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A Technique for Graphical Recording of Range of Motion Using an Improvised Paper Goniometer
PRACTICE FORUM
A Technique for Graphical Recording of Range of Motion Using an Improvised Paper Goniometer Clinicians frequently use finger goniometers to measure joint range of motion (ROM) in the digits. Other methods of depicting finger ROM can be beneficial in situations where therapists may not have access to finger goniometers, patients want to self-assess ROM, or therapists want to visually and graphically see composite ROM in the digits. This author describes a technique to obtain diagrams of hand joint angles by using an improvised goniometer made from paper.—VICTORIA PRIGANC, PhD, OTR, CHT, CLT, Practice Forum Editor
Valdas Macionis, MD Clinic of Rheumatology, Orthopaedics and Traumatology, and Reconstructive Surgery, Vilnius University Faculty of Medicine, Vilnius, Lithuania Department of Plastic and Reconstructive Surgery, Centre of Plastic and Reconstructive Surgery, Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania
The standard approach in assessing range of motion (ROM) of the hand is to measure individual joint angles with a goniometer and express the result in degrees representing the amplitude of joint movement in respect to a neutral position.1e3 This traditional goniometry carries a number of drawbacks. ROM expressed in degrees does not provide immediate view of the multiarticular digital motion, type of the deformity, and follow-up dynamics. Interpretation of goniometric records is also hampered by the lack of a standard notation system, the available ones possessing similar features.1e4 Notation of ROM in degrees may be especially confounded when the evaluator is obliged to record different types of synchronal motion at separate joints, for example, complex motion when evaluating tenodesis effect or a claw finger. Additional disadvantages of standard goniometry include limited adjustability of the goniometer in terms of the great range of dimensions and deformities of the hand4,5 and possibility of wrong reading of the goniometric scale.6 Many of the above drawbacks of goniometry can be overcome by graphical representation of digital motion.7 Wire tracing and other techniques Correspondence and reprint requests to Valdas Macionis, Department of Plastic and Reconstructive Surgery, Vilnius University Hospital, Zygimantu 3/1, Vilnius LT-01102, Lithuania; e-mail: ,[email protected].. 0894-1130/$ - see front matter Ó 2011 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved. doi:10.1016/j.jht.2011.05.003
374
JOURNAL OF HAND THERAPY
of silhouetting the dorsal digital surface have been used for recording simultaneous composite movements of digital joints.7 Tracing arms of a multiangular goniometer has been proposed to obtain actual angles of individual digital joints.8 Symbolic schematic diagrams of angles with arrows for indication of direction of motion and crisscross sign for ankylosis can also be used as graphical means in recording the ROM.4 The available graphical recording methods, however, still require certain explanatory verbalism. Wire tracing is clinically unreliable,9 and tracing the goniometer may be hindered by protruding hinge axis and/or one of the arms of the instrument. The other graphical techniques lack practicality because they require specific equipment and complex mathematical analysis.10e12 In an attempt to solve the above difficulties, the current report introduces a ROM assessment and notation technique, which combines a number of the features of classical goniometry and of the previous systems of graphical representation of digital motion.
TECHNIQUE Two paper strips, crisscrossed and held side by side, are aligned with the longitudinal axes of the appropriate hand segments just like it is done in standard goniometry. The joint angles are then transferred onto the record sheet by tracing the appropriate edges of the strips (Figure 1). Rectangular sheets of paper can be folded several times to obtain ruler-like strips of desired dimensions and form. Careful creasing while folding produces straight edges of the paper rulers. For obtaining digital angles, the length and width of the arms of the improvised goniometer can be adjusted according to the length of the phalanges and
FIGURE 1. Obtaining and recording the angle of the distal interphalangeal joint in a patient with Dupuytren’s contracture by use of folded paper strips. (A, B) Active flexion. (C, D) Passive hyperextension. The later motion was recorded using the original diagram of active motion (B). Note a turned up corner of one of the strips for fitting the improvised ruler into the narrow space between the distal phalanx and the palm (A, B). The invisible back side of the paper strips shown in A was turned to the viewer in B to have the strips laid down on the record sheet as flat as possible. The angle lines need not necessarily intersect each other (D). DIP ¼ distal interphalangeal joint.
