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Wrist Extensor Muscles - Statpearls - NCBI Bookshelf 12/17/2018 Anatomy, Shoulder and Upper Limb, Wrist Extensor Muscles - StatPearls - NCBI Bookshelf NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-. Anatomy, Shoulder and Upper Limb, Wrist Extensor Muscles Authors Jordan L. Ramage1; Matthew Varacallo2. Affilations 1 Lake Erie College of Osteopathic Med. 2 Department of Orthopaedic Surgery, University of Kentucky School of Medicine Last Update: December 3, 2018. Introduction The wrist extensor muscles make up a significant component of the posterior forearm musculature. In general, these muscles originate on or near the lateral epicondyle and insert on the distal forearm or in the hand. Clinical pathology affecting one or multiple muscles in this group is not uncommon. For example, lateral epicondylitis affects 1­5% of the general population.[1][2] Structure and Function To achieve neutral wrist extension movements, the extensor carpi radialis brevis (ECRB), extensor carpi radialis longus (ECRL), and the extensor carpi ulnaris (ECU) muscles act synergistically based on each muscle's insertion and dynamic function. Thus, in the setting of various clinical pathologies that may cause a dynamic imbalance between the radial­based extensors (ECRL and ECRB) versus the ulnar based extensor (ECU), wrist extension will occur with simultaneous and involuntary radial/ulnar deviation.[3] Thumb extension is carried out by abductor pollicis longus (APL), extensor pollicis brevis (EPB), and extensor pollicis longus (EPL).[3] When referencing off of the dorsal aspect of the wrist, the EPB and EPL tendons create the medial and lateral borders of the anatomic snuffbox, respectively. Extension of the second (index finger), third (long finger), fourth (ring finger), and fifth (small finger) digits occurs via the extensor digitorum communis (EDC) muscles. Independent index finger extension can be carried out by the extensor indicis proprius (EIP) muscle. Independent small finger extension is accomplished by the extensor digiti minimi (EDM) muscle.[3] Extensor tendon zones are a helpful way to identify the region where injuries to the extensor tendons occur in the hand and wrist. Below is a description of the extensor tendon zones: Zone I: covers the fingertip to the distal interphalangeal (DIP) joint Zone II: covers middle phalanx Zone III: located at the proximal interphalangeal (PIP) joint Zone IV: covers the proximal phalanx Zone V: situated at the metacarpal phalangeal (MP) joint Zone VI: covers the metacarpals Zone VII: covers the wrist Zone VIII: proximal to the wrist[3] https://www.ncbi.nlm.nih.gov/books/NBK534805/?report=printable 1/9 12/17/2018 Anatomy, Shoulder and Upper Limb, Wrist Extensor Muscles - StatPearls - NCBI Bookshelf The thumb zones are classified differently from the tip of the thumb to the carpal­metacarpal joint. Below is a description of the extensor tendon zones of the thumb: Zone I: covers the fingertip to the DIP joint Zone II: covers the interphalangeal joint Zone III: covers the proximal phalanx Zone IV: located over the MP joint[3] Blood Supply and Lymphatics The subclavian artery branches off from the aortic arch. As it traverses towards the upper extremity, it becomes the axillary artery at the lateral border of the first rib. It then becomes the brachial artery once it passes the lower border of the teres minor muscle. Immediately superior to the antecubital fossa, the brachial artery branches into ulnar and radial arteries.[4] The radial artery then continues laterally in the forearm eventually contributing to the superficial and deep palmar arches in the palmar aspect of the hand. The deep palmar arch has its main contribution deriving from the deep arterial branch of the radial artery. In contrast, the superficial palmar arch's predominant blood supply is derived from the ulnar artery. The superficial arch does receive contributions from the superficial branch of the radial artery as well. The posterior interosseous artery is a branch from the ulnar artery. Once it branches from the ulnar nerve, it travels posterolateral eventually supplying blood to muscles in the posterior compartment. Nerves The radial nerve divides off the posterior cord of the brachial plexus. As it travels to the elbow, it innervates the triceps muscle. A motor nerve that branches from the radial nerve is the posterior interosseous nerve. This nerve branches from the radial nerve at the level of the radiocapitellar joint and is typically located immediately proximal to the supinator muscle in an area of a fibrous band known as the arcade of Frohse.