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Hand Surgery and Rehabilitation 36 (2017) 211

Recent advance

Pronation and supination of the hand: Anatomy and biomechanics

Pronationsupination de la main : anatomie et biomcanique
M. Soubeyrand a,b,*, B. Assabah a, M. Bgin b, E. Laemmel c, A. Dos Santos b, M. Crz a,d
a
University Paris Sud, Faculty of Medicine, 63, rue Gabriel-Pri, 94270 Le Kremlin-Bictre, France
b
Department of Orthopaedic Surgery, University Hospital of Bictre (Public Assistance Hospitals of Paris), 78, rue du Gnral-Leclerc,
94270 Le Kremlin-Bictre, France
c
Laboratory of microcirculation, universit Paris-Diderot, Faculty of Medicine Lariboisire, 10, avenue de Verdun, 75010 Paris, France
d
Department of Radiology, University Hospital of Bicetre (Public Assistance Hospitals of Paris), 78, rue du Gnral-Leclerc, 94270 Le Kremlin-Bictre, France
Received 31 May 2016; received in revised form 29 August 2016; accepted 1st September 2016
Available online 27 October 2016

Abstract
Proper functioning of the hand relies on its capacity to rotate and point the palm upward (i.e. supination) or downward (i.e. pronation) when
standing up with the elbow in 908 flexion. Hand rotation is possible because of forearm rotation and also rotation of the whole upper limb at the
shoulder. Two distinct mechanisms contribute to hand rotation: one in which the ulna is immobile and another in which the ulna is mobile. In this
review, we first summarize how evolution of the human species has led to the progressive development of specific forearm anatomy that allows for
pronation and supination. Then we analyze how the three joints of the forearm (i.e. proximal, middle and distal radioulnar joints), in association
with the characteristic shape of both forearm bones, allow the forearm to rotate around a single axis. Lastly, we describe the neuromuscular
anatomy that controls these complex rotational movements. The anatomical and biomechanical points developed in this paper are analyzed while
considering clinical applications.
# 2016 SFCM. Published by Elsevier Masson SAS. All rights reserved.

Keywords: Forearm rotation; Pronation; Supination; Interosseous membrane; Anatomy; Proximal radioulnar joint; Middle radioulnar joint; Distal radioulnar joint

Rsum
Le fonctionnement correct de la main repose sur sa capacit tourner et diriger la paume vers le haut (supination) ou vers le bas (pronation)
lorsque le sujet est debout avec le coude flchi 908. La rotation de la main est rendue possible par la rotation de lavant-bras, qui est elle-mme
complte par la rotation de lensemble du membre suprieur au niveau de lpaule. Il est ainsi possible de distinguer deux mcanismes aboutissant
la rotation de la main: une rotation ulna fixe et une autre ulna mobile. Dans cet article, nous rsumons les grandes tapes volutives de lespce
humaine qui ont conduit au dveloppement dune anatomie spcifique de lavant-bras permettant la pronationsupination. Puis nous analysons
comment les trois articulations de lavant-bras (radio-ulnaires proximale, moyenne et distale) associes aux gomtries caractristiques des deux
os de lavant-bras permettent la rotation de lavant-bras autour dun axe unique. Enfin, nous dcrivons lanatomie neuromusculaire qui motorise ces
mouvements complexes de rotation. Les aspects anatomiques et biomcaniques dvelopps dans cet article sont envisags la lumire de leurs
applications cliniques.
# 2016 SFCM. Publi par Elsevier Masson SAS. Tous droits rservs.