position of the joint (Figures 1A and 1C). Both over-the-joint and lateral placement methods can be used. The paper strips should be manipulated gently to avoid their deformation by excessive pressure in any direction. One can allow the paper strips to align themselves by using their gravitation toward the dorsal surface of the digit. The strips can also be manipulated with one hand in the ‘‘fanning cards’’ manner. The latter maneuver should be useful both for the physician estimating passive motion and for the patient performing self-evaluation. One hand manipulation will be easier if the paper strips are initially crisscrossed at an angle larger or smaller than the visually estimated actual angle of flexion or hyperextension correspondingly. The strips then can be lightly squeezed over the joint letting them to slide apart until the perfect alignment is obtained. When the evaluator is satisfied with the position of the improvised goniometer, the paper rulers are pressed together more firmly at the approximate fulcrum of the device and laid down flat on the record sheet. Care should be taken to avoid displacement of the arms of the provisional goniometer. First, the arms are laid down, and then the
fulcrum, simultaneously pressing the paper strips against the record sheet with evaluator’s thumb, index, and middle finger of the other hand (Figures 1B and 1D). Holding the paper goniometer stable, the angle of the joint can be traced (Figures 1B and 1D). The measurement procedure can be repeated, if the paper goniometer is displaced in the process. Similarly, the other angles of the hand joints can be drawn. Interlinking them with each other allows obtaining a schematic silhouette of the digit. One can also choose to draw only separate diagrams of the joints with limited function, which would be space saving. Flexion and extension can be depicted in the same diagram relative to the same reference line representing a segment of the hand proximal to the evaluated joint (Figure 1D). However, if the amplitude of motion is very small, it may be more suitable to use separate diagrams for flexion and extension. Although, for assessment of the change in ROM, it may seem convenient to superimpose the follow-up records, multiple diagrams may partially or completely overlap because of slow or unequal progress in ROM of individual joints. Here again, a practical
OctobereDecember 2011 375
alternative is to draw separate schematic silhouettes for passive and active motion and compare them at follow-ups by remeasuring the angles with the standard or the described paper goniometer. It can also be helpful to choose different length of the nearly superimposing lines. It is notable that linear flexion and extension deficit can also be recorded graphically by setting a folded paper strip as a ruler to measure tip-topalm and tip-to-tabletop distance in the traditional way,13 then marking the length of the distance with a pen, and next, tracing the marked length on the record sheet. As active and passive motion are produced by internal and external forces;14 correspondingly, the type and direction of motion can be denoted by force vector style arrows similarly as they are used in the free-body diagrams.15 For active motion, a perpendicular arrow should start from the line representing the appropriate hand segment (Figure 1B); for passive motion, the arrow should be directed toward the line (Figure 1D); and for spontaneous motion because of tenodesis effect, no symbols are necessary. Combination of different types of arrows may be necessary to schematize multiarticular motion (Figure 2). The diagrams can also be supplied by the standard notations and abbreviations (Figure 2; Tables 1 and 2). There is no need, however, to draw a neutral line, which is commonly considered to be a continuation of the longitudinal axis of the hand segment proximal to the joint of interest.
