| Carpometacarpal joint | |
|---|---|
| Ligaments of wrist. Posterior view. | |
| Latin | articulationes carpometacarpeæ |
| Gray's | subject #88 330 |
The carpometacarpal (CMC) joints are five joints in the wrist that articulates the distal row of carpal bones and the proximal bases of the five metacarpal bones.
The CMC of the thumb or the first CMC differs significantly from the other four CMCs and is therefore described separately.
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The carpometacarpal joint of the thumb, also known as the first carpometacarpal joint, or the trapeziometacarpal joint (TMC) because it connects the trapezium to the first metacarpal bone, plays an irreplaceable role in the normal functioning of the thumb. The most important joint connecting the wrist to the metacarpus, osteoarthritis of the TMC is a severely disabling condition; up to twenty times more common among old women than in average. [1]
Pronation-supination of the first metacarpal is especially important for the pulp-to-pulp pinch[1] (i.e. "true opposition"). The movements of the first CMC is limited by the shape of the joint, by the capsulo-ligamentous complex surrounding the joint, and by the balance among involved muscles. If the first metacarpal fails to sit well 'on the saddle', for example because of hypoplasia, the first CMC joint tends to be subluxated (i.e. slightly displaced) towards the radius. [1]
The capsule is sufficiently slack to allow a wide range of movements and a distraction of roughly 3 mm, while reinforcing ligaments and tendons give stability to the joint. It is slightly thicker on its dorsal side than on the other. [1]
The first carpometacarpal joint is a frequent site of osteoarthritis in postmenopausal women.[2]
The description of the number and names of the ligaments of the first CMC varies considerably in anatomical literature. Imaeda et al. 1993 describe three intracapsular and two extracapsular ligaments:
Early, anatomically correct drawings of the ligaments of the first carpometacarpal joints where produced by Weitbrecht 1742.[3]
In this articulation the movements permitted are flexion and extension in the plane of the palm of the hand, abduction and adduction in a plane at right angles to the palm, circumduction, and opposition.
Range of motion for the first CMC is 53° of flexion/extension, 42° of abduction/adduction, and 17° of rotation [4]
The thumb's MP and CMC joints abduct and adduct in a plane perpendicular to the palm, a movement also referred to as "palmar abduction." The same joints flex and extend in a plane parallel to the palm, also referred to as "radial abduction," because the thumb moves toward the hand's radial side. Abduction and adduction occur around an antero-posterior axis, while flexion and extension occur around a lateral axis. [5]
For ease of orientation, the thumbnail can be considered as resting in the thumbs frontal plane. Abduction and adduction of the first CMC (and MP) joint(s) occur in this plane; flexion and extension of the first CMC, MP, and IP joints occur in a plane that is perpendicular to the thumbnail. This remains true regardless of how the first metacarpal bone is being rotated during opposition and reposition. [5]
Male and female thumb CMC joints are different in some aspects. In women, the trapezial articular surface is significantly smaller than the metacarpal surface, and its shape also differs from that of males. While most thumb CMC joints are more congruent in the radioulnar direction than the dorsovolar, female CMC joints are less globally congruent than male joints. [6]
A primitive autonomisation of the first ray took place in dinosaurs, while a real differentiation appeared in primitive primates approximately 70 million years ago. The shape of the human TMC joint dates back about 5 million years ago. As a result of evolution, the human thumb CMC joint has positioned itself at 80° of pronation, 40° of abduction, and 50° of flexion in relation to an axis passing through the stable second and third CMC joints, [1]
Among themselves, the four ulnar metacarpals also articulates with their neighbours at the intermetacarpal articulations. [7]
These four CMC joints are supported by strong transverse and weaker longitudinal ligaments: the dorsal carpometacarpal ligaments and the volar or palmar carpometacarpal ligaments. [7]
The interosseous ligaments consist of short, thick fibers, and are limited to one part of the carpometacarpal articulation; they connect the contiguous inferior angles of the capitate and hamate with the adjacent surfaces of the third and fourth metacarpal bones.
The carpometacarpal joints of second through fifth digits are arthrodial. The movements permitted in the second through fifth carpometacarpal joints is most readily observable in the (distal) heads of the metacarpal bones. The range of motions in these joints decrease from the fifth to the second CMCs.[8]
The second to fifth joints are synovial ellipsoidal joints with a nominal degree of freedom (flexion/extension). The second and third joints are however essentially immobile and can be considered to have zero degrees of freedom in practice. These two CMC provide the other three CMCs with a fixed and stable axis. While the mobility of the fourth CMC joint thus is perceptible, the first joint is a saddle joint with two degrees of freedom which except flexion/extension also enable abduction/adduction and a limited amount of opposition. Together the movements of the fourth and fifth CMCs facilitates for their fingers to oppose the thumb. [8]
The function of the finger CMC joints and their segments overall is to contribute to the palmar arch system together with the thumb. The proximal transverse arch of the palm is formed by the distal row of carpal bones. The concavity of this arch is augmented at the level of the metacarpal heads by the flexibility of the first, fourth, and fifth metacarpal heads around the fixed second and third metacarpal heads; a flexible structure called the distal transverse arch. For each finger there is also a longitudinal arch. Together, these arches allow the palm and the digits to conform optimally to objects as we grasp them (so called palmar cupping). Furthermore, as the amount of surface contact is maximized, stability is enhanced and sensory feedback increases. The deep transverse metacarpal ligament stabilises the mobile parts of the palmar arch system. [8]
As the finger are being flexed, palmar cupping is contributed to by muscles crossing the CMC joints when they act on the mobile parts of the palmar arch system. The oblique opponens digiti minimi muscle acts on the fifth CMC joint and is the only muscle that act on the CMC joints alone. It is optimally positioned to flex and rotate the fifth metacarpal bone about its long axis. Palmar arching is further increased when flexor carpi ulnaris (which is attached to the pisiform) and intrinsic hand muscles attached to the transverse carpal ligament acts on the arch system. The fixed second and third CMC joints are crossed by the radial wrist muscles (flexor carpi radialis, extensor carpi radialis longus, and extensor carpi radialis brevis). The stability of these two CMC joints is a functional adaptation that enhances the efficiency of these muscle at the midcarpal and radiocarpal joints. [8]
The synovial membrane is a continuation of that of the intercarpal joints. Occasionally, the joint between the hamate and the fourth and fifth metacarpal bones has a separate synovial membrane.
The synovial membranes of the wrist and carpus are thus seen to be five in number.
Occasionally the fourth and fifth carpometacarpal joints have a separate synovial membrane.
This article was originally based on an entry from a public domain edition of Gray's Anatomy. As such, some of the information contained within it may be outdated.
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