CHAPTER 5 THE ELBOW AND fOREARM 93 n the form a concave joint surface. The radial aspect of the Posterior radioulnar Articular disc joint is the convex head of the radius. ligament head ulurn The ulnar component of the inferior radioulnar joint is Radial styloid Ulnar meri· ;,{ the convex ulnar head (see Fig. 5-5). The opposing aeric- process styloid fossa;?;, ula< surface is the ulnar notch of the radius. process ~> The interosseous membrane, a broad sheet of collage- Ulnar nolch Anterior radioulnar n~ustissue linking the radius and ulna, provides stability of radius ligament \\i~': for both joints (Fig. 5-6). The following three structures provide stability for the superior radioulnar joint: the $1 allnular and quadrate ligaments and the oblique cord. Si\"bility of the inferior radioulnar joinr is provided by the \",\":<,,~; arti~ular disc and the anterior and posterior radioulnar ligaments (Fig. 5-7).\\ 1ge ofP .'-xte.n:l,,'!k,' ,:, Osteokinematics eXlontl: The superior and inferior radioulnar joints are mechani- ,1$' cally linked. Therefore, morion ar one joint is always ,::xten~-*, accompanied by morion at rhe orher joint. The axis for m~tion is a longitudinal axis extending from the radial FIGURE 5-7 Distal aspect of the inferior radioulnar joint showing the\\ articular disc and radioulnar ligaments. )lch Annular ---;\"\"~ \"'C-:- J Quadrate ligament head to the ulnar head. The mechanically linked joint is H head ligament Ulna a synovial pivot joint with 1 degree of freedom. The motions permitted are pronation and supination. In Oblique cord ---1-*,A Anterior radioulnar ligament pronation the radius crosses over the ulna, whereas in supinarion the radius and ulna lie parallel to one anorher. Radius Arthrokinematics Ar the superior radioulnar joint the convex rim of rhe head of the radius spins within the annular ligament and the concave radial notch during pronation and supina- tion. The aericular surface on rhe head of the radius spins posteriorly during pronation and anreriorly during supination. At the inferior radioulnar joint rhe concave surface of the ulnar norch on the radius slides over rhe ulnar head. The concave aericular surface of the radius slides anreri- orly (in the same direcrion as rhe hand) during pronation and slides posreriorly (in rhe same direcrion as the hand) during supinarion. Capsular Pattern According to Cyriax and Cyriax: Kalrenborn,5 and Magee\" rhe capsular partern is equal limitarion of pronation and supination. ar styloid Ar1icular disc cesS FI~YRE-- 5--6 Amedoe view of the superior and inferior nr r~di9,4Inar joinrs showing the annular ligament, quadrate liga- ?1;~rt,oblique cord, interosseous membrane, anterior radioul- ~~rIigamenr. and arricular disc.
94 PART II UPPER· EXTREMITY TESTING Mean (SD) Mean (50) I-~ 145.3 (1.2) 145.8 (6.3) 142.9 (5.6) I 0.6 (3.1) 84.4 (2.2) 75.8 (5.1) 76.9 (2.1) , 82.1 (3.8) \"\":1 • Values are for males 18 months to 54 years of age. t Values are for' 0 males and 10 females, 1B to 55 years of age. EF!l i Values are for 10 males and 20 females, with a mean age of 24.0 years. .Ii! $( ..~ 'T • Research Findings elhow ;111(.1 (0 rl':lr III , The null' i1nL! fClllale Infants A2 (b, Effects of Age, Gender, and Other Factors rl.'ported ill rhe ~tlld~' by \\\\';1Il:ltahL' ~llld I..'Ollclg11(,~ l-l had SIC Table 5-1 shows the mean values of ROM for various more J{O\\l in flcxioll, pnllulioll. ;llld supinarion [han motions at the elbow. The age, gender, and number of Be subjects that were measured (0 obtain the values (hc (lkk-r male:. in :,,>rudiL'~ hy Boone l \" and hy \\'('alker and tk' \\ reported by the American Academy of Orthopaedic /%(oworkns,];' }-'!owL'n:r. it \",:;111 hl' dilfiL'uh (0 I.:olllparc 37 Surgeons (AAOS)'·8 and the American Medical Association (AMA)' in Table 5-1 were nOt noted. Boone \\';l!llL':' ohtaincd fro III \\';lrious srudiL'S hn.:;lllsL' subject 1~ COl and Azen,10 using a universal goniometer, measured active ROM in 109 males between the ages of 18 months :,>~'In:(i(}j) ;lIJd 11ll',hurl.'llll'm Illethods \",:all dlt'kl', ';~~ an, and 54 years. Greene and Wolfll measured active ROM \\,(!irhill onc srui.,k of 109 111,l!es r;lfH:il1!~ in n!.:c from 18 ':{ . with a universal goniometer in 10 males and 10 females f1lonrhs to 54 ye\"rs~ Buon(' and AZL'n t!\\ 11(')[('(\\ ,l'significant Ge aged 18 to 55 years. Petherick and associates I! measured active ROM with a universal goniometer in 10 males and dift(:r('llcc in clhO\\\\' lh:xiol1 and supil1:niull he[ween Ulll 20 females with a mean age of 24.0 years. In addition to the sources listed in Table 5-1, Goodwin and cowork- SUhjL'([S less du;~ or ('qu;tl ro 19 yeJrs of age ,11ld those G RC ers IJ found mean active elbow flexion to be 148.9 grt;Ucr dun 19 :-'Clrs of ;lgL', Furrhn ;\\I\\:dys('s found that -~~ , degrees when measured with a universal goniometer in Fie 23 females between 18 and 31 years of age. thL' ~rOllp hetwL'cn 6 and 12 years of agc Iud IlHlrc c1bow:~~ rna sig! Age ,ikxioll <I!H.I ('xrcllsion rh;lll orhc:r ;l!.!.l' ~r()llps. The:'i[,?;\" EXI A comparison of cross-sectional studies of normative Y()lIJl~l:S( group {hi..'[\\vL'L'1l IS Illonths ;111:' .' ~yl,';lr5) had a-;~r ROM values for vatious age groups suggests that elbow bet and forearm ROM decreases slightly with age. Tables .signifiC:lllrly g,rc:1tcr :lI1l0ll11( of pronariol1 30d 511piJ1;ltion-~~, ' sub 5-2 and 5-3 summarize the effects of age on ROM of the rh:1I1 urhL'r ,1gL' groups. 1-10\\\\,('\\,('1', rhL' grL':Hcsr dift'crL'nces~{' . old bl'{\\\\'L'CIl rhe ,lgC groups wcrL' sm;\\lI: 6.8 dq;rL'l.:s of flex- -,~ Slip iOIl. 4.-1 degrees or' supin:Hion. 3,9 dC~rL'C5 of pl'ona(ion,-:~ not and 2.5 dc~rL'L'S of CX(('llsinll.]\" ~ Olda p~rs()ns ;lppL';lr [() h;1\\·c diftiL'ulty tully L'x(('nding~~~ StU( rhL'ir ('Ibows to 0 degrees, \\Valker Jnd ,lS:-'<H:I:ltL'Sli, found;~~ , sigr rlur rhe oklcr mcn ;1Ili.1 W0111CI1 (betwl'cll 60 ;\\11d 84 years:); (5 c (If agel ill thcir study WLTC' unable co ('x[cnd their clbows uni' (0 () degrces co :nuin ;\\ llL'urral s[;.1nin~ posirion tor flex~ wh, ang iOIl. 'rhe IlH.:JIl Lllul' tor thl' st:Hting j10Silioll was 6.~ fOr< . . =(It-~rl'L's ill lllell :\\11d I degrce ill WOI1l('/l, BoonL' and~~ art~ inTABLE 5-2 Effects of Age on Elbow and Forearm Motion: Mean Values Degrees for Newborns, .. of 1 Children, and Adolescents 2 Weeks to 19 Years of Age .. . age alth 146.5 (4.0) Megn (fiJi Thi, 2.1 (3.2) yea, 144.9 (6.0) ers. J 76.9 (3.6) 0.1 (3.8) 148 82.9 (2.7) had· 74.1 (5.3) fern, 81.8 (3.2) thar
CHAPTER 5 THE ELBOW AND FOREARM 95 Aze~IO)I~;' found that the oldest subjects in their study Escalante, Lichenstein, and Hazuda,2'in a study of 695 communiry-dwelling older subjects between 65 and 74 ibet\\vl'CnAO and 54 years of age) had lost elbow exren- years of age, found that females had an average of 4 degrees more elbow flexion than males. sian and' began flexion from a slightly flexed posirion. Body-Mass Index &rgstro;;'and colleagues,17 in a study of 52 women and 3711le~'aged 79 years, found rhat 11 percent had flexion Body-mass index (BM!) was found by Escalante, con;i;~iures of rhe right elbow greater than 5 degrees, Lichcnsrcin, and Hazuda 21 to be inversely associated andi.petC:~nt had bilateral flexion contracrures. with elbow flexion in 695 older subjects. Each unit increase in BM! (kg/mo) was significantly associated with G~%~~i a 0.22 decrease in degtees of elbow flexion. St~di€~;Seel)1' to concur that gender differences exist for Right versus Left Side e1bo~,~\"\",ion and extension ROM but these srudies are Comparisons between the right and the left or between u~,~e~~,~b<:g_n~erning forearm supination and pronation the dominant and the nondominant limbs have found no R0M-;,:~ell and Hoshizaki,18 using a Leighron clinically relevant differences in elbow and forearm FlexoIrt~te~ srudied the ROM of 124 females and 66 ROM. Boone and Azen '0 srudied 109 males berween the maie~:hehveen the ages of 18 and 88 years. Females had ages of 18 months and 54 years, who were subdivided signif~ca~t1y more elbow flexion than males. inra six age groups. They found no significant differences E,,-t~aJ?~faJing from a graph, the mean differences between right and left elbow flexion, extension, supina- b<t..v.~eri:1llales and females ranged from 14 degrees in tion, and pronation, excepr for the age group of subjects subiea~i~ged 32 to 44 years, to 2 degrees in subjects between 20 and 29 years of age, whose flexion ROM was osludg\"_c,;~\"~tit~i~:12IP.:_7:_5PE9nyaetaiornsR. OAMlthtohuagnhmafelems,altehsis greater on the left than on the right. This one significant had greater finding was attributed to chance. Escalante, Lichenstein, increase was and Hazudal,21 in a study of 695 older subjects, found significantly greater elbow flexion on the left than on the nqtii£~I!ifi,ant. Fairbanks, Pynsent, and Phillips,19 in a right, but the difference averaged only 2 degrees. Chang, Ssitg~pd;f~ji5g~flI~.4t~lnYmoortmeaellbaodwoleexstceennstiso,nfo(8unddegtrheaets)fetmhaanlems ahlaeds Buschbacher, and Edlich22 studied 10 power lifters and (~;9\"~f\",,~)'.Vhen measured on the extensor aspect with a 10 age-matched nonlifters, all of whom were right UI!i,y\"g~k&()lliometer. It is unclear from the method used handed, and found no differences between sides in elbow and forearm ROM. ,:;)YB,~iJl,'F0hrp\"rextension of the elbow or the carrying .';;' an,~I~}Y~~~;~imeasured. Salter and Darcus,20 measuring Sports f f?r>~a,..~\\H~~suf?ina[ion-pronation with a specialized It appears that the frequent use of the upper extremities in sparr activities may reduce elbow and forearm ROM. ·/at)~~![~\\i:r in 20 males and 5 females between the ages Possible causes for this association include muscle hyper- trophy, muscle righmess, and joint [faUma from overuse. of 16,'i!ita;29 years, found that the females had an aver- Chinn, Priest, and Kent,\" in a study of 53 male and 30 age :l\\f£~lfdegrees more forearm rotation than males, female national and international tennis players, found significantly less active pronation and supination ROM ~~\"~~i~e difference was not statistically significant. in the playing arms of all subjects. Male players also 'flY\"P#!er females and 30 older males, aged 60 to 84 e.yea¥,:2Yc\"i i'ncluded in a srudy by Walker and cowork- ·'E\"\"'r.\".{e4ts'::0JK\"!l!~.es. had significantly more flexion ROM (1 to ',';lfa' . :~}:tpan males (5 to 139 degrees), but males 'if{'\\(1calldy more supination (83 degrees) than \"'\\S\" ,,~.gegrees). Females had more pronation ROM )~.; mg1es,: but the difference was not significant. . _---_...-- .. ..,-~ ~_ _--_.---=~--
96 PA RT II UPPER-EXTREMITY TESTING if .~! 92.8 \" ..~,! 'Pronalii/i(':\" o\",:PSdp';-n-at;on,''\". ~: Arc Morreylr. 65 <~'\":~1f;~:..Rise frorft chair 74:2 >Max?:';::' , Max__ 63.5 Packer~' 8~ 40.9 22.6 Morrey Packt::r 33.4 33.8 9.5' 24.3 Money Open door \", ,.ii4.0J~~:.-l~{;;o:~.~5?.4. 26·1 35.-1 23.4 58.8 Morrey Read newspaper 77:9;',-\"\", t.· 104f 22.7 48.8 -7.3' 41.5 Morrcy is:6 c._.. 42.9 21.9 Money Pour pitcher 58.3c!, ?5,2 10.1 13.-1 64,8 Safaee-Rad16 57.7 \"-3.'1' 31.2 Morrey ,Pu,t 91as,5 ~p,rl)out~/;. 4.1:8('\",: 130.0 17.5 41.9 -26.9' 23.5 43.2 51.8 27.8 ~lorrey Drink from cup '.J 71.5 129.2 28.5 10.4 58.8 15.0 22.0 38.2 58.7 62.2 Sal,l('<.>-Rad Cut with knife 89.2 106.7 45 97.0 Saface-Rad 22.9 81.6 Packer Eat with fork 85.1' 128.3 93.8' 122.3 10):2. .123.2 70·> 115 • The minus sign indicates pronation. t The minus sign indicates supination. demonstrated a significant decrease (4.1 degrees) in h\\'t' hL';dthy \"ubic\". t~ p,lrtil.·ip;\\ll'<.lll1 ~I :-'l'lId~' h~' [\\h.:ker FI elbow extension in the playing arm versus the non playing ;1fld c()llc;l~lIl''''\"''; whidl l\";;\\millnl elhow RO.\\\\ during of arm. Chang, Buschbacher, and Edlich\" studied I 0 power dHt'l' tU1H,.-tlolnl Lbk\". ,\\ \\I11i~1:\\i;11l.'!L'C[T(lg\\)lli(l1l1('rerwas ell lifters and I 0 age-matched nonlifters and found signifi- cantly less active elbow flexion in the power lifters than llsed [0 del,Tllll1H' lZl)\\l n::\"jllirl'\\.1 tor U:-illg ;\\ il'lCf~h{)!le, Fe in the non lifters. No significant differences were found tor rising trOll! ;1 ch,lir t'n ,1 sr;llldlllg posirinJl. ,11ld for between (he twO groups for supination and pronation w: ROM. l',nillg with;1 SPO(lll,:\\ r;lllgc or\" 15 to 140 degrees of flex- de Functional Range of Motion iOIl W;)S nccded (or rhe\"l' rhl\\:': :Ii.:tl\\·jri(,..:., 'Thi:,> R()\\! is at slighrl~\" !-'-i\"c:ltLT rl1;111 rh\\': ;w..: r\\,:pol'tl,:d h~\" .\\lori\"c\\\" and The amount of elbow and forearm motion thar occurs :lSso.,:i;w,:s, hut thl,: ,h:ri\\'jtil':\" ,h;H required the minimal C, during activities of daily living has been studied by ,lIld Ill:n;illlal Ikxjpll ;lll~.dC:,> did IIIlI' ddin, The ;luthors several investigators. Table 5--4 has been adapted from \"'llgg~'st th;H the hci~hr 01 rhe (h:lir. rhl' typc 01 duir arms) In the works of Money and associates/A Packer and :111(\\ rhe posi(iol1ill~ of rh~' t('lt:pholll: ,,:(luld ;lCCOUI1r for colleagues,25 and Safaee-Rad and coworkers. 26 Morrey the dittlTel1r r;lIlgc'o found in th~· sltldil\". un and associatesH used a triaxial electrogoniomctcr to a measure elbow and forearm motion in 33 normal Sa tacc- rCld ;till! c(}\\\\\"(,)rkt'f:- ~;, tl:-l·d :1 rh rl'l'-di l1ll'n.sional ba subjects during performance of IS activities. They \\·ideo SYS(('Jll 10 llle;bllrl· RO\\ I dUl'lng three feeding we concluded that most of activities of daily living that were studied required a total arc of about 100 degrees of ;1di\\'jries: (::Hing widl a spoon, l.:;H;lIg widl :1 tork, <lnd eal elbow flexion (between 30 and 130 degrees) and 100 ,Jr;nkillg from ;I h,llIdkd (Up. Tl'l\\ hl,::lhhy male:... parrjci~ degrees of rotation (50 degrees of supination and 50 p:Hl'l1 ill tht St\"lHJy. Till' t\"l·l'llill~ ,h.:ri\"irio I'cllu;rcd :lpproX- m, degrees of pronation). Using a telephone necessitated the illlatdy 7() to 130 dcgrl'o of dh(l\\\\' flC.'\\;oll, 40 degrees of greatest total ROM. The greatest amount of flexion was proll:nioll, :\\nd 60 dq?rl'l':-> (It :-.upill,nitlll. Drlnklng \\\\'ith a sh, tequired to reach the back of the head ('144 degrees), whereas feeding tasks such as drinking from a cup (Fig. cup required thl\" grl':lll.::->t :lrl.: of l.'lhow flexion (58 Re 5-8) and eating with a fork tequired about 130 degrees dq~r(,(,sJ of the threl' :H.:ri\\·jtil''';. wlh:rl';h e:Hing with a of flexion. Reaching the shoes and rising from a chair spoon required the k;lst \\22. dl'~rl'l·::-l. E;ltill~ \\\\'ith a fork M. (Fig. 5-9) required the greatest amount of extension rcquirc'd rhc grea(est ;1I'C of I'roll;lril..lll-:,ul'iJl:nioll (between 16 and 20 degrees of elbow flexion). Among me the tasks studied, the greatest amount of supination was degret:s), whercas drinking fro!ll :l I.:up rl.·quin:d rhl' least hal needed for eating with a fork. Reading a newspaper (Fig. uri 5-10), pouring from a pitcher, and cutting with a knife (2}) dq;reesi. \\laxilllulll RO\\t \\':llm's during hig required the most pronation. tasks were COlllP:U:lhk with rhose rl'{HIITt:d hy wit Stu :ll1d ;lss(u:i;Hes. 1·lo\\\\,cvlT, mlnimulll \\\"lluts \\,;lrinL val RC hly owing [0 thl' ditt\"cl\"I..'1H (hair ;tml t;lhk hci~hts liSCO in the two studies. Scveral in\\'cstig;\\t'o[\":-> IL1Vl' t:lkclI ;\\ diffL'l'clH in determining the :lrllOUnr or l:ll.HJ\\\\· ;Illd forclrm needed for Jl'[iviries of <.Ltih· li\\'ilH~, Vasell ;llld :lSSOC1~ alcs-'-:' studied the :lhilit~, 01 5{) lll';llt'hy ;ldults to ably complete 12 ;tctivitit.::s of daily li\\'ing while 1
CHAPTER 5 THE ELBOW AND FOREARM 97 In a study published in 1949 by Hellebrandt, Duvall, and Moore,29 one therapist repeatedly measured 13 active upper extremity motions, including elbow flexion and extension and forearm pronation and supination, in 77 patients. The differences between the means of two trials ranged from 0.10 degrees for elbow exteosion to 1.53 degrees for supination. A significant difference between the measurements was noted for elbow flexion, although the difference between the means was only 1.0 degrees. Significant differences were also noted between measurements taken with a universal goniometer and those obtained by means of specialized devices, leading the author to conclude that different measuring devices could not be used interchangeably. The universal goniometer was generally found to be the more reliable device. Boone and colleagues3l) examined the reliability of measuring six passive motions, including elbow exten- sion-flexion. Four physical therapists llsed universal goniometers to measure these motions in 12 normal males weekly for 4 weeks. They found that intratester reliabiliry (r=0.94) was slightly higher than interrester reliability (r=0.88). Rothstein, Miller, and Roettger3l found high intra- rester and intertester reliability for passive ROM of FIGURE 5-8 Drinking from a cup requires about 130 degrees of elbow flexion. prox e1hows were resrricred in an adjustable Bledsoe brace. t't's a Forry-nine subjects were able to complete all of the tasks ,vith with the elbow motion limited to between 75 and 120 1 (5 degrees of flexion. Subjects used compensatory motions :;rh at adjacent normal joints to complete the activities. 1 for Cooper and colleagues28 srudied upper extremity motion in subjects during three feeding tasks, witb the elbow n (9 unrestricted and then fixed in 110 degrees of flexion with a splint. The 19 subjects were assessed with a video- : lca based, 3-dimensional motion analysis system while they 'cdin Wcre dtinking with a handled cup, eating with a fork, and eating with a spoon. Compensatory motions to accom- iorre modate the fixed elbow occurred to a latge extent at the shoulder and to a lesser extent at the wrist. poss ;cd i Reliability and Validity \\[any studies have focused on the reliabiliry of gonio- FIGURE 5-9 Studies report that rising from a chair using the metric measurement of elbow ROM. Most researchers upper extremities requires a large amount of elbow and wrist ha.ve found intratester and interrester reliability of meas- extension. ~~tng elbow motions with a universal goniometer to be Igh. Comparisoos between ROM measurement taken with diffetent devices have also been conducted. Fewer studies have examined the reliability and concurrent ~'hdlry of measuring forearm supination and pronation OM.
