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Functional ranges of motion of the wrist joint
Functional
ranges of motion of the wrist joint
We have examined 40 normal subjects (20 men and 20 women) to determine the ideal range of motion required to perform activities of daily living. The amount of wrist flexion and extension, as well as radial and ulnar deviation, was measured simultaneously by means of a biaxial wrist electrogoniometer. The entire battery of evaluated tasks could be achieved with 60 degrees of extension, 54 degrees of flexion, 40 degrees of ulnar deviation, and 17 degrees of radial deviation, which reflects the maximum wrist motion required for daily activities. The majority of the hand placement and range of motion tasks that were studied in this project could be accomplished with 70 percent of the maximal range of wrist motion. This converts to 40 degrees each of wrist flexion and extension, and 40 degrees of combined radial-ulnar deviation. This study provides normal standards for the functional range of motion of the wrist. (J HANDSURC1991;16A: 409-19.)
Jaiyoung Ryu, MD, William P. Cooney III, MD, Linda J. Askew, RPT, Kai-Nan An, PhD, aad Edmund Y. S. Chao, PhD, Rochester, Minn.
A
lthough normal maximum motion of the wrist has been previously documented with use of standard hand goniometry,‘-6 it was not until recently that instrumentation was developed to assess normal wrist motion during activities. Brumfield and associates’ presented data on the flexion-extension arcs using an uniaxial goniometer. Palmer et al.’ reported the results of their study of 10 normal subjects with use of an electrogoniometer. There has been considerable interest in the functional range of motion (ROM) after partial wrist fusion9-‘* total wrist arthroplasty,” and ligament reconstructive procedures of the wrist,14 yet there have been only a few articles addressing the question of range of motion in activities of daily living (ADL) among the normal population6-’ Several techniques described to measure joint motion include the following: (1) stereometric techniques’5‘20;
From the Orthopedic Biomechanics Foundation, Rochester, Mime. Received for publication March 6, 1990.
Laboratory,
Mayo Clinic/Mayo
Nov. 28, 1989; accepted
in revised form
Although none of the authors have received or will receive benefits for personal or professional use from a commercial patty related directly or indirectly to the subject of this article, benefits have been or will be received but are directed solely to a research fund, foundation, educational institution, or other non-profit organization with which one or more of the authors are associated. Reprint requests: William P. Cooney, MD, Deparatment of Orthopedics, Mayo Clinic/Foundation, 200 First St., SW, Rochester, MN 5.5905. 3/l/21556
(2) accelerometric methods2’, 22; and (3) electromechanical linkage. 23-26The biaxial electrogoniometer used in this study is an electromechanical linkage method, which has several advantages including ease of application, real-time analog data acquisition of biplanar joint motion, and reliability and reproducibility with acceptable accuracy. 23-25, *‘. 28The axes of rotation of the electrogoniometer can be made colinear with the estimated wrist axes of flexion-extension and ulnarradial deviation using anatomic landmarks on the hand and wrist and its position confirmed by biplanar x-ray film. This report describes our experience with a biaxial wrist goniometer designed to measure the pattern of wrist motion during selected ADL and to determine the median ROM required to perform these activities in the normal population. Materials
and methods
The wrist joint is assumed to have two degrees of freedom in flexion-extension and radioulnar deviation. The electrogoniometer used in this study (Fig. 1) to measure the functional range of wrist motion is biaxial and designed to record motion in flexion-extension and radioulnar deviation. The linkage between the potentiometers and the mounting apparatus employed geometric principles of the parallelogram. To achieve simultaneous measurements, two electropotentiometers are placed mutually perpendicular to each other and remain so throughout the range of wrist motion. The wrist electrogoniometer was custom-made in our laboratory and can be applied to either the left or right wrist. It is mounted on each subject with two universal
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Fig. 1. The biaxial electrogoniometer with 2 degrees of freedom for wrist motion measurement during activities of daily living. A, Dorsal potentiometer. B, Ulnar potentiometer.
