CHAPTER 6 The Wrist 135 TABLE 6.3 Effects of Age on Wrist ROM in Men 20 to 54 Years Old: Normal Values in Degrees Boone and Azen15,23 Stubbs et al21 20–29 yrs 30–39 yrs 40–54 yrs 25–34 yrs 35–44 yrs 45–54 yrs n = 19 n = 18 n = 19 n = 15 n = 20 n = 20 Motion Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Flexion 76.8 (5.5) 74.9 (4.0) 72.8 (8.9) 70.6 (9.3) 73.5 (10.4) 68.9 (8.4) Extension 77.5 (5.1) 72.8 (6.9) 71.6 (6.3) 78.3 (11.8) 76.4 (10.4) 76.7 (11.7) Radial deviation 21.4 (3.6) 20.3 (3.1) 21.6 (5.1) 23.8 (9.5) 22.5 (7.9) 18.9 (7.9) Ulnar deviation 35.1 (3.8) 36.1 (2.9) 34.7 (4.5) 51.1 (9.0) 49.9 (7.0) 44.1 (4.3) no significant difference among the age groups for wrist differences in the average amount of active motion in various flexion, extension, and radial deviation ROM. A significant age groups, but no statistical analyses were performed. Allander difference in ulnar deviation (7 degrees) was found between and coworkers,28 in a study of 309 Icelandic females, 208 the oldest and the youngest age groups, with the oldest group Swedish females, and 203 Swedish males ranging in age from having less motion. 33 to 70 years, found that with increasing age there was a decrease in flexion and extension ROM at both wrists. Males Wrist ROM values in males 60 years of age and older are lost an average of 2.2 degrees of motion every 5 years. Bell presented in Table 6.4. Flexion and extension ROM in these and Hoshizaki29 studied 124 females and 66 males ranging in older adults, as presented by Walker and associates,24 Chap- age from 18 to 88 years. A significant negative correlation arro and colleagues,25 and Kalscheur and coworkers26 are less was noted between ROM and age for wrist flexion–extension than the values for the age groups presented in Table 6.3. and radial–ulnar deviation in females and for wrist Chaparro and colleagues25 further subdivided the 62 male flexion–extension in males. As age increased, wrist motions subjects in their study into four age groups: 60 to 69 years of generally decreased. There was a significant difference age, 70 to 79 years of age, 80 to 89 years of age, and 90 years among the five age groups of females for all wrist motions, of age and older. They found a trend of decreasing ROM with although the difference was not significant for males. increasing age, with the oldest group having significantly Kalscheur and associates,30 in a study of 61 women between lower wrist flexion and ulnar deviation values than the two the ages of 63 and 85 years, found a significant linear relation- youngest groups. ship between age and right wrist flexion and extension with ROM decreasing an average of 0.4 to 0.5 degrees per year in Four other studies offer additional information on the these older women. The relationships between age and left effects of age on wrist motion. Hewitt,27 in a study of wrist motions were not statistically significant. 112 females between 11 and 45 years of age, found slight Gender TABLE 6.4 Effects of Age on Wrist ROM The following four studies offer evidence of gender effects on the wrist joint, with most supporting the belief that women in Men Older Than 60 Years: have slightly more wrist ROM than men. Cobe,31 in a study of 100 college men and 15 women ranging in age from 20 to Normal Values in Degrees 30 years, found that women had a greater active ROM in all motions at the wrist than men. Allander and coworkers28 com- Walker Chaparro Kalscheur pared wrist flexion and extension ROM in 203 Swedish men et al24 et al25 et al26 and 208 Swedish women between the ages of 45 and more than 70 years of age and noted that women had significantly 60–85 yrs 60–90+ yrs 66–86 yrs greater motion than men. Both studies measured active n = 30 motion with joint-specific mechanical devices. Walker and as- n = 62 n = 25 sociates,24 in a study of 30 men and 30 women aged 60 to 84 years, found that the women had more active wrist exten- Motion Mean (SD) Mean (SD) Mean (SD) sion and flexion than the men, whereas the men had more 62.0 (12.0) 50.8 (13.8) 64.9 (8.7) ulnar and radial deviation than the women. These differences Flexion 61.0 (6.0) 44.0 (9.9) 58.2 (10.9) were statistically significant for wrist extension (4 degrees) Extension 20.0 (6.0) and ulnar deviation (5 degrees). Chaparro and colleagues25 Radial 35.0 (9.5) 28.0 (7.0) deviation Ulnar deviation
136 PART II Upper-Extremity Testing examined wrist flexion, extension, and ulnar deviation ROM on the left compared with the right. However, mean differ- in 62 men and 85 women from 60 to more than 90 years ences between sides were only 2 degrees. The authors con- of age. Women had significantly greater wrist extension curred with Boone and Azen15 that a patient’s healthy limb (6.4 degrees) and ulnar deviation (3.0 degrees) than men. can be used to establish a norm for comparing with the Kalscheur and coworkers26 found that women had more wrist affected side. flexion and extension ROM than men in a study of 61 women and 25 men between the ages of 63 and 86 years. These dif- Testing Position ferences ranged from 1.7 to 5.3 degrees and were statistically Several studies have reported differences in wrist ROM significant for right wrist flexion (5.0 degrees) and left wrist depending on the testing position of the forearm during mea- extension (5.3 degrees). surement. These findings support the use of consistent fore- arm positions during wrist measurements. Cobe,31 in a study Right Versus Left Sides of 100 men and 15 women, found that ulnar deviation ROM Study results vary as to whether there is a difference between was greater in supination, whereas radial deviation was left and right wrist ROM. Boone and Azen,15 in a study of 109 greater in pronation. It is interesting that the total amount of normal males between 18 months and 54 years of age, found ulnar and radial deviation combined was similar between the no significant difference in wrist flexion, extension, and radial two positions. Hewitt27 measured wrist ROM in 112 females and ulnar deviation between sides. Likewise, Chang, in supination and pronation and found that ulnar deviation Buschbacher, and Edlich32 found no significant difference was greater in supination, whereas radial deviation, flexion, between right and left wrist flexion and extension in the and extension were greater in pronation. Werner and 10 power lifters and 10 nonlifters who were their subjects. Plancher,6 in a review article, also stated that ulnar deviation Solgaard and coworkers19 studied 8 males and 23 females has a greater ROM when the forearm is supinated than when aged 24 to 65 years. Right and left wrist extension and radial the forearm is pronated. They noted that radial and ulnar deviation differed significantly, but the differences were small deviation ROMs become minimal when the wrist is fully and not significant when the total range (i.e., flexion and flexed or extended. No specific references for these observa- extension) was assessed. The authors stated that the opposite tions were cited. wrist could be satisfactorily used as a reference. Spilman and Pinkston28 examined the effect of three fre- In contrast, several studies have found the left wrist to quently used goniometric testing positions on active wrist have greater ROM than the right wrist. Cobe31 measured radial and ulnar deviation ROM in 100 subjects (63 males, wrist motions in the positions of pronation and supination in 37 females). In Position One the subject’s arm was at the side, 100 men and 15 women. He found that men had greater ROM with the elbow flexed to 90 degrees and the forearm fully in their left wrist than in their right for all motions except pronated. In Position Two the shoulder was in 90 degrees of ulnar deviation measured in pronation. However, he reported flexion, with the elbow extended and the hand prone. In Posi- that the women had greater wrist motion on the right except tion Three the subject’s shoulder was in 90 degrees of abduc- for extension in pronation and radial deviation in supination. tion, with the elbow in 90 degrees of flexion and the hand No statistical tests were conducted in the 1928 study, but prone (in this position the forearm is in neutral pronation). Allander and associates28 reported that a recalculation of the Ulnar deviation and the total range of radial and ulnar devia- original data collected by Cobe found a significantly greater tion were significantly greater when measured in Position ROM on the left in men. Cobe31 suggests that the heavy work Three. Radial deviation was significantly greater when the that men performed using their right extremities may account subject was in Position Three or Position Two than in Position for the decrease in right-side motion in comparison with left- One. The differences between the means for the three posi- side motion. A study by Kalscheur and associates30 found a tions were small—approximately 3 degrees. significantly greater range of left wrist extension and right wrist flexion as compared to the contralateral side in 61 older Wrist ROM values have also been found to vary if differ- women. The mean differences between sides were small, ent wrist positions are used during testing. It appears that the ranging from 3 to 5 degrees. greatest ROM values are obtained with the wrist in a neutral position. Marshall, Morzall, and Shealy34 evaluated 35 men Allander and associates,28 in a study subgroup of 309 Ice- and 19 women for wrist ROM in one plane of motion while landic women aged 34 to 61 years, found no significant the subjects were fixed in secondary wrist and forearm posi- difference between the right and the left wrists. However, a tions. For example, during the measurement of radial and subgroup of 208 women and 203 Swedish men in the study ulnar deviation, the wrist was alternatively positioned in showed significantly smaller ranges of wrist flexion and 0 degrees, 40 degrees of flexion, and 40 degrees of extension. extension on the right than on the left, independent of gender. During the measurement of flexion and extension the wrist The authors state that these differences may be due to a higher was positioned in 0 degrees, 15 degrees radial deviation, and level of exposure to trauma of the right hand in a predominantly 25 degrees ulnar deviation. The effects of the secondary wrist right-handed society. Solveborn and Olerud20 measured wrist and forearm postures, although statistically significant, were ROM in 16 healthy subjects in addition to 123 patients with generally small (less than 5 degrees), with most motions hav- unilateral tennis elbow. Among the healthy subjects a signifi- ing the greatest range with the wrist in neutral. However, cantly greater ROM was found for wrist flexion and extension radial deviation ROM was greatest when performed in wrist
CHAPTER 6 The Wrist 137 extension. The authors believed that the changes that occur in activities generally required the least amount of extension wrist ROM with positional alterations might have been due to (6 to 24 degrees) and the smallest arc of motion (13 to changes in contact between articular surfaces and tautness of 20 degrees). Using the telephone (Fig. 6.29), turning a ligaments that span the wrist region. In a study of 10 subjects steering wheel or a doorknob and rising from a chair (see performing active circumduction, Li and associates35 found Fig. 5.31) required the greatest amounts of extension (40 to that maximum ROM in flexion and extension occurred with 63 degrees) and arc of motion (43 to 85 degrees). Turning a the wrist near 0 degrees of radial and ulnar deviation. Like- doorknob (Fig. 6.30) involved the greatest amount of flex- wise, maximum ROM in radial and ulnar deviation occurred ion (40 degrees). The greatest amounts of ulnar deviation with the wrist near 0 degrees of flexion and extension. Wrist (27 to 32 degrees) were noted while rising from a chair, deviation from the neutral position in one plane of motion re- turning a doorknob and steering wheel, and pouring from a duced wrist ROM in other planes of motions. pitcher. Functional Range of Motion Table 6.6 provides information on wrist position during the placement of the hand on the body areas commonly Several investigators have examined the range of motion that touched during personal care. The majority of positions occurs at the wrist during activities of daily living (ADLs) and required wrist flexion and less overall wrist motion than the during the placement of the hand on the body areas necessary ADLs presented in Table 6.5. Among the positions studied, for personal care. Tables 6.5 and 6.6 are adapted from the placing the palm to the front of the chest consistently works of Brumfield and Champoux,36 Ryu and associates,18 required the greatest amount of wrist flexion, whereas plac- Safaee-Rad and colleagues,37 and Cooper and coworkers.38 Dif- ing the palm to the sacrum required the greatest amount of ferences in ROM values reported for certain functional tasks ulnar deviation. were most likely the result of variations in task definitions, measurement methods, and subject selection. However, in spite Brumfield and Champoux36 used a uniaxial electrogo- of the range of values reported, certain trends are evident. niometer to determine the range of wrist flexion and extension during 15 ADLs performed by 12 men and 7 women. They A review of Table 6.5 shows that the majority of ADLs determined that ADLs such as eating, drinking, and using a required wrist extension and ulnar deviation. Drinking telephone were accomplished with 5 degrees of flexion to 35 degrees of extension. Personal care activities that involved TABLE 6.5 Wrist ROM During Functional Activities: Mean Values in Degrees Extension* Ulnar Deviation† Source Activity Min Max Arc Min Max Arc Brumfield36 Put glass to mouth Ryu‡18 Drink from glass 11.2 24.0 12.8 — — — Safaee-Rad37 Drink from handled cup 2 22 20 5 20 15 Brumfield Eat with fork –7.5* 13.4 8.3 16.1 Safaee-Rad 9.3 5.9 27.7 — — 7.8 Cooper (males)38 Feeding tasks: fork, spoon, cup 3.3 36.5 14.4 3.2 –4.9† — Brumfield Cut with knife –6.8* 17.7 27.2 18.7 –2.4† 8.1 Ryu –3.5* 20.9 23.7 — — 21.1 Brumfield Pour from pitcher 20.2 25 12 27 — Ryu –30* –5 21.0 — — 15 Ryu Turn doorknob 8.7 29.7 42 12 32 — Brumfield Use telephone 22 85 –2† 32 20 Ryu –20* 45 42.7 — — 34 Ryu Turn steering wheel –40* 42.6 55 –10† 12 — Brumfield Rise from chair 40 60 –17† 27 22 Ryu –0.1* 45 62.8 — — 44 –15 63.4 70 5 30 — –15* 60 25 0.6 –10* *The minus sign denotes flexion. †The minus sign denotes radial deviation. ‡Values from Ryu et al were extrapolated from graphs.