98 PART II UPPER-EXTREMITY TESTING men[ during t:;Kh :--l·:-'~l<HI. rhl' rhn:c ~L·....:-i(Jll:- \\\\'ere~~\" condul.-tnl hy OIh: phy:.i(al d1t.:r;lpi~( duril11!. ;1 2,wcek~~ period. \\Virhin-sl'ssioll rL'liahility was hi/:dlcr tor the:~W Llni\\\"l,;r:.a! gonio1llt.:tt:r. as indiclttd hy ICC \\',dllt:~ and 9Sj;~;i. pcn.:t:nr cOlltidl'llCI' illtl'rvals . .\\'lca~urt:!lll'nr .. Llkr.:n with thL' Onho Ranger \\.:orrl'LH(~d poorly with tho:\\\\'\" t<lkenc~;: with r1H.: univcrs.d ~ollinl1lctcr If -:-.: 0.11 w 0.21), andI;~ there \\\\'a:. ;1 ~i~llificant diftt'n:ncc in IllCasurt.:lllCnt;'r lp hc.:twccn tilt· tWO tkvin's, Goodwill ;\\nd co\\\\'orkt:rs l : C\\';J1u;Hcd the rcli;lhility oli-~ ~l llllivc.:r~al goniOll1l'tl'r. J fluid goniolllder. ;llld an e1~~ Z!-trro\"oniollll.:rCf for Illl':hurill1l, ;llrin' tlbow HO\\i in ,'\" <- >* FlG.URE 5-10 Approximately 50 degrees of pronation occur hl';llth\\, \\\\'{HUCll, -!'hrt'l' tester ... (\\)()k rhn::c \\,:ons('clitive1;::N dunng the action of reading a newspaper. fCi.ldings using C;lL,h type of goniOf1H:tU' on two ol.:casionS\" ' rhJt W(:fl' 4 wcC'ks ap;uL SigllifiL'ant di!ferellL'es were elbow flexion and exrension. Tbeir srudy involved 12 found hct\\Vecn typ(':\\ of gonio!1H.:tL·r:\\, n.:str:rs. ;\\nd rcpW~,_1 Rar testcrs who used three different commonly used universal \"::HiO!lS, .\\kasurClllc,:lH:-. cakcll with rht' uuivcr.s;d and flui:dQ:~ goniomerers (large plasrie, small plasric, and large meral) COlli()ll\\eter~ correlated rill: hest (t ~ 0,901. \\\\'hc:rl.';1s th~:--:..~ to ,measure 24 patients. Pearson product-moment corre- latIon values ranged from 0.89 to 0.97 for elbow flexion ~,kt.:tf()~()JliOlllerL'r (\\'fn..I;lr<:d pO(lr!\\' \\\\'ith tht' tltli\\'crsdiJ- and extension ROM, whereas inrcaclass correlation coef- \" ':=-9$- ficient (ICC) values ranged from 0.85 rO 0.95. goniolllt'[cr (r =.; 0,:'; I) ;llld fluid gOlliolllcrl'r (r = O,33)~ Inrr:Ht'stcf and inrt.'l'h.:<;t(·f reliability was high dUfing eaclf,~ : occasion. with cOf~dati(l1l cnd'ficicl\\ts ~,r<:;l,r~'f dun 0.9_ ; Fisb and Wingare\" found rhar rbe srandard deviarion ;llld 0,90, n,:spL·cfI\\·cly. Inrf:ltl,:~tt'f rc!lahllity hc:rwe~,~ of passive elbow ROM goniometric measurements (2.4 occlsiollS W;\\S highL'sr tor the UIlI\\'crS:l1 bOlliornetc(l:,; to 3.4 degrees) was larger than the standard deviarion ICC: v~Il11l'S Llllgcd from 0,6\\ tn n,92 for rlw universal;' . from photographic measurements (0.7 to 1.1 degtees). gOlliol11C'(cr, 0,53 10 0.85 tor dIe fluid goniometer, a~ These authors postulated that measurement error was 0,00 to 0,61 to:- the l'kctro~Olliollll:(cr. Silllibr ro or due to improper identification of bony landmarks, inac- rnclI\",.:htrs, rht authors do nor ath'isc Ell(: illtl'fchang curate alignment of the goniometer, and variations in the ;lhk lIS( pI ditt\"L'ft'nt typc'S 01 ~olliollJt:tcrs in rhe.: clini amOunt of torque applied by the tester. \";t'rtlll~. _ ,?rohrnann,33 in a study involving 40 testcrs and one :\\nllstTong. .1l1d a::-soci~Hcs ;,; L'X:llllillt'd [ltc illtfatt:st\" subJecr, found that no significant differences exisred lIHtTt('~tcr, and ilHl.'fdt'\\·ict' rcli.lhility of activc,,' RO between elbow measurements obtained by an ovcr-thc- llH.:;I~llfc,,'llll'llrs oj th\\\" L'lho\\\\' :Ind fOl't';HIll III 3X p;trien' joint method for goniometer alignment and the tradi- Five tc.:\"rl,:rs Illt'asufc\",d (::Kh mori(lll twicl' with L'<ll.:h oft\" tIonal lateral method. Differences between the means of the measurements were less than 2 degrees. The elbow IIl'-rhrl:l' (k\"icl's: a tllli\\'Cl'S:ll goni011l(71'(:r, Jil l'lecrrogollio tcr, :H1d ;1 flli..'c!I;\\ni(';11 rorJtioll llleJsuring dcvic, was held in two fixed pOsitions (an acute and an obtuse [nrr;l{(:..;tcr n::li;\\bilir~' \\\\,;b high {r valul's gt'llerally great angle) by a plywood stabilizing device. dun O_~)Oi tor all three- devin's ;lilt! ;III modo Pctherick and associates,12 in a study in which two IlHcrrL'.. rcr rcli:lhility \\\\,:IS high tor pron;nlon :llld supi testers measured 30 healrhy subjects, found rhat lion with ;dl threl' dn'i(L's. !nrertl'sta rcliahiliry fOf c1h~ mrenesrer reliabiliry for measuring active elbow ROM f1cxioll :lnd extcnsion W;IS hit-:h lor rhl.' dL'l.':[fogoniome wirh a fluid-based goniometer was higher than \\vith a :111<.1 llloderare lor rhe Ul1i\\'cfsal t!.oniome univers~1 goniometer. The Pearson product moment correhltlon ,~e\"\"een the two devices was 0.83. A signifi- .\\ll..:;lSUfl.'I1H.:JHS takcn with diffcrc,,'IH t.k,\\,i(cs \\';~ri('d wid cant ~!t;r~$nfe'YasJo,!ndbetween the two devices. The with 95 pl'rLcnt L'onfidcllcl: illtcrv;lls for 111(.';\\11 dcv author~)f(WFlt1dsdt~at'loconCUrrent validiry existed dift'i..\"I'L'l1Ll'S of 111OrL' rhall 30 degn_Ts lor most !lIi..\"<lSU berwee~.·th$;;ggi~;&~s'ed and the universal goniomerers The iluthors concludt'd dlJt lIlL';11lingful changL's in intr estcr RO:-d tJkell wirh a u!11\\'crs:l1 gtHliol1lct\"L'f occur w' and that these... instrumemscould not be used inter- lJ5 P(.'l'Lt:1H confickllcC it rhe}\" ~lfC greater thall 6 dcg changeably.' //, ' Grs.ene a~d'AW6Iftl compared the reliabiliry of the lor fkxioll, 7 dcgrn:s fOf t'xtcilsioll. ;llld S degrees, I Orrha .Ra.n.ge,,7~~, e1~ctronic p:~ndulum goniometer, with prollation ;llld supin:ltion. Mcaningful ch:lllgcs ;~, the rehablhry.Og~universal.goniometer for active upper extremlry ~oti?'11!,i');.20,hsaIthy adults. Elbow flexion illtc,,'f(cstcr RO;'.,t rakcll \\\\'it]) ;\\ uni\\Trs,,1 gOllinmcta oc~ and extenslofl''Yt;'femeasured: three times for.each instru- if th('y afC gn:atcr [h,w 10 <.Icgft'e.:S IOf flexion, cxtcns~91 . . . ':i.:<-;~~·i,~:/:,;,'\\',,',':':,',: c.:· .,.\", . ;1I1d proll;lriol1~ and gre.:atcr [h~lll I I l..kgrces tor sUPID1'~ [JOIL >/~:::((,:, ./!.\"
CHAPTER 5 THE ELBOW AND FOREARM 99 OJl!- were Range of Motion Testing Procedures: Elbow and Forearm a 2-wt,:ek r for rhe -',~.' ItS and 95 aktll With oleC~on Ulna OSl: raken 1.21 l. and. 9!Q~l::',5~13, /pcisre~ioI>view of the righr' 'upperiextrcmit),\" ,~: \";Fsln'Got']\\\\i,§i,niAr:'~~'~n4af'toiPnoicsatlc\"~li;oi'rndVlip1~1ra\\rr~:~:s.,;~p.f.:ko~c~:,\"'.hgco[niigohmtcl~lePrp'pcar~l,ei~:g<:~.I'r~..e\\inf~r\\m'>i/.;i?lj'? surl:lllcnts:\" jyi,n~i~tirfac¢ \"anaromtIandmarks f9,r goniometer align~,: :';'\" i'; l4u~ing the me~su..rement.of elbow and forearm\" ~O¥.-'>l,:/,/<:,:;; iability of,'/ t,s,'o~Tn~,;dtl,~i#p ;the::measurement of ,~l~ow, and, forearm R9:¥,::< d all ('lcc~;; ) \\'j in 23''- )Ils('curive OCG1SIOns nees were IIld repli.· I and tluid :H:rr<lS the 1IIlj\\\"(:rsal = 0.33).· .Iring c<'\\ch rhan 0.98,' b('rwccn'~1 lIliorncrer/3 un ivcrsal::] rlcrcr. and'Ji r to other.;; ('rchal1ge..'~ 1(.' dinical i Ilrr:Ht:srer, \" \\\"c ROM., : patients, ,h.:h of the Igol1lome· \" ~ device. ly grc:<Hcr[ motions:', :' d supina::% for\" clbowt;>~ )llJOmCrC(),:, 11 i() III etcr~'!J\\':?\" ..<.I \\Vidd)',';,~ .1 J1 device\" 11lC:l$urcS. in inrrat-, ccur with 6 ckgrees \" :grcc:s for angc:s ilF\" ~rer occur. xrcllsioo\" . r Sll pin3';\"{
::d -'-O-O--p-A-R-r-'-'--U-P-P-E-R-.-E-X-r-R-E-M-'r-y-r-E-S-r-'-N-C Lllh:t' ,0 runht'r 11l0(J0I1 l'> It'll -lnd .HI\\·mj'!\" TO o\\·-:r\\.-·Ol1le !!w 't·\"l'>Ulh.\"t· '-·.ltl ....t: dC'\\ltJlI 0; th~· ,,!louidt·r. ~II•«o::~ ~ Normal End·feel u.. , FLEXION t ·\"ll.diy £IlL' L\"lhl-tn...1i\" \",otl h\\.·--.lu\"t· lit ..:olllprc.....,ioll of the ~ Nlorion ~ccllrs in ~hc sagi[(~1 plane around a mc~ial. rlllhdL' huik I\"!f' iiI\\.' ;lIl{Cl\"lO(' fore.lrlll with dl.\\t O!· the arne- rior llppL'!'\" ~lflll. it rill.' 1l1u\"...:k bulk i... \"111.111, lik' end-feel « !ateral aXIS. Mean elbow fleXion ROM ranges from 140 1l1.\\~' hI.' !urd hn.·.lll:'>l· of COll£:h.l bl't\\\\\"l·t'fl t1w Lorolloid 3: ! degrees according to the AMA9 to 150 degrees according pr(lLl'~:' of rhe llln;l ;Ilhl !llt' i.:or(lIHlid ((lV\"l (If thl' o i;~ to the AAOS. 7.8 Sce Tablcs 5-' to 5-3 for additional ;llld hn:,lllsL' 01 ...-0I1U>.:1 hl.·rw\\'l:!l tht' hl·.ld uf {hl' informarion. Sec Figures 5-11 ro 5-J 4. . lilt! rht' r:1di;l! !OSS.:l of rhL' hlltlll·nr ..... The t'nd-fl·:.:1 Ill:'}' I:ii Testing Position ttrln hn:.lllo.;c of [l'n~ii.)11 in rhl..' pll\"fL'rior illinr C11)\\ulc, ,h,dn, I !.I(l'r.d .l!'i'-! IlInlj,ll hL';HI\" of ill(' tr!L\"l'p\" llllhLk.•lllt! 51 Position the subject supine, with the shoulder in 0 degrees k..1Ill,:llIlI'U' lIlu\\... I O. § of flexion, extension, and abduction so that the arm is tJ Iclose to the side of the body. Place a pad under the distal ~ end of the humerus ro allow full elbow extension. Jc... Position the forearm in full supinarion with rhe palm of Goniometer Alignment ~ rhe hand facing rhe ceiling. 1;; ~ 5tabilization Sn.· h~lIrl's 5-16 ;111d :\\-1-. 6 IwI- i~.. Srabilizc rhe humerus to prevent tlexion of the shoulder. orI. CCllter rht' fllknllil till,' ~llllit)l1ll'tl.·r on:r The pad under rhe distal humerus and the examining LI!I..·r;d cpiUHldyk (If till\" hU!lh.:rll'\" S::; lI- .. t:tblc prcvcnr extension of the shoulder. Testing Motion ) :\\lign [he pro'\\l1l\\al ,Ifill wl£h rill.' JaIL'Lll rllldlinc ['\\1(: humerus. lIsing rht' ,-'t'Jl{t\"f\" of the (5 ~ Flex the elbow by moving rhe hand toward the shoulder. pro(c\"s tor rct\"Cl\"l'lh.'I.'. w ~ !vlainmin the forearm in supination during the motion .) ..\\li,<';1l rill' di\"LJI ;lrlll with dlL' LHt'Lll lllidlill(' ot (Z,.J g (Fig. 5-15). The end of flexion ROM occurs when res is- Lldius. u\"ing rlll.: I'<lLli;lI lh:ad ~\\Ild LHlial s[;\"loid 0 prOi...·l'S\" tor rvkT\\,.'Il\":(:. «,,'\" ! t. ~ .~ ! I ~ it I I ~.... I I i ! ~ I I ~ i i I ~~Ii FIGURE 5-15 The end of elbow flexion ROM. Tht: l;X,lI11illcr's lund stahilll,cs Ihe IHII1It'rll~1 but it mm[ t' be positioned so it does nor limir the motion.
CHAPTER 5 THE HBOW AND FOREARM 101 \"' FIGURE 5-16 The alignment of the goniometer at the beginning of elbow flexion RONL A rowel is placed under the distal humerus to ensure that the supporting surface does not prevent full elbow exten~ sian. As can be seen in this photograph, the subject's elbow is in about 5 degrees of hyperextension. FIGURE 5-17 The alignment of the goniometer at the end of elbow flexion ROM. The proximal :lod distal arms of the goniometer have been switched from the starring position so that the ROM can be rcad from the pointer on the body of this 1SO·degree goniometer.