mounting components, one attached to the dorsal part of the hand (metacarpal component) and the other to the distal forearm (radial component) (Fig. 2). It is lightweight and of low profile design to reduce the inertia effects and to avoid any interference with normal wrist motion in performing ADL. Wrist motion was recorded in a wide variety of ADL. Motion obtained was recorded directly on a model 5314 strip chart recorder (Soltec Corp., Sun Valley, Calif.). The exact degree of wrist motion was hand reduced and calculated. Alignment of the goniometer to the wrist is essential to accurately record wrist ROM in multiple daily activities. We assumed that the head of the capitate nearest to the lunate contact area closely defines the center of rotation for both wrist extension and flexion and for radioulnar deviation.29, 3o From tests in five cadaveric hands we chose as anatomic landmarks the medial cortex of the third metacarpal, the palmar aspect of the pisiform, the base of the first metacarpal, the radial styloid, and the head of the ulna. The location of the radioulnar deviation axis was identified by drawing a
line along the ulnar border of the third metacarpal bone and choosing a midpoint between the distal radius and proximal end of the third metacarpal on this line (Fig. 3, A). To identify the location of the flexion-extension axis, this same point was extended ulnarly, perpendicular to the forearm bones to the midpoint between dorsal surface of the ulnar head and the palmar edge of the pisiform. Open dissection of the wrist and radiographic studies were done in cadavers to validate the T-marker placements (Fig. 3, B and C). To ensure further that this alignment method was correct, T-markers were also placed on the wrist of three subjects, and biplanar (anteriorposterior-lateral) x-ray films were obtained to demonstrate that the metal markers were in line with the ulnar border of the third metacarpal and that the crossbar approximated the head of the capitate. The electrogoniometer was calibrated before each subject test. With one arm of the electrogoniometer fixed to the frame of a hand-held goniometer and the second arm free to move, the zero axis position was chosen (scale 5 degrees per division). A total of 110 degrees of motion could be recorded along’ the
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Functional ranges of motion of wrist joint
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Fig. 2. A, From a distal to proximal view of the hand and wrist, alignment of the dorsal potentiometer (radioulnar deviation axis) is made with respect to the third metacarpal, and alignment of the ulnar potentiometer (flexion-extension axis) is made with the midposition of the forearm from previously determined skin markers. B, Dorsal view of the wrist, goniometer placement. Support straps attach the distal goniometer pad to the hand with alignment along the medial border of the third metacarpal. The dorsal potentiometer is centered over the head of the capitate. The position of the potentiometer can be adjusted through the set screw attached to the crossbars. An Orthopiast cuff and metal support secure the goniometer to the distal forearm. The ulnar potentiometer is positioned on the ulnar side of the wrist and is also centered in line with the head of the capitate. The placement of the ulnar potentiometer can be adjusted with the set screw attached to the wrist cuff.
sagittal axis (radioulnar deviation) and 180 degrees of motion could be recorded about the frontal axis (flexionextension). There was no measurement of axial rotation using this goniometric system. Study subjects. Forty normal subjects were tested. All were in good health, with no history of upper extremity injury or pathologic conditions. A total of 31
activities that reflected the major functional requirements of the wrist were studied. These activities ineluded the commonly performed ADL or represent commonly performed assessments of upper extremity function3. ‘O The first category of activities included seven “palm placement” positions in which the subject was asked to touch the top of the head, back of the
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Fig. 3. A, The dorsal potentiometer is aligned over the center of radioulnar rotation, which is determined by extending a straight line along the ulnar border of the third metacarpal to the distal radius. This line is marked at the distal radius and the proximal end of the metacarpal. The axis of motion is taken as the midpoint between the two marks on the line. The ulnar potentiometer is aligned on the ulnar side of the wrist at the midpoint between the palmar aspect of the pisiform and the dorsal aspect of the ulnar head. The goniometer is then centered on the dotted line (above). which extends perpendicular from the third metacarpal line. The wrist is maintained in a neutral position of flexion/extension and radioulnar deviation throughout the alignment procedure. B-C, PA view of T-markers; lateral view of T-markers. Based on anatomic landmarks the dorsal and ulnar potentiometer placement is confirmed in cadavers by radiographs of the wrist with T-markers (entered) on the radioulnar deviation axis (PA radiograph) and flexion-extension axis (lateral radiograph). In Fig. 3. B, line A-A’ is base of the first metacarpal; line B-B’ is the midpoint of the pisiform; fine C-C’ is the tip of the radial styloid. MC-MC’ is the medial border of the third metacarpal. In Fig. 3. C. line D-D’ is the dorsal aspect of the ulnar head. E-E’ is the palmar surface of the pisiform and line F-F’ is the midpoint between the ulnar head and pisiform.
head, front of the neck, chest, waist, sacrum, and right foot. The second category involved personal care and hygiene, the third, diet and food preparation, and the fourth, important work functions (writing, driving, tele-
phone use, hammering, using a screwdriver, turning a key or door knob). We could not demonstrate that any restriction of wrist motion was attributed to the presence of the electrogoniometer during these activities except
Vol. 16A, No. 3 May 1991
Functional ranges of motion of wrist joint
EXT.
O-
O-
. ..-. ._ ULNAR
4A;
2F;
Pound
Tie 8 Untie
with
Neck Tie/Scarf
1st Trial
6
-
Hammer
2nd Trial
h
45'Flex.
51’ Flex
Fig. 4. A, Range of motion required for each activity was assessed directly by strip chart recorder (Soltec Corp., model 3314). Motion from the rest position to the beginning of each activity (shaded areas) was discarded. In this example, three consecutive motions of the wrist used in pounding with a hammer are recorded. B, Reproducibility of the biaxial electrogoniometer is demonstrated in virtually all subjects and all activities drawing very similar patterns of motion (arrows above) in multiple trials even in complex wrist activities such as tying and untying a neck tie.