Mots cls : Rotation de lavant-bras ; Pronation ; Supination ; Membrane interosseuse ; Anatomie ; Articulation radio-ulnaire proximale ; Articulation radio-
ulnaire moyenne ; Articulation radio-ulnaire distale

* Corresponding author. University Paris Sud, Faculty of Medicine, 63, rue Gabriel-Pri, 94270 Le Kremlin-Bictre, France.
E-mail address: soubeyrand.marc@gmail.com (M. Soubeyrand).

http://dx.doi.org/10.1016/j.hansur.2016.09.012
2468-1229/# 2016 SFCM. Published by Elsevier Masson SAS. All rights reserved.
 M. Soubeyrand et al. / Hand Surgery and Rehabilitation 36 (2017) 211
1. Introduction
An essential prerequisite for proper functioning of the hand
is its positioning in space, in terms of location and orientation.
The hands orientation relies on its capacity to rotate and tilt.
Forearm rotation makes it possible to point the palm upward
(i.e. supination) or downward (i.e. pronation) and is inseparable
from the radius own orientation, given the strong attachments
between both of these structures.
Forearm rotation can be viewed as rotation of the hand
radius unit around the ulna (Fig. 1). However, the entire
forearm (i.e. radius + ulna) can also rotate because of
movements of the upper limb and trunk. Therefore, one must
distinguish between the forearms rotation around an immobile
ulna and the forearms rotation with a mobile ulna. This
conceptual distinction is artificial as daily movements use both
these mechanisms in synergy, but it will simplify the
biomechanical analysis of these complex motions.
The goal of this review is to outline the anatomical and
biomechanical bases of these mechanisms.
2. Evolutionary view
According to the taxonomic classification of species
(Retrieved May 23, 2016, from the Integrated Taxonomic
Information System http://www.itis.gov.) derived from works
of Carl Linnaeus (17071778) [1], Homo sapiens belongs to the
phylum Chordata, class Mammalia, order Primates, family
Hominidae, and genus Homo.
Human upper limbs have a similar structure to the forelimbs
of the other pentadactylous tetrapods given that they are
composed of four separate segments: the stylopodium (with the
humerus), the zeugopodium (with the radius and ulna), the
Fig. 1. The two units of hand rotation (a). There are two types of hand rotation, depending on whether the ulna is mobile or immobile (b).
3
mesopodium (with the carpal bones) and the autopodium (with
the hand skeleton) [2,3] (Fig. 2).
In several classes of the phylum Chordata including
Mammalians, Reptilians, and Amphibians, the upper limb/
forelimb is composed of a humerus, a radius and an ulna. The
oldest known specimen with this forelimb pattern is
Eusthenopteron, a lobe-finned fish that lived 380 million years
ago [4]. The forelimb evolved because of changes in the
behavior of our ancestors. The common ancestor of the
Primates lived about 56 million years ago. He was an arboreal
animal who grasped branches to move in and between trees.
With the progressive appearance of bipedalism, the upper limb
has gradually gained the ability to interact with the surrounding
environment (grasping, manipulating, modifying, interacting
with objects, animals, vegetals) as well as with its own body
(feeding, hygiene, self-care). The upper limb needed to be very
precise in order to position the autopodium (the hand) to
manipulate objects and hang from branches. Pronation and
supination developed gradually due to an increase in mobility
between the radius and ulna. Conversely, the hind limb was
tasked with providing support and propulsion activities that
require considerable stability thereby explaining why there
is very little motion between the bones in the lower leg (i.e. tibia
and fibula).
Consequences of this differential evolution between species
are now visible when various mammalians are compared. In
purely quadruped mammalians like elephants, horses or
rhinoceros, the radioulnar mobility is almost non-existent.
The two forearm bones are joined by a short, strong and wide
ligament that allows very little range of motion and, moreover,
undergoes ossification with advancing age. In mainly qua-
druped mammalians that have the ability to temporarily stand
on their hind limbs (i.e. transitory bipedalism) like rodents or
4 M. Soubeyrand et al. / Hand Surgery and Rehabilitation 36 (2017) 211

Fig. 2. Comparative anatomy of the upper limb.