DISCUSSION Technically, the described method mimics standard goniometry. Therefore, it may be expected that the positioning of the crisscrossed paper rulers during the procedure will be identical to that achieved with the traditional goniometer. The measurement difference between the two methods then should be due only to errors when transforming the angles into diagrams and when remeasuring the angles from the obtained drawings. Additional errors are possible when separate joint diagrams are sequentially added to each other to obtain combined schematic silhouettes of digits. The main advantage of the introduced technique over the traditional goniometry is the virtually unlimited adjustability of the dimensions of the improvised goniometer according to specific anatomical and clinical situations. The graphical goniometer made from paper is compact, patient friendly, and easy to handle. Unlike most of the other ROM assessment techniques, the proposed
376
JOURNAL OF HAND THERAPY
FIGURE 2. Schematization of hypothetical motion by using force vector style arrows. (A, B) Claw finger. (C, D) Tenodesis effect due to flexor tendon adhesions at the wrist. Two different type arrows for active extension and passive flexion denoted as AE (A) and PF (B), correspondingly, serve as a legend for the rest of the arrows. Note that removing passive extension arrows in diagram would result in an illustration of the natural tenodesis effect. MCP ¼ metacarpophalangeal joint; PIP ¼ proximal interphalangeal joint; DIP ¼ distal interphalangeal joint; AE ¼ active extension; PF ¼ passive flexion. method does not require a ready instrument at hand. The ad hoc goniometer can be easily made from the ubiquitous office materials and disposed after the use, which is appropriate in terms of infection spread prophylaxis. Ease of manufacturing of the paper goniometer and the possibility of one-handed manipulation opens a perspective for using the technique for patient self-evaluation at home. Such an application of the described TABLE 1. Adaptation of the Standard Notation System of Finger ROM1 for Complex Motion Depicted in Figures 2A and 2B Extension Lack Active
Motion Diagrammed in Figure 2A
Motion Diagrammed in Figure 2B
Wrist MCP PIP DIP
17 (blocked actively) 42 90 82
17 (blocked actively) 27 (blocked passively) 2 5
ROM ¼ range of motion; MCP ¼ metacarpophalangeal joint; PIP ¼ proximal interphalangeal joint; DIP ¼ distal interphalangeal joint.
TABLE 2. Adaptation of the Standard Notation System of Finger ROM1 for Complex Motion Depicted in Figures 2C and 2D Extension Lack Passive
Motion Diagrammed in Figure 2C
Motion Diagrammed in Figure 2D
Wrist MCP PIP DIP
25 (blocked passively) 52 70 59
34 (blocked passively) 11 9 6
ROM ¼ range of motion; MCP ¼ metacarpophalangeal joint; PIP ¼ proximal interphalangeal joint; DIP ¼ distal interphalangeal joint.
instrument has been supported by the author’s experience based on teaching the technique as a self-evaluation method to 49 hand patients within a framework of an ongoing study. The proposed technique should provide practitioners with a reasonable replacement of the universal goniometer in situations when the latter is not available and encourage instrumental evaluation of ROM instead of relying on the visual estimation, which has been shown to be unreliable.16,17 Having even a provisional drawing of the digital joint angles is better than having nothing. The technique could be used not only by the hand specialists, who are not necessarily the first ones who see the hand patient. It is also to be noted that in the developing countries not only the special finger goniometers but also the universal goniometers may be not obtainable, and in the technically advanced clinics, not every physician has a goniometer at hand, as well. Importance of graphical representation of digital motion has long been recognized.7 In fact, when assessing goniometric records, one always needs to transform mentally the degrees of the joint angles into an appropriate image of the posture of the digit, which may be a challenging task. The proposed force vector arrow notation is simpler than the available ROM recording systems, which may require explanatory notes indicating additional activities of the evaluator and patient (compare Figure 2 with Tables 1 and 2). Using the force vector arrows alongside the standard notations should provide for quicker estimation of the deformity type and for easier understanding of the notation system itself. The force vector
arrows should also be helpful when explaining and analyzing biomechanics of natural synchronal motion. It is obvious that the technique can be extended beyond the evaluation of the hand.