il-:;-1\";;O:;2---::P\"\":\"A-:R:\":T::-I-I--U-P-P-E-R-.-E-X-T-R-E-M--1T::-Y--=-T\":\"E\":\"S-=T\"\":\"I-:-N:-::C g;1 o(,:t:ur:-. wht'll fcsiSLllKC to funht.:r mOtiori' EXTENSION ~H{elllprS W OV<.'rCOlll(' fht.-' r(:~istanc.:c cause';' :::';';JZ<c !''~l the starting position from the end of elbow flexion ROM. l\\1orion OCCurs in the saginal plane around a mcdial- tion ;Illd abduction oj (he ~h(JlIldl.:r. '; lateral axis. Elbow extension ROM is not usually meas· I3: ured and recorded separately because it is the return to Normal End,feel ~ Testing Position, Stobilization, and Goniometer The l.:lld-tcd may hl.: hard bi.:c;\\lIs(· of conrac : ~ . Alignment lIhl~l ,lnd rhe radius, or if nuy he: firm beca ~_ _ The resring pOSition, stabilization, and alignment arc the in rhe.: dorsal radi()lIlll~lf lig'lllh.:m of rhe in~ rl:lr joint, rllt.: interosseous memhrane, and r 53 ! same as those used for elbow flexion. musck. ~I Testing Motion c:.: \"- Extend the elbow by moving the hand dorsally toward <..J Z the examining table. Maintain the forearm in supinarion ;:: during the mOtion. The end of extension ROM occurs ....VI when rcsisrance to further motion is fclt and attempts to I- overcome the resistance cause extension of the shoulder. z· o ;::'.\" Normal End·feel :;;:10 ' Usually the end·feel is hard because of contact between u.;.J the olecranon process of the ulna and the olecranon fossa 0' -~ of the humerus. Sometimes the end~feel is firm because of t).-.I tension in the anterior joint capsule, the collateral liga- «Z i~t' mcnrs l and the brachial is muscle. 0:: 11 m :PRONATION . Motion OCCurs in the transverse plane around a vertical ,, axis when the subject is in the anatomical position. \\X1hen the subject is in the testing position, the motion occurs in i the frontal plane around an anterior-posterior axis. Mean pronation ROM is 76 degrees according to Boone and F1CUHE :'-18 End of pron;uioll RO~'t. The s~ Azen,'o and 84 degrees according to Greene and WoIL\" 011 rhe l,dJ.:,c of a tahk· and II\\(: ,,'x:lI11inl,:r i$ stan Both the AMA9 and the AAOS7•S state that pronation suhjen, T'jlC examiner uses one lund to hold [he,' ROM is 80 degrees. See Tables 5-1 to 5-3 for additional rhl' sllbjc('('s hody and ill YO i.h.:);rl'cs (If elhow \" ROM information. (0 prC\\,('lH borh Illt.:dial wt,uiOIl :\\lld \"bdU<.:cion of: Till' l'X<llllinl'r's orher !l;\\IId pll..h,,'s Oil th(' r~H.lius Testing Position the sllbji..'L'c's h~llld, If till' l'X,llllilll'r pll:-.hl'S (Hl the 1l1OVClllCfl[ of the wrist 11l,1~' h(' lllisukr.:n for Position the subject silting, with the shoulder in 0 degrees fadiolll1l:11' joinTS, of flexion, extension, abduction, adduction, and rotation so that the upper arm is close to the side of the body. Flex the elbow to 90 degrees, and support the forearm. Initially position the forearm midway between supination and pronation so that the thumb points toward the ceiling. Stabilization Stabilize the distal end of the humerus to prevent medial rOlation and abduction of the shoulder. Testing Motion Pronate the forearm by moving the distal tadius in a volar direction so that the palm of the hand faces the floor. See Figure 5-18. The end of pronation ROM
CHAPTER 5 THE ELBOW AND fOREARM 103 Goniometer Alignment 3. Place the distal a,m across the dorsal aspee' of the See Figures 5-19 and 5-20. forearm, just proximal to the styloid processes of the radius and ulna, where the forearm is most level 1. Cenrer the fulcrum of the goniometer laterally and proximally to rhe ulnar styloid process. and free of muscle bulk. The dis'al arm of the goniomcrer should be parallel to the styloid 2. Align the proximal arm parallel to ,he anrerior processes of the radius and ulna. midline of the humerus. FIGURE 5-19 The alignment of the goniometer in the bcgin- FIGURE 5-20 Alignment of the goniometer ,n the cnd of ning of pronation ROM. The goniomcter is placed laterally to the distal radioulnar joint. The arms of the goniometer are pronation ROM. The examiner uses one hand to hold the aligned paralic! to the n.nterior midline of the humerus. proximal arm of the goniometer parallel to the anterior :(0 midline of the humerus. The examiner's other h;tnd supports rhe forc;trm and assists in placing [he distal arm of the ing goniomctcr across [he dorsum of lIle forearm just proximal [Q kr. nn the radial and ulnar styloid process. The fulcrulll of dIC goniometer is proximal ;Ind bteral to the ulnar styloid nd, ,<;..., process. th~ --.-------_.-------
104 PA RT II UPPER· EXTREMITY TESTING SUPINATION til(\" clhc,\\\\ In \")0 dt.'l',l'u:.'>, .111<,.1 _'>tlppnl': t!lv jorl'~lrrn. ., .wlorion occurs in the transverse plane around a longitu- IniH.ill\\\" l\"lhi1lilll th~· ':lIT.Hlll lnid\\',.':): he{\\\\\"l'l'll ,upill:nioll / dinal axis when the subject is in the anatomical position. and !lr;il·1.HliI11 ....0 du! [ill- !iWillb l,ullH\" IClw.l!d i1H: (l:!l· . \\Vhen the subject is in the testing position, the motion occurs in the framal plane around an anrerior·posrcrior Itl~. axis. w1ean supination ROIvi is 82 degrees according (0 Boone and Azen,lO and 77 degrees according to Greene Stobilizotion and Wolf. II Both the AMA9 and the AAOS7•• State that SLlhdi/t' tllt\" d, .. ul t\"nd p! th~' httllli.:ru .... !(i prnTnt supination ROM is 80 degrees. Sec Tables 5-1 ro 5-3 fot roLHiol! ,HIt! :H..ldlldloll IIi li't· .. houlth:r. additional ROM information. Testing Motion r.1h: ~li\"Ld t:ldiu>; in a'/;\"lf,{',i' Testing Position Iii lilt· h.'lnd. {:h:t·S. rhe~ 51l ,1'IILHt\" {'litI' '(H\\::li'l1,1,,- \"\"'\\\"\",'-. Position the subjee< si\"ing, with the shoulder in 0 degrees of flexion, extension, abduction, adduction, 2nd rotation dor.....d dn't',:uPll .. 0 rit.li rht· l'JJnl so tbat tbe uppet arm is close to the side of the body. Flex Ct.ilill!!-_ ~\"I..- hgul\"e )--2.1. T\"~' l'llll uf :'lI.l'llloi.no l.l ROM,:.' ..' oi..\"l.:ur.. w!l,-l\\ l\"t\":.i\"uw.:I..· {(J IUrlhe!\" IIlO{III!l is h:!r ~nd., :\\l[l'llll't~ I!'o ()\\'I..°r~:()lllC lit\" ;.l\".'.. bL,ll 1L-' ,:.wl... e'! 'l[1..°r:l1 roratlOn),:i,®} , and :H.idlldillll ut the .. lHJultkr. ,f ! / /, '\\ !;~\" ,- FI\\ s\"~ dis pai
CHAPTER 5 THE ELBOW AND FOREARM 105 Normal End-feel 2. Align rhe proximal arm parallel to the anrerior midline of the humerus. ,The end-feel is firm because of rension in the palmar 'ra4~9ulnar ligament of [he inferior radioulnar joint, 3. Place the distal arm across the ventral aspect of the oblique cord, inrerosseous membrane, and pronator teres forearm, just proximal to the styloid processes, where the forearm is most level and free of muscle ana pronaw[ quadratus muscles. bulk. The distal arm of rhe goniomerer should be '_.. , parallel to the styloid processes of the radius and ulna. a6~iometer Alignment see Figures 5-22 and 5-23. '/,:,:,,:c:'!~<(,~' ,.,'/}p'}Center the goniometer medially and proximally to \"\\;1.'\" lhe ulnar styloid process. iY;~~i[4i,{: '~4i2 Alignment of the goniometer at the beginning of FIGURE $-23 The alignment of the goniometer at the end of supination ROM. The examiner uses one hand to hold the ~~qM. The bod}' of the goniometer is medial to the proximal arm of the goniometer parallel to the anterior midline ~i9u.lnar joint, and the arms of the goniometer arc of the humerus. The examiner's other hand supporcs the fore- ~¥he anterior midline of the humerus. arm while holding tht::: distal arm of the goniometer acrosS rhe volar surface of the forearm just proximal to the radial and f ~,;:~- ulnar sryloid process. The fulcrum of the goniometer is proxi- mal and medial w [he ulnar styloid process.
.~«c...:. 106 PART II UPPER-EXTREMITY TESTING @c.:' , Muscle Length Testing Procedures: the !(In:arm III proll;ltion. If [he hi .. cp:-. hrachii i... ~horr, it 5 \"~\"'jl Elbow and Forearm limits L'lhuw C\\:ICllSioll whl'1I the shoulder IS positioned in ,I«, full c.'\\tl:ll~iOIl_ 1 BICEPS BRACHII U 3:~ It dhow l\"xtt:n~ioll i~ lilllifed rq';:lrdk..,.., lit ~hollldtr ~ The biceps brachii muscle crosses the glenohumeral, po\"i[illll, rhe lilllir.lIioll i\" 1..':lll~l.:d hy :lhnllflll:lliric.., of the n u:V humeroulnar, humcroradial, and superior radioulnar jOlnr :->Urt';h':L'S, .. ho([l,:nillg, ot the :lIHcrjor joim C:ll'''llll't :llld CO!L\\t'Cf:tllig:lIllCt!f\\, or b~'- illUSde.:\" lh;\\t' cro~s only the 1 \",,':, Vi:;', joints, The short head of the biceps brachii originates elho\\\\', such as til(: hr:H.:hiali;;; :lI'ld hr'lChior'ldi:lli\". E ri \":,' ~': proximally from the coracoid process of the scapula (Fig, Starting Position 'l', §{, 5-24), The long head originates from the supraglenoid n Posirioll (he ;\"uhjl.'e.,:t ..,upillt\" .11 rhL' edJ.!-\\..' (If rhe.: t\".,\\.lI11illing e gi, .... ' tubercle of the scapula, The biceps brachii attaches t:lhk, Set' Figun: S-25. Fkx lhe.: dhc)\\\\\" ;lIul PO\"ilioll the distally to the radial tuberosity, ..,houlder ill full L'XICllsion :111\\,.1 (i dq,.:rl·c~ (If .Ihdlll..'rioll, f c.:', When it contracts it flexes the elbow and shnulder and addth.:tioll, :Intl f(I(:Hioll. 1 b ::;i supinates the forearm, The muscle is passively lengtheoed ', ':', ~'{I by placing the shoulder and elbow in full extension and 1..-.-.<, Acromion Process :r'1-' Supra Glendoid Tubercle w\\zJ;-.;. u..-..o....J/·- Vl;-~ ::>1 ~01 ;~ .'~~ . Long Head of the Biceps ~ Short Head of -- \" H. the Biceps '.f--I_ _ Radial Tuberosity Ulna --+-I- Radius FIGURE 5-24 A lateral .... iew of the upper extremity showing nCUHE :1\"-2:1\" Tht: $(;ufing posilion for (e.'sling lhe.' h:lIgrh oi F Ihl\" bi<':t:!)s bLKhii. [f rhe origins and insertion of the biceps beachii while being srreeched over the glenohumeral, elbow, ;and superior radioul~ h nar joints. d
CHAPTER 5 THE ELBOW AND FOREARM 107 :.'; Stabifization Goniometer Alignment It Theexaminer stabilizes the subject's humerus. The exam- ining table and passive tcnsion in the serratus anterior See Figure 5-27. n i( muscle help to srabilize the scapula. :r I. Center the fulcrum of the goniometer over the Ie Testing motion lateral epicondyle of the humerus. Exrend rhe elbow while holding the forearm in prona- e, iiOn. See Figures 5-26 and 5-25. The end of the testing 2. Align the proximal arm with the lateral midline of motion occurs when resistance is felt and additional the humerus, using the center of the acromion Ie ,:- elbow extension causes shoulder flexion. pr9cess for reference. n, Normal End-feel 3. Align the distal arm with the lateral midline of the The end-feel is firm because of tension In the biceps ulna, using the ulna styloid process for reference. btachii muscle. q~U1<.\" 5-26 The end of the testing morion for the length of FIGURE 5-27 The alignment of the goniometer at the end of lhe'h;r,,,n< brachii. The examiner uses one hand to stabilize the humerus in full shoulder extension while the other hand holds testing the length of the biceps brachii. The cxaminer releases the forearm in pronation and moves the elbow into extension. the stabilization ohhe humcrus and now uses her hand to posi- tion the goniometer.
TRICEPS BRACHII C(I11[r;\\(['\" it n;rcnd\" rhl' ~h()lddcr :ll1d clbuw, ThL' long Testii ht',H.i of till' lrit:t.:p\", hLH,:hll h pa ...si\\\"(:-Iy ll.:llgdkllt.:d hy plac~ The triceps brachii muscle crosses rhe glenohumeral and lilg !IlL\" \"hnuidcr ,lIltl I.:lho\\\\' III full IlL-Stoll, II the long Flex r humeroulnar joints. The long head of rhe triceps brachi; 1Il,::h.1 of rhl..' IrlLl:!h br.h.:hii i\", \"hon, it limit:-- dhow flexion der. S muscle originates proximally from the infraglenoid tuber- w!lI..'ll the ... houldl'f i.; ,\",ositill!H:d III full ik'XlOll, cle of rhe scapula (Fig. 5-28). The lareral head of rhe moOO triceps brachii originates from the posterior and lateral If \":.,lho\\\\· flexion is limncd rl',l!.~Hdlc~~ of \\hollldcr posi. surfaces of the humerus, whereas the medial head origi· liOI1, thl' hilliu[lon i~ duL' to <lhllorrn:dirics of the elbow nates from the posrcrior and medial surfaces of the \",urlat:t.:s. sll()r!enin~ ot ihe po:-It::rior clpsuk (lr m'lIs<:lc,;,@J humerus. All pans of rhe triceps brachii insert distally on th:H I..TO\"'::- only the dho\\\\\", .I,lKh :1\" £Ill..' all(()nell~ :lnd the Nom rhe olecranon process of the ulna. When this muscle b((:I\":\\1 ;llld llwdi;\\l Ih.:ads ot the (ri\"':l'r~ hrachii, The e olrhe Starting Position Medial head ~S;~'?r- Olecranon of triceps 1\\lsilioll rhl' subjet:t supille, (lose to {he edge of {he procoss illill~ tahk. E;\":{l..'lId thl..' dhow and p()~i{ioll rhl..' ,h,[)\"I~\",: ill full t\"k;..:ioll :lIld () dl..'g.rn'\" of :lhdul.'lion, adduuion, (-/t-l-f-- Radius !\"OLHinll. Supilutc rill' fOfl'ann (Fig, 5-29), 11/1'+- Ulna Stabifization Inlra glenoid The c;\"::111lirlL'r sl',lbilizcs [\\ll' SUhjl,'''':(\"\\ hUIllLTus. tubercle \\\\\"1..'i~.dH of rhl' slIhjl..'(,.'I's trunk 011 dH: I.:;\":;llllinjll~ {;\\hlc thl' passivl· tCllsion in rht btiSSlll1ltlS dor\",i, minor, ,1I1d rhomhoid llujor and minor rllusdl's help ~{:Ihilil.l· rhl: ~;\":;lptlb. Scapula Hoad 01 humerus FIGURE 5-28 A !ateral view of the upper extremity showing the origins and insertions of the triceps beachii while being stretched over the glenohumeral and elbow joints. FIGURE 5-29 The starting position for testing the length of the triceps brachii. F1GUF {he eric hum en elbow
CHAPTER 5 THE ELBOW AND fOREARM 109 g Testing Motion Goniometer Alignment Flex the elbow by moving the hand closet to the shoul- Sec Figure 5-31. g der. See Figures 5-30 and 5-28. The end of the testing 1. Center the fulcrum of the goniometer over the n motion occurs when resistance is felt and additional lateral epicondyle of the humerus. elbow flexion causes shoulder extension. 2. Align the proximal arm with the lateral midline of l- the humerus, using the centcr of the acromion process for reference. 1t Normal End-feel es The end-feel is firm because of tension in the long head 3. Align the distal arm with the lateral midline of the 1e of the triceps braehii muscle. radius, using the radial styloid process for refer- cocc. n- let nd 'he .nd 1lis to FIGURE 5-30 The end of the tesring motion for the length of FIGURE 5-31 The alignment of the goniometer at the end of testing the length of the triceps brachii. The examiner uses one the triceps brachii. The examiner uses one hand to stabilize the hand to continue to stabilize the humerus and align the proxi- humerus in full shoulder flexion and rhe other hand to move the mal arm of the goniometer. The examiner's other hand holds elbow into flexion. the elbow in flexion and aligns the distal arm of the goniometer with the radius.