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Ryu et al
Table I Range Range
A. B. C. D. E.
Extension
Flexion
Extensionljlexion
59.3 68.9 69.3 9.6 -0.4
79.1 68.4 68.1 - 10.7 0.3
138.4 137.3 137.4 - 1.1 0.1
Hand goniometer Electrcgoniometer (first) Electrogoniometer (last) Electra (first)-hand First-last electro
(A-C) Mean extreme reading) is compared subject. The accuracy UD. Ulnar deviation:
UD
RD
WR)
37.7 42.1 42.9 5.0 -0.2
21.1 17.8 16.6 -3.3 1.2
58.8 60.5 59.5 1.7 1.0
range of wrist motion, measured by hand goniometer and electrogoniometer before and after subject study. (D) The electrogoniometer (first with the hand goniometer reading. (E) The first and last electrogoniometer reading after completing the test sequence are compared for each of the electrogoniometer is evident by the small difference in the range of extension/flexion and UR noted (D and E). RD, radial deviation; UR, ulnar and radial deviation.
Table II. Comparison
of extreme range of wrist motion in the study with previously
reported data
Range
Range
Extension
Flexion
(Extensionljlexion)
UD
RD
fuR)
AAOS (1) Boone et al.’ Brumfield et al.’ (male) Brumfield et al.’ (female)
75 74.9 64 65
73 76.4 73 82
144 151.3 137 147
33 36.0
19 21.5
52 57.5
Palmer et a1.j’ This study
59.3
79.1
133.3 138.4
37.7
21.1
40.5 58.7
UD. Ulnar deviation: RD. radial deviation: UR. ulnar and radial deviation
Table III. Positions of the wrist during palm placement activities (mean and standard deviation)
Top of the head Back of the head Front of the neck Front of the chest Front of the waist Sacrum Right foot
-20.9 -0.9 -3.3 -24.5 - 19.0 - 19.5 0.8
2 2 + ” 2 + 5
13.9 17.6 19.6 16.7 14.9 19.3 14.6
16.1 9.7 2.1 -5.1 -6.2 47.8 8.7
and ulnar deviation, were recorded at the beginning, between each of the four categories of activities, and at the end of each battery of tests to detect any movement of the goniometer in relation to the forearm and the hand. These measurements were compared with the hand goniometer measurements as a test for reliability of the instrument (Table I). ? 2 ” * ‘” ?
12.7 11.9 9.5 10.3 10.7 16.8 12.2
*Negative value denotes flexion. tNegative value denotes radial deviation.
for rising from a chair, where extreme extension appeared to be slightly impeded. Even in this situation, consistent measurements were obtained. The accuracy, reliability, and reproducibility of the goniometer (Fig. 4) was also determined. Extreme motions in all four directions, flexion, extension, and radial
Results Range of motion and palm placement Wrist range of motion. The average maximum range of wrist motion as determined by the wrist goniometer measurement was 60 degrees of extension to 78 degrees of flexion (a 138 degree arc of motion) and 21 degrees of radial deviation to 38 degrees of ulnar deviation (59 degree arc of motion). Comparison of these data and those previously published’, 2.‘. ’ showed general agreement, although our recording of full extension measurement was slightly smaller (Table II). Flexion and extension were measured with the forearm in neutral rotation, while radial and ulnar deviation were measured with the forearm pronated and the palm placed on a flat surface, thus limiting flexion and extension.
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Palm placement activities. The mean and standard deviations of the wrist positions during seven palm placement activities were obtained (Table III) (Fig. 5). During placement of the palm of the hand on the back of the neck, chest, waist, sacrum, and foot, the wrist was in slight flexion (0 to 24 degrees of flexion) (Table III). There was a wide range of wrist flexion and extension required to do these daily activities. In general most of the activities were done with the wrist in between neutral and 20 degrees of flexion, while more extension-oriented ranges were seen in the other ADL that required continuous motion. This finding agrees with the study by Brumfield and associates.’ Hand palm placement activities also required from 5 degrees of radial to 15 degrees of ulnar deviation. Placing the hand on the sacrum required the largest range of motion, 48 degrees of ulnar deviation. Functional wrist motion activities Twenty-four ADL require continuous motion of the wrist. These can be divided into the following three major categories: personal care and hygiene, diet and food preparation, and miscellaneous ADLs. Personal care and hygiene. Seven activities in this category included combing hair, perineal care, dental care, buttoning and unbuttoning, neck tie/scarf, and tying and untying shoe laces (Fig. 6). Wrist motion from 42 degrees of extension to 54 degrees of flexion and from 40 degrees of ulnar deviation to 15 degrees of radial deviation were required to perform all seven activities. A significantly larger amount of flexion was necessary for perineal care and tying and untying a neck tie/ scarf (54 degrees and 5 1 degrees, respectively) than for other personal care functions. The latter activity (scarf tying) also required the largest arc of radioulnar deviation of 55 degrees, including both extreme radial (15 degrees) and ulnar deviation (40 degrees). Diet and food preparation. A more limited ROM of the wrist was required for diet and food preparation. Wrist motion from 42 degrees of extension to 37 degrees of flexion and 40 degrees of ulnar deviation to 12 degrees of radial deviation was needed to perform six activities in this group (Fig. 7). Turning a spatula (73 degrees flexion-extension arc and 39 degrees ulnar deviation) and opening a jar lid (47 degrees radioulnar deviation) represented the extremes of motion in this category. Manipulating faucet or spatula required more extension (42 degrees and 37 degrees, respectively) than other activities. Miscellaneous ADLs. This category included frequently performed activities associated with work functions that require various levels of wrist motion (Fig.