138 PART II Upper-Extremity Testing TABLE 6.6 Wrist Motions During Hand Placement Needed for Personal Care Activities: Mean Values in Degrees Activity Extension Flexion Ulnar Deviation Radial Deviation Source Hand to top of head Hand to occiput Mean (SD) Mean (SD) Mean (SD) Mean (SD) Brumfield36 Hand to front of chest Ryu18 Hand to sacrum —— 2.3 (12.5) —— —— Brumfield Hand to foot —— 20.9 (13.9) 16.1 (12.7) —— Ryu 12.7 (9.9) —— —— —— Brumfield —— —— Ryu —— 0.9 (17.6) 9.7 (11.9) —— Brumfield —— 18.9 (8.9) —— 5.1 (10.3) Ryu —— 24.5 (16.7) —— —— Brumfield —— —— —— Ryu 14.2 (10.6) 0.6 (9.8) 47.8 (16.8) —— 0.8 (14.6) 19.5 (19.3) —— —— —— 8.7 (12.2) —— FIGURE 6.29 Using a telephone requires approximately placing the hand on the body required 20 degrees of flexion to 40 degrees of wrist extension. 15 degrees of extension. The authors concluded that an arc of wrist motion of 45 degrees (10 degrees of flexion to 35 degrees FIGURE 6.30 Turning a doorknob requires 40 degrees of of extension) is sufficient to perform most of the activities wrist flexion and 45 degrees of wrist extension. studied. Palmer and coworkers39 used a triaxial electrogoniometer to study 10 normal subjects while they performed 52 tasks. A range of 33 degrees of flexion, 59 degrees of extension, 23 de- grees of radial deviation, and 22 degrees of ulnar deviation was used in performing ADLs and personal hygiene. During these tasks the average amount of motion was about 5 degrees of flexion, 30 degrees of extension, 10 degrees of radial devi- ation, and 15 degrees of ulnar deviation. ROM values for in- dividual tasks were not presented in the study. Ryu and associates18 found that 31 examined tasks could be performed with 54 degrees of flexion, 60 degrees of exten- sion, 17 degrees of radial deviation, and 40 degrees of ulnar deviation. The 20 men and 20 women were evaluated with a biaxial electrogoniometer during performance of palm place- ment activities, personal care and hygiene, diet and food preparation, and miscellaneous ADLs. Studies by Safaee-Rad and coworkers37 and Cooper and coworkers38 examined wrist ROM with a video-based three- dimensional motion analysis system during three feeding tasks: drinking from a cup, eating with a fork, and eating with a spoon. The 10 males studied by Safaee-Rad and coworkers used from 10 degrees of wrist flexion to 25 degrees of exten- sion and from 20 degrees of ulnar deviation to 5 degrees of radial deviation during the tasks. Cooper and coworkers examined 10 males and 9 females during feeding tasks, with the elbow unrestricted and then fixed in 110 degrees of flex- ion. With the elbow unrestricted, males used from 7 degrees of wrist flexion to 21 degrees of extension and from 19 degrees of ulnar deviation to 2 degrees of radial deviation. Females had similar values for flexion and extension but used from
CHAPTER 6 The Wrist 139 3 degrees of ulnar deviation to 18 degrees of radial deviation. incidences of injury, studies have been conducted on the wrist Both studies found that drinking from a cup required less of positions used and the amount and frequency of wrist motions an arc of wrist motion than eating with a fork or spoon. required during grocery bagging,41 grocery scanning,42 piano playing,43 industrial work,44 and handrim wheelchair propul- Nelson40 took a different approach to determining the sion45,46 and in playing sports such as basketball, baseball amount of wrist motion necessary for carrying out functional pitching, and golf.6,47 The reader is advised to refer directly to tasks. He evaluated the ability of 9 males and 3 females to these studies to gain information about the amount of wrist perform 123 ADLs with a splint on the dominant wrist that ROM that occurs during these activities. In general, an asso- limited motion to 5 degrees of flexion, 6 degrees of extension, ciation has been noted between activities that require extreme 7 degrees of radial deviation, and 6 degrees of ulnar deviation. wrist postures and the prevalence of hand/wrist tendinitis.48 All 123 activities could be completed with the splint in place, Tasks that involve repeated wrist flexion and extreme wrist with 9 activities having a mean difficulty rating of greater than extension, repetitive work with the hands, and repeated force or equal to 2 (could be done with minimal difficulty or frustra- applied to the base of the palm and wrist have been associated tion and with satisfactory outcome). The most difficult activities with carpal tunnel syndrome.49 included putting on/taking off a brassiere (Fig. 6.31), washing legs/back, writing, dusting low surfaces, cutting vegetables, Reliability handling a sharp knife, cutting meat, using a can opener, and using a manual eggbeater. It should be noted that these sub- In early studies of wrist motion conducted by Hewitt27 and jects were pain free and had normal shoulders and elbows to Cobe31 in the 1920s, both authors observed considerable dif- compensate for the restricted wrist motions. The ability to ferences in repeated measurements of active wrist motions. generalize these results to a patient population with pain and These differences were attributed to a lack of motor control multiply involved joints may be limited. on the part of the subjects in expending maximal effort. Cobe suggested that only average values have much validity and Repetitive trauma disorders such as carpal tunnel syn- that changes in ROM should exceed 5 degrees to be consid- drome and wrist/hand tendinitis have been noted to occur ered clinically significant. more frequently in performing certain types of work, sports, and artistic endeavors. To elucidate the cause of these higher Later studies of intratester and intertester reliability were conducted by numerous researchers. The majority of these FIGURE 6.31 A large amount of wrist flexion is needed to investigators found that intratester reliability was greater than fasten a bra or bathing suit. This is one of the most difficult intertester reliability, that reliability varied according to the activities to perform if wrist motion is limited. motion being tested, and that different instruments should not be used interchangeably during joint measurement. Hellebrandt, Duvall, and Moore50 found that wrist motions measured with a universal goniometer were more reliable than those measured with a joint-specific device. Measurements of wrist flexion and extension were less reliable than measure- ments of radial and ulnar deviation, although mean differences between successive measurements taken with a universal goniometer by a skilled tester were 1.1 degrees for flexion and 0.9 degrees for extension. The mean differences between suc- cessive measurements increased to 5.4 degrees for flexion and 5.7 degrees for extension when successive measurements were taken with different instruments. In a study by Low,51 50 testers using a universal goniometer visually estimated and then measured the author’s active wrist extension and elbow flexion. Five testers also took 10 repeated measurements over the course of 5 to 10 days. Mean error improved from 12.8 degrees for visual estimates to 7.8 degrees for goniometric measure- ment. Intraobserver error was less than interobserver error. The measurement of wrist extension was less reliable than the measurement of elbow flexion, with mean errors of 7.8 and 5.0 degrees, respectively. Boone et al52 conducted a study in which four testers using a universal goniometer measured ulnar deviation on 12 male volunteers. Measurements were repeated over a period of 4 weeks. Intratester reliability was found to be
140 PART II Upper-Extremity Testing better than intertester reliability. The authors concluded that LaStayo and Wheeler16 studied the intratester and to determine true change when more than one tester measures intertester reliability of passive ROM measurements of wrist the same motion, differences in motion should exceed flexion and extension in 120 patients as measured by 32 ran- 5 degrees. domly paired therapists, who used three goniometric align- ments (ulnar, radial, and dorsal–volar). The reliability of In a study by Bird and Stowe,53 two observers repeat- measuring wrist flexion ROM was consistently higher than edly measured active and passive wrist ROM in three sub- that of measuring extension ROM. Mean intratester ICCs for jects. They concluded that interobserver error was greatest wrist flexion were 0.86 for radial, 0.87 for ulnar, and 0.92 for for extension (Ϯ8 degrees) and least for radial and ulnar dorsal alignment. Mean intratester ICCs for wrist extension deviation (Ϯ2 to 3 degrees). Error during passive ROM were 0.80 for radial, 0.80 for ulnar, and 0.84 for volar align- measurements was slightly greater than during active ROM ment. The authors recommended that these three alignments, measurements. although generally having good reliability, should not be used interchangeably because there were some significant differ- Greene and Wolf17 compared the reliability of the Ortho- ences between the measurements taken with the three align- Ranger, an electronic pendulum goniometer, with a universal ments. The authors suggested that the dorsal–volar alignment goniometer for active upper-extremity motions in 20 healthy should be the technique of choice for measuring passive wrist adults. Wrist ROM was measured by one therapist three times flexion and extension, given its higher reliability. In an invited with each instrument during each of three sessions over a commentary on this study, Flower55 suggested using the fifth 2-week period. There was a significant difference between metacarpal, which is easier to visualize and align with the instruments for wrist extension and ulnar deviation. Within- distal arm of the goniometer in the ulnar technique, rather session reliability was slightly higher for the universal goniome- than the third metacarpal, which was used in the study. Flower ter (ICC = 0.91 to 0.96) than for the OrthoRanger (ICC ϭ noted that the presence and fluctuation of edema on the 0.88 to 0.92). The 95 percent confidence level, which represents dorsal surface of the hand may reduce the reliability of the the variability around the mean, ranged from 7.6 to 9.3 degrees dorsal alignment and necessitate the use of the ulnar (fifth for the goniometer and from 18.2 to 25.6 degrees for the Ortho- metacarpal) alignment in the clinical setting. Ranger. The authors concluded that the OrthoRanger provided no advantages over the universal goniometer. Validity Solgaard and coworkers19 found intratester standard devi- We are unaware of any published studies that report criterion- ations of 5 to 8 degrees and intertester standard deviations of related validity of wrist ROM measurements taken with a 6 to 10 degrees in a study of wrist and forearm motions goniometer to radiographs. However, several studies have involving 31 healthy subjects. Measurements were taken with examined construct validity between impairment measures, a universal goniometer by four testers on three different occa- such as wrist ROM, and ratings of functional limitation or dis- sions. The coefficients of variation (percent variation) ability. A review of 32 published wrist outcome instruments between testers were greater for ulnar and radial deviation noted that ROM was the most frequently included variable, than for flexion, extension, pronation, and supination. present in 82 percent of the outcome instruments.56 Horger54 conducted a study in which 13 randomly paired Wagner and colleagues57 measured passive ROM of wrist therapists performed repeated measurements of active and flexion, extension, radial and ulnar deviation, and the strength passive wrist motions on 48 patients. Therapists were free to of the wrist extensor and flexor muscles in 18 boys with select their own method of measurement with a universal Duchenne muscular dystrophy. A highly significant negative goniometer. The six specialized hand therapists used an ulnar correlation was found between difficulty performing func- alignment for flexion and extension, whereas the nonspecial- tional hand tasks and radial deviation ROM (r = –0.76 to ized therapists used a radial goniometer alignment. Intratester –0.86) and between difficulty performing functional hand reliability of both active and passive wrist motions were tasks and wrist extensor strength (r = –0.61 to –0.83). highly reliable (all ICCs higher than 0.90) for all motions. Intratester reliability was consistently higher than intertester The relationship between wrist ROM and activity limita- reliability (ICC 0.66 to 0.91). Standard errors of measure- tion, pain, and disability following wrist fractures has been ments (SEM) ranged from 2.6 to 4.4 for intratester values and examined. Tremayne and associates,58 in a study of 20 patients from 3.0 to 8.2 for intertester values. Agreement between with distal radius fractures, found strong, significant correla- measures was better for flexion and extension than for radial tions (r = –0.51 to –0.76) between grip strength and tasks in and ulnar deviation. Intertester reliability coefficients for the Jebsen Test of Hand Function (JTHF) and weaker correla- measurements of active motion (ICC = 0.78 to 0.91) were tions (r = –0.17 to –0.55) between wrist extenson ROM and slightly higher than were coefficients for passive motion (ICC tasks in the JTHF. In a subset of 11 patients with Colles’ type = 0.66 to 0.86) except for radial deviation. Generally, reliabil- fractures, there were significant correlations (r = –0.74 to ity was higher for the specialized therapists than for the –0.84) between wrist extension ROM and three of seven tasks nonspecialized therapists. The author determined that the (turning cards, stimulated feeding, and lifting large light presence of pain reduced the reliability of both active and pas- objects) included in the JTHF. sive measurements, but active measurements were affected more than passive measurements.