REFERENCES 1. American Society for Surgery of the Hand. The Hand, Examination and Diagnosis. 2nd ed. New York, NY: Churchill Livingston; 1983, pp. 107e11. 2. Greene WB, Heckman JD (eds). The Clinical Measurement of Joint Motion. Rosemont, IL: American Academy of Orthopaedic Surgeons, 1994:35–61. 3. Cambridge-Keeling CA. Range-of-motion measurement of the hand. In: Mackin EJ, Callahan AD, Skirven TM, Schneider LH, Osterman AL, Hunter JM (eds). Rehabilitation of the Hand and Upper Extremity. 5th ed. St. Louis, MO: Mosby, 2002:169–86. 4. Lea RD, Gerhardt JJ. Current concepts review: range of motion measurement. J Bone Joint Surg. 1995;77:784–98. 5. Lewis E, Fors L, Tharion WJ. Interrater and intrarater reliability of finger goniometric measurements. Am J Occup Ther. 2010;64:555–61. 6. Stratford P, Agostino V, Brazeau C, Gowitzke R. Reliability of joint angle measurement: a discussion of methodology issues. Physiother Can. 1984;36:5–9. 7. Brand PW, Hollister A. Clinical Mechanics of the Hand. 2nd ed. St. Louis, MO: Mosby; 1993, pp. 223e53. 8. McCulley SJ. A new multiangle goniometer. Ann Plast Surg. 1999;42:221–2. 9. Ellis B, Bruton A, Goddard JR. Joint angle measurement: a comparative study of the reliability of goniometry and wire tracing for the hand. Clin Rehabil. 1997;11:314–20. 10. Chiu HY, Su FC, Wang ST, Hsu HY. The motion analysis system and goniometry of the finger joints. J Hand Surg Br. 1998;23:788–91. 11. Catalano LW 3rd, Browne RH, Carter PR, Frobish AC, Ezaki M, Littler JW. The Littler line method and the area under a Gaussian curve: a new method of assessing digital range of motion. J Hand Surg Am. 2001;26:23–30. 12. Georgeu GA, Mayfield S, Logan AM. Lateral digital photography with computer-aided goniometry versus standard goniometry for recording finger joint angles. J Hand Surg Br. 2002;27:184–6. 13. Ellis B, Bruton A. A study to compare the reliability of composite finger flexion with goniometry for measurement of range of motion in the hand. Clin Rehabil. 2002;16: 562–70. 14. McLester J, St. Pierre P. Applied Biomechanics: Concepts and Connections. Belmont, CA: Thompson Wadsworth; 2008, pp. 97e8. 15. Lucas G, Cooke F, Friis E. A Primer of Biomechanics. New York, NY: Springer; 1999, pp. 27e8. 16. Rose V, Nduka CC, Pereira JA, Pickford MA, Belcher HJ. Visual estimation of finger angles: do we need goniometers? J Hand Surg Br. 2002;27:382–4. 17. van de Pol RJ, van Trijffel E, Lucas C. Inter-rater reliability for measurement of passive physiological range of motion of upper extremity joints is better if instruments are used: a systematic review. J Physiother. 2010;56:7–17.
OctobereDecember 2011 377
A Technique for Graphical Recording of Range of Motion Using an Improvised Paper Goniometer Clinicians frequently use finger goniometers to measure joint range of motion (ROM) in the digits. Other methods of depicting finger ROM can be beneficial in situations where therapists may not have access to finger goniometers, patients want to self-assess ROM, or therapists want to visually and graphically see composite ROM in the digits. This author describes a technique to obtain diagrams of hand joint angles by using an improvised goniometer made from paper.—VICTORIA PRIGANC, PhD, OTR, CHT, CLT, Practice Forum Editor
Valdas Macionis, MD Clinic of Rheumatology, Orthopaedics and Traumatology, and Reconstructive Surgery, Vilnius University Faculty of Medicine, Vilnius, Lithuania Department of Plastic and Reconstructive Surgery, Centre of Plastic and Reconstructive Surgery, Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania
The standard approach in assessing range of motion (ROM) of the hand is to measure individual joint angles with a goniometer and express the result in degrees representing the amplitude of joint movement in respect to a neutral position.1e3 This traditional goniometry carries a number of drawbacks. ROM expressed in degrees does not provide immediate view of the multiarticular digital motion, type of the deformity, and follow-up dynamics. Interpretation of goniometric records is also hampered by the lack of a standard notation system, the available ones possessing similar features.1e4 Notation of ROM in degrees may be especially confounded when the evaluator is obliged to record different types of synchronal motion at separate joints, for example, complex motion when evaluating tenodesis effect or a claw finger. Additional disadvantages of standard goniometry include limited adjustability of the goniometer in terms of the great range of dimensions and deformities of the hand4,5 and possibility of wrong reading of the goniometric scale.6 Many of the above drawbacks of goniometry can be overcome by graphical representation of digital motion.7 Wire tracing and other techniques Correspondence and reprint requests to Valdas Macionis, Department of Plastic and Reconstructive Surgery, Vilnius University Hospital, Zygimantu 3/1, Vilnius LT-01102, Lithuania; e-mail: ,[email protected].. 0894-1130/$ - see front matter Ó 2011 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved. doi:10.1016/j.jht.2011.05.003
374
JOURNAL OF HAND THERAPY
of silhouetting the dorsal digital surface have been used for recording simultaneous composite movements of digital joints.7 Tracing arms of a multiangular goniometer has been proposed to obtain actual angles of individual digital joints.8 Symbolic schematic diagrams of angles with arrows for indication of direction of motion and crisscross sign for ankylosis can also be used as graphical means in recording the ROM.4 The available graphical recording methods, however, still require certain explanatory verbalism. Wire tracing is clinically unreliable,9 and tracing the goniometer may be hindered by protruding hinge axis and/or one of the arms of the instrument. The other graphical techniques lack practicality because they require specific equipment and complex mathematical analysis.10e12 In an attempt to solve the above difficulties, the current report introduces a ROM assessment and notation technique, which combines a number of the features of classical goniometry and of the previous systems of graphical representation of digital motion.