Functional ranges of motion of wrist joint
-50
A
I
I
I
Back TOP head
Neck
I
I Chest
Waist
I Sacrum
415
I Foot
Palm placements l
Average
A Avg. - S.D. V Avg. + SD.
i ! I A
A
I
I
Back Top .head
I A I Neck Palm
I
I
i
i
Chest
4 Waist
A I Sacrum
I Fool
placements
Fig. 5. Category one: Seven activities requiring positioning of the wrist for personal care and hygiene. A, Extensionflexion. B, Ulnar-radial deviation. 8) such as hammering, using a screw driver in different positions, turning a doorknob, key, and steering wheel, bringing a telephone to the ear, and rising from and sitting on a chair. For comparison we included writing because it is such an important task, even though it requires minimal motion of the wrist. Subjects were requested to use an arm rest for support when rising from a chair, and this required the most extreme extension of 60 degrees and radial deviation of 17 degrees among all 24 activities. Three different turning activities, hammering, and telephoning required extension of slightly more than 40 degrees. Inserting vertical screws while the subject was sitting required a large amount of flexion, 43 degrees, while inserting horizontal screws needed more ulnar deviation, 3 1 degrees. Hand writing required the least arc of motion, 14 degrees of extension-flexion and 12 degrees of radioulnar deviation.
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Ryu et al.
Personal Care/ Hygiene Flexion -60
Extension
-20
-40
20
0
40
60
Comb hair Tie & untiit;t$ Peroneal care Dental care (outside) Dental care (inside) Tie and untie neck tie/ scarf Tie & untie shoe
laces
Personal Care/ Hygiene Ulnar Deviation
Radial -20
-10
0
10
20
30
40
50
Comb hair Tie 8 urHi;,ti;;; Peroneal care Dental care (outside) Dental care (inside) Tie and untie neck tie/ scarf Tie & untie shoe laces bB
Fig. 6. Range of wrist motion required during personal care and hygiene activities. A, Extensionflexion. B, Ulnar-radial deviation. The grey striped area represents 70% of the maximum motion (40” extension, 40” flexion, 10” radial deviation, and 30” ulnar deviation).
Minimal motion requirements To perform all 24 activities in a normal, comfortable manner, a total of 60 degrees of wrist extension, 54 degrees of wrist flexion, 40 degrees of ulnar deviation, and 17 degrees of radial deviation were necessary. However, with 40 degrees each of wrist extension and wrist flexion (70% of the maximum range of motion required), most, but not all, of the studied activities could be performed. Thirteen activities could be performed normally, and another nine activities could be done with complimentary motion of the forearm. Two activities, raising from a chair (60 degrees of extension) and perineal care (54 degrees of flexion) could be performed satisfactorily, with 40 degrees each of flexion and extension, as splinting the wrist in these positions in our test subjects demonstrated. In addition we found that 30 degrees of ulnar deviation and 10 degrees of radial
deviation (70% of the extreme range) could also satisfy most of the activities studied. Fourteen activities could be done normally, while each of the other 10 activities required only slightly greater motion. We concluded that 40 degrees of extension, 40 degrees of flexion, and a combined 40 degrees of radial-ulnar deviation permitted a minimal functional range of motion in the normal population.
Reliability and reproducibility The accuracy of the electrogoniometer was measured against a hand-held goniometer (Table I). The electrogoniometer measured greater extension and less flexion but an equal arc of flexion-extension and radial-ulnar deviation. The difference in flexion-extension may be a reflection of the zero (or initial) starting place. The reliability of the electrogoniometer to perform repeat measurements was determined from comparing the first
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Functional ranges of motion of wrist joint
417
Diet/ Food Preparation Flexion -40 -30 -20 -to
Extension 0
10
20
30
40
5‘0
Open 8 close faucet handle Pour water from pitcher Drink water from glass Cut meat with knife Open & close jar lid Turn spatula
3A Diet/ Food Preparation Radial
Ulnar Deviation
Open & close faucet handle Pour water from pitcher Drink water from glass Cut meat with knife Open 8 close jar lid Turn spatula
Fig. 7. Range of wrist motion required during diet and food preparation activities. A, Extensionflexion. B, Ulnar-radial deviation.
and last electrogoniometer recording of maximum motion (Table I, bottom) and was extremely tight (less than 1.2 degrees). The reproducibility of the electrogoniometer is demonstrated by repeat measurements of the same activity (Fig. 4, B). For each subject tested, standard deviations of three trials of each task (Fig. 4, A) were 3 degrees in extension, 4 degrees in flexion, 3 degrees in ulnar deviation, and 3 degrees in radial deviation. Discussion Although knowledge of the functional ROM of the wrist joint is extremely important, only limited, singleplane data were available until the report by Palmer et al.* In our study that analyzed wrist motion in 40 subjects we found an average total range of motion of 138 degrees of flexion-extension and 58 degrees of
radial-ulnar deviation. We studied 24 different ADL and found a minimal ROM of 60 degrees of extension, 54 degrees of flexion, 17 degrees of radial deviation, and 40 degrees of ulnar deviation was required. Seventy percent of this extreme range (40 degrees each of extension and flexion, 10 degrees of radial deviation, 30 degrees of ulnar deviation) assured completion of a majority of the 24 functional tasks studied. Two activities, rising from a chair and perineal care, could not be done using the affected wrist within this limited ROM. We believe, however, that this range provides a reasonable representation of the arcs of motion required for most ADL. The range of wrist motion for ADL required from our studies is significantly larger than that previously reported.7, * The difference between these studies may be related to different data reduction methods and the
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The Journal of HAND SURGERY
Ryu et al.
