculotendonal Structure of the Human Finger. The.
. ., n.d.)
Movements of Wrist
Radial deviation Ulnar deviation
Side view Anterior (palmar) view Anterior (palmar) view
Movements of Fingers
www.researchgate.net/figure-motion
Movements of Thumb
Moore et al. (2018) Fig. 3.76 (8th ed.)
Synergistic & Stabilizing Effect
of Muscles of the Wrist
Wrist flexion >> automatic finger extension
Functional Position:
Slight wrist extension (40-45o)
Slight ulnar deviation (15o)
Architecture of the Hand
• Metacarpal shafts
concave longitudinally on
palmar surface.
• Metacarpal II, III,IV, V 90o
lie side by side.
• Metacarpal I
lies on a more anterior plane.
rotated medially on its long axis
through 90o
Architecture of the Hand
On a flat surface, the hand spreads out
& becomes flattened. Making contact
at . . . .
palmar surfaces thenar eminence
of phalanges
metacarpal heads
hypothenar eminence
Architecture of the Hand
Arches of the Hand
• three arches
proximal transverse arch
distal transverse arch
longitudinal arch
• enable the hand to grasp objects of
different sizes and shapes
• direct the skilled movement of your fingers
and control the power of your grasp
mitchmedical.us/extremity-splinting/hand-wrist-and-forearm.html
Architecture of the Hand
lies over heads of 2nd, 3rd, 4th metacarpus
Learn what
each flexure
line indicates
or
what structures
lie underneath
it.
indicates the limit of the main flexor
synovial sheaths across the shaft of MC,
& superficial palmar arch
Architecture & Clinical Application
A.D.A.M.
Clinical Implications
Dupuytren’s Contracture
• progressive shortening, thickening, and fibrosis of the
palmar fascia and aponeurosis
• the contracture is frequently bi1ateral
• is seen in some men >50 years of age
• the fibrous degeneration of the longitudinal bands of the
palmar aponeurosis on the medial side of the hand pulls
the 4th and 5th fingers into partial flexion at the
metacarpophalangeal and proximal interphalangeal
joints
• its cause is unknown, but evidence points to a Dupuytren’s Contracture
hereditary predisposition
healthnet/content.php?artid=6913
A.D.A.M.
Clinical Implications
de Quervain's tenosynovitis
• the tendon of extensor pollicis brevis and
abductor pollicis longus muscles become swollen
• the swelling causes the tendon sheath covering
these two tendons to become inflamed
• pain is typically increased with extension of the
thumb and ulnar deviation of the wrist
• gripping or rotating the wrist
• risk factors include certain repetitive movements,
pregnancy, trauma, and rheumatic diseases de Quervain's tenosynovitis
healthnet/content.php?artid=6913
A.D.A.M.
Clinical Implications
Carpal Tunnel Syndrome
• results from any lesion that significantly reduces the
size of the carpal tunnel
• increases the size of some of the nine structures or
their coverings that pass through it
• compression of the median nerve in the carpal
tunnel
• a combination of numbness, tingling, pain and
weakness in the hand
• risk factors include wrist fracture, diabetes, body fluid
changes, and workplace factors such as working with
vibrating tools or prolonged flexing of the wrist
2minutemedicine.com/patient-basics-carpal-tunnel-syndrome/
Clinical Implications A.D.A.M.
Trigger Finger
• stenosing tendovaginitis
• thickening of a fibrous digital sheath on the palmar aspect
• the flexor tendons (FDS and FDP) become secondarily enlarged
proximal to the tunnel
• is a common problem that has its origin at the level of the first
annular pulley of the digital flexor tendon sheath
• A size discrepancy between the sheath and tendon interferes with
the normal tendon gliding process, causing pain and/or
snapping upon extension.
• the person is unable to extend the finger
• in severe case, the finger may become locked in a bent position
• risk factors include repeated gripping, diabetes, rheumatoid
arthritis
Moore et al. (2018) Fig. B3.31 (8th ed).)
Q4. Dupuytren’s Contracture refers to
inflammation of which structure?
a) Synovial sheath
b) Flexor tendon
c) Extensor expansion
d) Palmar aponeurosis
Q5. Which nerve is compressed to cause
Carpal Tunnel Syndrome?
a) Radial nerve
b) Ulnar nerve
c) Median nerve
d) Musculocutaneous nerve
References
• Moore KL, Dalley AF, Agur AMR (2018). Clinically Oriented Anatomy, 8th Edition. Philadelphia: Lippinocott Williams & Wilkins
• Intrinsic muscles of hand. (n.d.). Cynical Anatomy. Retrieved March 14, 2024, from https://cynical-
anatomy.tumblr.com/post/148059774774/intrinsic-muscles-of-the-hand-the-intrinsic
• Themes, U. (2016, June 7). Wrist and Hand. Musculoskeletal Key. https://musculoskeletalkey.com/wrist-and-hand/
• Themes, U. (2019, March 11). THE WRIST AND HAND. Musculoskeletal Key. https://musculoskeletalkey.com/the-wrist-and-hand-7/
• Palmer aponeurosis. (n.d.). phyio-pedia.com. Retrieved March 14, 2024, from https://www.physio-
pedia.com/Palmar_Aponeurosis#/media/File:Palmar_aponeurosis.jpeg
• Figure 1. Musculotendonal structure of the human finger. The. . . (n.d.). ResearchGate. https://www.researchgate.net/figure/Musculotendonal-
structure-of-the-human-finger-The-musculotendonal-structure-of-the-human_fig1_261735584