TECHNIQUE Two paper strips, crisscrossed and held side by side, are aligned with the longitudinal axes of the appropriate hand segments just like it is done in standard goniometry. The joint angles are then transferred onto the record sheet by tracing the appropriate edges of the strips (Figure 1). Rectangular sheets of paper can be folded several times to obtain ruler-like strips of desired dimensions and form. Careful creasing while folding produces straight edges of the paper rulers. For obtaining digital angles, the length and width of the arms of the improvised goniometer can be adjusted according to the length of the phalanges and
FIGURE 1. Obtaining and recording the angle of the distal interphalangeal joint in a patient with Dupuytren’s contracture by use of folded paper strips. (A, B) Active flexion. (C, D) Passive hyperextension. The later motion was recorded using the original diagram of active motion (B). Note a turned up corner of one of the strips for fitting the improvised ruler into the narrow space between the distal phalanx and the palm (A, B). The invisible back side of the paper strips shown in A was turned to the viewer in B to have the strips laid down on the record sheet as flat as possible. The angle lines need not necessarily intersect each other (D). DIP ¼ distal interphalangeal joint.
position of the joint (Figures 1A and 1C). Both over-the-joint and lateral placement methods can be used. The paper strips should be manipulated gently to avoid their deformation by excessive pressure in any direction. One can allow the paper strips to align themselves by using their gravitation toward the dorsal surface of the digit. The strips can also be manipulated with one hand in the ‘‘fanning cards’’ manner. The latter maneuver should be useful both for the physician estimating passive motion and for the patient performing self-evaluation. One hand manipulation will be easier if the paper strips are initially crisscrossed at an angle larger or smaller than the visually estimated actual angle of flexion or hyperextension correspondingly. The strips then can be lightly squeezed over the joint letting them to slide apart until the perfect alignment is obtained. When the evaluator is satisfied with the position of the improvised goniometer, the paper rulers are pressed together more firmly at the approximate fulcrum of the device and laid down flat on the record sheet. Care should be taken to avoid displacement of the arms of the provisional goniometer. First, the arms are laid down, and then the
fulcrum, simultaneously pressing the paper strips against the record sheet with evaluator’s thumb, index, and middle finger of the other hand (Figures 1B and 1D). Holding the paper goniometer stable, the angle of the joint can be traced (Figures 1B and 1D). The measurement procedure can be repeated, if the paper goniometer is displaced in the process. Similarly, the other angles of the hand joints can be drawn. Interlinking them with each other allows obtaining a schematic silhouette of the digit. One can also choose to draw only separate diagrams of the joints with limited function, which would be space saving. Flexion and extension can be depicted in the same diagram relative to the same reference line representing a segment of the hand proximal to the evaluated joint (Figure 1D). However, if the amplitude of motion is very small, it may be more suitable to use separate diagrams for flexion and extension. Although, for assessment of the change in ROM, it may seem convenient to superimpose the follow-up records, multiple diagrams may partially or completely overlap because of slow or unequal progress in ROM of individual joints. Here again, a practical
OctobereDecember 2011 375
alternative is to draw separate schematic silhouettes for passive and active motion and compare them at follow-ups by remeasuring the angles with the standard or the described paper goniometer. It can also be helpful to choose different length of the nearly superimposing lines. It is notable that linear flexion and extension deficit can also be recorded graphically by setting a folded paper strip as a ruler to measure tip-topalm and tip-to-tabletop distance in the traditional way,13 then marking the length of the distance with a pen, and next, tracing the marked length on the record sheet. As active and passive motion are produced by internal and external forces;14 correspondingly, the type and direction of motion can be denoted by force vector style arrows similarly as they are used in the free-body diagrams.15 For active motion, a perpendicular arrow should start from the line representing the appropriate hand segment (Figure 1B); for passive motion, the arrow should be directed toward the line (Figure 1D); and for spontaneous motion because of tenodesis effect, no symbols are necessary. Combination of different types of arrows may be necessary to schematize multiarticular motion (Figure 2). The diagrams can also be supplied by the standard notations and abbreviations (Figure 2; Tables 1 and 2). There is no need, however, to draw a neutral line, which is commonly considered to be a continuation of the longitudinal axis of the hand segment proximal to the joint of interest.