110 PART II UPPER. EXTREMITY TESTING REFERENCES IX. lid!. I\\,l I ..1Ild 111l~hl/.lj.;1. 'I~: I<l·I.L::\"Il~htjh or .1)-:\\· .Hi,1 ~\\.:, 1. Levangie, PK, and Norkin, CC: Joint Structure and Functioll: A Lllir.\\' ,'I llj('II(,I) j,t ~l'''\\'n1n'll jl'Il:1 ,ldl('tl~ ill hiHlJ;llh. (,,'11.1 Comprehensive Analysis, cd 3. FA Davis, Philadelphia, 200 I. :-'pl \\, I f.:~IJ:!. \"):-;'. 2. HoppcnfclJ. 5: Physical Examination of the Spine and Extremities. AppletOn-Century-Crofts, New York. 1977. !< . \"I'..I~) . 1·.llrh.1l1k~. 1'·'-Jl~\\:1l1. ,wd l'hdllJ'~. I I: (!ll.llll!l.lll\\·\\· llk·as. 3. Morrey, UFt and Ch::lo. EYS; !l:lssivc morion of the elbow joint. J HI'I·Illt\"III~ (,! I\"ll;l rl!f,i>dll~ HI .l\\~\"!'·~C-I·lll~ ..-\\llll R!l\\'Ull\\ 111~'\\ ;:2SS, BOlle Joint Surg Am 58:50. t 976. 4. Cyriax, JH, .:md C)'riax, PJ; lIIusrran:d M:ll\\ual of Orthopaedic InS·:. Medicine. BUHcrworrhs, London, 1983. 20, ~.d.n. .-...: . .Lll,i [l.lfdh. III I: l'lH' ~lllll'lilU,k \"i :\"l\"l'.11\"1l1 5. Kalrcnborn, FM; M:lnu:11 Mobili7..'ltion of the Extremity Joints, cd 1\\ll:Hn.Li roL!fl\"rl. J .-\\U.I! S··:·I!J-. I'J'i:. 5. Olaf Norlis Bokhandcl, Oslo, 1999. 6. Magce. DJ: Orthopedic Ph)'sical Asscssmenr, cd. 2. Wil Saunders, 21. !'....,:.d.IIlII'. :\\. 1,lchl'lhlc\"lll . .\\1]. .\\ilt! Il.l/ud.\\. 1 if': 11rICrl1l111.lllh of Philadelphia, 1992. _~I1(,uf,in .Im! \"Ihp\\~ Ik\"H'l1 r.:II;:l': R,·_'lll\" tfl'lll :it\\\" ....m :\\nlollio i. Amcric:1I1 Academy of Orthopaedic Surgeons: Joint Motion: t.\"Il,l:Hlhllll.ll\\!Lldv ill '-\\i:IIl~:. ;\\rThrlll~ (.lrl·l{o 1:':2.:-. 1<}\"'I. Methods of Mi..';lsuring :lOd Recording, AAOS. Chicago. 1965. 8. Green. WR. and Heckman, JD (cds): The Clinical Me:tsurcfllcnr of 22. (il:lll~. I IF. HIl'l·j,b.lchn. II'..md hllt,.-h. tU·: l.~lllltl\"lII\"'I1( illuhil- i!1 11\\'l'own l:ih·h. __\\IIII .... I'(ln~ .\\In! Ih:~sO. 1\":\\:-;. Joim Morioll. Amcric:l.n Acadcm)' of Orrhop:tcdie Surgeons, Rosemonr, Ill.. 1994. 23. {,limo. (I. Pnnt. III ..ln~i hl·lli. 1',:\\: t'l'pn <'''[I~'lIll!:- l'.ill~l· of _9. American Medical Association: Guides to the Ev:tluation of Penn:tnem Imp:tirmclH, cd 3. AMA, Chicago. 1988. IllI11H\":, ':-:(11' ~lfl·l1~~lh .111,i ;.:ioh II: hi,.:h!:- ~kd!l\"! l ..mlJ~ 1,1.1:;1·(s. ] 10. Boone. DC, ;lOd Azen, SP: NormJ! r<lngc of motion in malc PhI ,I hl\"l\" \\·1:·:-'·1. ['J-.1. Ra subjects. J Bone Joim Surg Am 61;756, 1979. 24. .\\ il',r~l'\\' HI·, .\\\"k~·l·.. 1\\..-\"': •. md ( h.HI. ,. Y\": :\\ bl ••m'·...-h.HJlCll ~lIId\\\" of AT 11. Grecne, BL. :tnd Wolf. SL: Upper extremity joint movemcnt: llt>rlll.li tlll\\c·l!l)~l.il ,·Ib\"w lli(l!I'>!!.! 1:;,)[\\\\\" ,Ihlll! :-':11;.: ..\\m h,:;:~72, Comparison of c\\vo measurement devices. Arch Phys 1\\-1cd Rehabil l'I S r. Th 700288. 1989. Th 25, I',kl..\\·r. -II . \\·t .,1: I' ,.lrnillln,.: (\\1\\. dh .1': dunng !::l\"!~i'l1.l! .lc\"rl',-jli<-s. 12. Petherick, M. et al: Concurrent v:tlidit)' and intcncstcr reliability of universal and fluid-based goniometers for activc elbow range of ()c·... 1l1' rhd 11{~·~. 10:,2,. 1<\"'\\1. motion. Phys Ther 68:966. 1988. 26. \\.II.;,·;·.IC1.L R. ,': .11: ,-\"':\"1'111.\\1 Illlld:ll!l,d r,L:;~l' \"I ll\\l'lH>l! \"r Upper 13. Goodwin. J. ct nl: Clinicalmcthods of goniometrr: :\\ comparacivc hlllh 1<11ll! .. dunn;: !,~.,.!\"rm.l!lc,· ~.l :hrl\"l' in'dul,.: ,k'!I\\I!I,'~. :\\rdl Hud)\". Disabil Rt.·habil, 14: 10, 1992. I'h\\'~ .\\Ie,: Ih-ll.lhd -!:~(.~. j·J'lf!. 14. Wan:ttabc. H, ct al: Thc rangc of joint motions of the extremities 27. \\';I~,·n. .-\\1'. l\" .l!: h:nc:illll,d f.\\I1.l:\" III 11\\<)ll(\"11 nl- rhl' \\·!!1L\\\\\\\". 111.1Ild in healthy Japanese people: The difference according to nge. \\uro.: 2ft..\\; 2:-;~. I<'<'_~. Nippon Seikeigcb Gakkai Z:tsshi 53:275, _1999. (Cited in Walker, JM: Musculoskeletal development: A revie\\\\'. Phys Thcr 71:878, l ,,(·,pn. IF. l'l .11: 1'lh(,\\\\- lollH (,'<In,(I''n: I:!!,·c: \"11 llln..·tional 1991.) 15. noone, DC: Techniques of measurement of joint motion. IIPpn lnnb mO(IOll ,!unllt: 1',·rll,rrll.ll1~·I· '11 thrn' j\"n!m~: .\\;.:rivitlc-s. (Unpublished supplement to Boone, DC, and t\\zen, SP: Normal ..\\·r~h I'h\" .\\!t-,llh·h:.bd ':'.1::->0\\. ~'.I'J_'. range of motion in male subjects. J Bone Joint Surg Am 61:756, 29. Ildkl'r;{ll,it. 1':\\, Ih!l.dJ. 1::\\, .Ill,] .\\I\"llf'·. -'II: I\"h\\, 1::,',I'Ul'l'IllC!lt 1979.1 0: l\"ilH HHJtl0!1. 1'.lrt Ill: I\\di.lhili~ (Ii (,UllltJ:Il'·l!~. I'h:·.. Th,·: Rev 16. Walker. JM, CC 31: Active mobility of the extremities in older .!'.J;.'02. 1')·j(l. subjects. Phys Titer 64:919,1984. 17. Bergstrom, G, et 31: Prevalence of symptOms and signs of joint 30. IIm'Ill\". [l(_. l't .11: I\\di,lhrhl\\ i,f l:illHilllll\":rlc :lh\".b\\lf\\·llWllh. Phys impairment. Scand J Rehabil ~led 17: 173, 1985. Thl\"l' 'S:l ,~~. 1'}-S. 31. Ru(h~~\\·in. ].\\1 . .\\hlla. \"I. .Illd R\"CUL.:I·f. Rr: (;\"ni\"l11l\"rrk' n.·li.lbi!· Ily 1H.l c·lll;lc·.d ~l\"ltini:: 1-.111;,\\\\ ,Ill,; :';l<\"l' l1l'·,bllrl·ll1l\"nh. I'hy~ Thcr \".l;I{,II.I<J:-U. 3~. h~h, 01\\ . .m,l \\X·lll!~.lIL I.: \\I'llr~-~'''' of ~:IHll(lllldnc- ,·rr,,: .If dhl'w. l'll\\\"~ 'nl l \"( (,_~: li'(,i'. l'IS'. .u. (;n,hmall;I • .IE1: (·lllllp.!r\"'Ul (,I 1\\·.llll1l\"tlli,d~III ).:lllllt\"ollll\"lfY. Th~'r (>3:')22., l'IS ,. \"''c'.\"\"\"\"\"\"\"'..\\r1ll_'1T<1I1).:. :\\1), l'! .11: !{di.lhlhl~· (,i r:lI1gl··nr'·llH'I1<J1l In thl\" dhow .l!1d llirl·Jrtll..1 :-'ho\\lllkr UbI'\\\\\" ~ur~: -:5-:\"3, l1j9S. Th ( F th t
I study of 63:872, The Wrist\\(tivirics. ~ Structure and Function lar disc (Fig. 6-1; see also Fig. 5-7).1 The disc connecrs the medial aspecr of rhe distal radius to the distal ulna. Radiocarpal and Midcarpal Joints The radial facets and the disc form a continuous concave Anatomy surface.2,3 The distal joint surface includes rhree bones from the proximal carpal row: the scaphoid, lunate, and The radiocarpal joint attaches the hand to the forearm. triquetrium (Fig. 6-1). The carpal bones, which are The proximal joint surface consisrs of the lateral and connected by interosseous ligaments, form a convex medial facets on the distal radius and radioulnar articu- surface. The lateral radial facet articulates with the scaphoid, and the medial radial facet with the lunate. The ,1998. Trapezium radioulnar disc articulates with the triquetrium and, to a lesser extent, the lunate. The pisiform, although found in First metacarpal Trapezoid the proximal row of carpal bones, does not participate in the radiocarpal joint. The joint is enclosed by a strong Capitale Radius capsule and reinforced by the palmar radiocarpal, ulno- carpal, dorsal radiocarpal, ulnar collateral, and radial Scaphoid collateral ligaments, as well as numerous intercarpalliga- Radiocarpal ments (Figs. 6-2 and 6-3). join! The midcarpal joint is considered to be a functional Radial collateral ligament Palmar radiocarpal ligament Radioulnar disc Lunate Ulna Pisiform Fi«h Ulnar collateral Ulnocarpal ligament metacarpal ligament 6-1 An anterior (palmar) view of the wrist showing FIGURE 6-2 An anterior (palmar) view of the wrist showing the palmar radiocarpal, ulnocarpal, and collateral ligaments. radiocarpal and midcarpal joints. 111
112 PA RT II UPPER-EXTREMITY TESTING Radial collateral Arthrokinematics ligament .\\{otiO!l at th!.: r:HliOl.:afp;l! j(lim O\"':Cllr\", bl.:C:H1~l' the Radius COil v!.: X ~urf.lCl'''' of rill.: pro:\\illul row of (;11\"1':11\", \",lidl.: Oil rhe ((lIK'<I\\T surL!((:s of the radius ~lnd LHJiolllrl:H disc. Ulnar collaleral 'llle proximal row of c1rpals slides ill a dirl'l..\"t'ioll oppo- ligament \",ilt' to thL' 11lO\\'I.'lll':1H of lht: lund, \\,S The (.Ifpal:- I!lOVe dor\"',lll~' on lilt: r:tdiu .. :1l1~1 dl\"'\\'\" durill b wri\",r fkxioll, ;lI1J Ulna Dorsal radiocarpal \\'L'llIr;dly ww;ud the p,dm during \\ni:-r l'Xlt·llsioll. During ligament lllll:lr L!('\\'I:Hlon, rhl: c:lrp:Jis \",Iidl' ill .1 r;H!i;l1 dlrn:lIon, ()lIrin~ Lldiallk\"i:nioo, the)' ... li<!l- in ;1ll Ulll.lf dirl.·c[ton . FIGURE 6-3 A posterior view of the wrist showing the dorsal radiocarpal and collateral lig<1mcnts. .\\tOlion ;1[ lill.\" Illidl.:arp;ll joilH occur\", bn:,Hht: the dist.ll r(}\\\\' of l',upals slides Oil till' pro\\'illl,ll ro\\\\'o During rather than an anaromical joint. It has a joint capsule that flexion, the (()!l\\'l'.\\' sllrt'1L.'e\" of till' (;lpiLHl' ,nIl! h:lInare s is cominuous with each intercarpal joint and some slide dors,dly on rill' ('OIl(:l\\'(' Sl1l'f:IL:l~S of pnrt'iolls of the f carpometacarpal and intermetacarpal joints. The joint scaphoid, lunar..... ;lnd lTlqUl'[rUlll. ;.r: Tht: \"urL11..\"l'S of rhe surfaces arc reciprocally convex and concave and consist rf<lI'l.'ziufTl and ~rap('z(lid .He (OIlL'.l\\'(: .UHJ \"lidl' \\'{)I.lr'l~' on c of the scaphoid, lunate, and ttiquetrum proximally, and Ihe (IIl\\\"t:,;; _surLll't' (If rhe s;\";;lphoiti. During l'\\'It.:lhioll, lhe c the trapezium, trapezoid, capitate, and hamate bones (,1pi{<l[L' :lIId ham;HL' ... Iide \\'obrly Oil the sl.\".lphnid, Illn;ltC, distally (Fig. 6-1). Many of the ligaments that teinforce :llld !riquerrllm; tht' rr:lpl'ziulll .\\IlL! rilt' rL1pC/oid ,dide j the radiocarpal joint also support the midcarpal joint d()r~:dly on rhe 'i1.·.lphoid. [)lIrill~ l',li.Ji:ii lln'i,lIioll, rhe (Figs. 6-2 and 6-3). clpir;ul' and kllll;ltL' slidt.: uln:lrly. and thl' trapo,ium <lnd 1 rrJp...·/(lid slide J(lr\":ll1~·. III ulJnr dl,\\·j,nion, the .....lpirarc Osteokinematics .wd h<llll;HI' slidl' LH.Il:1I1y; [he tr:lpaiu!ll and trapl'zoid c. slidt \\'obrly. The radiocarpal and midcarpal joints are of the condy- Co loid type, with 2 degrees of freedom.' The wrist complex Capsular Pattern (radiocarpal and midcarpal joints) permits flexion-exten- b sion in the sagittal plane around a medial-lateral axis, Cyriax ;llld Cyri:1x'l l't:por( tint' thl' clpsubr p;lHefll a[ and radial-ulnar deviation in the frontal plane around an thl' wri\";l is Jil eLju:11 lillliuriol\\ (If fkxioll ;lIld ('XIl'llsion v: anterior-posterior axis. Both joints contribute to these :lIld :1 ;,;Iiglu lilllit:uion (If r:H.lial :llli.l ulJur tIL,\\·j;Hion. \"r;,. motions.4-6 Some sources also report that a small amount K:lltl.'nhorll; norl'\" rh:u rhe cap\",ubr p.1Ul'I'll i\", ;lll equal la of supinacion-pronacion occurs at the wrist complex/ l't'srri(ciofl in all Ill(llioll~. I: bur this rotation is not usually measured in the clinical ul setting, iml: Research Findings mv, Effects of Age, Gender, and Other Factors pI Tlhlc ,,-I pn)\"id('''' r;lll~(, (If IlHHitlll lRO.\\I) illt'()l'lllilrion tor all wrist Il1otions. Tht: :Igt'. gcuder, ;1Ilt! Ilumher of n, suhjl'l.'IS rb:H wnt' 1lll';l\";Ul\"l'd to obtain rlw L1IllL'S rq'Jorrcd hy rhl' :\\llll'ric.lIl AL';Hkmy or' ()rrhup:ll'tliL' SlIrgt.'ons Flexion 76.4 (6.3) 73.3(2.1) I 74.9 (6.'1) 64.9 (2.2) ~lensJon 21.S (4.0) 25.4 (2.0) I 39.2 (2.1) Radial deviation 36.0 (3.8) Ulnar de,,;iat!on, I * Values are for males 18 months to 54 years of age. I Values are for 10 males and 10 females, 18 to 55 years of age. *Values are for 20 males and 20 females (ages unknown).
CHAPTER 6 THE WRIST 113 11ratef~ .'-:·,f·: \" larger for males 6 to 12 years of age than for those in other age groups. :zoid,;~: (MaS):o,11 and the Ametican Medical Association (AMA)'- were not noted. Boone and Azen,1J using a Table 6-3 provides wrist ROM values obtained with '---,,'? universal goniometer, measured active ROM in 109 universal goniometers from male adults. Boone and healthy male subjects aged 18 months to 54 years. Azen 13 found a significant difference in wrist flexion and ;~Iioa~i' . extension ROM between males less than or equal to 19 Greene and Wolf,14 using a universal goniometer, meas· years of age and those who were older. However, the tion'3~Ji - uied active ROM in 10 males and 10 females aged 18 effeers of age on wrist motion in adults from 20 to 54 to' 55 years. The values presented in Table 6-1 for Ryu years of age appear to be very slight. Values for flexion ''1 ual . and associates 15 were obtained with a hand goniometer and extension in adults 60 years of age and older, as from 20 males and 20 females (ages unknown). Other presented by Walker and associates 19 and Chaparro and -:£ - colleagues,20 are less than values for other age groups studies which provide normative wrisr ROM dara presented by Boone.22 Chaparro and colieagueslO further ;cons for' various age and gender groups include Slogaard divided the 62 male subjeers in their study into four age and colleagues,'6 Solveborn and Olerud,17 Stubbs and groups: 60 to 69 years of age, 70 to 79 years of age, 80 ;:'{; ;:, coworkers,'8 Walker and associates, 19 and Chaparro and to 89 years of age, and older than 90 years of age, They colleagues. 2o found a trend of decreasing ROM with increasing age, ;';~- with the oldest group having significantly lower wrist Age flexion and ulnar deviation values than the twO youngest groups. Table 6-2 provides wrist ROM values for newborns and children. Although caution muSt be used in drawing Four other studies offer additional information on the conclusions from cqrnparisons between values obtained effects of age on wrist motion. Hewitt,23 in a study of by different researchers, the mean flexion and extension 112 females between 11 and 45 years of age, found slight values for infants from Wanatabe and coworkers21 are differences in the average amount of active motion in larger than values reponed for males aged 18 months to diffetent age groups. A group of 17 individuals ranging in 19 years reported by BooneP The ROM values for both age from 11 to 15 years had slightly less flexion and ulnar and radial deviation for the youngest age group (18 radial deviation but more ulnar deviation and extension l110nths to 5 years) were significantly larger than the than the general average. Allander and coworkers,24 in a values for other age groups reported by Boone22 and presented in Tables 6-2 and 6-3, Boone and Azen 13 noted that wrist extension ROM values were significantly TABLE 6-3 Effects of Age on Wrist Motion: Mean Values in Degrees for Men
114 PA RT II UPPER-EXTREMITY TESTING study of 309 Icelandic females, 208 Swedish females, and nonlitfer:,> who wcre their !'>Uhjl'cfs, Solg;\\:ud :lIld (ownrk~ d 203 Swedish males ranging in age from 33 to 70 years, L'rS 1h :->rtIdil'l1 S fluk .. and 2_) ftlllah:-s agL'(.1 24 to (l5 years, found that with increasing age there was a decrease in I{ighr :lIld left wrist (,:xtcll:->ioll alld r:ldi:d dcviation \"d flexion and extension ROM at both wrists. Males losr an diffl'rn.l significalHly, hur chl..' dift\"l\"fCll(C .. \\\\'l'rl' :->l1Iall ~lnd \" average of 2.2 degrees of motion every 5 years. Bell and not :'>i~llifiGlIH when rhl' rmal range (i,e., flexion ~lnd Hoshizaki25 studied 124 females and 66 males ranging in l..'xtt:llsionl was as:->l':'>~l..'d. The:: ,lurhor.. \\f;l{l,d that the eJ age from 18 ro 88 years. A significant negarive correla- t)ppo~itl' wrist could h,,' .. :ui.. bcrorily t1!'>nl :1:'> :1 rdl'n:ncc, fr tion was noted between range of motion and age for wrist flexion-extension and radial-ulnar deviation in III l..'oJ1[r:lst, se\\'l\"fal sllldil..'s han,: found thl.' kfr wrist to \\~ females, and for wrist flexion-extension in males. As age h,l\\'<': grl'ater I{O\\l than the right wrist. COhl\":l , nH:asured increased, wrist motions generally decreased. There was wrist' motiolls in thl.' IXlSiti()!ls of pro!urion llnd sllpina~ IT a significant difference among the five age groups of [ioll in Ion Illen ,lilt! 1,-) WCJllli..'n, He found thin llli..'ll had females for all wrist motions, although the difference was i\"i nor significant for' males. Stubbs, Fernandez, and Glenn IS ~rc;Htr 1\\0.\\1 ill rhl'ir Id't wrist rh:\\1l ill rh,·;1' 1';~I1t for all (( placed 55 male subjects berween the ages of 25 and 54 i't years into three age groups. There was no significant Illotion\" eXCl'pr uhur d,,'\\'i:Hioll llll';t,urni ill pronation, ~ difference among the age groups for wrist flexion, exren- 1~lc)wC\\\"tT~ he rep0r[\",\\.1 th;lt th\", WOllH:11 h:ld gr\"';1tcr wrist sian, and radial deviation ROM. A significant difference i~ in ulnar deviation (7 degrees) was found between the motion (Ill thl' right l..'Xl.:l'\\)t tor i.:xr,,'IlSiOIl ill I'nmarion o oldesr and the youngesr age groups, with the oldest group and r:ldial d(',\"i;lIion in :-llpill;niol1. \\:0 ::.LHi:'>ti(:d tests having less motion. aJ \"\"\\,'I'l..\" (olldlll.:rnl ill tltl,' !l.J2S :->rlldv, hur :\\Ibndn ,ltld :lSSQ· Gender l..:i,ltl,::...!\"j rl'\\){)f[ed rh,u :1 rl\"<:,1kuJ.;tioll of rhL' (lri~ill~d d:.Ha [( l..\"Olln:I,,'<.I h\\\" Cohe found :1 ,ignifi<:~1lHk gn::l{,,\"r !\\U\\! on The following four srudies offer evidence of gender co effects on the wrist joint, with most supporting the belief rill..' IdL C(\")hc\"!\" ~ll~~c..b dl;l~ the hl..'a'\\\"~~ \\,\"ork rh:u men d, that women have slightly more wrist ROM than men. ir Cobe,26 in a study of 100 college men and 15 women pl..'rforllH:d ll:,in~ rh\\.\"ir right exrrcmiti,,':,> 1l1:IY ,1...\\.:Otlllt for T ranging in age from 20 to 30 years, found that women rh,,' d\",(\"fl'ast: III righr·:'>ilk' ll\\()[ion in ...