felidae, there is a moderate capacity for forearm rotation. The 4.1. Humeroulnar and radio-hand unit
presence of a considerable range of forearm rotation appears
specific to the Primates order and especially humans. Hence, At the elbow, the connection between the humerus and the
the human forearm can be regarded as an exceptional structure forearm mainly consists of the humeroulnar joint. The
in terms of shape and biomechanics. humeroradial joint participates in flexionextension but it also
allows rotation of the radius. This explains the clinical impact
3. Forearm rotation with mobile ulna of malunions involving the humeral capitulum or the radial
fovea on forearm rotation [5]. At the wrist, the connection
The ulna provides the primary mechanical connection between the forearm and the hand mainly consists of the
between the forearm and the upper arm thanks to the radiocarpal joint, with the ulnocarpal joint being less important.
humeroulnar joint. If we consider the configuration in which Therefore, one can distinguish the humeroulnar unit from the
the forearm and the hand form a single unit, the orientation and
position of the hand are driven by the ulna. The latter is
controlled by the positions and orientations of the elbow,
glenohumeral, and scapulothoracic joints as well as those of the
trunk.
This is illustrated by the fact that patients with radioulnar
synostosis (congenital or posttraumatic) still have fairly good
hand rotation. Another example is the ability of the upper limb
to rotate pinched fingers around several axes (Fig. 3).
However, the involvement of joints distant to the hand limits
de facto the precision of the hands orientation and positioning.
It is therefore obvious that the addition of intrinsic mobility in
the forearm is a major biomechanical contribution.