Extension
FI%xion -so
-40
-!M
-20
-10
0
10
20
30
40
50
Polmd wtul hammer
Usescrewdriver(Verll
stt)
use screwdrtver (Horv aa) use
screwdrtver(Vwtl
Stand)
Use screwdrtvff (n0rnstand)
Srtng telephona
to eer
Turn doorknob Tun key stand & dl on chat Turn steertng wheel
Radial I
Ulnar Deviation
-10
Pomd with hamier
use screwdrber (Ver!/ sit) Uss screwdriver (Horil sit) Use screwdriver (Vertl
atand)
Use screwdriver (Horil sta@ Sring teiephone to ear TufTIdoorkrob Turn key Stand & sit on chair Turn stecwing wheet Writing
Fig. 8. Range of wrist motion required during other frequently used ADLs. A, Extension-flexion. B, Ulnar-radial deviation. difference in wrist goniometer design and application.24 The goniometer used in this study was aligned with the axes of flexion-extension and radioulnar deviation with use of a parallelogram linkage design.25 We did not specifically address the question of wrist rotation since axial rotation occurs mainly in the forearm. Although supination-pronation may be present at the wrist because of the compound motion among the carpal bones, it actually is rather sma11.3’ Our main goal was to quantitate the main components of the wrist motion in flexion-extension and ulnar-radial deviation, and, as a result, we chose to ignore the minute amount of localized axial rotation within the wrist joint. Axial rotation was allowed, however, in the goniometer design to avoid binding action of the linkage during motion. From this study we would agree with others’. 4,’ that
ulnar deviation and extension are the most important positions for wrist activities. Thus when a wrist arthrodesis or prolonged immobilization is carried out, the position of the wrist should generally be in extension and ulnar deviation. Optimal wrist fusion or splinting position must be judged by the specific occupation and avocational activities of the patient.” Wrist electrogoniometer measurements could be used as an adjunctive technique to quantitate the special requirements of wrist motion in patients with specific functional demands. From a clinical standpoint this study suggested that 40 degrees of wrist extension, 40 degrees of wrist flexion, and a total of 40 degrees of radial-ulnar deviation is needed to perform a majority of the activities of daily living. Future studies are needed to determine if surgical procedures such as limited wrist fusion, wrist ligament
Vol. 16A, No. 3 May 1991
reconstruction, or wrist joint prosthetic replacements are able to provide such motion in most patients. It is our opinion that the biaxial electrogoniometer used in this study is a reliable, reproducible, and easyto-use instrument for sequential measurement of wrist motion, and that this device could be utilized to evaluate performance efficiency of sporting equipment and work tools that will require the use of the hand and wrist. In addition this technique could also provide quantitative data on wrist movement for functional impairment assessment.
Functional ranges of motion of wrist joint
16.
17.
18.
19.
REFERENCES 1. American Academy of Orthopaedic Surgeons. Joint mo-
tion: Method of measuring and recording. Chicago: The American Academy of Orthopaedic Surgeons, 1965. 2. Boone DC, Azen SP. Normal range of motion of joints in male subjects. J Bone Joint Surg 1979;61A:756-9. 3. &aft G, Detels P. Position of function of the wrist. Arch Phys Med Rehabil 1972;53:272-5. 4. Pryce JC. The wrist position between neutral and ulnar deviation that facilitates the maximum power grip strength. J Biomech 1980;13:505-11. 5. Sarrofian S, Melamed JL, Goshgarian GM. Study of wrist motion in flexion and extension. Clin Orthop 1977;126:153-9. 6. Volz RG, Lieb M, Benjamin J. Biomechanics of the wrist. Clin Orthop 1980;149:112-17. 7. Brumfield R, Nickel V, Nickel E. Joint motion in wrist flexion and extension. South Med J 1966;59:909-10. 8. Palmer AK, Werner FW, Murphy D, Glisson R. Functional wrist motion: a biomechanical study. J HAND SURG 1985;lOA(1):39-46. 9. Kleinman WB, Steichen JB, Strickland JW. Management of chronic rotatory subluxation of the scaphoid by scapho-trapezio-trapezoid arthrodesis. J HAND SLJRG 1982;7:125-36. 10. Speltz S, Schutt A, Beckenbaugh R. Functional wrist position for arthrodesis. J HAND SURG 1983;8:627. 11. Watson HK, Hempton RF. Limited wrist arthrodesis. J HAND SURC 1980;5(4):320-7. 12. Watson HK, Ryu J, DiBella A. An approach to Kienbock’s disease. J HAND SURG 1985;1OA:179-87. 13. Cooney WP, Beckenbaugh RD, Linscheid RL. Total wrist arthroplasty. Clin Orthop 1984;187:121-8. 14. Palmer AK, Dobyns JH, Linscheid RL. Management of post traumatic instability of the wrist secondary to ligament rupture. J HAND SURG 1978;3:507-32. 15. Ayoub MA, Ayoub MM, Ramsey JD. A stereometric