·oll1p:uison with Idt· had a greater active ROM in all motions ar the wrist than :-idL' l1lotion, a, men. Allander and coworkers\" compared wrist flexion and extension ROM in 203 Swedish men and 208 :\\lbndcr :llld ;ls\"'(il.:i,l(l..':'>,.!\": III ;1 \"rlld~\" slIht.:roup of 309 \" Swedish women between the ages of 45 and more than !n'L1I1diL\" \\\\\"OIlH:Jl ,lgl..'d 34 t(j b I ye;H\", found !lO sqJ,nifictnt 70 years of age, and noted that women had significantly 0' greater motion than men. Both studies measured active difll:ri..'lll..'L' bcrwci..'n the right ;llld rill' lett wrists. j'\"!OWi..'VCfl motion with joint-specific mechanical devices. Walker :1 suhgroup of 2uS: \\\\\"(llll('j) alld 203 Swedish 111l'll ill the \"p and associates,\" in a study of 30 men and 30 women :,rudy showed SIi!.lljt\"i(:;lllll~\" snl;t1ler l';lll~l'S of wri:'>l flexion aged 60 to 84 years found that the women had more :lIld extellsioll on the right rhall Oil the Idr, indl'pcndclU d, active wrist extension and flexion than the men, whereas « the men had more ulnar and radial deviarion than the of gC:lldcr\" The ,lllt!tors :-.rati.: that the.. e difkn.'Ill..'l'S lllay he 9 women. These differences were statistically significant for wrist extension (4 degrees) and ulnar deviation (5 du,,' ro ;1 highn len' I of l'xpOSllre ro tr:ltIl11:1 of rh,,' right \" degrees). Chaparro and colleagues20 examined wrist flex- h:lI)(1 ill ,1 prcdomillillltly righr·h:lIldnl ~o(iL'tY, Sol\\'l:born ion, extension, and ulnar deviation ROM in 62 men and :lnd Olcrud ' - l1lCJ5tJrl,d \\\\\"ri~t RO\\l in 16 he;llthy I 85 women from 60 to more than 90 years of age. Women Sotl!:ljl..'dS in i.lddiriol1 (0 123 patients \\\\\"irh 1I1lilatccd renllis had significantly greater wrist extension (6.4 degrees) and dhow. Among the ht,:althy sllbil,'l...'rs a signiti...-andy gf(:~Hcr .' ulnar deviation (3.0 degrees) than men. RO\\l W~lS fOllnd for wrist tkxion and ,,'xrcllsioll 011 the Id{ cOlllp:u,,'d wirh th,,' right. l-Iown\"er, llll..':lll dift\"nences t• Right versus Left Sides hct\\\\\"l'l.'11 sidcs were onl~\" 2 dq.;rci..'s, Thl' authors COIll..'ul'lTd with Bonne :tlld :\\I.CIl 1; rh;H ;1 p;ltil,'Il('S hl..':llrhy \" Study results vary as to whether there is a difference between left and right wrist ROM. Boone and Azen,13 in limb call he llsed to cs[ahlish a norm for comp;\\rillg with a srudy of 109 normal males between 18 months and 54 years of age, found no significant difference in wrist flex- thi..' ;1ffceted side, ion, extension, or radial and ulnar deviation between sides. Likewise, Chang, Buschbacher, and Edlich27 found Testing Position no significant difference between righr and left wrist flex- ion and extension in the 10 power lifters and 10 S,,'\\'cral :->lltdii.:S h:1\\'(' r('{'onnl differcn.:cs in wri:'t RO:\\l d(:p('ndill~ on dH.' tl'sting posirion lIsed during llle;1sure· Illem, C:ohL'.~i> in a srudy of 100 men ;llld 15 WOlllen, found th;lt ulnar dcviation RONt \\\\';lS grc~ltcr in supina· tion. WhCfC;lS r~di:d d('\\,i;ltion W;1S greatl'l' in prol1~1tion, ~:\"\" ' IntCl'csringly, the roLlI ,1IllOUTlt of llln;\\r and r;ldial dc\\\"ia· rion l.,:nmhillcd W;lS similar ht.'rween rhe 1'\\\\'0 positions, I·k\\\\'i{[~:;' me:lsured \\\\'rist RONI in I 12 t\"elll:lks in supiu<l\" rion ;md proll:lliotl ;\\nd foulld rh:H uln;H dc\\'iarioll was gf\"';lH\"T in supin:lriI.Hl, wh,,'rcas r;ldi;ll deviation, tkxion, and l..'xrClls!on were greater in prollation, \\X/(,rJ\\cr ;llld (-1 1<1IH.:: he 1',;' ill a revitw arricle. also stated rh:H tlln:.H de\\'!· arion has a grtater RO\\:t when the t'orclrm is supin.ltcd
CHAPTER 6 THE WRIST 115 \"'\"~hn~(n'Fih1ii1\"!ArfdoerveiaarrmionisR pronared. They nored rhar cant, were small (less than 5 degrees), except for rhe OMs become minimal when effect of wrist flexion and extension on radial deviation. ,\" ';fglly flexed or exrended. No specific rcier- Radial deviation ROM was greatest when performed in o \"';~'~observations were cited. wrist extension and lowest in wrist flexion, with a decrease of over 30 percent. The authors believed that the ridPinksron28 examined the effeer of three changes that occur in wrist ROM with positional alter- arions might have been due to changes in contact ,;-~:~,(rgoniomctric testing positions on active between anicular surfaces and tautness of ligamenrs that span the wrist region. att~iid'ulnar deviation ROM in 100 subjeers (63 1f~Iii~les).ln Position One the subject's arm was Functional Range of Motion sid~, \\vitb the elbow flexed to 90 degrees and the for~rm'fuaypronarcd. In Position Two the shoulder was Several investigators have examined the range of motion ._~O degree~;()ffleXion, with rhe elbow extended and the that occurs at the wrist during activities of daily living (ADLs) and during the placement of the hand on the ;~1fl(pr6h'~\\,&;P()sirionThree the subject's shoulder was body areas necessary for personal care. Tables 6-4 and g'1ftm9~0~\\9aieV&~~,l,1~d}othfaebdhuacntdiopnr,owneith(inthtehieslbpoowsitiinon90rhdeegfroerees- 6-5 are adapted from the works of Brumfield and 4r.Jiiifif))~l1eutral pronation). Ulnar deviarion and the Champoux,JO Ryu and associates,15 Safaee-Rad and t,#f~i\":'~angeof radial and ulnar deviation were signifi- colleagues,31 and Cooper and coworkers.:n Differences in ,'cali~li greater when measured in Position Three. Radial ROM values reported for certain functional tasks were most likely the result of variations in task definitions. 'deviation was significantly greater when the subject was measurement methods, and subject selection. However, in spite of the range of values reponed, certain trends are \"'in position Three or Position Two than in Position One. evident. 0\" The.difference berween the means for the three positions A review of Table 6-4 shows that tbe majority of ADLs required wrist extension and ulnar deviation. was approximarely 3 degrees. Drinking activities generally required the least amount of extension (6 to 24 degrees) and the smallest arc of motion Marshall, Morzall, and Shealy\" evaluated 35 men (13 to 20 degrees). Using the telephone (Fig. 6-4), turn- ing a steering wheel or a doorknob, and rising from a and,l9- women for wrist ROM in one plane of motion chair (see Fig. 5-9) required the grearest amounts of while the subjects were fixed in secondary wrist and fore- ann': positions. For example, during the measurement of radial: and ulnar deviation, the wrist was alternatively positioned in 0 degrees, 40 degrees of flexion, and 40 degrees of extension. These three wrist positions were repeated with the forearm in 45 degrees of pronation and 90 degrees of pronarion. The effects of rhe secondary wrist and forearm postures, although statistically signifi- TABLE 6-4 Wrist Motions During Functional Activities: Mean Values in Degrees p()u:l{:frg;m;;p#,?B~'rjL{ ,;:/;'.~. ii;-)f;'i/jy<'><'\" Turn doork ons. Use te'ePh~:j~~~ii~ \"oi llna· Turn steerin'g\"~WeeJ:\" W~lS Rise from c;t)aRt1,y~t' .Theion, ~;~, ,~~~0!L~~;.. '~~ .1Od minus sign denotes flexion. t The minus sign denotes radial deviation. ~ Values from Ryu et al were extrapolated from graphs. ----~-_._\"-_.,-~-\"-,---~-~~--------
116 PA R T II UPPER· EXTREMITY TESTING FIGURE 6-:~ Turnillg.\\ dllorklltlb rl'qlllr,-'~ -10 dq~n.Ts 01 wrist fkxioll <111\\.1 45 dq.~n:l·~ 01 \\\\'(1\\[ CXklbioll. FIGURE 6-4 Using a telephone requires approximarcly 40 lliolllctl'!' (0 dctcrminl' rhe r:lllgt' wrist t'kxioll and degrees of wrist extension. ~ioll during 15 ADI. performed hy 12 1l11:11 alld 7 W':Jllllen LlIlgillg from 2S to 60 ~'c,lrs nt' ~q,:,c. Thl.·Y dctermined extension (40 (() 64 degtees) and ate of motion (43 (() 85 :\\DLs ~L1ch as e:ltillg, drinking ,\\lld using ~l degtees). Turning a doorknob (Fig. 6-5) involved the wert' 'H.:\\.'omplishcd with S tlt.:grct.:,s of flexion to .greatest amount of flexion (40 degrees). The greatest amOllnts of ulnar deviation (27 to 32 degrees) were noted degrees of cxtcnsion. Persollal (';11'(' ;letivirics while rising from a chair, turning a door knob and steer~ ing wheel, and pouring from a pitcher. involved pbclIlg the lund 011 rilL' hody rcquired Table 6-5 provides information on wrist position degrecs of f1c\\:lon to 15 dcgrLTs of L'xrcnsiofl, The during the placement of the hand on the body areas commonly touched during personal care. The majority of concluded th,H an arc of wrist llHlrioll of 45 degrees positions required wrist flexion, and less overall wrist degrces of flexion to .;5 dq.!.r('e~ of extellsIon) is motion than the activities of daily living prcsemcd in to perform most of till.' ~H. tiv;ties studll.'ll. Table 6-4. Among the positions studied, placing the palm to the front of the chest consistently required the greatest P~llm('r ~lIld <.:o\\\\'orkc.:rs; \\ used :l rria\\:i~ll amount of wrist flexion, whereas placing the palm to the lliO!HCIL'r to qud~ 10 normal sllhjl:<.:rS while sacrum required the greatest amount of ulnar deviation. performed 52 t~lsks. :\\ r:lIlge of 32.,) d<.·/:.rt·cs of flexion; 5S.6 degrees of ex[clIsion, 23.0 degn:es of radial devia: Brumfield and Champoux3o used a uniaxial electrogo· [ion. and 21.5 degrees (.If uln~H de\\'i:nioll was lIsed i~ paforllling :\\DLs and pcrsonal hygiL·Jle. During thes~, t:1sks the ,l\\Tragc ~lm()llIH oi motion was about 5 degtee~ of flexion, 30 degrecs of extension, 10 degrecs of radi 16.1 (12.7) Brumfiel c 9.7 (11.9) Ryu 1S e Brumfiel 47.8 (16.8) t. 8.7 (12.2) Ryu 5.1 (10.3) Brumfiel Ryu Brumfield Ryu Brumfield Ryu
CHAPTER 6 THE WRIST 117 ';: deviation, and 15 degrees of ulnar deviation. ROM FIGURE 6-6 A large amount of wrist flexion is needed to ',yal~es for individual tasks were nor presented in the fasten a bra or bathing suit. This is one of the most difficult activities ro perform if wrist morion is limited. stlldy. c'Ryu and associates15 found that 31 examined tasks and frequency of wrist motions required during grocery : ,c()uld be performed with 54 degrees of Aexion, 60 degrees of extension, 17 degrees of radial deviation, and bagging,35 grocery scanning,36 piano playing,37 industrial 40 degrees of ulnar deviation. The 40 normal subjects (20 work,J8 handrim wheelchair propulsion,39.40 and in play- men and 20 women) were evaluated with a biaxial elec- ing sports such as basketball, baseball pitching, and golf.6,4! The reader is advised to refer directly to these :/iH3goniometer during performance of palm placement studies to gain information about the' amount of wrist , ':a\"tivitie\" personal care and hygiene, diet and food prepa- ROM that occurs during these activities. In general, an association has been noted between activities that require raoon; and miscellaneous ADLs, extreme wrist poscures and the prevalence of hand/wrist i'Studies by Safaee-Rad and coworkersJ' and Cooper tendinitis:2 Tasks that involve repeated wrist flexion and ~;{d;cpv;orkersJ2 examined wtist ROM with a video- extreme wrist extension, repetitive work with the hands, based, three-dimensional motion analysis system during and repeated force applied to the, base of the palm and three feeding tasks: drinking from a cup, eating with a wrist have been associated with carpal tunnel fork, and eating with a spoon. The 10 males studied by Safaee-Rad and coworkers used from 10 degrees of wrist syndromc.43 fkxion to 25 degrees of extension, and from 20 degrees o{ulnar deviation to 5 degrees of radial deviation during Reliability and Validity the tasks. Cooper and coworkers examined 10 males and 9 females during feeding tasks, with the elbow unte- In early studies of wrist motion conducted by Hewitt23 stricted and then fixed in 110 degrees of flexion, With the and Cobe,26 both authors observed considerable differ- elbow untescricted, males used from 7 degrees of wrist ences in repeated measurements of active wrist motions. flexion to 21 degrees of extension, and from 19 degrees These differences were attributed to a lack of motor of ulnar deviation to 2 degrees of radial deviation. control on the part of the subjects in expending maximal i Females had similar values for Aexion and extension but effort. Cobe suggested that only average values have used from 3 degrees of ulnar deviation to 18 degrees of radial deviation. Both studies found that drinking from a cup required less of an arc of wrist motion than eating with a fork or spoon. Nelson34 took a different approach to determining the amount of wrist modon necessary for carrying out func- tional tasks. He evaluated the ability of 12 healthy subjects (9 males and 3 females) to perform 123 ADLs with a splint on the dominant wrist that limited motion to 5 degrees of Aexion, 6 degrees of extension, 7 degrees of radial deviation, and 6 degrees of ulnar deviation. All 123 activities could be completed wirh the splint in place, with 9 activities having a mean difficulty rating of greater than or equal to 2 (could be done with minimal difficulty or frustration and with satisfactory outcome). The most difficult activities included: putting on/taking off a btassiere (Fig. 6-6), washing legslback, writing, dusting low surfaces, cutting vegetables, handling a sharp knife, cutting meat, using a can opener, and using a manual eggbeater. It should be noted that these subjects were pain free and had normal shoulders and elbows to compensate for the restricted wrist motions. The ability to generalize these results to a patient population with pain and multiply involved joints may be limited. Repetitive trauma disorders such as carpal tunnel syndtome and wtist/hand tendinitis have been noted to Occur more frequently in performing certain types of work, SpOrts, and artistic endeavors. To elucidate the cause of these higher incidences of injury, studies have been conducted on the wrist positions used, the amount
118 PART II UPPER-EXTREMITY TESTING much validity and that changes in ROM should exceed 5 Orrh(lI{:ln~l.-'r {ICC <l,XX tn (1.')2), The ()5 pal.-'I.:IH ~on(i degrees [Q be considered clinically significant. dl.-'Ih,:e 1l'\\'I.:I. W/lll:11 n'pn'\\ell[\\ rhL' \\-';lri;lhiliry :Irolilld rhe L1rcr studies of inrrarcsrcr and inrcrrcsrcr reliability ;1IIll',ll), r;lIlgnl trem) -,(, III l), 1 dq\"!,rl'l\"'\" tor i1ll: gOllinlJll'rer, were conducted by numerous researchers. The majoriry of these investigators found that intraresccr reliability was :llld frolll 1:),2 It) 2).(, tlq~r('l.-'''' for rill' ()nhIlIClIlger, The .Hlrhor~ condlltlnl Ih:lt the ()nh()R;lll~cr pro\\'itll'd no greater than interresrcr reliability, that reliability varied :ldv.IIlLlgl''l O\\T' the llnivl.:r,;!I gOlliollll'h:r, according to the motion being tested, and that different instruments should not be used interchangeably during ~olg:1;1rd :llld cOWOrkl.-T\", II, fOllnd llHrall.-',{\\,:r \"'LlIh.lard JOint measurement. dL'vi:llions of 5 (():-; th:grct:\\ :llld imcrtl'\"rl.-'r SI:1lllbrd devi- ;Hioll:'o ot' 6 (0 I U degrL'l':'o ill ~1 srudy of wrist alld forearm Hellebrandt, Duvall, and Moore44 found that wrist motions measured with a universal goniometer were 11'1oriollS i!l\\'olving ,) I healthy <.,uhicets, iv!casUITITK'nrs more reliable than those measured with a joint-specific device. Measurements of wrist flexion and extension W('rC LIken wirh ;1 universal goniollletlT hy (uur resters on were less reliable than measurements of radial and ulnar dm,:l' diffcrciH OCl'~hioIlS, The codficic!HS of variation dcviarion, although mean differences between successive \\ptr~l'n[ v:lri:lrillll) hC1Wl.-'I,'II reSll'rs wcr\\,' grL';lIl.-'r fllf ulnar measurements raken with a universal goniometer by a :llH.I f.H.lia! devi;l(l(lll th:ll1 tor flexioll, cXfl.:lI:--iOIl. prona- skilled tester were 1.1 degrees for flexion and 0.9 degrees lillll. :lIl1..1 \"llpill:lrioll, for extension. The mean differences between successive II(lrgcr'\"ls cOlldudL'd ,1 :\"lrudy ill whi~h I,; randomly measurements increased to 5.4 degrees for flexion and 5.7 degrees for extension when successive measurements p;\"lircd rilt:r:lpi\"r-. !Wrftlrll1l:tl rcpl';lr\\\"d lllcl'\\lfell1l'llrS of were taken with different instruments. ;lui\\'\"(, ;1111.1 p;hsi\\'\"l: wri ... r 11l01iOll\", (In ·IX p,ni('rHs, In a study by LOW,45 50 testers using a universal 'I\"hl'ral'isr, were frl.'l.' It I ...cln:1 lhelr \\)Wll IIIL'I!lCHI ()t lllcas- goniometer visually estimated and then measured the lll'l.-'lIleIH with ,1 ullivl'r':11 gOlliOllll'rCL Thl' \"'l,X \",pn\"ializcd aurno['s active wrist extension and elbow flexion. Five hand rhlT.lpish (\\~l'd ;111 1I11l~lI' Jlignllll'lli tor flexion :lnd testcrs also took '10 repeated measurements ovcr the cxrl'lbi()ll. \\\\'hcrc~l:-- rill' IIOII..;pcci;lllzed rill.-'Llpi ...!'> llscd course of 5 to 10 days. Mean error improved from 12.8 ,I r,llli,d gOlliOlll\\\"lt\":r ,lli~llllll.-\"Ilt. llltLHl':\"lll'r rdiJhiliry of degrees for visual estimates to 7.8 degrees for goniomet- hoth ;Idi\\'(' Jlld p,b:...i\\'l' wriS[ mOlio!l\"; \\\\'l'!'L' high!