CHAPTER 6 The Wrist 141 In a study of 120 patients with distal radius fractures, They concluded that grip strength, followed by wrist exten- MacDermid and coworkers59 found that higher patient-rated sion and forearm pronation, were the most sensitive clinical pain and disability scores 6 months post-injury (6-month indicators of return of wrist function. In another report of Patient-Rated Wrist Evaluation [PRWE] scores) were moder- 31 patients recovering from distal radial fracture, the same ately associated (r = –0.41) with lower composite ROM authors noted that flexion–extension and pronation–supination scores. Composite ROM scores were based on wrist flexion, arcs of motion (expressed as percentages of the unaffected extension, ulnar and radial deviation, supination, pronation, side) were not significantly associated with total PRWE and finger flexion. scores in a multiple regression model that included grip strength, age, gender, presence of high-energy injury, and Karnezis and Fragkiadakis,60 in a study of 25 patients re- intra-articular fracture.61 The possibility that some of the vari- covering from distal radial fractures, reported correlations be- ables included in the regression model may be inadvertent tween the “Function Score” of the PRWE score and grip markers for diminished ROM values may have affected the strength (r = 0.80), wrist extension ROM (r = 0.78), pronation findings. (r = 0.70), supination (r = 0.63), and wrist flexion (r = 0.62).
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Phys Ther 74:162, 1994 in various seating positions: Implication to wrist pain. Clin Biomech 18:S46, 2003. 17. Greene, BL, and Wolf, SL: Upper extremity joint movement: Compari- 47. Ohinishi, N, et al: Analysis of wrist motion during basketball shooting. In son of two measurement devices. Arch Phys Med Rehabil 70:288, 1989. Nakamura, RL, Linscheid, RL, and Miura, T (eds): Wrist Disorder: Cur- rent Concepts and Challenges. New York, Springer-Verlag, 1992. 18. Ryu, J, et al: Functional ranges of motion of the wrist joint. J Hand Surg 48. Bernard,BP (ed): Musculoskeletal disorders and workplace factors. 16A:409, 1991. Cincinnati, Ohio: National Institute of Occupational Safety and Health. 1997. 19. Solgaard, S, et al: Reproducibility of goniometry of the wrist. Scand 49. Armstrong, TJ, et al: Ergonomic considerations in hand and wrist ten- J Rehabil Med 18:5, 1986. dinitis. J Hand Surg 12A: 830, 1982. 50. Hellebrandt, FA, Duvall, EN, and Moore, ML: The measurement of joint 20. Solveborn, SA, and Olerud, C: Radial epicondylalgia (tennis elbow): motion. Part III: Reliability of goniometry. Phys Ther Rev 29:302, 1949. Measurement of range of motion of the wrist and the elbow. J Orthop 51. Low, JL: The reliability of joint measurement. Physiotherapy 62:227, Sports Phys Ther 23:251, 1996. 1976. 52. Boone, DC, et al: Reliability of goniometric measurements. Phys Ther 21. Stubbs, NB, Fernandez, JE, and Glenn, WM: Normative data on joint 58:1355, 1978. ranges of motion of 25- to 54-year-old males. International Journal of 53. Bird, HA, and Stowe, J: The wrist. Clin Rheum Dis 8:559, 1982. Industrial Ergonomics 12; 265, 1993. 54. Horger, MM: The reliability of goniometric measurements of active and passive wrist motions. Am J Occup Ther 44:342, 1990. 22. Wanatabe, H, et al: The range of joint motions of the extremities in 55. Flower, KR: Invited commentary. Phys Ther 74:174, 1994. healthy Japanese people: The difference according to age. Nippon 56. Bialocerkowski, AE, et al: A systematic review of the content and qual- Seikeigeka Gokkai Zasshi 53:275, 1979. (Cited in Walker, JM: Muscu- ity of wrist outcome instruments. Int J Qual Health Care 12:149, 2000. loskeletal development: A review. Phys Ther 71:878, 1991.) 57. Wagner, MB, et al: Assessment of hand function in Duchenne muscular dystrophy. Arch Phys Med Rehabil 74:801, 1993. 23. Boone, DC: Techniques of measurement of joint motion. (Unpublished 58. Tremayne, A, et al: Correlation of impairment and activity limitation supplement to Boone, DC, and Azen, SP: Normal range of motion in after wrist fracture. Physiother Res Int 7:90, 2002. male subjects. J Bone Joint Surg [Am] 61:756, 1979.) 59. MacDermid, JC, et al: Patient versus injury factors as predictors of pain and disability six months after a distal radius fracture. J Clin Epidemiol 24. Walker, JM, et al: Active mobility of the extremities in older subjects. 55:849, 2002. Phys Ther 64:919, 1984. 60. Karnezis, IA, and Fragkiadakis, EG: Objective clinical parameters and patient-rated wrist function. J Bone Joint Surg (Br) 85-B supplement I:7, 25. Chaparro, A, et al: Range of motion of the wrist: Implications for design- 2003. ing computer input devices for the elderly. Disabil Rehabil 22:633:2000. 61. Karnezis, IA, and Fragkiadakis, EG: Association between objective clin- ical variables and patient-rated disability of the wrist. J Bone Joint Surg 26. Kalscheur, JA, et al: Gender differences in range of motion in older (Br) 84-B:967, 2002. adults. Phys Occup Ther Geriatr 22:77, 2003. 27. Hewitt, D: The range of active motion at the wrist of women. J Bone Joint Surg (Br) 26:775, 1928. 28. Allander, E, et al: Normal range of joint movements in shoulder, hip, wrist and thumb with special reference to side: A comparison between two populations. Int J Epidemiol 3:253, 1974. 29. Bell, RD, and Hoshizaki, TB: Relationships of age and sex with range of motion of seventeen joint actions in humans. Can J Appl Spt Sci 6:202, 1981.
7 The Hand Structure and Function Osteokinematics The MCP joints are biaxial condyloid joints that have 2 degrees Fingers: Metacarpophalangeal of freedom, allowing flexion–extension in the sagittal plane and Joints abduction–adduction in the frontal plane. Abduction–adduction is possible with the MCP joints positioned in extension, but it is Anatomy limited with the MCP joints in flexion because of tightening of The metacarpophalangeal (MCP) joints of the fingers are the collateral ligaments.2 A small amount of passive axial rota- composed of the convex distal end of each metacarpal and the tion has been reported at the MCP joints,2-4 but this motion is not concave base of each proximal phalanx (Fig. 7.1). The joints usually measured in the clinical setting. are enclosed in fibrous capsules (Figs. 7.2 and 7.3). The ante- rior portion of each capsule has a fibrocartilaginous thicken- Arthrokinematics ing called the palmar plate (palmar ligament), which is The concave base of the phalanx slides and rolls on the convex loosely attached to the metacarpals and firmly attached to the head of the metacarpal in the same direction as movement of proximal phalanx.1,2 Ligamentous support is provided by pal- the shaft of the phalanx.5 During flexion the base of the phalanx mar, collateral, and deep transverse metacarpal ligaments. slides and rolls anteriorly toward the palm, whereas during extension the base of the phalanx slides and rolls dorsally. In 3rd 4th 2nd Distal interphalangeal Palmar joints plates Proximal 5th Joint interphalangeal 1st Distal capsules phalanx joints Deep 5th transverse metacarpal Metacarpophalangeal Middle ligament joints phalanx 5th Proximal phalanx 5th Metacarpal FIGURE 7.1 An anterior (palmar) view of the hand showing FIGURE 7.2 An anterior (palmar) view of the hand showing metacarpophalangeal, proximal interphalangeal, and distal joint capsules and palmar plates of the metacarpophalangeal, interphalangeal joints. proximal interphalangeal, and distal interphalangeal joints and the deep transverse metacarpal ligament. 143
144 PART II Upper-Extremity Testing Joint extension, the base of the middle phalanx slides and rolls capsules toward the dorsum of the hand. Collateral Capsular Pattern ligaments The capsular pattern is an equal restriction of both flexion and extension, according to Cyriax and Cyriax.6 Kaltenborn7 Joint Collateral notes that all motions are restricted with more limitation in capsule ligament flexion. FIGURE 7.3 A lateral view of a finger showing joint capsules Thumb: Carpometacarpal Joint and collateral ligaments of the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints. Anatomy The carpometacarpal (CMC) joint of the thumb is the articula- abduction, the base of the phalanx slides and rolls in the same tion between the trapezium and the base of the first metacarpal direction as the movement of the finger. (Fig. 7.4). The saddle-shaped trapezium is concave in the sagit- tal plane and convex in the frontal plane (Fig. 7.5).1,5 The base Capsular Pattern of the first metacarpal has a reciprocal shape that conforms to Cyriax and Cyriax6 report that the capsular pattern is an equal that of the trapezium, so that the base of the metacarpal is con- restriction of flexion and extension. Kaltenborn7 notes that all vex in the sagittal plane and concave in the frontal plane. The motions are restricted with more limitation in flexion. joint capsule is thick but lax and is reinforced by radial, ulnar, palmar, and dorsal ligaments (Fig. 7.6).1,2 Fingers: Proximal Interphalangeal and Distal Interphalangeal Joints Osteokinematics The first CMC joint is a saddle joint with 2 degrees of free- Anatomy dom: flexion–extension in the frontal plane parallel to the The structure of both the proximal interphalangeal (PIP) and the palm and abduction–adduction in the sagittal plane perpen- distal interphalangeal (DIP) joints is very similar (see Fig. 7.1). dicular to the palm.1,5 These planes of movement for the CMC Each phalanx has a concave base and a convex head. The joint joint of the thumb are at right angles to the planes of move- surfaces comprise the head of the more proximal phalanx and ment of the fingers because the trapezium is anterior to the the base of the adjacent, more distal phalanx. Each joint is sup- other carpals, effectively rotating the palmar surface of the ported by a joint capsule, a palmar plate, and two collateral thumb medially.1,8 The laxity of the joint capsule also permits ligaments (see Figs. 7.2 and 7.3).1,2 1st Interphalangeal Osteokinematics Distal joint The PIP and DIP joints of the fingers are classified as synovial phalanx hinge joints with 1 degree of freedom: flexion–extension in Metacarpophalangeal the sagittal plane. 1st joint Proximal Arthrokinematics phalanx Sesamoid Motion of the joint surfaces includes a sliding and rolling of bones the concave base of the more distal phalanx on the convex 1st head of the proximal phalanx. Sliding and rolling of the base Metacarpal of the moving phalanx occurs in the same direction as the movement of the shaft.5 For example, in PIP flexion the base Trapezium Carpometacarpal of the middle phalanx slides and rolls toward the palm. In PIP joint FIGURE 7.4 An anterior (palmar) view of the thumb showing carpometacarpal, metacarpophalangeal, and interphalangeal joints.