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system for measuring human motion. Hum Factors 1970;12:523-35. Engen TJ, Spencer WA. Method of kinematic study of normal upper extremity movement. Arch Phys Med Rehabil 1968;49:9-12. DeRoos JP, Chao EY, Cooney WP. A biomechanical method for evaluation of normal and pathologic thumb function. Las Vegas: Proc 23rd Ann Orth Res Sot, 1977;2:201. Eberhart HD, Inman VT. An evaluation of experimental procedures used in a fundamental study of human locomotion. Ann NY Acad Sci 1967;51:1213-28. Erdman AG, Dorman F, Isaacson R, Scott D, Weinberg I. Stereoscopic instrumentation for analyzing gross motion. American Society of Mechanical Engineering Paper 1976;No 76-DET-23. Youm YS. Analytical development in investigation of wrist kinematics. J Biomech 1979;12:613-21. Hayes WC, Feldman JM, Oatis C, Nixon JE. Gait analysis by multiaxial accelerometry. Dallas: Trans 24th Orth Res Sot, 1978;3: 104. Morris JRW. Accelerometry-a technique for the measurement of human body movement. J Biomech 1973; 6:729-36. An KN, Chao EYS. Kinematic analysis of human movement. Ann Biomedical Engrg 1984;12:585-97. Chao EYS. Justification of triaxial goniometer for the measurement of joint rotation. J Biomech 1980;13:9891006. Chao EYS. Experimental methods for biomechanical measurements of joint kinematics. In: Feinberg BN, Fleming DG, eds. CRC Handbook of Engineering in Medicine and Biology, Section B: instruments and measurements. West Palm Beach, Florida: CRC Press, 1978:385-411. Chao EYS, Morrey BF. Three-dimensional rotation of the elbow. J Biomech 1978;11:57-73. Karpovich PV, Karpovich GP. Electrogoniometer: a new device for study of joints in action. Fed Proc 1959;18:79. Money BF, Askew LJ, An KN, Chao EYS. A biomechanical study of normal functional elbow motion. J Bone Joint Surg 1981;63A:872-7. Youm Y, Flatt AE. Kinematics of the wrist. Clin Orthop 1980;149:21-32. Youm Y, McMurtry RY, Flatt AE, Gillespie TE. Kinematics of the wrist. J Bone Joint Surg 1978;60A(4):42331. Ruby LK, Cooney WP, An KN, Linscheid RL, Chao EYS: Relative motion of selected carpal bones. A kinematic analyses of the normal wrist. J HAND SURG 1988;13A:l-10.
ranges of motion of the wrist joint
We have examined 40 normal subjects (20 men and 20 women) to determine the ideal range of motion required to perform activities of daily living. The amount of wrist flexion and extension, as well as radial and ulnar deviation, was measured simultaneously by means of a biaxial wrist electrogoniometer. The entire battery of evaluated tasks could be achieved with 60 degrees of extension, 54 degrees of flexion, 40 degrees of ulnar deviation, and 17 degrees of radial deviation, which reflects the maximum wrist motion required for daily activities. The majority of the hand placement and range of motion tasks that were studied in this project could be accomplished with 70 percent of the maximal range of wrist motion. This converts to 40 degrees each of wrist flexion and extension, and 40 degrees of combined radial-ulnar deviation. This study provides normal standards for the functional range of motion of the wrist. (J HANDSURC1991;16A: 409-19.)
Jaiyoung Ryu, MD, William P. Cooney III, MD, Linda J. Askew, RPT, Kai-Nan An, PhD, aad Edmund Y. S. Chao, PhD, Rochester, Minn.
A
lthough normal maximum motion of the wrist has been previously documented with use of standard hand goniometry,‘-6 it was not until recently that instrumentation was developed to assess normal wrist motion during activities. Brumfield and associates’ presented data on the flexion-extension arcs using an uniaxial goniometer. Palmer et al.’ reported the results of their study of 10 normal subjects with use of an electrogoniometer. There has been considerable interest in the functional range of motion (ROM) after partial wrist fusion9-‘* total wrist arthroplasty,” and ligament reconstructive procedures of the wrist,14 yet there have been only a few articles addressing the question of range of motion in activities of daily living (ADL) among the normal population6-’ Several techniques described to measure joint motion include the following: (1) stereometric techniques’5‘20;
From the Orthopedic Biomechanics Foundation, Rochester, Mime. Received for publication March 6, 1990.