4. Forearm rotation with immobile ulna: the forearm

The forearm, contrary to the lower leg its counterpart in

the lower limb is not only a segment intercalated between the
elbow and the wrist. Although they both have support, load
transfer and muscular insertion functions, the forearm has a
supplementary function: hand rotation. Its osteoarticular
anatomy is precisely designed to achieve these goals.
Fig. 3. The hand can be rotated around multiple axes. Proper alignment with
this axis recruits the forearm but also the elbow and the shoulder, thereby
implying mobility of the ulna.
 M. Soubeyrand et al. / Hand Surgery and Rehabilitation 36 (2017) 211
radiocarpalhand unit. The humeroulnar joint allows flexion
extension of the elbow while the radiocarpal joint allows
flexionextension and radial and ulnar tilt of the hand. The
remaining motion (i.e. the rotation of the forearm) can be
therefore assigned to the remaining articulations, namely the
radioulnar joints.
4.2. Joints involved in forearm rotation
Forearm rotation typically involves three joints, namely the
proximal and distal radioulnar joints (PRUJ and DRUJ) and the
humeroradial joint (Fig. 4). The PRUJ and the DRUJ are
cylindrical joints while the humeroradial joint is spheroid joint.
The PRUJ corresponds to the joint between the perimeter of the
radial head and the radial notch of the ulna, completed by the
annular ligament. The humeroradial joint is between the
humeral capitulum and the fovea radialis. In the DRUJ, the
ulnar head is articulated with the ulnar notch of the radius.
Along with the PRUJ and DRUJ, a third radioulnar joint has
recently been described, the middle radioulnar joint (MRUJ)
[6,7]. This joint consists of both the ulnar and radial shafts
linked by the interosseous membrane (IOM) [8]. Conversely to
the cylindrical PRUJ and DRUJ, the MRUJ may be considered
as a particular kind of syndesmosis, i.e. a joint in which the
bony surfaces are connected by an interosseous ligament.
In the clinical setting, all three joints must be taken into
consideration when managing a case of forearm instability,
stiffness or deformity a classical mistake is to focus on the
elbow or wrist while ignoring the overall forearm.
The Sauv-Kapandji procedure used to manage DRUJ
pathologies is a rare example of a procedure in which
modifying the anatomy loss of the DRUJ due to
Fig. 4. The three radioulnar joints, the forearm stabilizers and the concepts of vertical and transverse instability.
5
arthrodesis does not compromise the range of motion [9].
In this procedure, segmental resection of the ulna induces intra-
ulnar mobility that compensates for loss of the DRUJ. Given the
distal location of this resection, it remains close to the DRUJ
and the rotational axis of the forearm is just slightly deviated
ulnarly. Using the same logic, it is possible to fuse the PRUJ and
to resect a proximal segment of the radius in order to create a
neo-PRUJ inside the radius. This can be likened to a reverse
Sauv-Kapandji procedure [10].
The motion and stability of the three radioulnar joints are
intimately entangled, as is their pathology. It is noteworthy to
recap two clinical facts to illustrate that:
 first, forearm rotation can be preserved even though one joint
is removed, if the other two remain intact. This explains why
procedures such as resection of the radial or ulnar head can
have satisfactory outcomes [11];
 second, stiffness of a single radioulnar joint is enough to
compromise the forearms rotation. Therefore, general
forearm stiffness can be the result of various pathological
conditions involving individually the MRUJ (e.g. radioulnar
synostosis, IOM retraction, radial/ulnar shaft malunion, etc.),
the PRUJ or the DRUJ (e.g. infectious or inflammatory
arthritis, etc.) [1214].
4.3. Bone anatomy applied to biomechanics of the forearm
4.3.1. Bone curvatures
Both forearm bones are curved (Fig. 5). When considering
the forearm in the anatomical (reference) position (i.e. maximal
supination), the radius and the ulna are curved anteriorly in the
sagittal plane and also in the frontal plane. The two radius
6 M. Soubeyrand et al. / Hand Surgery and Rehabilitation 36 (2017) 211
Fig. 5. The curvatures of the forearm bones are essential to forearm physiology. If these bones were straight, forearm rotation would be limited.
curvatures are referred to as the supinator curvature and the
pronator curvature. The former corresponds to the proximal
third of the radial shaft including the radial tuberosity, while the
latter corresponds to the distal two-thirds of the radial shaft.
The term supinator curvature stems from the fact that the two
most important supinator muscles (i.e. biceps brachii and the
supinator) insert on it. The pronator curvature draws its name
from the insertion of the pronator muscles (pronator quadratus
and pronator teres). The ulna has two opposite curvatures in the
frontal plane that make it resemble a stretched-out S. In the
sagittal plane, it has an anterior concavity.
These curvatures in both bones are essential to forearm
rotation; if the ulna and/or radius were perfectly straight, the
radius would abut against the ulna too early during pronation,
significantly limiting pronation amplitude. To illustrate this
point, forearm rotation can be compared to a high jump event in
which the radius is the jumper and the ulna is the bar:
supination, neutral rotation and pronation would correspond