CHAPTER 7 The Hand 145 FIGURE 7.5 The saddle-shaped joint surface of the trapezium Arthrokinematics at the first carpometacarpal (CMC) joint is convex in the frontal The concave joint surface of the first metacarpal slides and plane (flexion–extension) and concave in the sagittal plane rolls on the convex surface of the trapezium in the same direc- (abduction–adduction). The base of the metacarpal of the tion as the metacarpal shaft to produce flexion–extension.5,7 thumb has a shape that is reciprocal to that of the trapezium. During flexion, the base of the metacarpal slides and rolls in Reproduced with permission from Levangie, PL, and Norkin, an ulnar direction. During extension, it slides and rolls in a ra- CC: Joint Structure and Function: A Comprehensive Analysis, dial direction. ed 4. FA Davis, Philadelphia, 2005. To produce abduction–adduction the convex joint surface some axial rotation. This rotation allows the thumb to move of the first metacarpal slides on the concave portion of the into position for contact with the fingers during opposition. trapezium in the opposite direction to the shaft of the metacarpal The sequence of motions that combines with rotation and but rolls in the same direction as the shaft of the metacarpal. 5,7 results in opposition is as follows: abduction, flexion, medial Therefore, the base of the metacarpal slides toward the dorsal axial rotation, and adduction.1,5 Reposition returns the thumb surface of the hand and rolls toward the palmar surface of the to the starting position. hand during abduction. The base of the first metacarpal slides toward the palmar surface of the hand and rolls toward the dor- Palmar plate Collateral sal surface of the hand during adduction. ligaments Sesamoid Capsular Pattern bones Capsule The capsular pattern is a limitation of abduction according to Cyriax and Cyriax.6 Kaltenborn7 reports limitations in abduc- Palmar plate Cruciate tion and extension. ligaments Thumb: Metacarpophalangeal Capsule Joint Collateral ligaments Anatomy The metacarpophalangeal (MCP) joint of the thumb is the artic- Capsule ulation between the convex head of the first metacarpal and the concave base of the first proximal phalanx (see Fig. 7.4). The FIGURE 7.6 An anterior (palmar) view of the thumb showing joint is reinforced by a joint capsule, palmar plate, two sesamoid joint capsules, collateral ligaments, palmar plates, and cruciate bones on the palmar surface, two intersesamoid ligaments (cru- (intersesamoid) ligaments. ciate ligaments), and two collateral ligaments (see Fig. 7.6).1 Osteokinematics The MCP joint is a condyloid joint with 2 degrees of free- dom.1,8 The motions permitted are flexion–extension and a minimal amount of abduction–adduction. Motions at this joint are more restricted than at the MCP joints of the fingers. Arthrokinematics At the MCP joint the concave base of the proximal phalanx slides and rolls on the convex head of the first metacarpal in the same direction as the shaft of the phalanx.5,7 The base of the proximal phalanx moves toward the palmar surface of the thumb in flexion and toward the dorsal surface of the thumb in extension. Capsular Pattern The capsular pattern for the MCP joint is a restriction of motion in all directions, but flexion is more limited than extension.6,7 Thumb: Interphalangeal Joint Anatomy The interphalangeal (IP) joint of the thumb is identical in structure to the IP joints of the fingers. The head of the prox- imal phalanx is convex, and the base of the distal phalanx is concave (see Fig. 7.4). The joint is supported by a joint
146 PART II Upper-Extremity Testing capsule, a palmar plate, and two lateral collateral ligaments same direction as the shaft of the phalanx.5,7 The base of the (see Fig. 7.6). distal phalanx moves toward the palmar surface of the thumb in flexion and toward the dorsal surface of the thumb in Osteokinematics extension. The IP joint is a synovial hinge joint with 1 degree of free- dom: flexion–extension. Capsular Pattern The capsular pattern is an equal restriction in both flexion and Arthrokinematics extension according to Cyriax.6 Kaltenborn7 notes that all At the IP joint the concave base of the distal phalanx slides motions are restricted with more limitation in flexion. and rolls on the convex head of the proximal phalanx, in the
CHAPTER 7 The Hand 147 RANGE OF MOTION TESTING PROCEDURES: placement of the goniometer was preferred by Range of Motion Testing Procedures/FINGERS Fingers 73 percent of 231 surveyed therapists.9 However, swelling and bony deformities sometimes require that Included in this section are common clinical tech- the examiner either measure the MCP and IP joints niques for measuring joint motions of the fingers and from the lateral aspect or create alternative evaluation thumb. These techniques, which often place the techniques. Photocopies, photographs, and tracings goniometer on the dorsal surface of the digits, are of the hand at the beginning and end of the range of appropriate for evaluating motions in the majority motion (ROM) may be helpful. of people. Groth and Ehretsman found that dorsal Landmarks for Testing Procedures 5th Distal phalanx 5th Middle phalanx 5th Proximal phalanx 5th Metacarpal FIGURE 7.7 Posterior view of the right hand showing FIGURE 7.8 Posterior view of the right hand showing bony surface anatomy landmarks for goniometer alignment anatomical landmarks for goniometer alignment during the during measurement of finger range of motion. measurement of finger range of motion. The index, middle, ring, and little fingers each have a metacarpal and a proxi- mal, middle, and distal phalanx.
148 PART II Upper-Extremity Testing Range of Motion Testing Procedures/FINGERS FINGERS: extension because tension in the transverse metacarpal METACARPOPHALANGEAL ligament will restrict the motion. FLEXION Testing Motion Motion occurs in the sagittal plane around a medial–lateral axis. Normal ROM values for adults are Flex the MCP joint by pushing on the dorsal surface 90 degrees according to the American Association of of the proximal phalanx, moving the finger toward the Orthopaedic Surgeons (AAOS)10 and the American palm (Fig. 7.9). Maintain the MCP joint in a neutral Medical Association (AMA)11 and 100 degrees accord- position relative to abduction and adduction. The end ing to Hume and coworkers.12 MCP flexion appears of flexion ROM occurs when resistance to further to increase slightly in an ulnar direction from the motion is felt and attempts to overcome the resis- index finger to the little finger. See Research Findings tance cause the wrist to flex. and Tables 7.1 and 7.2 for additional normal ROM values. Normal End-Feel Testing Position The end-feel may be hard because of contact between the palmar aspect of the proximal phalanx Place the subject sitting, with the forearm and hand and the metacarpal, or it may be firm because of resting on a supporting surface. Place the forearm tension in the dorsal joint capsule and the collateral midway between pronation and supination, the wrist ligaments. in 0 degrees of flexion, extension, and radial and ulnar deviation and the MCP joint in a neutral position Goniometer Alignment relative to abduction and adduction. Avoid extreme flexion of the PIP and DIP joints of the finger being See Figures 7.10 and 7.11. examined. 1. Center fulcrum of the goniometer over the dorsal Stabilization aspect of the MCP joint. Stabilize the metacarpal to prevent wrist motion. 2. Align proximal arm over the dorsal midline of the Do not hold the MCP joints of the other fingers in metacarpal. 3. Align distal arm over the dorsal midline of the proximal phalanx. FIGURE 7.9 During flexion of the metacarpophalangeal (MCP) joint, the examiner uses one hand to stabilize the subject’s metacarpal and to maintain the wrist in a neutral position. The index finger and the thumb of the examiner’s other hand grasp the subject’s proximal phalanx to move it into flexion.
CHAPTER 7 The Hand 149 Range of Motion Testing Procedures/FINGERS FIGURE 7.10 The alignment of the goniometer at the beginning of metacarpophalangeal (MCP) flexion range of motion. In this photograph, the examiner is using a 6-inch plastic goniometer in which the arms have been trimmed to approximately 2 inches to make it easier to align over the small joints of the hand. Most examiners use goniometers with arms that are 6 inches or shorter when measuring ROM in the hand. FIGURE 7.11 At the end of metacarpophalangeal (MCP) flexion range of motion, the examiner uses one hand to hold the proximal goniometer arm in alignment and to stabilize the subject’s metacarpal. The examiner’s other hand maintains the proximal phalanx in MCP flexion and aligns the distal goniometer arm. Note that the goniometer arms make direct contact with the dorsal surfaces of the metacarpal and proximal phalanx, causing the fulcrum of the goniometer to lie somewhat distal and dorsal to the MCP joint.
150 PART II Upper-Extremity Testing Range of Motion Testing Procedures/FINGERS FINGERS: Stabilization METACARPOPHALANGEAL Stabilize the metacarpal to prevent wrist motion. Do not hold the MCP joints of the other fingers in full EXTENSION flexion because tension in the transverse metacarpal ligament will restrict the motion. Motion occurs in the sagittal plane around a medial- lateral axis. Normal ROM values for adults are Testing Motion 20 degrees according to the AMA11 and 45 degrees according to the AAOS.10 Passive MCP extension Extend the MCP joint by pushing on the palmar ROM is greater than active extension. Mallon, Brown, surface of the proximal phalanx, moving the and Nunley13 report that extension ROM at the MCP finger away from the palm (Fig. 7.12). Maintain the joints is equal across all fingers, whereas Skvarilova MCP joint in a neutral position relative to abduction and Plevkova14 and Smahel and Klimova15 note that and adduction. The end of extension ROM occurs the little finger has the greatest amount of MCP ex- when resistance to further motion is felt and tension. See Research Findings and Tables 7.1 and attempts to overcome resistance cause the wrist 7.2 for additional normal ROM values. to extend. Testing Position Normal End-Feel Position the subject sitting, with the forearm and hand The end-feel is firm because of tension in the palmar resting on a supporting surface. Place the forearm joint capsule and in the palmar plate. midway between pronation and supination; the wrist in 0 degrees of flexion, extension, and radial and Goniometer Alignment ulnar deviation; and the MCP joint in a neutral posi- tion relative to abduction and adduction. Avoid exten- See Figures 7.13 and 7.14 for alignment of the sion or extreme flexion of the PIP and DIP joints of goniometer over the dorsal aspect of the fingers. the finger being tested. (If the PIP and DIP joints are positioned in extension, tension in the flexor digito- 1. Center fulcrum of the goniometer over the dorsal rum superficialis and profundus muscles may restrict aspect of the MCP joint. the motion. If the PIP and DIP joints are positioned in full flexion, tension in the lumbricalis and interossei 2. Align proximal arm over the dorsal midline of the muscles will restrict the motion.) metacarpal. 3. Align distal arm over the dorsal midline of the proximal phalanx. FIGURE 7.12 During metacarpophalangeal (MCP) extension, the examiner uses her index finger and thumb to grasp the subject’s proximal phalanx and to move the phalanx dorsally. The examiner’s other hand maintains the subject’s wrist in the neutral position, stabilizing the metacarpal.
