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Wrist Joint: Anatomy

Wrist Joint: Anatomy

The wrist connects the forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term "forearm" is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm: Anatomy to the hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy. It consists of 8 carpal bones Carpal bones The eight bones of the wrist: scaphoid bone; lunate bone; triquetrum bone; pisiform bone; trapezium bone; trapezoid bone; capitate bone; and hamate bone. Carpal Tunnel Syndrome, multiple joints, and various supporting ligaments, as well as the distal bones of the forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term "forearm" is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm: Anatomy and the proximal portion of the 5 metacarpal bones of the hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy. The wrist is crucial for the functioning of the upper limb, and it provides stability while positioning the hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy for intricate motions.

Last updated: 9 Mar, 2022

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Contents

Bones of the Wrist

The bones of the wrist consist of:

  • Distal radius Radius The outer shorter of the two bones of the forearm, lying parallel to the ulna and partially revolving around it. Forearm: Anatomy and ulna Ulna The inner and longer bone of the forearm. Forearm: Anatomy: The distal ulna Ulna The inner and longer bone of the forearm. Forearm: Anatomy is not technically part of the wrist, as it articulates distally with the triangular fibrocartilage Fibrocartilage A type of cartilage whose matrix contains large bundles of collagen type I. Fibrocartilage is typically found in the intervertebral disk; pubic symphysis; tibial menisci; and articular discs in synovial joints. Cartilage: Histology complex (TFCC).
  • 5 proximal metacarpals 
  • 8 carpal bones Carpal bones The eight bones of the wrist: scaphoid bone; lunate bone; triquetrum bone; pisiform bone; trapezium bone; trapezoid bone; capitate bone; and hamate bone. Carpal Tunnel Syndrome, arranged in 2 rows:
    1. Proximal row (lateral to medial): scaphoid, lunate, triquetrum, and pisiform
    2. Distal row (lateral to medial): trapezium, trapezoid, capitate, and hamate

There are many mnemonics to help memorize the order and location of the carpal bones Carpal bones The eight bones of the wrist: scaphoid bone; lunate bone; triquetrum bone; pisiform bone; trapezium bone; trapezoid bone; capitate bone; and hamate bone. Carpal Tunnel Syndrome. They are learned from lateral to medial and proximal to distal: scaphoid, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate, hamate.

  • So Long To Pinky, Here Comes The Thumb
  • Some Lovers Try Positions That They Can’t Handle
  • Sam Likes To Push The Toy C ar AR Aortic regurgitation (AR) is a cardiac condition characterized by the backflow of blood from the aorta to the left ventricle during diastole. Aortic regurgitation is associated with an abnormal aortic valve and/or aortic root stemming from multiple causes, commonly rheumatic heart disease as well as congenital and degenerative valvular disorders. Aortic Regurgitation H ard ARD Number Needed to Treat
Proximal and distal rows of the carpal bones

The proximal and distal rows of the carpal bones Carpal bones The eight bones of the wrist: scaphoid bone; lunate bone; triquetrum bone; pisiform bone; trapezium bone; trapezoid bone; capitate bone; and hamate bone. Carpal Tunnel Syndrome

Image by Lecturio.
  • 8 carpal bones

    Wrist joint, featuring the 8 carpal bones Carpal bones The eight bones of the wrist: scaphoid bone; lunate bone; triquetrum bone; pisiform bone; trapezium bone; trapezoid bone; capitate bone; and hamate bone. Carpal Tunnel Syndrome plus the radius Radius The outer shorter of the two bones of the forearm, lying parallel to the ulna and partially revolving around it. Forearm: Anatomy and ulna Ulna The inner and longer bone of the forearm. Forearm: Anatomy

    Image by Lecturio.
  • X-ray of the wrist

    X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests of a left wrist, showing normal anatomy and no injuries

    Image: “ X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests of normal wrist” by Mikael Häggström, M.D. License: CC0 1.0, edited by Lecturio.

Related videos

4:59
Considerations of the Wrist and Hand

Joints of the Wrist

The wrist is able to move in multiple directions, as it functions as a stable platform for the hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy.