respectively to the approach, take-off/bar crossing and landing.
Two actions can make it easier to crossover the bar: (1) lower
the bar and (2) twist the jumpers body. This allows each part of
the body to successively pass above the bar like in the Fosbury
flop technique. The ulnas curvature corresponds to lowering of
the bar. The pronator curvature of the radius corresponds to the
jumpers twist. Together, both of these morphological features
project the radius epiphysis as far as possible and allow a
maximum pronation of about 908. Therefore, insertion of the
pronator muscles on the pronator curvature is not
coincidental but rather extremely logical from a biomechanical
standpoint. The importance of the specific geometry of both
bones is illustrated by the potential stiffness in forearm rotation
induced by malunion of forearm fractures [1517].
4.3.2. Asymmetry of the epiphyses
The proximal and distal epiphyses of both bones are
asymmetric. At the elbow, the ulnar epiphysis is larger than the
radial one, while it is the opposite at the wrist. Moreover, the
proximal ulna is more proximal than the radius while the distal
radius ends more distally than the ulna (i.e. radioulnar variance).
This asymmetric configuration helps to explain why, at the level
of the wrist, most of the longitudinal forces pass from the carpus
to the radius, while at the level of the elbow, most of the
longitudinal forces travel from the ulna to the humerus [1823].
This biomechanical asymmetry implies a load transfer between
the radius and ulna. This transfer is primarily performed by the
taut IOM between the radius and ulna, and is essential to the
forearms longitudinal stability [24]. In fact, the radius naturally
tends to migrate proximally because of the constant action of
several muscles pulling it proximally, in a direct or indirect
manner: the extrinsic muscles of the hand inserted on the ulna or
the humerus (pulling proximally the hand with the radius) and
the muscles inserted above the elbow and on the radius (biceps
brachii and brachioradialis). Pathological proximal migration of
the radius occurs in Essex-Lopresti injuries (ELI) and leads to
ulnocarpal impingement as a consequence of the inversion of
distal radioulnar index [25].
 M. Soubeyrand et al. / Hand Surgery and Rehabilitation 36 (2017) 211
4.3.3. Rounded epiphyses
The radial and ulnar heads are rounded, which is essential
for forearm rotation.
At the PRUJ, the radial head can be roughly approximated to
a cylinder. But more detailed analysis reveals that the radial
head is slightly oval in the transverse plane, given that it has a
greater and a lesser diameter (about 28 mm and 24 mm,
respectively). It is covered with cartilage on its superior
concave surface (i.e. the fovea) and on its rim (i.e. its articular
circumference). Interestingly, the height of the rim is not
constant: it is thinner in an area that is never in contact with the
ulnar notch of the radius. This area is important when the radial
head must be stabilized surgically because it is the exact
location where a plate needs to be positioned to avoid any
impingement with the ulna during forearm rotation.
At the DRUJ, the ulnar head can be also approximated to a
cylinder. The ulnar styloid process is offset from the center of
the cylinder. Comparing these epiphyses to cylinders allows us
to introduce the concept of rotation and to determine the
forearms rotational axis.
4.4. Rotational axis of the forearm
The rotation of the radius, which is connected to the hand,
occurs around a single axis [26] (Fig. 6). This axis roughly
Fig. 6. The forearms rotational axis.
7
intersects the center of the radial head and the base of the ulnar
styloid process, at the center of the ulnar head cylinder.
Kapandji compared the rotation of the radius to the opening and
closing of a book: the forearms rotational axis corresponds to
the books binding [27]. The open and closed positions
correspond to supination and pronation, respectively. Inter-
estingly, this axis intersects a protuberance on the interosseous
edge of the radius referred to as the interosseous tubercle of the
radius. This tubercle is of major importance as it corresponds to
the insertion of the IOMs central band.
4.5. Stabilization of the forearm
The corollary of forearm rotation is the need for perfect
stability. Stability is required in the longitudinal (i.e. vertical)
and transverse (i.e. horizontal) directions. Transverse stability
guarantees that the distance between both bones is maintained,
as is their physiological relationships in the axial plane.
Longitudinal stability maintains the height of the radius relative
to the ulna (i.e. radioulnar variance). This longitudinal and
transverse stability is made possible by a series of ligaments.
4.5.1. At the PRUJ
Transverse stability is mainly due to the annular ligament
and to a lesser extent, the squared ligament.
The annular ligament surrounds the radial head since it
inserts on the anterior and posterior rims of the radial notch of
the ulna. As opposed to conventional ligaments, its inner aspect
is covered with fibrocartilage that makes it easier for the radial
head to slide during forearm rotation.
The squared ligament is located at the inferior part of the
PRUJ; it tightens in pronation and supination by wrapping
around the radial neck, thereby drawing the radial head closer