~· rcli- ric measurcmcnL Intraobserver error was less than inrcr- ;thlt (;111 ICC>; JhO\\'l' ll,9(}) tor ;111 !l1oti(Jns, llltr;Hesrer observer error. The measurement of wrist extension was !'di;lhilil'~\" \\\\\";lS l..:oll:'oisr(:rHly hlghn rl1;111 irltl'l'll'stn relia- less reliable than the measurement of elbow flexion, with hility llCC 0,66 ('00,1.)1). Scu1d:1rd nror\", td rIll';lSurC- mean errors of 7.8 and 5.0 degrees respectively. Il\\l'llt~ !SE\\-1} r,lngcd frolll 2,6 to.;JA f(Jr ilHr;\\ll\"S!l'I'\" \\'~llues ;ll1tl frolll 3.0 10 s,2 for illlcncS{cr \\·,dlll'S, Agrl'l'menr Boone et al 46 conducted a study in which fouf testcrs using a universal goniometer measured ulnar deviation bl.-'t\\\\'l'l'll lllC;I:-.urcs \\Vol:... hl'tter for fk'\",ioll .IIH.I exrcnsion on 12 male volunteers. Nleasurcments were repeated over rh.m for r~ldi:ll ;1I1d ulnar d('\\'i~lIi(lIl, Illrccrl':-.rn rdi:thility a period of 4 weeks. lntratester reliability was found to L:odfi.,:il.'llts for lllC1:...11rL'l1k'llb of ;Kti\\'l' Illotioll (ICC 0,78 be greater than intertester reliability. The aurhors to 0,91) \\\\'l'r\\,' ,;;Iighrly highn rl1;111 COt:ffi .:il.-'IlI\" tor p~\\ssive concluded that to determine true change when more than motiull dCC: O,h6 to {1.~6J l\"X(('pr for r;llli;ll dl'\\'iarion, one tester measures the same motion, differences in (;l.-'l1l'r;lll~'. rdi:lhilil~' \\\\',1\"; hi~hl'f for the :-'Pl'i.:i~llii'nllht:ra motion should exceed 5 degrees, pi:-'b rh:lIl for rhl' 1l011\"pl'l'i:1Iiznl thcr;lpish, The :lllrhor In a study by Bird and Srowe;P two observers repeat- dl'll'\"rJnincd thar rhe preSl'nCl' of p;lin rl'dul:l\"d rhl' rdiahil· edly measured active and passive wrist ROM in three iry of hOlh ;\\l.-'ri\\'{: and pas:,i\\'L' !1ll';lS11rl'I1ll.-'llfS, hut ;H:ri\\'c subjects, They concluded that interobscrvcr error was greatest for extension (:': 8 degrees), and least for radial llH.::l:'llITlllCnr\" Wl'rL' ;tft'\"l'ued Illore 111:111 passive Illl';\\SUfC- and ulnar deviation (:':2 to 3 degrees). Error during passive ROM meaSuremems was slightly greater than ll)('I1tS, during acdvc ROM measurements. L;1St;1~'(J :lIld \\V!lt'l.-'!t'r,\\'j stLldil,d I Ill' 11Hl\\w:srcr ;Hld Greene and Wolf'·' compared the reliability of the irl!'l'rtl.-'stl'r rcli;lhtlity of p;l:-isi\\'l' IZO\\\\ 1ll1';bUfcJllCI1t:-i of OrthoRanger, an electronic pendulum goniometer, with a wrist fk'\\:ioll :\\l1t! (,,'\\:{i.'llS;Oll in 120 P;Uil'llb a:-, 11ll':lSllfCd universal goniometer for active upper-extremity motions in 20 healthy adults. Wrist ROM was measured by one by 32 r:llH.lolllly I':lirl'll Ihl'l'.tpisb, who used rhrl'l.-' gonio- therapist three times with each instrumcnt during cach of three sessions over a 2-wcek period. There was a signifi- llll'rric ;dignllll'l1ts (llln:lr. radial. :lnd dors:d-\\'\"llbr). The cant difference betwcen instruments for wrist extension I'd ia hi lir y of llll';lsuring wrist nl'X ion R() \\ I \\\\';1:-. l:Ol1sis- and ulnar deviation, Within-session reliability was slightly higher for the universal goniometer (intraclass IL'ntly higher than th:\\{ of llleasuring l·Xll·l1:-t.ioll correlation coefficient [ICC] 0.91 to 0.96) than for the ~k:l1l irllr:Hl'stCl' ICCs for wrist fkxiol1 Were O,~6 r:ldi;ll, (l.Xi for uln:ll', and O,l)!,. for dorsal aligllllll'nt. \\k:lIl inrr:Hl'SH:r ICes for wrist l'.\\{cnsioll Wl'l'\\,' O,SO r:1I.lial. (UW for uillar. :llld O,X4 for vobr ;lligllllll'llt, The :lurhors J'ccolllllll.-'Ildcd rh:l{ thl:'sC thrl'l' ;Ildwll~h gCIl(:r:1I1~' h;lving good rl..'li;lhiliry. should nor lIsl:d illlcrchan)l.l';lbJ)' bcc:lu..;c rhert wcrc sOllle sigl1ifiGlllf dift'nL'l1cl's hetwcen tilt, 11li.:;lSlll'CIllClHs [;lkt'll with three ~diglllllelHs, Tbe allthors suggcstcd that ell('
CHAPTER 6 THE WRIST 119 fi· volar alignment should be tbe tecbnique of choice for metacarpal, which was used in the study. Flower noted he measuring passive wrist flexion and extension, given its that the presence and fluctuation of edema on the dorsal higher reliability. In an invited commentary on tbis study, surface of the hand may reduce the reliability of the flower5o suggested using the fifth metacarpal, which is dorsal alignment and necessitate the usc of the ulnar easier to visualise and align with the distal arm of the (fifth metacarpal) alignment in the clinical setting. . goniometer in the ulnar technique, rather than the third Ird 'vi~ Range of Motion Testing Procedures: Wrist [10n. )('ra- ahar .<\\bil· 01110- . The .111515- '.OM. il for 1Tll.:nt. :0 for '. The h:l1rs, lor be til.\\HH II the orsa!- _ _............- .. ... ............\"...~--
l- 120 PA R T II UPPER· EXTREMITY TESTING V) \"s\": Normol End-feel FLEXION The l'nd-tcl'] i~ firm hn'::IU\";c of rension ill rhe dorsal r;Hliol,:arp:ll hg;llllelH :llld rhe dors;d joillt (,::1 This motion occurs in the sagitral plane around .1 medial- Tl:n ... itlll ill rhe eXh:llSo!\" c;upi r.ldiali~ hrt:\\·i:-. and longus .;: lateral axis, \\'Vrist flexion is somctimes referred [Q as ;Hld l..\"xrensor L:Hpi ulnaris 1Il1lSClt:S Jllay alsol,:olHrihulC volar or palmar flexion. Mean wrist flexion ROlvl values rhl..\" firm CIH.I-tccl. arc 60 degrees according to the AMA 12 and 76 degrees according to Boone and Azen.\" Sec Tables 6-1 to 6-3 for Goniometer Alignment additional information, S('l: l:igul'cS 6-10 and 6-1 I. Testing Position I. CClHcr rhe fulcrul1I of rhe gonlofllet('r 011 rhe Position the subject so that he or she is sitting next to a :Ispccr ot' r1w wrist (I\\'('f the triquetrul11, supporting surface with the shoulder abducted to 90 2, Align lhc proxim;d ;lrlll with the Iac<..\"r;l! midline rhl.' Ulll;l. using rhe ob.:r;lIlon and uln;lf degrees and the elbow flexed to 90 degrees. Place the prO(l..\"~Sl\"S for n::terl.'IK<,:. forearm midway betwecn supination and pronation so 3. Aligll rhe disr;ll ;\\rlll widl rhe br<.'f;tI midline of fifth rHer:lCarp;ll. Do /lot usc rhe soft tis:-'lle of that rhe palm of the hand faces the ground. Rest the fore- hYP(Hhc!l;lr cminl:Ilt..:c for rl'krcnce. arm on the supporting surface. but Icave thc hand free to Alternative Goniometer Alignment -w-~ -, movc. Avoid radial or ulnar deviation of the wrist and This alrcfIl<1rivc gOlli<lTnCla alignment IS tension in h~' rhe '-\\,\\IA Guides tf} tlJe hld/niltiull (1{ P\"\"\"\"\"\"m flexion of the fingers. If the fingers are flexed, IHl/hlirl1t('''!I.~ ,111d L;\\Sl'Oya and \\'lheL'lcr.'l\" (.\",!l:lll;l may make 'H.:curatL' ;l]iglllllenl over rhe ~ the extensor digitorum communis, extcnsor indicis, and surfaL·l:s of rhe forl'arm ;lnd h:1l1d difficult. extensor digiti minimi musclcs will restrict the motion. I. CClHLT the fulcrullI of thl' gOTliOllll'tcr over the t;Hl' on rhl' dorsal :lSP('U of the wrisr joilH. Stabilization 1. Align rill' proximal arm along rh,' dorsallllidlinc Stabilize the radius and ulna to prevent supination or rhL\" forearm. pronation of the forearm and m0tion of the elbow. 3. Align the disral arm Wilh rhe Jor~al asp('([ of Testing Motion third mcr;l(\"arpal. Flex the wrist by pushing on the dorsal surface of the '''/'',~ third metacarpal, moving the hand toward the floor IFig. 6-9). Maintain the wrist in 0 degrees of radial and ulnar deviation. The end of flexion ROM occurs when resis- tance to further motion is felt and attempts to overcome the resismnce cause the forearm to lift off the supporting surface. FIGURE ~9 The end of wrist flexion ROM. On I)' ;)hOllr three-quarrel's 01 rhe !-iuhjecr\\ fore,Hlll is supported by the examining rabie, so thar there is suffi,ii..'IH span: tor rhe hand ro ,oll1plcte the ll1ori\\.lIl.
:>rsal CHAPTER 6 THE WRIST 121 sule. ngus FiGURE 6-10 The alignment of the goniometer at the beginning of wrist flexion ROM. Ice co .Heral inc of ryloid of the of the 'ended 'wncnt hough dorsal Ie capi- FIGURE 6-11 At the end of wrist flexion ROM the examiner uses one hand CO align the distal arm of the gonimeter with the fifth metacarpal while maintaining the wrist in flexion. The cxaminer exerts pres- sure on the middle of the dorsum of the subject's hand and avoids exerting pressure directly on the fifth metacarpal bccause such pressure will distort the goniometer alignment. The examiner uses her ochcr hand to stabilize thc forearm and hold the proximal arm of the goniomcter. - - - - - - - - - ._ .
122 PA R T 11 UPPER. EXTREMITY TESTING EXTENSION' Normal End-feel Motion OCCurs in the s;lgirtal plane around a mcdial- U~lI;dly the end-tcl:l is (inn hCCHI'C of tt'llsion in rhe lateral axis. \\Vrisr extension is sometimes referred to as p;llnur radio(;Jrp;ll ligallltllt. ulnot.:<lrpal ligJ[~ll:Jlt, and dorsal flexion. Mean wrist extension ROM values arc 60 palmar joint clpsuk. Tl:nsioll in ~he p;1.11l1arl~ longus, degrees according to the A!vlA 12 and 75 degrees accord~ f1txor carpi r;H.lialis. and fll:xor carp' ulnans Illusclcs may ing to Boone and Azen. 13 Sec Tables 6-1 to 6-3 for addi- also (.:onrribun: to Ihe finn end-feel. Sometimes the end- tional information. fLocl is hard bce;lUSt: of (ollta....:t hct\\\\'ct!l the radius and the Testing Position ca rpa I bOllCS. Position the subject sitting next to a supporting surface with the shoulder abducted to 90 degrees and the elbow Goniometer Alignment flexed to 90 degrees. Place the forearm midway between supination and pronation so that the palm of the hand Sec Figures 6-13 and 6-14. faces the ground. Rest the forearm on the supporting surface, blll leave the hand free to move. Avoid radial or I. Center the fulcrum of [ill' goniolTIL·ttr on rhl' tHeral ulnar deviation of the wrist, and extension of the fingers. aspen of the: wrist O\\'l'r the triqlll.:trum. . . If the fingers atc held in extension tension in the flexor digirorum superficial is and profundus muscles will 2. AIi','1l the proximal ;lrlll with the bteral I1lH.lIlllc of restrin the motion. the\" 1I111:1, using the oll'l.:ranon ilnd ulnar styloid pro(os for rc!l...'r<,'fl(C. .. . 3. AlilJ,Jl th .... dist;ll arlll wirh rh .. Iareral mldllllt' (J~ rhe fifth Illt,:·raclfp;.lL Do not LIse the soft rissuc ot rhe hYPllthl'nar L·llllilt.'IlCl' f{)f rckrellc..... Stabilization Alternative Goniometer Alignment .' ;-', '.,\"\",'., •·drl'rJutln: ;tlil~'ll111Cf.lt is rL'colllmcnded hy rh.e A,\\-fAp C/f;dC5 to the h',rfuOf;Ol1 of flermllHi'H! lmfJoumcl1/- Stabilize the radius and ulna (0 prevent supination or ;11ld L1SUVO ;l1HI \\\\'!lL·clcr.·\\'i ;l!rhol11!-h nkma lll;lY Ill.:lke pronarion of the forcarm~ and motion of the elbow. .1....:cur;l[L· ;l!igIlJlli:!H (lVl'r the palm.H· sllrt;lt.:l·s of rhl' fore- ;Hlll and 1l;1;~d difficlIlr. Testing Motion I. Cl.'llter dl(' tulcrum over rhl' wrist joi!H at rhl' level \";; Extend the wrist by pushing evenly across the palmar I, surface of thc mctacarpals, moving the hand in a dorsal of the ....::lpi(;1[(,'. 2. Align (he pro:-':II11;1I ;lrl1l wirh tht p;llmar midline of direction toward the ceiling (Fig. 6-12). Maintain the rhl.' tore;lrm. wrist in 0 degrees of radial and ulnar deviation. The end of extension ROM occurs when resistance to further ~' ..\\lign rhe distal ;HIll w;th rhl' pallluf midline of the motion is felt and attempts to overcome the resistance thi;d 11letacarpal. \" cause the forearm to lift off of the supporting surface. Ji~ 1jIl' FIGURE 6-12 Ar the 1.'lId ot lill' wrist.&' I.\"x[(.·nsioll RO\\t. [he n:;ulIilll,.'r ~{;\\bi!izcsr\";~ {hl' subjn:r's forearm with {Hit.· h,llld ;md:? use\" hI.'!' Olhcl' hand (0 hold rhe :'llbil\"t'S~}\" . '¥'l' wrist in I.:'X [(,,'1\\ sion. Thl.:' (,,'x;lIniller is C:HC·~: till to disrrihuh': pn.:SSlIrl· L'qually ;lcrosS~ ;~' rhe sllbic<:t's lIlct;\\(,lrpak
CHAPTER 6 THE WRIST 123 FIGURE 6--13 The alignment of (he goniomcccr at rhe beginning of wrist extension ROM. FIGURE 6-14 At the end of the ROM of wrist extension, the examiner aligns the distal goniometer arm with the fifth metacarpal while holding the wrist in extension. The cX<1miner avoids exerting excessive pressure on the fihh mcracarpal.
124 PAR T II UPPER-EXTREMITY TESTING RADIAL DEVIATION ROtvl occurs whell rtsist~lrlCc co furrher Inorion is felt and ;]rn::mprs to overcome the resisrancL' ';lUSt: the elbow rvlmion occurs in the frontal plane around an anterior· ro flex. posterior axis. Radial deviation is sometimes referred to as radial flexion or abduction. Mean radial deviation Normal End-feel ROM i. 20 degree. according to rhe AMA 12 and 25 degree. according to Greene and Wolf. 14 Sec Tobie. 6-1 Usually the end-feel is hard because of contact between /. ro 6-3 for addirional informotion. the radial styloid process and rhe scaphoid, bur it may be firm because of tension in rhe ulnar collateral ligament, Testing Position rhe uhwcarprd ligament, and the ulnar porrion of the jOlnr capsule. Tension in rhe extensor carpi uln~tris and Position the subject sitting next to a supporting surface flexor cupi ulnaris muscles may also comributc ro the with the .houlder abducted to 90 degree. and the elbow firm cnd 4 fcd. flexed to 90 degree•. Place the forearm midway between supination and pronation so that the palm of the hand Goniometer Alignment faces rhe ground. Rest the forearm and hand on the supporting surface. Sec Figures 6-16 and 6-17. Stabilization I. Center rhe fulcrum of the goniometer on the dorsal' <lspeer of the wrist 0\\'<,.'[ the: capitare. Stabilize the radius and ulna to prevem pronation or .upination of the forearm and elbow Aexion beyond 90 2. Align rht proxim,ll ~1r11l with rhe dorsal midline of degree•. the forearm. If the shoulder is in 90 degrees 00' Testing Motion abduction and rhe elbow is in 90 of tlexion, the' Radially deviare the wrist by moving the hand toward the bteral epicondyle of rhe humerus can be llsed for thumb (Fig. 6-15)_ Maimain the wrist in 0 degrees of reference. flexion and extension. I! The end of radial deviation 3. Align the distal arm with the docs;\"'ll midline of the third meracarpal. Do nor lise rhe third phalanx for, reference. FIGURE 6-15 The ~xamincr srabilizes the subject's forearm to prevent flexion of the dbow beyond 90 degrees when the wrist\" is moved imo radial deviation. The examiner avoids moving rhe wrist into either flexion or exrension.
CHAPTER 6 THE WRIST 125 FIGURE 6-16 The alignment of the goniometer at the start of radial deviation ROM. The examining table can be used to support the hand. FIGURE 6-17 The alignment of the goniometer at the end of the radial deviation ROM. The examiner must center the fulcrum over the dorsal surface of the capitate. If the fulcrum shifts [Q the ulnar side of the wrist, there will be an incorrect measurement of excessive radial deviation. I ,_.,-;-,\";-':\"!'~'_'_,*~\",,:,=,\"m':\"' \"/-'.,.
·1 II.r:_. -'2-6--------------T-G v, PAR T II U P PER· EXT RE MIT Y T E SIN 11w ULNAR DEVIATION et: weisr in 0 degrees of tlexion and extension, and avoid o::I•. Motion occurs in [he frontal plane around an anterior- rorating rhe hane!. The end of ulnar deviation ROM occurs when resistnncc to further motion is fclt and w posterior axis. Ulnar deviation is sometimes referred (0 as attempts co overcome the resistance cnllst: the e1how to oU ulnar flexion or adducrion. !vlcan ulnar deviation RO!vl extend. et: is 30 degrees according to the AMA\" and 39 degrees Normal End·feel c.; according to Greene and Wolf.'\" Sec Tables 6-1 to 6-3 L? The end-feci is firm becausc of tcnsion in the radial Z for additional informarion. collarcrnl ligament and rhe radial pOrtion of the cnpsuk. Tension in rhe extensor pollicis brevis .a;: I5;. Testing Position abducror pollicis longus Illuscles Illa)' contribute co w firm cnd-fl:el. r- Posirion rhe subject sitcing next [0 a supporting surface Goniometer Alignment with the shoulder abducted to 90 degrees and the elbow Hexed to 90 degrees. Place the forearm midway between Sec Figures 6-19 and 6-20. . ~.. supination and pronation so that the palm of the hand t. Center the fulcrum of the goniometer on the faces the ground. Rest the forearm and hand on the aspect of the wrist over the capirnce. .0...., , supporti.ng stirface. 2. Align the proximal arm with the dorsal midline the forcann. If the shoulder is in 90 degrees w· abduction and the elbow is in 90 degrees of the bteral epicondyle of the humerus can be zL?· Stabilization for reference. <C. Srabilize [he radius i.lnd ulna to prevenr pronation or 3. Align the distal arm with the dorsal midline of et: supination of the forearm and less than 90 degrees of third metacarpal. Do nor usc the third phalanx 'U'/0'!I/ reference. elbow flexion. Testing Motion Deviate the wrist in the ulnar direction by moving rhe hand toward the little finger (Fig. 6-18). Maintain the FIGURE 6-18 The examiner uses one hand co sC:lbilize the subj<:cc's fOH.'arm and l1lainrain rhe dhow in 90 degrees of flexion. The eX:lmincr's mher hand moves tht: wrist into ulnar deviation. being I.:'ardul not to f1t:x or extend the wrist.
CHAPTER 6 THE WRIST 127 FIGURE 6-19 The alignment of the goniometer <'It the beginning of ulnar deviation ROM. Sometimes if <1 half-circle goniometer is used, the proximal and distal arms of the goniometer will have to be rc\\'crsed so that the pointer remains on rhe body of the goniometer at the end of the ROM. FIGURE 6-20 The alignment of the goniometer at the end of the ulnar deviation ROM. The examiner must center the fulcrum over the dorsal surface of the capitate. If the fulcrum shifts to the radial side of the wrist, there will be an incorrect measurement of excessive ulnar deviation.