Laboratory,
Mayo Clinic/Mayo
Nov. 28, 1989; accepted
in revised form
Although none of the authors have received or will receive benefits for personal or professional use from a commercial patty related directly or indirectly to the subject of this article, benefits have been or will be received but are directed solely to a research fund, foundation, educational institution, or other non-profit organization with which one or more of the authors are associated. Reprint requests: William P. Cooney, MD, Deparatment of Orthopedics, Mayo Clinic/Foundation, 200 First St., SW, Rochester, MN 5.5905. 3/l/21556
(2) accelerometric methods2’, 22; and (3) electromechanical linkage. 23-26The biaxial electrogoniometer used in this study is an electromechanical linkage method, which has several advantages including ease of application, real-time analog data acquisition of biplanar joint motion, and reliability and reproducibility with acceptable accuracy. 23-25, *‘. 28The axes of rotation of the electrogoniometer can be made colinear with the estimated wrist axes of flexion-extension and ulnarradial deviation using anatomic landmarks on the hand and wrist and its position confirmed by biplanar x-ray film. This report describes our experience with a biaxial wrist goniometer designed to measure the pattern of wrist motion during selected ADL and to determine the median ROM required to perform these activities in the normal population. Materials
and methods
The wrist joint is assumed to have two degrees of freedom in flexion-extension and radioulnar deviation. The electrogoniometer used in this study (Fig. 1) to measure the functional range of wrist motion is biaxial and designed to record motion in flexion-extension and radioulnar deviation. The linkage between the potentiometers and the mounting apparatus employed geometric principles of the parallelogram. To achieve simultaneous measurements, two electropotentiometers are placed mutually perpendicular to each other and remain so throughout the range of wrist motion. The wrist electrogoniometer was custom-made in our laboratory and can be applied to either the left or right wrist. It is mounted on each subject with two universal
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Fig. 1. The biaxial electrogoniometer with 2 degrees of freedom for wrist motion measurement during activities of daily living. A, Dorsal potentiometer. B, Ulnar potentiometer.
mounting components, one attached to the dorsal part of the hand (metacarpal component) and the other to the distal forearm (radial component) (Fig. 2). It is lightweight and of low profile design to reduce the inertia effects and to avoid any interference with normal wrist motion in performing ADL. Wrist motion was recorded in a wide variety of ADL. Motion obtained was recorded directly on a model 5314 strip chart recorder (Soltec Corp., Sun Valley, Calif.). The exact degree of wrist motion was hand reduced and calculated. Alignment of the goniometer to the wrist is essential to accurately record wrist ROM in multiple daily activities. We assumed that the head of the capitate nearest to the lunate contact area closely defines the center of rotation for both wrist extension and flexion and for radioulnar deviation.29, 3o From tests in five cadaveric hands we chose as anatomic landmarks the medial cortex of the third metacarpal, the palmar aspect of the pisiform, the base of the first metacarpal, the radial styloid, and the head of the ulna. The location of the radioulnar deviation axis was identified by drawing a
line along the ulnar border of the third metacarpal bone and choosing a midpoint between the distal radius and proximal end of the third metacarpal on this line (Fig. 3, A). To identify the location of the flexion-extension axis, this same point was extended ulnarly, perpendicular to the forearm bones to the midpoint between dorsal surface of the ulnar head and the palmar edge of the pisiform. Open dissection of the wrist and radiographic studies were done in cadavers to validate the T-marker placements (Fig. 3, B and C). To ensure further that this alignment method was correct, T-markers were also placed on the wrist of three subjects, and biplanar (anteriorposterior-lateral) x-ray films were obtained to demonstrate that the metal markers were in line with the ulnar border of the third metacarpal and that the crossbar approximated the head of the capitate. The electrogoniometer was calibrated before each subject test. With one arm of the electrogoniometer fixed to the frame of a hand-held goniometer and the second arm free to move, the zero axis position was chosen (scale 5 degrees per division). A total of 110 degrees of motion could be recorded along’ the
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Fig. 2. A, From a distal to proximal view of the hand and wrist, alignment of the dorsal potentiometer (radioulnar deviation axis) is made with respect to the third metacarpal, and alignment of the ulnar potentiometer (flexion-extension axis) is made with the midposition of the forearm from previously determined skin markers. B, Dorsal view of the wrist, goniometer placement. Support straps attach the distal goniometer pad to the hand with alignment along the medial border of the third metacarpal. The dorsal potentiometer is centered over the head of the capitate. The position of the potentiometer can be adjusted through the set screw attached to the crossbars. An Orthopiast cuff and metal support secure the goniometer to the distal forearm. The ulnar potentiometer is positioned on the ulnar side of the wrist and is also centered in line with the head of the capitate. The placement of the ulnar potentiometer can be adjusted with the set screw attached to the wrist cuff.