to the ulna [28]. As a consequence, it provides transverse
stability to the PRUJ and also longitudinal stability by limiting
vertical migration of the radius.
4.5.2. At the MRUJ
The IOM prevents both bone shafts from moving apart. The
IOM is made of several groups of fibers arranged in a way to
optimize stability [29].
A first group of ventral fibers is proximally and radially
oriented. This group has several bundles, with the most
important being the so-called central band. The latter has an
average angle of 218 to the long axis of the ulna and represents
the thickest part of the IOM. It inserts on the interosseous
tubercle of the radius described above.
A second group of fibers is dorsal with fibers oriented
proximally and ulnarly. This group is much thinner than the
ventral fibers. It is also less important from a biomechanical
standpoint.
The final bundle, the oblique cord, is noteworthy because it
is macroscopically distinct from the main body of the IOM. It
runs proximally and ulnarly from the radial tuberosity to the
ulnar metaphysis.
In order to understand the IOMs stabilizing role, it is
necessary to keep in mind that the mechanical role of a
8 M. Soubeyrand et al. / Hand Surgery and Rehabilitation 36 (2017) 211
ligament fiber can be represented by a vector parallel to this
fiber [30]. Yet, a vector can be divided geometrically into two
orthogonal secondary vectors. Therefore, it is possible to
demonstrate that each oblique IOM fiber provides longitudinal
stability (vertical vector) as well as transverse stability
(horizontal vector) [31,32]. Because of the proximal and
ulnar angulation of its fibers, the anterior group is the most
important as it prevents proximal migration of the radius. For
the same reasons, it is also responsible for longitudinal load
transfer between the radius and ulna [20,24]. Fibers in the
posterior group, by preventing distal migration of the radius,
are of lesser importance given that the radius naturally tends to
migrate proximally [3335].
The IOM fibers alternatively tighten and relax during
forearm rotation, which corresponds to a phenomenon of
progressive recruiting [23,3639]. The latter guarantees that
there are always tight fibers, making the IOM mechanically
efficient no matter the amount of forearm rotation. The distal
part is nearly tight in maximum supination and relaxed in
maximum pronation. The central part is mostly tight in neutral
rotation and the proximal part in pronation.
In case of IOM disruption as in the ELI, some authors
proposed about 20 years ago to reconstruct the IOM with
ligaments or synthetic devices [4043]. Despite a variety of
grafts and designs, the common approach is to replace only part
of the IOM with a single bundle graft. Therefore, they must be
associated with stabilization of the other forearm joints in case
of overall destabilization. Such reconstruction techniques are
relevant for restoring the stability of the MRUJ but given the
rarity of ELI, the outcomes of these techniques have not yet
been reported.
4.5.3. At the DRUJ
The distal radioulnar ligaments (palmar and dorsal) as well
as the triangular fibrocartilage (TFC) discus are responsible for
transverse stability [44]. In addition to transverse stabilization
of the DRUJ, the TFC also limits vertical migration of the
radius, thereby contributing to the forearms longitudinal
stability. The TFC is triangle-shaped; at the top of this triangle,
the ulnar styloid process exactly intersects the forearms
rotational axis. The TFC at the DRUJ and the annular ligament
at the PRUJ have the same mechanical purpose, namely to
guide radius rotation; however, they use two different tools to
reach this goal. At the PRUJ, the radial head is contained by the
annular ligament, while at the DRUJ the radius is held back by
the TFC (Fig. 6).
The DRUJ is also stabilized by the extensor retinaculum of
wrist. By surrounding the distal forearm, it holds the radius and
the ulna together, thereby providing transverse stability.
4.5.4. Radiocapitular compartment
A final mechanism contributes to longitudinal stability of the
forearm, namely abutment of the radial head against the
humeral capitulum. If the longitudinal stabilizers of the forearm
were to fail, proximal migration could occur but radiohumeral
abutment prevents further migration of the radius. However, in
such a case, the consequence can be overload of the
radiocapitular joint with the development of osteoarthritis.
This phenomenon is observed in ELI cases, when the radial
head is replaced by a metallic implant that increases wear of the
capitular cartilage. This phenomenon emphasizes the fact that
isolated resection of the radial head (i.e. without replacement)
should be avoided as much as possible in case of acute injury.
Moreover, it strengthens the concept of IOM ligament
reconstruction to restore longitudinal stability of the forearm
and to unload the radiocapitular joint.
4.5.5. Magnitude and limitation of pronation and
supination
The amplitude of forearm rotation ranges from about 908 in
pronation to about 908 in supination when neutral rotation (i.e.
thumb parallel to the humerus) is considered as 08. In order to
avoid excessive rotation of the forearm, two mechanisms exist.
Supination is limited mainly by soft tissues, with the IOMs
anterior bundle and the squared ligament being the main players.
Conversely, pronation is limited by the radioulnar abutment that