CHAPTER 7 The Hand 151 Range of Motion Testing Procedures/FINGERS FIGURE 7.13 A full-circle, 6-inch plastic goniometer is being used to measure the beginning range of motion for metacarpophalangeal (MCP) extension. The proximal arm of the goniometer is slightly longer than necessary for optimal alignment. If a goniometer of the right size is not available, the examiner can cut the arms of a plastic model to a suitable length. FIGURE 7.14 The alignment of the goniometer at the end of metacarpophalangeal (MCP) extension. The body of the goniometer is aligned over the dorsal aspect of the MCP joint, whereas the goniometer arms are aligned over the dorsal aspect of the metacarpal and proximal phalanx.
152 PART II Upper-Extremity Testing Range of Motion Testing Procedures/FINGERS Alternative Goniometer Alignment: 1. Center fulcrum of the goniometer over the palmar Palmar Aspect aspect of the MCP joint. See Figure 7.15 for alignment of the goniometer over 2. Align proximal arm over the palmar midline of the metacarpal. the palmar aspect of the finger. This alignment should 3. Align distal arm over the palmar midline of the not be used if swelling or hypertrophy is present in proximal phalanx. the palm of the hand. FIGURE 7.15 An alternative alignment of a finger goniometer over the palmar aspect of the proximal phalanx, the metacarpophalangeal joint, and the metacarpal. The shorter goniometer arm must be used over the palmar aspect of the proximal phalanx so that the proximal interphalangeal and distal interphalangeal joints are allowed to relax in flexion.
CHAPTER 7 The Hand 153 FINGERS: from the midline of the hand (Fig. 7.16). Maintain the Range of Motion Testing Procedures/FINGERS METACARPOPHALANGEAL MCP joint in a neutral position relative to flexion and ABDUCTION extension. The end of abduction ROM occurs when resistance to further motion is felt and attempts to Motion occurs in the frontal plane around an anterior– overcome the resistance cause the wrist to move into posterior axis. No sources were found for normal radial or ulnar deviation. abduction ROM values measured with a universal goniometer at the MCP joint. Some values have been Normal End-Feel reported for the maximal angles between adjacent fin- gers using tracings15, and between fingers and the mid- The end-feel is firm because of tension in the collat- line of the hand using a gravity-based goniometer.16 eral ligaments of the MCP joints, the fascia of the web space between the fingers, and the palmar interossei Testing Position muscles. Position the subject sitting, with the forearm and hand Goniometer Alignment resting on a supporting surface. Place the wrist in 0 degrees of flexion, extension, and radial and ulnar See Figures 7.17 and 7.18. deviation; the forearm in full pronation so that the palm of the hand faces the ground; and the MCP joint 1. Center fulcrum of the goniometer over the dorsal in 0 degrees of flexion and extension. aspect of the MCP joint. Stabilization 2. Align proximal arm over the dorsal midline of the metacarpal. Stabilize the metacarpal to prevent wrist motions. 3. Align distal arm over the dorsal midline of the proximal phalanx. Testing Motion Abduct the MCP joint by pushing on the medial sur- face of the proximal phalanx, moving the finger away FIGURE 7.16 During metacarpophalangeal (MCP) abduction, the examiner uses the index finger of one hand to press against the subject’s metacarpal and prevent radial deviation at the wrist. With the other index finger and thumb holding the distal end of the proximal phalanx, the examiner moves the subject’s second MCP joint into abduction.
154 PART II Upper-Extremity Testing Range of Motion Testing Procedures/FINGERS FIGURE 7.17 The alignment of the goniometer at the beginning of metacarpophalangeal abduction range of motion. FIGURE 7.18 At the end of metacarpophalangeal (MCP) abduction, the examiner aligns the arms of the goniometer with the dorsal midline of the metacarpal and proximal phalanx rather than with the contour of the hand and finger.
CHAPTER 7 The Hand 155 FINGERS: in the lumbricalis and interossei muscles will restrict Range of Motion Testing Procedures/FINGERS METACARPOPHALANGEAL the motion.) ADDUCTION Stabilization Motion occurs in the frontal plane around an anterior– posterior axis. MCP adduction is not usually measured Stabilize the proximal phalanx to prevent motion of and recorded because it is the return from full abduc- the MCP joint. tion to the 0 starting position. There is very little ad- duction ROM beyond the 0 starting position. No Testing Motion sources were found for normal MCP adduction ROM values. Flex the PIP joint by pushing on the dorsal surface of the middle phalanx, moving the finger toward the FINGERS: PROXIMAL palm (Fig. 7.19). The end of flexion ROM occurs when INTERPHALANGEAL FLEXION resistance to further motion is felt and attempts to overcome the resistance cause the MCP joint to flex. Motion occurs in the sagittal plane around a medial– lateral axis. Normal ROM values for adults are 100 de- Normal End-Feel grees according to the AAOS10 and the AMA11 and 105 degrees according to Hume and coworkers12 and Usually, the end-feel is hard because of contact Mallon, Brown, and Nunley.13 PIP flexion ROM is equal between the palmar aspect of the middle phalanx for all the fingers.13 See Research Findings and Tables and the proximal phalanx. In some individuals, 7.1 and 7.2 for additional normal ROM values. the end-feel may be soft because of compression of soft tissue between the palmar aspect of the Testing Position middle and proximal phalanges. In other individuals, the end-feel may be firm because of tension in Place the subject sitting, with the forearm and hand the dorsal joint capsule and the collateral resting on a supporting surface. Position the forearm ligaments. in 0 degrees of supination and pronation; the wrist in 0 degrees of flexion, extension, and radial and ulnar Goniometer Alignment deviation; and the MCP joint in 0 degrees of flexion, extension, abduction, and adduction. (If the wrist and See Figures 7.20 and 7.21. MCP joints are positioned in full flexion, tension in the extensor digitorum communis, extensor indicis, or ex- 1. Center fulcrum of the goniometer over the dorsal tensor digiti minimi muscles will restrict the motion. If aspect of the PIP joint. the MCP joint is positioned in full extension, tension 2. Align proximal arm over the dorsal midline of the proximal phalanx. 3. Align distal arm over the dorsal midline of the middle phalanx. FIGURE 7.19 During proximal interphalangeal (PIP) flexion, the examiner stabilizes the subject’s proximal phalanx with her thumb and index finger. The examiner uses her other thumb and index finger to move the subject’s PIP joint into full flexion.
156 PART II Upper-Extremity Testing Range of Motion Testing Procedures/FINGERS FIGURE 7.20 The alignment of the goniometer at the beginning of proximal interphalangeal (PIP) flexion range of motion. FIGURE 7.21 At the end of proximal interphalangeal (PIP) flexion, the examiner continues to stabilize and align the proximal goniometer arm over the dorsal midline of the proximal phalange with one hand. The examiner’s other hand maintains the PIP joint in flexion and aligns the distal goniometer arm with the dorsal midline of the middle phalanx.
CHAPTER 7 The Hand 157 FINGERS: PROXIMAL Stabilization Range of Motion Testing Procedures/FINGERS INTERPHALANGEAL EXTENSION Stabilize the proximal phalanx to prevent motion of Motion occurs in the sagittal plane around a the MCP joint. medial–lateral axis. PIP extension is usually recorded as the starting position for PIP flexion ROM. Normal Testing Motion ROM values for adults are 0 degrees according to the AAOS10 and the AMA.11 Mallon, Brown, and Nunley13 Extend the PIP joint by pushing on the palmar surface report a mean of 7 degrees of active PIP extension of the middle phalanx, moving the finger away from and 16 degrees of passive PIP extension. PIP exten- the palm. The end of extension ROM occurs when sion is generally equal for all fingers.13 See Research resistance to further motion is felt and attempts to Findings and Tables 7.1 and 7.2 for additional normal overcome the resistance cause the MCP joint to ROM values. extend. Testing Position Normal End-Feel Place the subject sitting, with the forearm and hand The end-feel is firm because of tension in the palmar resting on a supporting surface. Position the forearm joint capsule and palmar plate (palmar ligament). in 0 degrees of supination and pronation; the wrist in 0 degrees of flexion, extension, and radial and ulnar Goniometer Alignment deviation; and the MCP joint in 0 degrees of flexion, extension, abduction, and adduction. (If the MCP joint 1. Center fulcrum of the goniometer over the dorsal and wrist are extended, tension in the flexor digito- aspect of the PIP joint. rum superficialis and profundus muscles will restrict the motion.) 2. Align proximal arm over the dorsal midline of the proximal phalanx. 3. Align distal arm over the dorsal midline of the mid- dle phalanx.
158 PART II Upper-Extremity Testing Range of Motion Testing Procedures/FINGERS FINGERS: DISTAL Stabilization INTERPHALANGEAL FLEXION Stabilize the middle and proximal phalanx to prevent further flexion of the PIP joint. Motion occurs in the sagittal plane around a medial–lateral axis. Normal ROM values for adults Testing Motion range from 70 degrees according to the AMA11 to 90 degrees according to the AAOS.10 Hume and Flex the DIP joint by pushing on the dorsal surface coworkers12 and Skvarilova and Plevkova14 report a of the distal phalanx, moving the finger toward the mean of 85 degrees of active DIP flexion. DIP flexion palm (Fig. 7.22). The end of flexion ROM occurs ROM is generally equal for all fingers.13 See Research when resistance to further motion is felt and at- Findings and Tables 7.1 and 7.2 for additional normal tempts to overcome the resistance cause the PIP ROM values. joint to flex. Testing Position Normal End-Feel Position the subject sitting, with the forearm and hand The end-feel is firm because of tension in the dorsal resting on a supporting surface. Place the forearm in joint capsule, collateral ligaments, and oblique reti- 0 degrees of supination and pronation; the wrist in nacular ligament. 0 degrees of flexion, extension, and radial and ulnar deviation; and the MCP joint in 0 degrees of flexion, Goniometer Alignment extension, abduction, and adduction. Place the PIP joint in approximately 70 to 90 degrees of flexion. (If See Figures 7.23 to 7.25. the wrist and the MCP and PIP joints are fully flexed, tension in the extensor digitorum communis, extensor 1. Center fulcrum of the goniometer over the dorsal indicis, or extensor digiti minimi muscles may restrict aspect of the DIP joint. DIP flexion. If the PIP joint is extended, tension in the oblique retinacular ligament may restrict DIP flexion.) 2. Align proximal arm over the dorsal midline of the middle phalanx. 3. Align distal arm over the dorsal midline of the dis- tal phalanx. FIGURE 7.22 During distal interphalangeal (DIP) flexion, the examiner uses one hand to stabilize the middle phalanx and keep the proximal interphalangeal joint in 70 to 90 degrees of flexion. The examiner’s other hand pushes on the distal phalanx to flex the DIP joint.
CHAPTER 7 The Hand 159 Range of Motion Testing Procedures/FINGERS FIGURE 7.23 Measurement of the beginning of distal interphalangeal (DIP) flexion range of motion is being conducted by means of a half-circle plastic goniometer with 6-inch arms that have been trimmed to accommodate the small size of the DIP joint. FIGURE 7.24 The alignment of the goniometer at the end of distal interphalangeal (DIP) flexion range of motion. Note that the fulcrum of the goniometer lies distal and dorsal to the proximal interphalangeal joint axis so that the arms of the goniometer stay in direct contact with the dorsal surfaces of the middle and distal phalanges.