Joint Type Components Ligaments Function
Distal radioulnar Pivot joint Head of ulna Ulna The inner and longer bone of the forearm. Forearm: Anatomy and ulnar notch on radius Radius The outer shorter of the two bones of the forearm, lying parallel to the ulna and partially revolving around it. Forearm: Anatomy
  • Palmar and dorsal radioulnar ligaments
  • Articular disk
 Supination Supination Applies to movements of the forearm in turning the palm forward or upward. When referring to the foot, a combination of adduction and inversion movements of the foot. Examination of the Upper Limbs– pronation Pronation Applies to movements of the forearm in turning the palm backward or downward. When referring to the foot, a combination of eversion and abduction movements in the tarsal and metatarsal joints (turning the foot up and in toward the midline of the body). Examination of the Upper Limbs
Radiocarpal Synovial ellipsoid joint Distal radius Radius The outer shorter of the two bones of the forearm, lying parallel to the ulna and partially revolving around it. Forearm: Anatomy and proximal row of carpal bones Carpal bones The eight bones of the wrist: scaphoid bone; lunate bone; triquetrum bone; pisiform bone; trapezium bone; trapezoid bone; capitate bone; and hamate bone. Carpal Tunnel Syndrome (except pisiform)
  • Radial and ulnar collateral ligaments
  • Palmar and dorsal radiocarpal ligaments
Midcarpal Compound synovial Proximal and distal row of carpal bones Carpal bones The eight bones of the wrist: scaphoid bone; lunate bone; triquetrum bone; pisiform bone; trapezium bone; trapezoid bone; capitate bone; and hamate bone. Carpal Tunnel Syndrome Intercarpal, volar, dorsal, radial, and ulnar ligaments Sliding and gliding
Intercarpal Amphiarthroses Among the carpal bones Carpal bones The eight bones of the wrist: scaphoid bone; lunate bone; triquetrum bone; pisiform bone; trapezium bone; trapezoid bone; capitate bone; and hamate bone. Carpal Tunnel Syndrome of each row Intercarpal, dorsal, and volar ligaments Stabilize the wrist
Carpometacarpal Amphiarthroses (2nd–5th) Distal carpal and 2nd–5th metacarpals Dorsal and palmar carpometacarpal ligaments Limited gliding
Saddle (thumb) Trapezium and 1st metacarpal Intermetacarpal, dorsoradial, collateral, and volar ligaments
  • Coronal cross-section of the right wrist

    Coronal Coronal Computed Tomography (CT) cross-section of the right wrist featuring the distal radioulnar, radiocarpal (labeled wrist joint), midcarpal, intercarpal, and carpometacarpal joints of the wrist

    Image by Lecturio.
  • Ligaments of the wrist

    Posterior view of the wrist, featuring its supporting ligaments

    Image by BioDigital, edited by Lecturio

Related videos

4:01
Joints of the Hand – Joints of Upper Limb

Movements of the Wrist and Associated Muscles

The wrist acts as a transition between the forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term “forearm” is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm: Anatomy and hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy. The table below summarizes the forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term “forearm” is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm: Anatomy muscles and their associated movements. The name of each muscle is a reflection of the action of the muscle on the wrist and hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy.

Table: Forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term “forearm” is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm: Anatomy muscles and their associated movements
Movement Muscle
Flexion Flexion Examination of the Upper Limbs Main:Assisted by:
Extension Extension Examination of the Upper Limbs Main:Assisted by: extensor retinaculum
Abduction Abduction Examination of the Upper Limbs The following extensor and flexor muscles work in tandem to cause abduction Abduction Examination of the Upper Limbs:
Adduction Adduction Examination of the Upper Limbs The following extensor and flexor muscles work in tandem to cause adduction Adduction Examination of the Upper Limbs: flexor and extensor carpi ulnaris Extensor carpi ulnaris Forearm: Anatomy

Notable Anatomical Features

Carpal tunnel Carpal Tunnel The carpal tunnel is formed by the transverse carpal ligament (flexor retinaculum) superiorly and the carpal bones inferiorly. Carpal Tunnel Syndrome

The carpal tunnel Carpal Tunnel The carpal tunnel is formed by the transverse carpal ligament (flexor retinaculum) superiorly and the carpal bones inferiorly. Carpal Tunnel Syndrome is formed by the following:

Structure and contents of the carpal tunnel

Structure and contents of the carpal tunnel Carpal Tunnel The carpal tunnel is formed by the transverse carpal ligament (flexor retinaculum) superiorly and the carpal bones inferiorly. Carpal Tunnel Syndrome

Image by Lecturio.

Ulnar canal (Guyon’s canal)

  • The ulnar canal or Guyon’s canal is formed by the following:
  • Contents of the ulnar tunnel:
    • Ulnar nerve Ulnar Nerve A major nerve of the upper extremity. In humans, the fibers of the ulnar nerve originate in the lower cervical and upper thoracic spinal cord (usually C7 to T1), travel via the medial cord of the brachial plexus, and supply sensory and motor innervation to parts of the hand and forearm. Axilla and Brachial Plexus: Anatomy
    • Ulnar artery Ulnar Artery The larger of the two terminal branches of the brachial artery, beginning about one centimeter distal to the bend of the elbow. Like the radial artery, its branches may be divided into three groups corresponding to their locations in the forearm, wrist, and hand. Forearm: Anatomy
Guyon’s canal wrist