occurs in extreme pronation. Therefore, stiffness in forearm
rotation may result from retraction of the IOM or malunion of
the radius/ulna when the physiological curvatures are compro-
mised.
4.6. Neuromuscular anatomy of forearm rotation
4.6.1. Muscles involved and nerve supply
The rotator muscles of the forearm can be divided in two
groups (Fig. 7). Three muscles are dedicated to supination:
biceps brachii, brachioradialis and supinator. Two muscles
provide pronation: pronator quadratus and pronator teres.
The forearms rotation is controlled by the C5 to T1 roots.
More specifically, supination is controlled by C5 and C6
through the musculocutaneous nerve (for the biceps brachii)
and the radial nerve (for the brachioradialis and supinator).
The axons for the brachioradialis arise from the radial
nerve upstream of its division into superficial and deep
branches. Conversely, the axons for the supinator muscle
arise from the deep branch of the radial nerve (also named
posterior interosseous nerve), after the division of the
radial nerve.
Pronation is entirely under control of the median nerve. The
latter receives axons from C6 and C7 for the pronator teres and
from C8 and T1 for the pronator quadratus. The axons for the
pronator teres arise directly from the median nerve while those
for the pronator quadratus arise from the anterior interosseous
nerve.
4.6.2. Mechanism of action of the muscles
How does contraction of the muscle fibers of the forearm
rotators get converted into rotation of the radius? This
phenomenon is puzzling if we consider that contraction of a
muscle fiber decreases the distance between both of its
insertions: the basic motion induced by a muscular contraction
therefore corresponds to translation along an axis parallel to the
fiber. Transformation of a translation movement into rotation
relies on two geometrical conditions.
 M. Soubeyrand et al. / Hand Surgery and Rehabilitation 36 (2017) 211
Fig. 7. Description of the pronator and supinator muscles, and mechanism that converts a translation motion into rotation.
The first condition is that the muscular fibers of the rotator
muscles are wrapped around the radius. The fibers of the
supinator muscles wrap around the radius when the forearm is
in pronation, and conversely for the pronator muscles. The
second condition is that the insertions of the rotator muscles on
the radius do not intersect the forearms rotational axis. If this
was not the case, rotation would not be induced by contraction
of the forearm rotators; instead, a translation motion would
occur.
Both of these conditions are present for each of the rotator
muscles: the biceps brachii wraps around the medial aspect of
the supinator curvature (i.e. radial tuberosity), the supinator
muscle wraps around the lateral aspect of the supinator
curvature, the pronator teres wraps around the proximal part of
the pronator curvature and the pronator quadratus wraps around
the distal part of the pronator curvature. One exception is the
brachioradialis because it inserts on the suprastyloid crest
(belonging to the pronator curvature), not on the supinator
curvature. However, this muscle is considered a supinator
because it wraps around the radius when the forearm is fully
pronated, thereby pulling the radius into supination when it
contracts.
The importance of the first condition (i.e. the tendon is
wrapped around the radius in pronation) is demonstrated by the
clinical results of distal biceps tendon repair. When the
insertion site is too anterior on the radius, thereby failing to
reproduce the anatomy, the supination strength is significantly
9
inferior relative to patients who have an anatomical insertion
[45,46].
It is also interesting to note that the pronator teres, pronator
quadratus and supinator muscles can be divided into two layers:
deep and superficial. The deep heads of the pronator teres and
supinator muscles are inserted on the ulna while their
superficial heads are inserted on the humerus. From a
biomechanical standpoint, the deep heads contribute to forearm
stabilization, while the superficial heads contribute to forearm
rotation.
Along with these five rotator muscles, some other muscles
referred to as accessory rotator muscles can contribute to a
lesser extent to forearm rotation. These are muscles inserted
proximally on the medial and lateral epicondyles of the
humerus and distally on the hand (carpus, metacarpal or
phalanx). Given that they are not inserted on the radius, they do
not directly induce its rotation. They induce indirect rotation of
the radius by directly moving the hand skeleton, which
subsequently drags the radius. Spasticity of these muscles plays
a key role in the pathophysiology of abnormal postures in
neurological diseases involving the upper limb.
5. Conclusion
Pronation and supination of the hand require forearm
rotation. The radius and the hand form a functional unit, which
rotates around the ulna thanks to a series of three radioulnar
10 M. Soubeyrand et al. / Hand Surgery and Rehabilitation 36 (2017) 211
joints: proximal, middle and distal. During this complex
motion, the forearm requires longitudinal and transverse
stabilization. The stabilization is provided by a series of
ligaments, among which the interosseous membrane plays a
key role.
Disclosure of interest
The authors declare that they have no competing interest.
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