160 PART II Upper-Extremity Testing Range of Motion Testing Procedures/FINGERS FIGURE 7.25 Distal interphalangeal flexion range of motion also can be measured by using a finger goniometer that is placed on the dorsal surface of the middle and distal phalanges. This type of goniometer is appropriate for measuring the small joints of the fingers, thumb, and toes. FINGERS: DISTAL Stabilization INTERPHALANGEAL EXTENSION Stabilize the middle and proximal phalanx to prevent Motion occurs in the sagittal plane around a extension of the PIP joint. medial–lateral axis. DIP extension is usually recorded as the starting position for DIP flexion ROM. Most Testing Motion references, such as the AAOS10 and the AMA,11 report normal ROM values to be 0 degrees. However, Extend the DIP joint by pushing on the palmar sur- Mallon, Brown, and Nunley13 report a mean of face of the distal phalanx, moving the finger away 8 degrees of active DIP extension and 20 degrees of from the palm. The end of extension ROM occurs passive DIP extension. DIP extension ROM is gener- when resistance to further motion is felt and at- ally equal for all fingers.13 See Research Findings and tempts to overcome the resistance cause the PIP Tables 7.1 and 7.2 for additional normal ROM values. joint to extend. Testing Position Normal End-Feel Position the subject sitting, with the forearm and hand The end-feel is firm because of tension in the resting on a supporting surface. Place the forearm in palmar joint capsule and the palmar plate (palmar 0 degrees of supination and pronation; the wrist in ligament). 0 degrees of flexion, extension, and radial and ulnar deviation; and the MCP joint in 0 degrees of flexion, Goniometer Alignment extension, abduction, and adduction. Position the PIP joint in approximately 70 to 90 degrees of flexion. (If 1. Center fulcrum of the goniometer over the dorsal the PIP joint, MCP joint, and wrist are fully extended, aspect of the DIP joint. tension in the flexor digitorum profundus muscle may restrict DIP extension.) 2. Align proximal arm over the dorsal midline of the middle phalanx. 3. Align distal arm over the dorsal midline of the dis- tal phalanx.
CHAPTER 7 The Hand 161 FINGERS: COMPOSITE FLEXION Testing Motion Range of Motion Testing Procedures/FINGERS OF THE MCP, PIP, AND DIP JOINTS Flex the MCP, PIP, and DIP joints by pushing on Composite finger flexion (CFF) is a simple method of the dorsal surface of the finger, moving the finger quickly assessing multiple joints in a finger to indicate toward the palm. The end of flexion ROM occurs the functional ability to make a fist. However, a disad- when resistance to further motion is felt and vantage of CFF is the inability to localize an impair- attempts to overcome the resistance cause the ment or response to treatment in a specific joint. wrist to flex. Normally when the MCP, PIP, and DIP joints are maxi- mally flexed, the distance between the fingertip and Normal End-Feel the distal palmar crease of the hand is zero. Ellis and Bruton17 report that repeated CFF measurements fell Usually, the end-feel is soft because of contact within 5 to 6 mm 95 percent of the time when taken between the palmar aspect of the proximal, middle, by the same tester and fell within 7 to 9 mm 95 per- and distal phalanx and palm of the hand. In other cent of the time when taken by different testers. individuals, the end-feel may be firm because of tension in the dorsal joint capsules and the collateral Testing Position ligaments. Place the subject sitting, with the forearm and hand Measurement Method resting on a supporting surface. Position the forearm in neutral supination and pronation and the wrist in See Figures 7.26 and 7.27. Measure the perpendicular 0 degrees of flexion, extension, and radial and ulnar distance between the distal palmar crease and the tip deviation. Alternatively, the forearm could be posi- of the finger.18,19 Alternatively, the distance between tioned in full supination. the distal palmar crease and the distal corner of the nail bed on the radial border of the finger can be Stabilization measured.17 Stabilize the metacarpals to prevent motion of the wrist. FIGURE 7.26 Composite finger flexion (CFF) is determined by measuring the distance between the distal palmar crease and the tip of the finger at the end of flexion of the MCP, PIP, and DIP joints. Normally, the tip of the finger is able to touch the palm at the distal palmar crease. This subject has limited range of motion.
162 PART II Upper-Extremity Testing Range of Motion Testing Procedures/THUMB RANGE OF MOTION TESTING PROCEDURES: Thumb Landmarks for Testing Procedures Proximal Tip digital Pulp crease Proximal Distal palmar palmar crease crease Distal Distal digital wrist crease crease Proximal digital crease FIGURE 7.27 A, B Anterior (palmar) view of the right hand showing the digital and palmar creases used for measuring composite finger flexion and CMC opposition of the thumb. Pisiform 1st Distal phalanx 1st Proximal phalanx 1st Metacarpal Trapezium Scaphoid Radial styloid process FIGURE 7.28 Anterior (palmar) view of the right hand FIGURE 7.29 Anterior (palmar) view of the right hand show- showing surface anatomy landmarks for goniometer align- ing bony anatomical landmarks for goniometer alignment ment during the measurement of thumb range of motion. during the measurement of thumb range of motion.
CHAPTER 7 The Hand 163 Landmarks for Testing Procedures (continued) Range of Motion Testing Procedures/THUMB FIGURE 7.30 Posterior view of the right hand 2nd showing surface anatomy landmarks for go- MCP niometer alignment during the measurement of joint thumb range of motion. 2nd Metacarpal 1st Distal phalanx 1st Proximal phalanx 1st MCP joint 1st Metacarpal Trapezium Scaphoid Radial styloid process FIGURE 7.31 Posterior view of the right hand showing bony anatomical landmarks for goniometer alignment during the measurement of thumb range of motion.
164 PART II Upper-Extremity Testing Range of Motion Testing Procedures/THUMB THUMB: CARPOMETACARPAL The end of flexion ROM occurs when resistance to further motion is felt and attempts to overcome the FLEXION resistance cause the wrist to deviate ulnarly. Motion occurs in the plane of the hand. When the Normal End-Feel subject is in the anatomical position, the motion occurs in the frontal plane around an anterior– The end-feel may be soft because of contact between posterior axis. Normal ROM is 15 degrees according muscle bulk of the thenar eminence and the palm of to the AAOS.10 the hand, or it may be firm because of tension in the dorsal joint capsule and the extensor pollicis brevis Testing Position and abductor pollicis brevis muscles. Position the subject sitting, with the forearm and hand Goniometer Alignment resting on a supporting surface. Place the forearm in full supination; the wrist in 0 degrees of flexion, See Figures 7.33 and 7.34. extension, and radial and ulnar deviation; and the CMC joint of the thumb in 0 degrees of abduction. 1. Center fulcrum of the goniometer over the palmar The MCP and IP joints of the thumb are relaxed in a aspect of the first CMC joint. position of slight flexion. (If the MCP and IP joints of the thumb are positioned in full flexion, tension in the 2. Align proximal arm with the ventral midline of the extensor pollicis longus and brevis muscles may radius using the ventral surface of the radial head restrict the motion.) and radial styloid process for reference. Stabilization 3. Align distal arm with the ventral midline of the first metacarpal. Stabilize the carpals, radius, and ulna to prevent wrist In the beginning position for flexion and exten- motions. Movement of the wrist will affect the accu- sion, the goniometer will indicate an angle of approxi- mately 30 to 50 degrees rather than 0 degrees, racy of the ROM measurement. depending on the shape of the hand and wrist posi- tion. The difference between the beginning-position Testing Motion degrees and the end-position degrees is the ROM. For example, a measurement that begins at Flex the CMC joint of the thumb by pushing on the 35 degrees and ends at 15 degrees should be dorsal surface of the metacarpal, moving the thumb recorded as 0 to 20 degrees. toward the ulnar aspect of the hand (Fig. 7.32). Maintain the CMC joint in 0 degrees of abduction. FIGURE 7.32 During carpometacarpal (CMC) flexion, the examiner uses the index finger and thumb of one hand to stabilize the carpals, radius, and ulna to prevent ulnar deviation of the wrist. The examiner’s other index finger and thumb flex the CMC joint by moving the first metacarpal medially.
CHAPTER 7 The Hand 165 Range of Motion Testing Procedures/THUMB FIGURE 7.33 The alignment of the goniometer at the beginning of carpometacarpal (CMC) flexion range of motion of the thumb. Note that the goniometer does not read 0 degrees. FIGURE 7.34 At the end of carpometacarpal (CMC) flexion range of motion, the examiner uses the hand that was stabilizing the wrist to align the proximal arm of the goniometer with the radius. The examiner’s other hand maintains CMC flexion and aligns the distal arm of the goniometer with the first metacarpal. During the measurement, the examiner must be careful not to move the subject’s wrist further into ulnar deviation or the goniometer reading will be incorrect (too high).
166 PART II Upper-Extremity Testing Range of Motion Testing Procedures/THUMB Alternative Goniometer Alignment This alternative alignment method avoids errors in ROM measurement due to inadvertent movement of See Figures 7.35 and 7.36. the wrist. The goniometer in the beginning position will indicate an angle of approximately 40 to 1. Center fulcrum of the goniometer over the palmar 70 degrees rather than 0 degrees, depending on the aspect of the first CMC joint. shape and size of the hand. The difference between the beginning-position degrees and the end-position 2. Align proximal arm with an imaginary line between degrees is the ROM. the palmar surfaces of the trapezium and pisiform. This line is often parallel to the distal wrist crease (refer to Figure 7.27). 3. Align distal arm with the ventral midline of the first metacarpal. FIGURE 7.35 An alternative method of measuring the beginning of carpometacarpal (CMC) flexion aligns the proximal arm of the goniometer with the palmar surface of the trapezium and pisiform. Note that the goniometer does not read 0 degrees. FIGURE 7.36 An alternative method of aligning the goniometer to measure the end of carpometacarpal (CMC) flexion range of motion. The difference between the degrees on the goniometer at the beginning and the end positions is the range of motion.
CHAPTER 7 The Hand 167 THUMB: CARPOMETACARPAL The MCP and IP joints of the thumb are relaxed in a Range of Motion Testing Procedures/THUMB EXTENSION position of slight flexion. (If the MCP and IP joints of the thumb are positioned in full extension, tension in Motion occurs in the plane of the hand. When the the flexor pollicis longus muscle may restrict the subject is in the anatomical position, the motion motion.) occurs in the frontal plane around an anterior– posterior axis. This motion is sometimes called radial Stabilization abduction. Reported values for CMC thumb extension ROM are 35 degrees according to the AMA11 (this is Stabilize the carpals, radius, and ulna to prevent wrist the difference between an angle of 15 degrees of motions. separation between the first and second metacarpal at the beginning of the motion and an angle of Testing Motion 50 degrees at the end of the motion), and vary from 20 degrees to 80 degrees according to the AAOS.10,18, Extend the CMC joint of the thumb by pushing on the However, the measurement methods used by the palmar surface of the metacarpal, moving the thumb AAOS and the AMA appear to differ from the method toward the radial aspect of the hand (Fig. 7.37). Main- suggested here. tain the CMC joint in 0 degrees of abduction. The end of extension ROM occurs when resistance to further Testing Position motion is felt and attempts to overcome the resis- tance cause the wrist to deviate radially. Position the subject sitting, with the forearm and hand resting on a supporting surface. Place the forearm in Normal End-Feel full supination; the wrist in 0 degrees of flexion, extension, and radial and ulnar deviation; and the The end-feel is firm because of tension in the anterior CMC joint of the thumb in 0 degrees of abduction. joint capsule and the flexor pollicis brevis, adductor pollicis, opponens pollicis, and first dorsal interossei muscles. FIGURE 7.37 During carpometacarpal (CMC) extension of the thumb, the examiner uses one hand to stabilize the carpals, radius, and ulna thereby preventing radial deviation of the subject’s wrist. The examiner’s other hand is used to pull the first metacarpal laterally into extension.