128 PA RT II UPPER·EXTREMITY TESTING Muscle length Testing Procedures: mally from the medial epicondyle of the humerus, Wrist ulnar collateral ligament, and the coronoid process of [he ulna (Fig. 6-22). The radial head of the flexor digi[oturn';,jk •• •• •• ••• • superficialis muscle originates proximally from the ame~ rior surface of the radius. It inserts distally via two slips The flexor digitorum profundus crosses the elbow, wrist, into [he sides of the bases of the middle phalanges of [he' metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints. The flexor fingers. When the flexor digiroroum superficialis digitorum profundus originates proximally from the contracts, it flexes the MCP and PIP joints of [he fingers upper three-fourths of the ulna, the coronoid process of and flexes [he wrist. The muscle is passively lengthene the ulna, and the interosseus membrane (Fig. 6-21). This by placing the elbow, wrist, MCP, and PIP joints in exten muscle inserts distally onto the palmar surface of the bases of the distal phalanges of the fingers. When sian. it contracts, it flexes the MCP, PIP, and DIP joints of the fingers and flexes the wrist. The flexor digirorum If the flexor digirorum profundus and flexor digitotu profundus is passively lengthened by placing the elbow, superficialis muscles are shorr, they will limit wrist Cxtcn' wrist, MCP, PIP, and DIP joints in extension. sian when the elbow, MCP, PIP, and DIP joints arc posi' .....•.. '••.,. The flexor digitorum superficialis crosses the elbow, tioned in extension. If passive wrist extension is limited regardless of [he position of the MCP, PIP, and DIP joints; wrist, MCP, and PIP joints. The humeroulnar head of the the limitation is due to abnormalities of wrist join'- flexor digitocum superficialis muscle originates proxi- surfaces or shorrcning of the palmar joint capsule-- palmar radiocarpal ligament, ulnocarpal ligament palmaris longus, flexor carpi radialis, or flexor carp' ulnaris muscles. Flexor digitorum profundus FIGURE 6-21 An anterior vicw of the forearm showing the atrachmems of the flexor digitorum profun- dus muscle. Medial epicondyle Flexor digitorum superficialis of humerus Ulna fiGURE 6-22 An anterior view of the forearm and hand showing the attachments of the flexor digiro- rum supcrficialis muscle.
CHAPTER 6 THE WRIST 129 Starting Position Stabilization Stabilize the forearm to prevent elbow flexion. Position the subject sitting next to a supporting surface ,,' with the upper extremity resting on the surface. Place the \" elbow, Mep, PIP, and DIP joints in extension (Fig. 6-23). s ',: Pronate the forearm and place the wrist in neutral. C IS rs :g['. ,d n- -. AGURE 6-23 The starting position for testing the length of the flexor digitorum profundus and flexor digitorum superficialis muscles.
130 PA RT II UPPER-EXTREMITY TESTING Testing Motion End-feel Hold the Mep, PIP, and DIP Joints 10 extension while The end-feel is firm because of tension in the flexor digi- exrending the wrist (Figs. 6-24 and 6-25). The end of torum profundus and flexor digitorum superficialis the resting motion occurs when resistance is felt and muscles. additional wrist extension causes the fingers or elbow to flex. FIGURE 6-24 The end of the testing motion for the length of the flexor digitorurn profundus and flexor digirocum superficialis muscles. The examiner uses one hand to stabilize the forearm, while the other h:md holds the fingers in extension and moves the wrist imo extension. The examiner has moved her right thumb from the dorsal surface of the fingers to allow a dearer phorograph, bur keeping the rhumb placed on the dorsal surface would help to prevent the fingers from flexing at the PIP joints. Flexor digitorum superficialis (radial head) Flexor digitorum Flexor digitorum superficialis profundus (humeral + ulnar heads) FIGURE 6-25 A latcr:ll view of the forc<lrm and hand showing the flexor digirorum profundus and flexor digirorum supcrficialis being strctched over the elbow, wrist, Mer, PIP, and DIP joints.
CHAPTER 6 THE WRIST 131 ~or!qmeter Alignment Se~ligure 6-26. l. Cenrer rhe fulcrum of rhe goniomerer on rhe lareral aspect of the wrist over the rriquetrum. 2. Align rhe proximal arm with the lateral midline of the ulna, using the olecranon and ulnar styloid process for reference. 3: Align the distal arm with the lateral midline of the '<''X fifth metacarpal. Do not use the soft tissue of the \"iI' hypothenar eminence for reference. , i; FIGURE 6-26 The alignment of the goniometer at the end of testing the length of the flexor digi[Qcum profundus and flexor digirorum superficialis muscles. fl ._-~-~.,;;;;,..;....::..-~ __ il
132 PART II UPPER·EXTREMITY TESTING \",:' c.ii- S ••. ;.~: p, Ie •• •o::l 51 w The extensor digirorum, extensor indicis, and extensor U digiti minimi muscles cross the elbow, wrist, and MCP) in Pl PIP, and DIP joints. When these muscles contract, they /(j'f-- Distal nh,b.,,' fe /fhl;f-- Middle phalanx extend the MCP, PIP, and DIP joints of the fingers and SI -\"i\"'-- Proximal phalanx extend the wrist. These muscles are passively lengthened St by placing the elbow in extension, and the wrist, MCP, PIP, and DIP joints in full flexion. The extensor digitorum originates proximally from the lateral epicondyle of the humerus and inserts distally onro the middle and distal phalanges of the fingers via the ,v~,_;· _ u.l. extensor hood (Fig. 6-27). The extensor indicis originates proximally from the posterior surface of the ulna and the .........--';':''--'.:(' interosseous membrane. This muscle inserts distally onto U the extensor hood of the index finger. The extensor digiti <Il minimi also originates proximally from the lateral ~::l. epicondyle of the humerus but inserts distally onto the Radius --++- -+1!--Ulna extensor hood of the little finger. Extensor --t~ :+t-- Extensor indicis ;;Y;;;;;~I If the extensor digitoruffi, extensor indicis, and extcn- digitorum Extensor digiti soc digiti minimi muscles are short, they will limit wrist minimi flexion when the elbow is positioned in extension and the MCP, PIP, and DIP joints are positioned in full flexion. If wrist flexion is limited regardless of the position of the MCP, PIP, and DIP joints, the limitation is due to abnor- malities of joint surfaces of the wrist. or ·shortening of the dorsal joint capsule, dorsal radiocarpal ligament, exten- FIGURE 6-27 A posterior view of the forearm and hand ing the distal attachments of the extensor digitorum, exttllSl\" sor carpi radialis longus, extensor carpi radialis brevis, or indicis, and extensor digit minimi muscles. \":\", extensor carpi ulnaris muscles.
CHAPTER 6 THE WRIST 133 I phalanx Starting Position Testing Motion ~ phalanx position the subject sitting next to a supporting surface. Ideally, the upper arm and the forearm should rest on the Hold the MCP, PIP, and DIP joints in full flexion wh'l phalanx supporting surface, but the hand should be free to move into flexion. Place the elbow in extension and the MCP, flexing the wrist (Figs. 6-29 and 6-30). The end of t~c testing motion occurs when resistance is felt and add·~ and DIP joints in full flexion (Fig. 6-28). Place the tiona I wrist flexion causes the fingers to extend or th~ for,earm in pronation and the wrist in neutral. elbow to flex. Staloili:ze the forearm to prevent elbow flexion. Normal End-feel The end-feel is firm because of tension in the extenso digitorum, extensor indicis, and extensor digiti minim: muscles. s 11, FIGURE 6-28 The starting position for testing the length of the extensor digitorum, extensor indicis, and extensor digit minimi muscles. The forearm must be elevated or the hand positioned off the end of the examining table to allow room for finger and wrist flexion.
134 PA RT II UPPER-EXTREMITY TESTING FIGURE 6-29 The end of the testing motion for the length of the extensor digitorum. extensor indicis, and extensor digit minimi muscles. One of the examiner's hands stabilizes the forearm, while the other hand holds the fingers in full flexion and moves the wrist into flexion. Extensor digitorum Radius Humerus Extensor Extensor digiti indicis minim! Lateral epicondyle Extensor indicis of humerus tendon FIGURE 6-30 A posterior view of the forearm and hand showing the extensor digirorum, extensor indi- cis, and extensor digit minimi muscles stretched over the elbow, wrist, Mep, PIP, and DIP joints.
iometer Alignment CHAPTER 6 THE WRIST 135 Igure 6-31. the ulna, using the olecranon and ulnar styloid Center the fulctum of the goniometer on the lateral process for reference. aspect of the wrist over the triquetrum. Align the proximal arm with the lateral midline of 3. Align rhe distal atm with the lateral midline of the fifth metacarpal. Do not use the soft tissue of the hypmhenar eminence for reference. FIGURE 6-31 The alignment of the goniometer at the end of testing the length of the extensor digito- rum, extensor indicis, and extensor digit minimi muscles. ----------_.
136 PA RT II UPPER-EXTREMITY TESTING REFERENCES 25. Ill'll, I{J), and IlmhlLlkl, TI:I: Rel:l(I()[hhip~ of age and ~ex with M, r:lllge or motlOfl or ~nT!lln~11 jOint ;H.:ti(l!l~ ill hU[Jl:lll~, C;lfl.J :\\prl 1. Linscheid, RL: Kinematic considerations of the wrist. Clio Drehop SPI Sci {i:2.fJ2, I 9S I. 202,27,1986. 26. Cobe, H\\I; TIH~ clllge of aCtive motion oi the wnq ot whitt 2. Levangie, PK, and Norkin, CC: Joint Structure and Function: A Comprehensive Analysis, cd 3. FA Davis, Philadelphia, 2001. :ldult~. .I Bone .lOltlt Surg {Br) 2Ei; 7fi.\\, 192.S. 3. Kaltenborn, FM: Manual Mobilization of the Joims, Vol I: The Chang, DF, Bus(hh:ll'lwr, LP, :llld Edli,,'h, RF: Llmiled I(JIIH mobil. Extremities, cd 5. Olaf Norlis Bokhandel, Oslo, Norway, 1999. ns.ity in [1()\\Vl'r litters. :\\m J Sports \\led 16:280, 1 4. Sarrafian, SH, Melamed, ]L, and Goshgarian, GM: Study of wrist motion in flexion and extension. Clio Drthop 126:153, 1977. 28. Spilm:uJ, H\\X/, and l'inblOrl, D: Rda!ioll oi leq pO~Hiom to radial :llld ulnar devi:ltion. Phn Ther 49:S37, 1969. 5. Youm,Y, ct al: Kinematics of the wrist: I. An experimental study of radial~ulnar deviation and flexion~extension.] Bone Joim Surg 29. \\Lmhall, \\1\\1, \\\\()r:t.,~ll, JR, and Sht:;l!y, .IF: Till' effects of (Am) 60A23, 1978. CUlTlplex wn~t ,Jnd fore;Hrn po~ttlrc on wrr~t rangl' of motion. Hurn:\\fl F:](,:rors, 4 I :205, 1999. 6. Werner, SL, and Planchet, KD: Biomechanics of wrist injuries in sports. Clio Sports Med 17:407, 1998. 30. Brumrield, RH, and Cll<HnpOllX, .1:\\: A hio!lH:C1l;lIli,,':ll study of 7. Riu, M, et 31: Rotational stability of the carpus relative to the nOffn:J! flillction:d wrist 1ll00inf]. Clin Orthop I S7:2,), 19S4. 31. Safaec-Rad, R, ct ,II: Normal functional range of motion ot upper forearm. J Hand Surg 20A:305, 1995. 8. Kisner, C, and Colby, LA: Therapeutic Exercise: Foundarions and Illnh jOintS dtlrlllg pertrom;lllce ol threl..' it'l'dll1g t:b.b ...\\r(h Phl's \\led RdLlhil 7 1:S0S, 1990, Techniques, ed 4. FA Davis, Philadelphia, 2002. 9. Cyriax, JH, and Cyriax, PJ: llIustrated Manual of Orthopaedic 32. Cooper\" .IE, et al: Elbow joint \"rL'striction:, EHl'et Oil !unuional Medicine. Butterworths, London, 1983. upper limb motion dUring pt'rrorrnarlCl' 01 threl' feeding tasks. 10. American Academy of Orthopaedic Surgeons: Joint Motion: :\\rch Phys \\,It·d Rehabil7·I:S0S, 1993. Methods of Measuring and Recording. AAOS, Chicago, 1965. 33. Palmer, :\\K, l't al: Funcriorul wrist motion: A hiornl'l.·hanical 11. Greene, WB, and Heckman, JD {eds):The Clinical Measurement ~Itldy. .I Hand Surg 10A:39, 19X5. of Joint Motion. American Academy of Orthopaedic Surgeons, Rosemont, Ill., 1994. 34. Nelson, DL: Funcrional wrist motion. I-hnd Clin 13::'U, 1997. 12. American Medical Association: Guides to the Evaluation of 35. Estill, CF, and Krot'fl)(\"r, KH: Ev;l1t1ation of SUpt'rrlLJrket Permanent Impairment, ed 3. AMA, Chicago, 1990. using a wrist motioll monitor. Hum F;KfOrs 40:624, [99X. 13. Boone, DC, and t\\zen, SP: Normal range of motion in male 36. \\brr,ls, \\'('5. et :Jl: QuanrJticllloll of WfiSt motion dunng subjects. J Bone Joint Surg (Am) 61:756, 1979. fling. Hlllll bctors 37:412,1995. 14. Greene, Bl., and Wolf, S1.: Upper extremity joint movement: 37. \\X',lgtler, CH: The pianist's h;lnd; t\\!lIhrnpOt11Ctr~' and bi,,,,,,,,han. Comparison of twO measurement devices. Arch Phys Med Renabil ics. Ergono[1w,:s 31 :97, 19S5. 70,288,1989. 15. Ryu, J, et al: Functional ranges of motion of the wrist joint. J 38. \\Llrra~, \\,\\'5. ,llld Sl.·hOe[lm,Hklln, R\\V: \\X'rist flIoti()n~ ill Hand Surg 16A:409, 1991. ErgOnomicS .)(';:,)41, [995. 16. Solgaard, S, et al: Reproducibility of goniometry of the wrist. Scand J Rehabil Med 18:5, 1986. 39. \\\"(:~gcr, DHE.l, et ;11: \\\"('rist motion in 1l;lI1drim wht:elduir 17. Solveborn, SA, and Olerud, C: Radial epicondylalgia (tennis sion. I Rehabil Res Dev 35:30S, 19';!S. elbow): Measurement of range of motion of the wrist and the dhow. J Orthop Sports Phys Ther 23:251,1996. 40. gonir;gl'r, \\,n., ct al: W'rist biotlltch;lllics during two spl'ccls 18. Stubbs, NB, Fernandez, JE, and Glenn, WM: Normative dara on joint ranges of motion of 25· to 54-year·old males. International wheelchair propulsion: An analysis using a loed Journal of Industrial Ergonomics 12; 265, 1993. 19. Walker, JM, et al: Active mobility of the extremities in older svsrl'm, Arch Phvs \\'led Rehabil 78:364, 199'. subjects. Phys Ther 64:919,1984. 20. Chaparro, A, et a1: Range of motion of the wrist: Implications for 41. ()hillishi, N, et' al: Analysis 01 wrist motion during designing computer input devices for the elderly. Disabil RehabiJ 22,633,2000. shooting. In Nakamura, Rl., Linscheid, RL ;ll1d \\lll.lra, T 21. Wanatabe, H, et al: The range of joint motions of the extremities Wrist Disorder: C:urrl'nt Conct,'pts and Ch'll1l'nges. \\Jew in healthy Japanese people: The difference according to age. Nippon Seikeigeka Gokkai Zasshi 53:275, 1979. (Cited in 5prrngt:r·Vcrlag. 1992. 42. Ikrn;\\fd,BP ledl: \\\\usculoskl'lt·tal disorders and Walker, JM: Musculoskeletal development: A review. Phys Ther 7H78, 1991.) f:Krors. Cincinnati, Oh.: I\",ltiOlUI Institute 01 O ..xup,nional 22. Boone, DC: Techniques of measurement of joint motion. (Unpublished supplement to Boone, DC, and Azen, SP: Normal ,lnd I-Ie'llth. 1997, range of motion in male subjects. J Bone Joint Sueg (Am) 61:756, 1979.) 43. Armstrong, ·f.!, l'[ ;11: Ergonomic considerations in hand and 23. Hewitt, D: The range of active motion at the wrist of women. J tcndinitis . .I Hand Surg. 12:\\: SJO, 1982.. Bone Joint Surg (Br) 26:775, 1928. 44. Hellebr:1l1dt, FA, Duvall, EI\", and \\\\ool'e, ;vll.: The m,,,,,,,,,,ment)/, 24. Al1ander, E, et al: Normal range of joint movements in shoulder, of ioinr motlOll. Part Ill: Reliabilir~' of goniorn(\"try. Thtl',lpy Review 2.9:302, 1949. hip, wrist and thumb with special reference to side: A comparison between two populations. Int J Epidemiol 3:253, 1974. 45. Low, .11.: The r(\"liability of jornt measurclllent. 62.:227, 1976. 46. Boone, DC, l't al: Reli,lhility 01 gOl1iometri( rll(\",lSllreIlH:nts. Ther 5S: I355, 1975. 47. Bird, HA, ;Hld Swwc,.I: The wrist. ClinicS ill Rheum,nic Dise\",;(jJ§1 S:,)'59, 1982. 48. fl()r~er, \\1\\1: The rdi:lhilin' 01 gOl\\iornetrtc measurements :lCtl\\~e ;ll1d passive wrist mort(·ll1s. A'm J Occur Ther '~;;;:~:n;;;i~iR(;!1 49. LaSt~l\\\"(), PC and \\'('heeler, DL: Rl'liahilit\\' 01 ras~ive wrist ;md t:xtensiofl me:lsurelTJents: A rnlllti~erHer study-. Phys 74: I62. 1994 50. F!mV('r, KR: lrn-ited Cornrnenury. Phy-s Ther 74: 174, 1994.