[5][6] The posterior interosseous nerve (PIN, also known as the dorsal branch of the radial nerve) innervates and then courses between the two heads of the supinator muscle before entering the posterior compartment of the forearm. [7] The PIN innervates the EDC, EDM, and ECU muscles from the superficial wrist extensor compartment. It then innervates the APL, EPB, EPL, and EIP muscles. The superficial branch of the radial nerve (SBRN) provides sensation to the distal forearm and hand. The SBRN branches from the radial nerve and runs deep to the brachioradialis muscle in the forearm, before emerging between the brachioradialis and ECRL muscles approximately 9 cm proximal to the radial styloid. There is variability in the SBRN’s course in the distal forearm.[8] Muscles The muscles of the superficial compartment originate on the lateral epicondyle of the humerus. This muscle group is comprised of the brachioradialis muscle, ECRL, ECRB, EDC, EDM, ECU, and anconeus. Below a summary of the general origin and insertion points can be found. Brachioradialis origin: proximal lateral epicondyle of the humerus Brachioradialis insertion: lateral distal radius ECRL origin: proximal lateral epicondyle of the humerus ECRL insertion: dorsal surface of the second metacarpal base ECRB origin: lateral epicondyle of the humerus https://www.ncbi.nlm.nih.gov/books/NBK534805/?report=printable 2/9 12/17/2018 Anatomy, Shoulder and Upper Limb, Wrist Extensor Muscles - StatPearls - NCBI Bookshelf ECRB insertion: dorsal surface of the second and third metacarpal bases EDC origin: lateral epicondyle of the humerus EDC insertion: extensor hoods of the pointer, long, ring, and small finger EDM origin: lateral epicondyle of the humerus EDM insertion: extensor hood of the small finger ECU origin: lateral epicondyle of the humerus ECU insertion: medial base of the fifth metacarpal Anconeus origin: lateral epicondyle of the humerus Anconeus insertion: olecranon and proximal posterior ulna The deep compartment originates in the region of the posterior radius, ulna, or both. The supinator muscle, abductor pollicis longus muscle, extensor pollicis brevis muscle, extensor pollicis longus muscle, and extensor indicis muscle comprise this deep compartment. Below a summary of the general origin and insertion points can be found. Supinator origin: superficial lateral epicondyle of the humerus, radial collateral ligament, and annular ligament Supinator insertion: the lateral proximal third of the radius APL origin: the posterior proximal surface of the ulna and radius APL insertion: lateral base of the first metacarpal EPB origin: the posterior proximal surface of the radius (distal to abductor pollicis longus) EPB insertion: dorsal surface of the base of the thumb EPL origin: the posterior proximal surface of the radius (distal to abductor pollicis longus) EPL insertion: dorsal surface of the base of the thumb EIP origin: posterior surface of the proximal ulna EIP insertion: extensor hood of the index finger There are six extensor compartments of the wrist that serve as tunnels for tendons to pass from the forearm to the wrist.[9] At the wrist, the extensor retinaculum of the hand overlies the tendons of the extensor compartment of the wrist. It provides support as well as preventing bowstringing of the tendons.[3] The first extensor compartment is comprised of the APL and EPB tendons. The second extensor compartment is comprised of the ECRB and ECRL muscle tendons. The third extensor compartment is comprised of the EPL muscle tendon. The fourth extensor compartment is made up of the EIP and EDC muscle tendons. The fifth extensor compartment contains the EDM muscle tendon. The sixth extensor compartment harbors the ECU muscle tendon. Physiologic Variants It is common for physiologic variants to occur in the wrist extensors. Separate synovial sheaths can be present in the first compartment. In this case, the total number of wrist extensor compartments increases from six to seven. There have been reports of fusion of the APL and EPB muscles. A complete absence of the EPB muscle has also been observed.[9] Estimations are that in 30­60% of cases, the tendons of the first compartment are partially or wholly separated by a septum. These variations can lead to snapping wrist syndrome.[9] Reports exist that anatomic variants of the EIP muscle have an incidence of 16%. Variations in the extensor digitorum brevis muscle have a 9% rate of occurrence. In 22% of cadaveric specimens, an aberrant slip of the ECU muscle was https://www.ncbi.nlm.nih.gov/books/NBK534805/?report=printable 3/9 12/17/2018 Anatomy, Shoulder and Upper Limb, Wrist Extensor Muscles - StatPearls - NCBI Bookshelf observed inserting on the fifth metacarpal.[10] Three variants of superfluous wrist extensor muscles have previously been described. These variants are the extensor carpi radialis intermedius (ECRI),
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