Cross-section of the wrist showcasing Guyon’s canal containing the ulnar artery Ulnar Artery The larger of the two terminal branches of the brachial artery, beginning about one centimeter distal to the bend of the elbow. Like the radial artery, its branches may be divided into three groups corresponding to their locations in the forearm, wrist, and hand. Forearm: Anatomy and nerve, superior to the flexor retinaculum Flexor Retinaculum Ankle Joint: Anatomy and carpal tunnel Carpal Tunnel The carpal tunnel is formed by the transverse carpal ligament (flexor retinaculum) superiorly and the carpal bones inferiorly. Carpal Tunnel Syndrome

Image by Lecturio.

The anatomical snuff box

  • Boundaries of the anatomical snuff box (or radial fossa Radial fossa Arm: Anatomy):
  • Contents of the anatomical snuff box:
    • Radial artery Radial Artery The direct continuation of the brachial trunk, originating at the bifurcation of the brachial artery opposite the neck of the radius. Its branches may be divided into three groups corresponding to the three regions in which the vessel is situated, the forearm, wrist, and hand. Forearm: Anatomy
    • Superficial branch of radial nerve Radial Nerve A major nerve of the upper extremity. In humans the fibers of the radial nerve originate in the lower cervical and upper thoracic spinal cord (usually C5 to T1), travel via the posterior cord of the brachial plexus, and supply motor innervation to extensor muscles of the arm and cutaneous sensory fibers to extensor regions of the arm and hand. Axilla and Brachial Plexus: Anatomy ( meralgia paresthetica Meralgia Paresthetica Mononeuropathy and Plexopathy: compression Compression Blunt Chest Trauma or injury of this nerve at the wrist)
    • Origin of the cephalic vein
    • Scaphoid and trapezium bones
Wrist - anatomical snuff box

Medial view of the hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy and wrist, featuring the borders and contents of the anatomical snuff box

Image by Lecturio.

Related videos

3:33
Carpal Tunnel – Anatomy of the Hand

Clinical Relevance

Common problems associated with the wrist

  • Carpal tunnel Carpal Tunnel The carpal tunnel is formed by the transverse carpal ligament (flexor retinaculum) superiorly and the carpal bones inferiorly. Carpal Tunnel Syndrome syndrome: the most common compressive neuropathy Neuropathy Leprosy, which may be precipitated by repetitive vibration Vibration A continuing periodic change in displacement with respect to a fixed reference. Neurological Examination and motions. Associated with diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus, thyroid Thyroid The thyroid gland is one of the largest endocrine glands in the human body. The thyroid gland is a highly vascular, brownish-red gland located in the visceral compartment of the anterior region of the neck. Thyroid Gland: Anatomy disease, rheumatoid arthritis Rheumatoid arthritis Rheumatoid arthritis (RA) is a symmetric, inflammatory polyarthritis and chronic, progressive, autoimmune disorder. Presentation occurs most commonly in middle-aged women with joint swelling, pain, and morning stiffness (often in the hands). Rheumatoid Arthritis, and pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care. Occurs from the narrowing of the carpal tunnel Carpal Tunnel The carpal tunnel is formed by the transverse carpal ligament (flexor retinaculum) superiorly and the carpal bones inferiorly. Carpal Tunnel Syndrome and subsequent compression Compression Blunt Chest Trauma of the median Median After arranging the data from loWest to highest, the median is the middle value, separating the lower half from the upper half of the data set. Measures of Central Tendency and Dispersion nerve and the 9 flexor tendons within it. Can lead to pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways and paresthesia in the median Median After arranging the data from loWest to highest, the median is the middle value, separating the lower half from the upper half of the data set. Measures of Central Tendency and Dispersion nerve distribution and thenar muscle atrophy Thenar Muscle Atrophy Carpal Tunnel Syndrome.
  • Scaphoid fracture Scaphoid Fracture Hand and Wrist Pain: the most commonly fractured carpal bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types; occurs secondary to a fall onto an outstretched hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy and presents with tenderness at the anatomical snuffbox. Treatment can include prolonged wrist immobilization Immobilization Delirium or surgical intervention and complications including nonunion Nonunion Hip Fractures and avascular Avascular Corneal Abrasions, Erosion, and Ulcers necrosis Necrosis The death of cells in an organ or tissue due to disease, injury or failure of the blood supply. Ischemic Cell Damage.
  • Lunate dislocation Lunate Dislocation Hand and Wrist Pain: anterior dislocation may precipitate acute carpal tunnel Carpal Tunnel The carpal tunnel is formed by the transverse carpal ligament (flexor retinaculum) superiorly and the carpal bones inferiorly. Carpal Tunnel Syndrome syndrome. These injuries are commonly missed on initial presentation Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor.
  • De Quervain’s tenosynovitis: a stenosing tenosynovitis of the 1st dorsal compartment, which consists of the abductor pollicis longus Abductor pollicis longus Forearm: Anatomy and extensor pollicis brevis Extensor pollicis brevis Forearm: Anatomy. Usually occurs secondary to repetitive motion/overuse and may be associated with  rheumatoid arthritis Rheumatoid arthritis Rheumatoid arthritis (RA) is a symmetric, inflammatory polyarthritis and chronic, progressive, autoimmune disorder. Presentation occurs most commonly in middle-aged women with joint swelling, pain, and morning stiffness (often in the hands). Rheumatoid Arthritis and mothers with toddlers. Classic physical examination test is Finkelstein’s maneuver.  
  • Ulnar nerve Ulnar Nerve A major nerve of the upper extremity. In humans, the fibers of the ulnar nerve originate in the lower cervical and upper thoracic spinal cord (usually C7 to T1), travel via the medial cord of the brachial plexus, and supply sensory and motor innervation to parts of the hand and forearm. Axilla and Brachial Plexus: Anatomy neuropathy Neuropathy Leprosy or entrapment: The ulnar nerve Ulnar Nerve A major nerve of the upper extremity. In humans, the fibers of the ulnar nerve originate in the lower cervical and upper thoracic spinal cord (usually C7 to T1), travel via the medial cord of the brachial plexus, and supply sensory and motor innervation to parts of the hand and forearm. Axilla and Brachial Plexus: Anatomy may be compressed or traumatically injured at the wrist within the ulnar or Guyon’s canal. The injury causes paresthesias Paresthesias Subjective cutaneous sensations (e.g., cold, warmth, tingling, pressure, etc.) that are experienced spontaneously in the absence of stimulation. Posterior Cord Syndrome, numbness, and/or pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways in the ulnar half of the hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy, and in severe cases may lead to “claw hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy” (4th and 5th finger hyperextension at metacarpophalangeal joints Metacarpophalangeal joints The articulation between a metacarpal bone and a phalanx. Examination of the Upper Limbs and flexion Flexion Examination of the Upper Limbs of the interphalangeal joints Interphalangeal joints Hand: Anatomy).  Also called “handlebar palsy Palsy paralysis of an area of the body, thus incapable of voluntary movement Cranial Nerve Palsies” in cyclists.