DISCUSSION Technically, the described method mimics standard goniometry. Therefore, it may be expected that the positioning of the crisscrossed paper rulers during the procedure will be identical to that achieved with the traditional goniometer. The measurement difference between the two methods then should be due only to errors when transforming the angles into diagrams and when remeasuring the angles from the obtained drawings. Additional errors are possible when separate joint diagrams are sequentially added to each other to obtain combined schematic silhouettes of digits. The main advantage of the introduced technique over the traditional goniometry is the virtually unlimited adjustability of the dimensions of the improvised goniometer according to specific anatomical and clinical situations. The graphical goniometer made from paper is compact, patient friendly, and easy to handle. Unlike most of the other ROM assessment techniques, the proposed
376
JOURNAL OF HAND THERAPY
FIGURE 2. Schematization of hypothetical motion by using force vector style arrows. (A, B) Claw finger. (C, D) Tenodesis effect due to flexor tendon adhesions at the wrist. Two different type arrows for active extension and passive flexion denoted as AE (A) and PF (B), correspondingly, serve as a legend for the rest of the arrows. Note that removing passive extension arrows in diagram would result in an illustration of the natural tenodesis effect. MCP ¼ metacarpophalangeal joint; PIP ¼ proximal interphalangeal joint; DIP ¼ distal interphalangeal joint; AE ¼ active extension; PF ¼ passive flexion. method does not require a ready instrument at hand. The ad hoc goniometer can be easily made from the ubiquitous office materials and disposed after the use, which is appropriate in terms of infection spread prophylaxis. Ease of manufacturing of the paper goniometer and the possibility of one-handed manipulation opens a perspective for using the technique for patient self-evaluation at home. Such an application of the described TABLE 1. Adaptation of the Standard Notation System of Finger ROM1 for Complex Motion Depicted in Figures 2A and 2B Extension Lack Active
Motion Diagrammed in Figure 2A
Motion Diagrammed in Figure 2B
Wrist MCP PIP DIP
17 (blocked actively) 42 90 82
17 (blocked actively) 27 (blocked passively) 2 5
ROM ¼ range of motion; MCP ¼ metacarpophalangeal joint; PIP ¼ proximal interphalangeal joint; DIP ¼ distal interphalangeal joint.
TABLE 2. Adaptation of the Standard Notation System of Finger ROM1 for Complex Motion Depicted in Figures 2C and 2D Extension Lack Passive
Motion Diagrammed in Figure 2C
Motion Diagrammed in Figure 2D
Wrist MCP PIP DIP
25 (blocked passively) 52 70 59
34 (blocked passively) 11 9 6
ROM ¼ range of motion; MCP ¼ metacarpophalangeal joint; PIP ¼ proximal interphalangeal joint; DIP ¼ distal interphalangeal joint.