168 PART II Upper-Extremity Testing Range of Motion Testing Procedures/THUMB Goniometer Alignment In the beginning positions for flexion and exten- sion, the goniometer will indicate an angle of approxi- See Figures 7.38 and 7.39. mately 30 to 50 degrees rather than 0 degrees, depending on the shape of the hand and wrist posi- 1. Center fulcrum of the goniometer over the palmar tion. The difference between the beginning-position aspect of the first CMC joint. degrees and the end-position degrees is the ROM. For example, a measurement that begins at 2. Align proximal arm with the ventral midline of the 35 degrees and ends at 55 degrees should be radius, using the ventral surface of the radial head recorded as 0 to 20 degrees. and the radial styloid process for reference. 3. Align distal arm with the ventral midline of the first metacarpal. FIGURE 7.38 The goniometer alignment for measuring the beginning of carpometacarpal (CMC) extension range of motion is the same as for measuring the beginning of CMC flexion. FIGURE 7.39 The alignment of the goniometer at the end of carpometacarpal (CMC) extension range of motion of the thumb. The examiner must be careful to move only the CMC joint into extension and not to change the position of the wrist during the measurement.
CHAPTER 7 The Hand 169 Alternative Goniometer Alignment This alternative alignment method avoids errors in Range of Motion Testing Procedures/THUMB ROM measurement due to inadvertent movement of See Figures 7.40 and 7.41. the wrist. The goniometer in the beginning position will indicate an angle of 40 to 70 degrees rather than 1. Center fulcrum of the goniometer over the palmar 0 degrees, depending on the shape and size of the aspect of the first CMC joint. hand. The difference between the beginning and the end-position degrees is the ROM. For example, a 2. Align proximal arm with an imaginary line between measurement that begins at 50 degrees and ends at the palmar surface of the trapezium and pisiform. 30 degrees should be recorded as 0 to 20 degrees. This line is often parallel to the distal wrist crease (refer to Figure 7.27). 3. Align distal arm with the ventral midline of the first metacarpal. FIGURE 7.40 The alternative method of measuring the beginning of CMC extension is the same as the alternative method for measuring the beginning of CMC flexion. FIGURE 7.41 The alternative method of aligning the goniometer to measure the end of CMC extension ROM.
170 PART II Upper-Extremity Testing Range of Motion Testing Procedures/THUMB THUMB: CARPOMETACARPAL of abduction ROM occurs when resistance to further motion is felt and attempts to overcome the resis- ABDUCTION tance cause the wrist to flex. Motion occurs at a right angle to the palm of the Normal End-Feel hand. When the subject is in the anatomical position, the motion occurs in the sagittal plane around a The end-feel is firm because of tension in the fascia medial–lateral axis. This motion is sometimes called and the skin of the web space between the thumb and palmar abduction. Abduction ROM is 70 degrees the index finger. Tension in the adductor pollicis and according to the AAOS10,18. However, the measure- first dorsal interossei muscles also contributes to the ment method used by the AAOS appears to differ firm end-feel. from the method suggested here. Goniometer Alignment Testing Position See Figures 7.43 and 7.44. Position the subject sitting, with the forearm and hand resting on a supporting surface. Place the forearm 1. Center fulcrum of the goniometer over the lateral midway between supination and pronation; the wrist aspect of the radial styloid process. in 0 degrees of flexion, extension, and radial and ulnar deviation; and the CMC, MCP, and IP joints of 2. Align proximal arm with the lateral midline of the the thumb in 0 degrees of flexion and extension. second metacarpal, using the center of the second MCP joint for reference. Stabilization 3. Align distal arm with the lateral midline of the first Stabilize the carpals and the second metacarpal to metacarpal, using the center of the first MCP joint for reference. prevent wrist motions. Note that the proximal surface of the first Testing Motion metacarpal contacts the trapezium, while the proxi- mal surface of the second metacarpal contacts the Abduct the CMC joint by moving the metacarpal trapezoid. Contact of the metacarpals with two away from the palm of the hand (Fig. 7.42). The end FIGURE 7.42 During carpometacarpal (CMC) abduction, the examiner uses one hand to stabilize the subject’s second metacarpal. Her other hand grasps the subject’s first metacarpal just proximal to the metacarpophalangeal joint to move it away from the palm and into abduction.
CHAPTER 7 The Hand 171 different carpals and the palmar position of the MCP joints as easily identifiable landmarks to indi- Range of Motion Testing Procedures/THUMB trapezium relative to the trapezoid create difficulties cate CMC abduction of the thumb. As the motion in identifying a fulcrum and alignment for the arms progresses toward the end of CMC abduction, these of the goniometer in this motion. We have chosen landmarks will be better aligned with the first and the radial styloid process and the first and second second metacarpals. FIGURE 7.43 At the beginning of carpometacarpal (CMC) abduction range of motion, the distal end of the subject’s first metacarpal of the thumb lies over the second metacarpal of the index finger. FIGURE 7.44 The alignment of the goniometer at the end of carpometacarpal (CMC) abduction range of motion.
172 PART II Upper-Extremity Testing Range of Motion Testing Procedures/THUMB THUMB: CARPOMETACARPAL the thumb so that there is consistency between repeated measurements on an individual. ADDUCTION Testing Position Motion occurs at a right angle to the palm of the hand. When the subject is in the anatomical position, Position the subject sitting with the forearm and hand the motion occurs in the sagittal plane around a resting on a supporting surface. Place the forearm in medial–lateral axis. Adduction of the CMC joint of the full supination and the wrist in 0 degrees of flexion, thumb is not usually measured and recorded sepa- extension, and radial and ulnar deviation. rately because it is the return to the 0 starting posi- tion from full abduction. Stabilization THUMB: CARPOMETACARPAL Stabilize the fifth metacarpal to prevent motion at the fifth CMC joint and wrist. OPPOSITION Testing Motion This motion is a combination of abduction, flexion, medial axial rotation (pronation), and adduction at the Grasp the first metacarpal and move it away from the CMC joints of the thumb. Contact between the tip of palm of the hand (abduction) and then in an ulnar the thumb and the base of the little finger (proximal direction toward the base of the little finger (flexion digital crease) is usually possible at the end of opposi- and adduction), allowing the first metacarpal to medi- tion ROM, providing that some flexion at the MCP ally rotate (Fig. 7.45). The end of opposition ROM oc- and IP joints of the thumb is allowed. If no flexion of curs when contact is made between the tip of the the MCP and IP joints of the thumb is allowed, there thumb and the base of the little finger, if some flexion will be a distance of several centimeters between the of the MCP and IP joints of the thumb is allowed thumb and base of the little finger at the end of (Fig. 7.46). If no flexion is allowed at the MCP and IP opposition. Many methods of measuring CMC oppo- joints, the end of opposition will occur when resis- sition have been suggested.10,11,18–21 It is important to tance to further motion is felt and attempts to over- note the landmarks that are being used and the come the resistance cause the wrist to deviate or the amount of motion allowed at the MCP and IP joints of forearm to pronate.
CHAPTER 7 The Hand 173 Range of Motion Testing Procedures/THUMB FIGURE 7.45 Midway through the range of motion of carpometacarpal (CMC) opposition, the metacarpal of the thumb is in abduction, flexion, and medial rotation. The fifth metacarpal is stabilized by the examiner. FIGURE 7.46 At the end of the range of opposition the tip of the subject’s thumb is normally in contact with the base of the little finger. The thumb has moved through carpometacarpal (CMC) abduction, flexion, medial rotation, and adduction, while the metacarpophalangeal (MCP) joint is allowed to flex.
174 PART II Upper-Extremity Testing Range of Motion Testing Procedures/THUMB Normal End-Feel digital crease of the little finger at the end of oppo- sition (Fig. 7.47).10,18 The end-feel may be soft because of contact between the muscle bulk of the thenar eminence and the palm Alternately, the shortest distance between the or between the tip of the thumb with the base of the center of the proximal digital crease of the thumb little finger. In some individuals it may be firm because and the distal palmar crease directly over the fifth of tension in the CMC joint capsule, fascia, and skin of MCP joint can be measured (Fig. 7.48). In this the web space between the thumb and the index fin- manner, motion at the MCP and IP joints of the ger and tension in the adductor pollicis, first dorsal thumb will not affect the measurement of opposition. interossei, extensor pollicis brevis, and extensor polli- cis longus muscles. The AMA Guides to the Evaluation of Permanent Impairment11 recommends measuring the longest dis- Measurement Method tance from the flexion crease of the thumb IP joint to the distal palmar crease directly over the third The goniometer is not commonly used to measure the MCP joint (Fig. 7.49). However, this measurement angular range of opposition. Instead, a ruler is often method seems more consistent with the measurement used to measure the shortest distance between the of CMC abduction. A distance of less than 8 cm is tip of the thumb and the center of the proximal considered impaired.11 FIGURE 7.47 The range of motion (ROM) in opposition can be determined by measuring the shortest distance between the tip of the thumb and the proximal digital crease of the little finger. The examiner is using the arm of a goniometer to measure, but any ruler would suffice. This subject’s hand does not have full ROM in opposition.
CHAPTER 7 The Hand 175 Range of Motion Testing Procedures/THUMB FIGURE 7.48 Another method of measuring thumb opposition is to record the distance between the proximal digital crease of the thumb and the distal palmar crease over the fifth metacarpophalangeal (MCP) joint. FIGURE 7.49 In an alternative method of measuring thumb opposition proposed by the American Medical Association, the examiner uses a ruler to find the longest possible distance between the distal palmar crease directly over the metacarpophalangeal joint of the middle finger and the flexion crease of the thumb interphalangeal joint. (From Stanley, BG, and Tribuzi, SM: Concepts in Hand Rehabilitation. FA Davis, Philadelphia, 1992, p 546, with permission.)
176 PART II Upper-Extremity Testing Range of Motion Testing Procedures/THUMB THUMB: Testing Motion METACARPOPHALANGEAL Flex the MCP joint by pushing on the dorsal aspect of the proximal phalanx, moving the thumb toward the FLEXION ulnar aspect of the hand (Fig. 7.50). The end of flex- ion ROM occurs when resistance to further motion is Motion occurs in the frontal plane around an anterior– felt and attempts to overcome the resistance cause posterior axis when the subject is in the anatomical the CMC joint to flex. position. Normal ROM values for adults are 50 degrees according to the AAOS,10,18 60 degrees according to the Normal End-Feel AMA,11 and 55 degrees according to DeSmet and col- leagues.22 See Research Findings and Table 7.3 for addi- The end-feel may be hard because of contact tional normal ROM values. between the palmar aspect of the proximal phalanx and the first metacarpal, or it may be firm Testing Position because of tension in the dorsal joint capsule, the collateral ligaments, and the extensor pollicis Position the subject sitting, with the forearm and hand brevis muscle. resting on a supporting surface. Place the forearm in full supination; the wrist in 0 degrees of flexion, Goniometer Alignment extension, and radial and ulnar deviation; the CMC joint of the thumb in 0 degrees of flexion, extension, See Figures 7.51 and 7.52. abduction, adduction, and opposition; and the IP joint of the thumb in 0 degrees of flexion and extension. (If 1. Center fulcrum of the goniometer over the dorsal the wrist and IP joint of the thumb are positioned in aspect of the MCP joint. full flexion, tension in the extensor pollicis longus muscle will restrict the motion.) 2. Align proximal arm over the dorsal midline of the metacarpal. Stabilization 3. Align distal arm with the dorsal midline of the Stabilize the first metacarpal to prevent wrist motion proximal phalanx. and flexion of the CMC joint of the thumb. FIGURE 7.50 During metacarpophalangeal (MCP) flexion of the thumb, the examiner uses the index finger and thumb of one hand to stabilize the subject’s first metacarpal and maintain the wrist in a neutral position. The examiner’s other index finger and thumb grasp the subject’s proximal phalanx to move it into flexion.
CHAPTER 7 The Hand 177 Range of Motion Testing Procedures/THUMB FIGURE 7.51 The alignment of the goniometer on the dorsal surfaces of the first metacarpal and proximal phalanx at the beginning of metacarpophalangeal (MCP) flexion range of motion of the thumb. If a bony deformity or swelling is present, the goniometer may be aligned with the lateral surface of these bones. FIGURE 7.52 At the end of metacarpophalangeal (MCP) flexion, the examiner uses one hand to stabilize the subject’s first metacarpal and align the proximal arm of the goniometer. The examiner uses her other hand to maintain the proximal phalanx in flexion and align the distal arm of the goniometer.