ys I , 'ill \" al The Hand:5. •1 ng n- !Iii Structure and Function (palmar ligament), which is firmly attached to the prox- imal phalanx.' Ligamentous support is provided by n- collateral and deep transverse metacarpal ligaments. 'Y. Fingers; Metacarpophalangeal Joints 01- Anatomy Osteokinematics of The metacarpophalangeal (MCP) joints of the fingers are The MCP joints are biaxial condyloid joints that have 2 He composed of the convex distal end of each metacarpal degrees of freedom, allowing flexion-extension in the lall and the concave base of each proximal phalanx (Fig. sagittal plane and abduction-adduction in the frontal Is), 7-1). The joints are enclosed in fibrous capsules (Figs. plane. Abduction-adduction is possible with the MCP rk, 7-2 and 7-3). The anterior portion of each capsule has a joints positioned in extension, but limited with the MCP fibrocartilaginous thickening called the palmar plate Ice cry rist enr 3rd ical 2nd 4th Palmar apy Distal Interphalangeal _ _ .\". plates joints -i 5th hys Distal Joint \" phalanx capules Proximal f!fi1---7 :ase interphalangeal 5th joints Middle ; of phalanx 190. :ion 5th 'her Proximal phalanx 7-1 An anterior (palmar) view of the hand showing FIGURE 7-2 An anterior (palmar) view of rhe hand showing proximal interphalangeal, and distal joint capsules and palmar plates of the metacarpophalangeal, joints. proximal interphalangeal, and distal interphalangeal joints;' as well as the deep transverse metacarpal ligament. 137
138 PA RT II UPPER· EXTREMITY TESTING Joinl more proximal phal;1I1.'\\ ;lIld rill.: hase of rhl..· :Hlj;Ktll{, capsules Inort: disul plulanx. Each joint i!'> supported hy a ioilH (,,:ap~uk. a palm:lr pbrl..·. and [Wo colbr<:ralligalllt.·nrs (sec Fig~. 7-2 :tnd 7-3). J Collateral Osteokinematics ligaments Thc PilI ;lIld DIP joint'- of rill: fingL'rs ;1ft.\" t.:bssitied as ~Yll(lvial hing\\: joilHs with I degrn' of freedolll: flexion· cxrc:n.-..ioll in rhe s:lgirta! pblll..'. Joint ~ Collateral Arthrokinematics capsule ligament .\\-lotioll of tht: joim slirfat.:t:s illdudc~ a ~Iiding ot\" rhe (Olh:;!VI..' h;lSt: of [he more di~[;ll ph;lbllx Oil the lOllVt:x hL';HI of rhe proximal phabnx. Sliding (If the basL' of the lIloving ph:danx o((urs in the S;llll(: din.'(rio!l a~ rhe 1ll0\\'('llll..'nr of rhl..' shat\"r. For l:x<1l1lpk, ill PIP flexion, rhe hase of the middle ph:1L.lIlX slides [()\\\\\";lrd the p;l!lll, In PIP c:\\tcnsiun. dl(' h:1Se (If the Illiddk' plulall:\\ slidc.:s row:lrd rhl' dllr~llJll of rhe h:lllli. AGURE 7-3 A later;}1 view of a finger showing joint capsules Capsular Pattern and collateral ligaments of the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints. 'rhe.: c;lpsubr pannll is ,W l'qual rl'srriGioll ot horh t\"kx· ion :llld (.':\\[l'n:-..ioll, ,\\c(ordillg [(I Cyri,l.\\ ,11ll! C~Ti;lX, K;lhenhorn;; nOrl''; thar :111 motions :Hl' rl':-.rricrtd with !llore limitatioll in flexicln. Jomts in flexion because of tightening of the collatetal Thumb: Carpometacarpal Joint ligamenrs.2 A small amoum of passive axial rotation has been reported at the MCP joinrs,2.3 but this motion is not Anatomy usually measured in the clinical setting. The' c;Hpomct;h:;trpa! (C;\\-IC) joinr 0'\" rhe rhumb is rhe Arthrokinematics :lni.,:ubriol1 ht.'[\\\\,t.TB rhl' rrapa.iulll and [ht.' hast.' of the first nll..'{;K\"lrpal (Fig, 7-4). The s\"lddk'·sll;lpl~d rrapl'zium The concave base of the phalanx glides over the convex is t.'OIll.::lVI' in [he s;lgirral pLlIll' ;lIld COIl\\\"ex ill rht.' fromal head of the metacarpal in the same direction as the shaft pbnc The h;lSI..' of the firsr mCr;l(;lfp;!I h:15 ,1 rc.:t.'iprocal of the phalanx. In flexion, the base of the phalanx glides :-.h a pl' rhar (onforms to rhat of rhe rrapo.iul1l, The joinr toward the palm, whereas, in extension, the base glides (apsull' is rhi'.:k bur bx and is rcinforct.'d hy r,ldial, ulnar, dorsally on the metacarpal head. In abduction, the base palmar, <lnd dorsallig;llllenrs {Fig. 7-51, of the phalanx glides in the same direction as the move- ment of the finger. Osteokinematics Capsular Pattern 'The firsr C:\\1C joint is <l saddle joint with 2 degrees freedom: fh:.'xiOlH:xrensioll in tht frontal plc\\lle parallel Cyriax and Cyriax· report that the capsular pattern is an to rhe palm ..lnd ahdm:rioll- .ldduerioll ill rhl' sagirral equal restriction of flexion and extension. Kalrenborn5 pblle pt.Tpt:lH.li(ubr ro rhl..' palm,l The bxiry of the notes that all motions acc restricted with more limitation l.'apsule also pennirs some axial rotation. This ,·,,,,,r,,\"\" in flexion. allows ('hl\" thumh ro mo\\'(' inro posirion lor (onraCl Fingers: Proximal Interphalangeal and Distal \"\"\"i,)ns£fll' fing.L'rs during opposition. Thl' SC'!Ut'!H..'(' of Interphalangeal Joints rhat comhinl's wirh rorarion :md results ill Anatomy is as follows: \"bducrioll, flexion. and Rl'pnsirioll rl'rurlls rhe rhumb ro rll(\" q;Hrill~ posirion- The structure of both the proximal interphalangeal (PIP) and the distal interphalangeal (DIP) joinrs is very similar Arthrokinematics (see Fig. 7-1). Each phalanx has a concave base and a convex head. The joint surfaces comprise the head of the -fhe (OI1(;1\\'l' porrion of tht: fir~t 1111't\"lc;Hpal slidl'~ on <.:ollveX porrion of rhe rr;lpl'zilllll ill r!ll- sallle direction rhe llll't<.\\clrpal shaft to produce fk'xioll-cxtCl1sion During flexion, rhe h;lSC ot rhl..' Illt'[:h.::lrp~ll slides in af! ulnar dirccrion, During tX[L'nsion , ir slidcs in a radial:
CHAPTER 7 THE HAND 139 .:=\" lhe fingers. Extension beyond neutral is not usually pres- ent. Arthrokinematics _,'7~::;:::,,... Interphalangeal At the MCP joint the concave base of lhe first phalanx joint glides on the convex head of the first metacarpal in the 1sl III same direction as the shaft. The base of the proximal Metacarpophalangeal phalanx moves toward the palmar surface of the thumb Proximal - - - i joint in flexion and toward the dorsal surface of the lhumb in ex[ension. phalanx /\\ Capsular Pattern The capsular pattern for the MCP joint is a restriction of 1st Sesamoid motion in all directions, but flexion is more limited than Metacarpal bones ex[ension.\",5 e \" -:s Thumb: Interphalangeal Joint Carpometacarpal joint Anatomy Trapezium - - - - \\.. !': The interphalangeal JOtnt of the rhumb is identical in x- structure to the IP joints of the fingers. The head of the x. FIGURE 7-4 An anterior (palmar) view of the thumb showing proximal phalanx is convex and the base of the distal carpometacarpal, metacarpophalangeal, and interphalangal phalanx is concave (see Fig. 7-4). The joint is supported th , joints by a joint capsule, a palmar plate, and two lateral collat- eraI ligaments (see Fig. 7-5). the direction. The convex portion of the first metacarpal base Collateral the slides on the concave porrion of the uapezium in a direc- ligaments tion opposite to rhe shaft of the metacarpal to produce um abduction-adduction. The base of the first metacarpal Palmar plale Hal :slides toward the dorsal surface of the hand in abduction and toward the palmar surface of the hand in adduction. Sesamoid )cal bones ~-u..'. :>int :,c;apsular Pattern nar, \"\"_-...,,Palmar plale -~;>o.-' Collateral 'The capsular pattern is a limitation of abduction accord- f-:=-Iigaments ~s of ing to Cyriax and Cyriax.4 KaltenbornS reports limita- 'alle! tion in abduction and extension. Capsule ;irtal joint l), AGURE 7-5 An anterior (palmar) view of the thumb showing· join[ capsules, colla[cral ligaments, palmar plates, and crucia,te :Irion \"1humb: Metacarpophalangeal Joint (intersesamoid) ligaments. ,4~.atomy with ,[ions <Jh~ MCP joint of the thumb is the articulation between iition \"the convex head of the first metacarpal and the concave ;tiOll. oase of the first proximal phalanx (see Fig. 7-4). The 'jd.oint is reinforced by a joint capsule, palmar plate, twO :.Hl. ':.(sesamoid bones on the palmar surface, two intersesamoid ligaments (cruciate ligaments), and two collateral liga- ments (see Fig. 7-5). \" f Osteokinematics The MCP joint is a condyloid joint with 2 degrees of ,_~_freedom.l.6 The motions permitted are flexion-ex[ension ::J::\"nd a minimal amount of abduction-adduction. Motions >'i~t this joint are more resrricted than at the MCP joints of
140 PART II UPPER-EXTREMITY TESTING Osteokinematics goniOITlL'[C'r OTl the I.Hcra! aspecr of both hands. Mallon, The IP joint is a synovial hinge joint with 1 degree of free- Brown. and Nunley-Iii measured active finger motions in dom: flexion-extension in the sagittal plane. 60 men and 60 womcn \\virh a special digit;'!] goniomcter Arthrokinematics on rlH: dorsal surface of hmh hands. Sk varilova and At the IP joint the concave base of the distal phalanx glides on the convex head of the proximal phalanx, in P!t.:\\'ko\\';\\ II used a I1lc[\"lIic slide goniometer [0 measure the same direction as the shaft of the bone. The base of the distal phalanx moves toward the palmar surface auin: finger m()[ions 011 the dorsal aspL'ct of borh hands of the thumb in flexion and toward the dotsal surface of the thumb in extension. oj Ion 1111:n and J 00 WOl1len, Capsular Pattern ;0,,1 a11011, Hrown, and NunlcylO and Skvarilov<1 Jnd !'Ievkova ll also assessee! p~lssiv(' and active joinr motion The capsular pattern is an equal restriction in both flex- ion and extension according co Cyriax.4 Kaltenborn5 III individual fingers, \"Table 7-2 presents passive RC)jvl notes that all motions are restricted with more limitation in flexion. value:; for rhe ioifl(s of individual fingc.:rs, SOIllL: diffcr- ~ Research Findings tnets in RO~'I vallH':s an: nmcd herwccn rhl.: fingers, Effects of Age, Gender, and Other Factors Flexion RO;\\'{ at thl: :vICP joillts increases liTlc~Hly in an Table 7-1 provides a summary of range of motion ulnar direction from rhl' index fingtr ro rhe Iitrle (ROM) values for rhe MCP, PIP, and DIP joints of the fingers. Although rhe values reported by the different finger.llI,11 \\ttallon, Brown, and Nun'ltylO feporr rhar sources in Table 7-1 vary, certain trends are evident. The PIP joints, followed by the MCP and DIP joints, have the extension at the Mep joilHs is approximarely N]llal for greatest amount of flexion. The MCP joints have the greatest amount of extension, whereas the PIP joints have all fingi:rs, 1\"{C)\\\\'(:VL'f. Skvarilnvi.l and P]evkova 11 nore rhat the least amount of extension. Toral active motion (TAM) is the sum of flexion and extension ROM of the Mep, rhe linlc: finger has rhe grt;ltL'St amount of \\1(;1\" exten- PIP, and DIP joints of a digit. The mean TAM varies from 290 to 310 degrees for rhe fingers. sion. PIP (Jexioll and extension and DIP flexion arc gt'ner;tll~' equal fur all fingc.:rs. iii SOnll.: p;lssi\\T extension The age, gender, and number of subjecrs used to obtain rhe values reported by the AAOS7 and the AMA' beyond nL'utral is possible;1£ the DIP ioilHS, with a minor in Table 7-1 are not noted. Hume and coworkers' meas- ured active finger motions in 35 men by means of a incrc:lsc in :1 radial direcrioll from the link finl!.cr toward rhe index {inger. lf' \" Only the \\1CP joints of the fingers have a considerable <lmOllllt of ahdll(:t'ion-'lddu([ioll. The amount of abduc- tion-aduuction \\'aries with rh<: rositiOIl of the ;\\ilCP joint. o Abduction-adduction ROM is grearest in cxren:;ion and 'I least in full flexion. The colbtl'ral ligi.\\lllenrS of rhe Mep go joints afe sLtck Clnd allow full abduction in exrension, rej jel Howeva, the collateral ligamcms tighren and r('sHier thl abduction in the fully flexed posirion,l.l.ll The index and co little fingl'fs have a greater ROi\\it in abducrion-adduction col dun rhe middk and ring fingers. I Table 7-3 presems ROM values for the CMC, Mep, and It> joints of the rhumh. Flexion is grc:ltcst ;H rhe IP joint and Ieasr i.H the crvlc joint. The grearcst amounr of cxtension is reported at rhe IP and CiviC joints. The age, TABLE 7-1 Finger Motion: Mean Values in Degrees from Selected Sources '. . 84.5 (7.9) \\Toli'_ a .__ ~A\"_oUo~ 309.2 (6.6) MOS = American Association of Orthopaedic Surgeons; AMA = American Medic(li Association; DIP := distill interphalangeal; Mep \"\" (Me pophalangeal; PIP = proximal interphalangeal; (SO) = standard deviation. ·Yalu • Values are fOf 35 males aged 26 to 28 years. tYalUI t Values are for 60 males and 60 females, aged 18 to 35 years. Values were recalClJlated to inclllde both genders and all fingers. *Valu~ *Values are for 100 males and 100 females, aged 20 to 25 years. Values were recalculated to include both genders, both hands, illl fingers, can' and converted from a 360-degree to a lSO.degree recording system,
CHAPTER 7 THE HAND 141 TABLE 7-2 Individual Passive Finger Motion: Mean Values in Degrees from Selected Sources pIP = Distal interphalangeal; Mep = metacarpophalangeal; PIP = proximal interphalangeal. • Va,lues are for 60 males and 60 females, aged 18 to 35 years. Flexion values were measured with the contiguous proximal joint extended, I except for DIP flexion in which the PIP joint was flexed. Extension values were measured with the contiguous proximal joint flexed. These contiguous proximal joint positions resulted in the greatest ROM values in the measured joint. t f Values are for 100 males and 100 females, aged 20 to 25. Values were converted from a 360.degree to a 180·degree recording system. J n gender, and number of subjects used to obtain the values to the dorsal aspect of both thumbs in 58 females and .), reported by the AAOS7 and rhe AMA8 are not noted. 43 males. Skvarilova and Plevkova II used a metallic slide P Jenkins and associates lJ measured active motions of both goniometer [Q measure active and passive motions on the ,f thumbs in 69 females and 50 males by means of a dorsal aspect of both thumbs of 100 men and 100 -, computetized Greenleaf goniometer. DeSmet and women. colleagues 14 measured ROM with a goniometer applied I = Carpometacarpal; IP = interphalangeal; MCP = metacarpophalangeal; (SD) = standard deviation. . ,.,.~_. are for active ROM in 69 females and 50 males, aged 16 to 72 years. are for 58 females and 43 males, aged 16 to 83 years. <,.t!.;,·~··;-e;a~r,e~d.for 100 males and 100 females, aged 20 to 25 years. Values were recalculated to include both thumbs for both genders and i'· from a 360-degree to a l80·degree recording system.
142 PA R T II UPPER-EXTREMITY TESTING . ~] joinr. I.kighton. Solomon, Jnd So~k()11lt:,1~ ill :l study of:'P'~ Age 456 m(\"11 ;Illd 625 WOl1lt'n ot ;Hl .'\\fri~;ln villagc::, and'~ Goniometric studies focusing on the effects of age on ROM typically exclude the joints of the fingers and Fairh:lllk, PyIlSl'£t, ;lIH.I Phillip~, I\" in a study of 227 male thumb; therefore, not much information is available on and 21 SJ tClll~l\\v \"do!l.:S-:CIl[S, Illcasured passivl..· opposition' these joints. DeSmet and colleagues\" found a significant ot tht.: thullIh 1O\\\\';Hd the :lIHaior surface of rhe fOrt,lr ' correlation between decreasing MCP and IP flexion of the thumb and increasing age. The 58 females and 43 oi-.HId hypcrl..·xtensioll of rhe .\\IC:P joims of the fiirh males who were included in the study ranged in age from 16 to 83 years. Beighton, Solomon, and Soskolne'5 used middle fingas, Both studies reporred an inl\"rl..'asl..' in laxi passive opposition of the thumb (with wrist flexion) to in f<:rll;lks compared with l1lales. the anteriot aspecr of the forearm and passive hyperex- tension of the MCP joint of the fifth finger beyond 90 Right versus Left Sides degrees as indicators of hypermobility in a study of 456 men and 625 women in an African village. They found The few srudil'S thar h;l\\'e <.:olllp;lred RO,\\·1 in the ri that joint laxity decreased with age. However, Allander ;lnt! left joinrs of dlt' fingas luvt' gcnt:r;llly fOllnd and associarcs l6 found that active flexion and passive signifi(<llH differencc h('[\\\\'l..'cn si(k·s. ~vbll()n~ Brown, a~ extension of the MCP joint of the thumb demonstrated Nunley.11I in ;1 srudy in whidl half of the 120 subje-·' no consistent pattern of age-related effects in a study of wcre ri~dH-hal\\(k'd and rh(' ()r!l(,:r half left-handed, not\" 517 women and 208 men (between 33 and 70 years of flO difference hctwl'L'n sides in finger motions tH tht M age). These authors stated that the eypical reduction in PIP. ;Illd DI P joinrs, Sb'~lril()va and PltTkov~II repon'- mobility with age resulting from degenerative arthritis only sm;11l ri~ht-ldr diffcrcnC{'.s in thl..' nujoriry of - found in other joints may be exceeded by an accumula- tion of ligamentous ruptures that lessen the stability of oilljoilHs uf the fingl'rs and thumh in 200 suhje<.:ts, the first MCP joint. :\\,IC:P cxtl'nsion of the fingers allli thumh ;1(1<.1 IP fie'· Gender of rhl' rhumh SCl'llled [0 have gn::;l[(,:r ROi\\l valul:s on kit. Studies that examined the effect of gender on the ROM of the fingers reporred varying results. Mallon, Brown, Similar to findings ill srudies of 1I1l' fiJlgt'rs. most st and NunleylO found no significant effect of gender on the ics have I'L'pofted no differcflL:l' in RO\\t betwC'l'1l rhe ri amount of flexion in any joints of the fingers. However, and left thumbs, .Joseph l - ,md Sh~lW and t\\.torris,18·' in this study women generally had more extension at :,wJy of 144 and 2.n: subjects. rcspL'divl'ly. fOlln all joints of the fingers than men. Skvarilova and significl1lt dit\"fcr('llce be(wl'tn sides in \\ICP and IP Plevkova\" found that PIP flexion, DIP flexion, and MCP ion RO\\I of rhl' rhumh. DeSmet and colk:1gucs l4 e.' extension of the fingers were greater in women than in ill<,'J 10 I healthy subjl'('(s ~md fl'ported no differ men, whereas MCP flexion of the fingers was greater in be['wl'l'n sides for the \\lei> ;uld IP ioims of the rh men. No diffc::rl'llcl' hcrwl'{'n sides in III flexion ot' [he rh was found by JL'nkins ;Iud assll(i;HL'S \\, in a study of Several srudies have found no significant differences :-.uhjt'crs, :\\ sutisricllly signit\"iL.':lm greJrl'f amoun· between males and females in the ROM of the thumb, .\\,ICP flexion W;IS rl'por[(:d for rhe righr rhumb rita whereas other studies have reported more mobility in rhl' Idr; ho\\\\'ever, rhis dit\"ft'I'<.'Ill\"e was only 2 de females. Joseph'? used radiographs to examine MCP and :\\lIandcr and aSS{.lL:i;lt('S II' also found no differe IP flexion ROM of the thumb in 90 males and 54 ;1trriblHCd ro sick in MCP motions of thl' thumb i', females; no significant differences were found between the two groups. He found two general shapes of MCP suhjt.'crs, joints, round and flat, with the round MCP joints having greater range of flexion. Shaw and Morris\" noted no Testing Position differences in MCP and IP flexion ROM between 199 males and 149 females aged 16 to 86 years. Likewise, :vlallon. Brown, and Nunley, tl) in addition to esrab: DeSmet and colleagues, '4 as well as Jenkins and associ- ates,13 found no differences in MCP and IP flexion of the llofm:Hiv(' RO,vt values for rhe fingers, also s\" thumb owing to gender. passivl' joinr RO~.'1 while positioning the next mos~~ illlal joint in 111:1xilllal flexion ~l1ld extension. Th' Allander and associates\" found that, in some age joint h;ld significanrly flIOrc:: flt'xioll (I S degrees) w groups, females showed more mobility in the MCP joint PIP joinr W;,lS flexed tll,lll WhL'Jl the PIP join of the thumb than their male counterparts_ Skvarilova extended, This finding has bCt'n cited ~lS an indica and PlevkovaII noted that MCP flexion and extension of abnormal tighOlt'SS of rhe oblique fl'rinJ.culi.1f Ii' the thumb were greater' in females, whereas differences (l.andsmel:r's L.iga!l\"1eflr}.2o Howl'ver. rhe res owing to gender were small and unimportant at the IP \\lbllon, Brown, and Nunky's study suggesr t finding is normal. Thl\" MCP joinr had abolH 6 mon' flexion whcn rhe wrist was t'x(cnc!ed dwn \\ wrist was flext'd. ~llrhotlgh [his diff('fl'IKC w~s no;, ric:l11y significant. Th(,: t'xn:nSOf digiwflun, t:xrcns ds, and extl'nsor digirj minimi wert 1110re sla<.:k r greater fk:don of ~hc ivtCPjoinr whL:n the w •
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