instrument has been supported by the author’s experience based on teaching the technique as a self-evaluation method to 49 hand patients within a framework of an ongoing study. The proposed technique should provide practitioners with a reasonable replacement of the universal goniometer in situations when the latter is not available and encourage instrumental evaluation of ROM instead of relying on the visual estimation, which has been shown to be unreliable.16,17 Having even a provisional drawing of the digital joint angles is better than having nothing. The technique could be used not only by the hand specialists, who are not necessarily the first ones who see the hand patient. It is also to be noted that in the developing countries not only the special finger goniometers but also the universal goniometers may be not obtainable, and in the technically advanced clinics, not every physician has a goniometer at hand, as well. Importance of graphical representation of digital motion has long been recognized.7 In fact, when assessing goniometric records, one always needs to transform mentally the degrees of the joint angles into an appropriate image of the posture of the digit, which may be a challenging task. The proposed force vector arrow notation is simpler than the available ROM recording systems, which may require explanatory notes indicating additional activities of the evaluator and patient (compare Figure 2 with Tables 1 and 2). Using the force vector arrows alongside the standard notations should provide for quicker estimation of the deformity type and for easier understanding of the notation system itself. The force vector
arrows should also be helpful when explaining and analyzing biomechanics of natural synchronal motion. It is obvious that the technique can be extended beyond the evaluation of the hand.
REFERENCES 1. American Society for Surgery of the Hand. The Hand, Examination and Diagnosis. 2nd ed. New York, NY: Churchill Livingston; 1983, pp. 107e11. 2. Greene WB, Heckman JD (eds). The Clinical Measurement of Joint Motion. Rosemont, IL: American Academy of Orthopaedic Surgeons, 1994:35–61. 3. Cambridge-Keeling CA. Range-of-motion measurement of the hand. In: Mackin EJ, Callahan AD, Skirven TM, Schneider LH, Osterman AL, Hunter JM (eds). Rehabilitation of the Hand and Upper Extremity. 5th ed. St. Louis, MO: Mosby, 2002:169–86. 4. Lea RD, Gerhardt JJ. Current concepts review: range of motion measurement. J Bone Joint Surg. 1995;77:784–98. 5. Lewis E, Fors L, Tharion WJ. Interrater and intrarater reliability of finger goniometric measurements. Am J Occup Ther. 2010;64:555–61. 6. Stratford P, Agostino V, Brazeau C, Gowitzke R. Reliability of joint angle measurement: a discussion of methodology issues. Physiother Can. 1984;36:5–9. 7. Brand PW, Hollister A. Clinical Mechanics of the Hand. 2nd ed. St. Louis, MO: Mosby; 1993, pp. 223e53. 8. McCulley SJ. A new multiangle goniometer. Ann Plast Surg. 1999;42:221–2. 9. Ellis B, Bruton A, Goddard JR. Joint angle measurement: a comparative study of the reliability of goniometry and wire tracing for the hand. Clin Rehabil. 1997;11:314–20. 10. Chiu HY, Su FC, Wang ST, Hsu HY. The motion analysis system and goniometry of the finger joints. J Hand Surg Br. 1998;23:788–91. 11. Catalano LW 3rd, Browne RH, Carter PR, Frobish AC, Ezaki M, Littler JW. The Littler line method and the area under a Gaussian curve: a new method of assessing digital range of motion. J Hand Surg Am. 2001;26:23–30. 12. Georgeu GA, Mayfield S, Logan AM. Lateral digital photography with computer-aided goniometry versus standard goniometry for recording finger joint angles. J Hand Surg Br. 2002;27:184–6. 13. Ellis B, Bruton A. A study to compare the reliability of composite finger flexion with goniometry for measurement of range of motion in the hand. Clin Rehabil. 2002;16: 562–70. 14. McLester J, St. Pierre P. Applied Biomechanics: Concepts and Connections. Belmont, CA: Thompson Wadsworth; 2008, pp. 97e8. 15. Lucas G, Cooke F, Friis E. A Primer of Biomechanics. New York, NY: Springer; 1999, pp. 27e8. 16. Rose V, Nduka CC, Pereira JA, Pickford MA, Belcher HJ. Visual estimation of finger angles: do we need goniometers? J Hand Surg Br. 2002;27:382–4. 17. van de Pol RJ, van Trijffel E, Lucas C. Inter-rater reliability for measurement of passive physiological range of motion of upper extremity joints is better if instruments are used: a systematic review. J Physiother. 2010;56:7–17.
OctobereDecember 2011 377