178 PART II Upper-Extremity Testing Range of Motion Testing Procedures/THUMB THUMB: Testing Motion METACARPOPHALANGEAL Extend the MCP joint by pushing on the palmar surface of the proximal phalanx, moving the thumb EXTENSION toward the radial aspect of the hand. The end of extension ROM occurs when resistance to further Motion occurs in the frontal plane around an anterior– motion is felt and attempts to overcome the resis- posterior axis when the subject is in the anatomical tance cause the CMC joint to extend. position. Normal extension ROM values are 0 degrees according to the AAOS,10,18 40 degrees according to the Normal End-Feel AMA,11and 14 degrees (actively) and 23 degrees (passively) according to Skvarilova and Plevkova.14 See The end-feel is firm because of tension in the palmar Research Findings and Table 7.3 for additional normal joint capsule, palmar plate (palmar ligament), inter- ROM values. sesamoid (cruciate) ligaments, and flexor pollicis brevis muscle. Testing Position Goniometer Alignment Position the subject sitting, with the forearm and hand resting on a supporting surface. Place the forearm in 1. Center fulcrum of the goniometer over the dorsal full supination; the wrist in 0 degrees of flexion, aspect of the MCP joint. extension, and radial and ulnar deviation; the CMC joint of the thumb in 0 degrees of flexion, extension, 2. Align proximal arm over the dorsal midline of the abduction, and opposition; and the IP joint of the metacarpal. thumb in 0 degrees of flexion and extension. (If the wrist and the IP joint of the thumb are positioned in 3. Align distal arm with the dorsal midline of the full extension, tension in the flexor pollicis longus proximal phalanx. muscle may restrict the motion.) Stabilization Stabilize the first metacarpal to prevent motion at the wrist and at the CMC joint of the thumb.
CHAPTER 7 The Hand 179 THUMB: INTERPHALANGEAL Stabilization Range of Motion Testing Procedures/THUMB FLEXION Stabilize the proximal phalanx to prevent flexion or Motion occurs in the frontal plane around an extension of the MCP joint. anterior–posterior axis when the subject is in the anatomical position. Normal ROM values for adults Testing Motion are 67 degrees according to Jenkins and associates23 and 80 degrees according to the AAOS,10,18 AMA,11 Flex the IP joint by pushing on the dorsal surface of DeSmet and colleagues,22 and Skvarilova and the distal phalanx, moving the tip of the thumb Plevkova.14 See Research Findings and Table 7.3 for toward the ulnar aspect of the hand (Fig. 7.53). The additional normal ROM values. end of flexion ROM occurs when resistance to further motion is felt and attempts to overcome the resis- Testing Position tance cause the MCP joint to flex. Position the subject sitting, with the forearm and hand Normal End-Feel resting on a supporting surface. Place the forearm in full supination; the wrist in 0 degrees of flexion, extension, Usually, the end-feel is firm because of tension in and radial and ulnar deviation; the CMC joint in the collateral ligaments and the dorsal joint capsule. 0 degrees of flexion, extension, abduction, and opposi- In some individuals, the end-feel may be hard tion; and the MCP joint of the thumb in 0 degrees of because of contact between the palmar aspect of flexion and extension. (If the wrist and MCP joint of the the distal phalanx, the palmar plate, and the proxi- thumb are flexed, tension in the extensor pollicis longus mal phalanx. muscle may restrict the motion. If the MCP joint of the thumb is fully extended, tension in the abductor pollicis brevis and the oblique fibers of the adductor pollicis may restrict the motion through their insertion into the extensor mechanism.) FIGURE 7.53 During interphalangeal (IP) flexion of the thumb, the examiner uses one hand to stabilize the proximal phalanx and keep the metacarpophalangeal joint in 0 degrees of flexion and the carpometacarpal joint in 0 degrees of flexion, abduction, and opposition. The examiner uses her other index finger and thumb to flex the distal phalanx.
180 PART II Upper-Extremity Testing Range of Motion Testing Procedures/THUMB Goniometer Alignment 3. Align distal arm with the dorsal midline of the dis- tal phalanx. See Figures 7.54 and 7.55. 1. Center fulcrum of the goniometer over the dorsal surface of the IP joint. 2. Align proximal arm with the dorsal midline of the proximal phalanx. FIGURE 7.54 The alignment of the goniometer at the beginning of interphalangeal (IP) flexion range of motion. The arms of the goniometer are placed on the dorsal surfaces of the proximal and distal phalanges. However, the arms of the goniometer could instead be placed on the lateral surfaces of the proximal and distal phalanges if the nail protruded or if there was a bony prominence or swelling. FIGURE 7.55 The alignment of the goniometer at the end of interphalangeal (IP) flexion range of motion. The examiner holds the arms of the goniometer so that they maintain close contact with the dorsal surfaces of the proximal and distal phalanges.
CHAPTER 7 The Hand 181 THUMB: INTERPHALANGEAL Stabilization Range of Motion Testing Procedures/THUMB EXTENSION Stabilize the proximal phalanx to prevent extension or Motion occurs in the frontal plane around an anterior– flexion of the MCP joint. posterior axis when the subject is in the anatomical position. Normal extension ROM at the IP joint of the Testing Motion thumb is 20 degrees according to the AAOS,10 30 degrees according to the AMA,11 and 23 degrees Extend the IP joint by pushing on the palmar surface (actively) and 35 degrees (passively) according to of the distal phalanx, moving the thumb toward the Skvarilova and Plevkova.14 See Research Findings and radial aspect of the hand. The end of extension ROM Table 7.3 for additional normal ROM values. occurs when resistance to further motion is felt and attempts to overcome the resistance cause the MCP Testing Position joint to extend. Position the subject sitting, with the forearm and hand Normal End-Feel resting on a supporting surface forearm. Place the forearm in full supination; the wrist in 0 degrees of The end-feel is firm because of tension in the palmar flexion, extension, and radial and ulnar deviation; the joint capsule and the palmar plate (palmar ligament). CMC joint of the thumb in 0 degrees of flexion, extension, abduction, and opposition; and the MCP Goniometer Alignment joint of the thumb in 0 degrees of flexion and exten- sion. (If the wrist and MCP joint of the thumb are 1. Center fulcrum of the goniometer over the dorsal extended, tension in the flexor pollicis longus muscle surface of the IP joint. may restrict the motion.) 2. Align proximal arm with the dorsal midline of the proximal phalanx. 3. Align distal arm with the dorsal midline of the dis- tal phalanx.
182 PART II Upper-Extremity Testing Muscle Length Testing Procedures/FINGERS MUSCLE LENGTH TESTING PROCEDURES: of the extensor digitorum profundus of the same fin- Fingers ger (Fig. 7.57). The second and third palmar interossei muscles originate proximally from the radial sides of LUMBRICALS, PALMAR the metacarpal of the ring and little fingers, respec- tively, and insert distally into the ulnar side of the INTEROSSEI, AND DORSAL proximal phalanx and the extensor mechanism of the extensor digitorum profundus of the same fingers. INTEROSSEI The four dorsal interossei are bipenniform mus- The lumbrical, palmar interossei, and dorsal interossei cles that originate proximally from two adjacent muscles cross the MCP, PIP, and DIP joints. The first metacarpals (Fig. 7.58): the first dorsal interossei and second lumbricals originate proximally from the from the metacarpals of the thumb and index finger, radial sides of the tendons of the flexor digitorum the second from the metacarpals of the index and profundus of the index and middle fingers, respec- middle fingers, the third from the metacarpals of the tively (Fig. 7.56). The third lumbrical originates on the middle and ring fingers, and the fourth from the ulnar side of the tendon of the flexor digitorum pro- metacarpals of the ring and little fingers. The fundus of the middle finger and the radial side of the dorsal interossei insert distally into the bases of the tendon of the ring finger. The fourth lumbrical origi- proximal phalanges and the extensor mechanism nates on the ulnar side of the tendon of the flexor of the extensor digitorum profundus of the same digitorum profundus of the ring finger and the radial fingers. side of the tendon of the little finger. Each lumbrical passes to the radial side of the corresponding finger When these muscles contract, they flex the MCP and inserts distally into the extensor mechanism of joints and extend the PIP and DIP joints. These muscles the extensor digitorum profundus. are passively lengthened by placing the MCP joints in extension and the PIP and DIP joints in full flexion. If The first palmar interossei muscle originates the lumbricals and the palmar and dorsal interossei are proximally from the ulnar side of the metacarpal of short, they will limit MCP extension when the PIP and the index finger and inserts distally into the ulnar side DIP joints are positioned in full flexion. of the proximal phalanx and the extensor mechanism 1st Palmar interossei 3rd Lumbrical 1st 2nd Palmar 4th Lumbrical Lumbrical interossei 2nd 3rd Palmar Lumbrical interossei Flexor digitorum profundus FIGURE 7.56 An anterior (palmar) view of the right hand FIGURE 7.57 An anterior (palmar) view of the right hand showing the proximal attachments of the lumbricals. The showing the proximal and distal attachments of the palmar lumbricals insert distally into the extensor digitorum on the interossei. The palmar interossei also attach distally to the posterior surface of the hand. extensor digitorum on the posterior surface of the hand.
CHAPTER 7 The Hand 183 2nd Dorsal 4th Dorsal If MCP flexion is limited regardless of the position Muscle Length Testing Procedures/FINGERS interossei interossei of the PIP and DIP joints, the limitation is due to abnor- malities of the joint surfaces of the MCP joint or short- 1st Dorsal 3rd Dorsal ening of the palmar joint capsule and the palmar plate. interossei interossei Starting Position Extensor indicis Abductor digiti Position the subject sitting, with the forearm and hand minimi resting on a supporting surface. Place the forearm midway between pronation and supination and the Extensor digiti wrist in 0 degrees of flexion, extension, and radial and minimi ulnar deviation. Flex the MCP, PIP, and DIP joints (Fig. 7.59). The MCP joints should be in a neutral po- sition relative to abduction and adduction. Stabilization Stabilize the metacarpals and the carpal bones to prevent wrist motion. Extensor digitorum FIGURE 7.58 A posterior view of the right hand showing the proximal attachments of the dorsal interossei on the metacarpals and the distal attachments into the extensor mechanism of the extensor digitorum, extensor indicis, and extensor digiti minimi muscles. FIGURE 7.59 The starting position for testing the length of the lumbricals and the palmar and dorsal interossei. The examiner uses one hand to stabilize the subject’s wrist and the other hand to position the subject’s metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints in full flexion.
184 PART II Upper-Extremity Testing Muscle Length Testing Procedures/FINGERS Testing Motion Goniometer Alignment Hold the PIP and DIP joints in full flexion while See Figure 7.62. extending the MCP joint (Figs. 7.60 and 7.61). All of the fingers may be screened together, but if abnor- 1. Center fulcrum of the goniometer over the dorsal malities are found, testing should be conducted on aspect of the MCP joint. individual fingers. The end of flexion ROM occurs when resistance to further motion is felt and attempts 2. Align proximal arm over the dorsal midline of the to overcome the resistance cause the PIP, DIP, or wrist metacarpal. joints to extend. 3. Align distal arm over the dorsal midline of the proximal phalanx. Normal End-Feel The end-feel is firm because of tension in the lumbri- cal, palmar, and dorsal interossei muscles. FIGURE 7.60 The end of the motion for testing the length of the lumbricals and the palmar and dorsal interossei. The examiner holds the subject’s proximal interphalangeal and distal interphalangeal joints in full flexion while moving the metacarpophalangeal joint into extension.
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