Important physical examination tests of the wrist

  • Watson’s test: used to assess for ligamentous instability between the scaphoid and lunate bones. The examiner grasps the wrist in slight extension Extension Examination of the Upper Limbs and ulnar deviation with thumb over the scaphoid tubercle on the palmar side of the wrist. Pressure is then applied to the scaphoid while the patient’s hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy is deviated radially. A positive test is localized pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways or laxity.
  • Finkelstein’s test Finkelstein’S Test Hand and Wrist Pain: used in the assessment of de Quervain’s tenosynovitis. The patient makes a fist around their thumb and moves the hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy into ulnar deviation. A positive test is sharp pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways over the tendons in the first dorsal compartment along the distal radial styloid.
  • Tinel’s sign: Used in the evaluation of carpal tunnel Carpal Tunnel The carpal tunnel is formed by the transverse carpal ligament (flexor retinaculum) superiorly and the carpal bones inferiorly. Carpal Tunnel Syndrome syndrome, this test is done by lightly tapping over the median Median After arranging the data from loWest to highest, the median is the middle value, separating the lower half from the upper half of the data set. Measures of Central Tendency and Dispersion nerve on the volar surface of the wrist. A positive test elicits paresthesia in the median Median After arranging the data from loWest to highest, the median is the middle value, separating the lower half from the upper half of the data set. Measures of Central Tendency and Dispersion nerve distribution.
  • Phalen’s sign: Patient flexes both wrists and pushes the dorsal surfaces of both hands together for 30–60 seconds. A positive test elicits burning or tingling Tingling Posterior Cord Syndrome in the distribution of the median Median After arranging the data from loWest to highest, the median is the middle value, separating the lower half from the upper half of the data set. Measures of Central Tendency and Dispersion nerve, suggestive of carpal tunnel Carpal Tunnel The carpal tunnel is formed by the transverse carpal ligament (flexor retinaculum) superiorly and the carpal bones inferiorly. Carpal Tunnel Syndrome syndrome.

References

  1. Drake, R.L., Vogl, A.W., & Mitchell, A.W.M. (2014). Gray’s Anatomy for Students (3rd ed.). Philadelphia, PA:  Churchill Livingstone.
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