sagittal axis (radioulnar deviation) and 180 degrees of motion could be recorded about the frontal axis (flexionextension). There was no measurement of axial rotation using this goniometric system. Study subjects. Forty normal subjects were tested. All were in good health, with no history of upper extremity injury or pathologic conditions. A total of 31
activities that reflected the major functional requirements of the wrist were studied. These activities ineluded the commonly performed ADL or represent commonly performed assessments of upper extremity function3. ‘O The first category of activities included seven “palm placement” positions in which the subject was asked to touch the top of the head, back of the
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Fig. 3. A, The dorsal potentiometer is aligned over the center of radioulnar rotation, which is determined by extending a straight line along the ulnar border of the third metacarpal to the distal radius. This line is marked at the distal radius and the proximal end of the metacarpal. The axis of motion is taken as the midpoint between the two marks on the line. The ulnar potentiometer is aligned on the ulnar side of the wrist at the midpoint between the palmar aspect of the pisiform and the dorsal aspect of the ulnar head. The goniometer is then centered on the dotted line (above). which extends perpendicular from the third metacarpal line. The wrist is maintained in a neutral position of flexion/extension and radioulnar deviation throughout the alignment procedure. B-C, PA view of T-markers; lateral view of T-markers. Based on anatomic landmarks the dorsal and ulnar potentiometer placement is confirmed in cadavers by radiographs of the wrist with T-markers (entered) on the radioulnar deviation axis (PA radiograph) and flexion-extension axis (lateral radiograph). In Fig. 3. B, line A-A’ is base of the first metacarpal; line B-B’ is the midpoint of the pisiform; fine C-C’ is the tip of the radial styloid. MC-MC’ is the medial border of the third metacarpal. In Fig. 3. C. line D-D’ is the dorsal aspect of the ulnar head. E-E’ is the palmar surface of the pisiform and line F-F’ is the midpoint between the ulnar head and pisiform.
head, front of the neck, chest, waist, sacrum, and right foot. The second category involved personal care and hygiene, the third, diet and food preparation, and the fourth, important work functions (writing, driving, tele-
phone use, hammering, using a screwdriver, turning a key or door knob). We could not demonstrate that any restriction of wrist motion was attributed to the presence of the electrogoniometer during these activities except
Vol. 16A, No. 3 May 1991
Functional ranges of motion of wrist joint
EXT.
O-
O-
. ..-. ._ ULNAR
4A;
2F;
Pound
Tie 8 Untie
with
Neck Tie/Scarf
1st Trial
6
-
Hammer
2nd Trial
h
45'Flex.
51’ Flex
Fig. 4. A, Range of motion required for each activity was assessed directly by strip chart recorder (Soltec Corp., model 3314). Motion from the rest position to the beginning of each activity (shaded areas) was discarded. In this example, three consecutive motions of the wrist used in pounding with a hammer are recorded. B, Reproducibility of the biaxial electrogoniometer is demonstrated in virtually all subjects and all activities drawing very similar patterns of motion (arrows above) in multiple trials even in complex wrist activities such as tying and untying a neck tie.
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Table I Range Range
A. B. C. D. E.
Extension
Flexion
Extensionljlexion
59.3 68.9 69.3 9.6 -0.4
79.1 68.4 68.1 - 10.7 0.3
138.4 137.3 137.4 - 1.1 0.1
Hand goniometer Electrcgoniometer (first) Electrogoniometer (last) Electra (first)-hand First-last electro
(A-C) Mean extreme reading) is compared subject. The accuracy UD. Ulnar deviation:
UD
RD
WR)
37.7 42.1 42.9 5.0 -0.2
21.1 17.8 16.6 -3.3 1.2
58.8 60.5 59.5 1.7 1.0
range of wrist motion, measured by hand goniometer and electrogoniometer before and after subject study. (D) The electrogoniometer (first with the hand goniometer reading. (E) The first and last electrogoniometer reading after completing the test sequence are compared for each of the electrogoniometer is evident by the small difference in the range of extension/flexion and UR noted (D and E). RD, radial deviation; UR, ulnar and radial deviation.
Table II. Comparison
of extreme range of wrist motion in the study with previously
reported data
Range
Range
Extension
Flexion
(Extensionljlexion)
UD
RD
fuR)
AAOS (1) Boone et al.’ Brumfield et al.’ (male) Brumfield et al.’ (female)
75 74.9 64 65
73 76.4 73 82
144 151.3 137 147
33 36.0
19 21.5
52 57.5
Palmer et a1.j’ This study
59.3
79.1
133.3 138.4
37.7
21.1
40.5 58.7
UD. Ulnar deviation: RD. radial deviation: UR. ulnar and radial deviation
Table III. Positions of the wrist during palm placement activities (mean and standard deviation)
Top of the head Back of the head Front of the neck Front of the chest Front of the waist Sacrum Right foot
-20.9 -0.9 -3.3 -24.5 - 19.0 - 19.5 0.8
2 2 + ” 2 + 5
13.9 17.6 19.6 16.7 14.9 19.3 14.6
16.1 9.7 2.1 -5.1 -6.2 47.8 8.7
and ulnar deviation, were recorded at the beginning, between each of the four categories of activities, and at the end of each battery of tests to detect any movement of the goniometer in relation to the forearm and the hand. These measurements were compared with the hand goniometer measurements as a test for reliability of the instrument (Table I). ? 2 ” * ‘” ?
12.7 11.9 9.5 10.3 10.7 16.8 12.2
*Negative value denotes flexion. tNegative value denotes radial deviation.
for rising from a chair, where extreme extension appeared to be slightly impeded. Even in this situation, consistent measurements were obtained. The accuracy, reliability, and reproducibility of the goniometer (Fig. 4) was also determined. Extreme motions in all four directions, flexion, extension, and radial
Results Range of motion and palm placement Wrist range of motion. The average maximum range of wrist motion as determined by the wrist goniometer measurement was 60 degrees of extension to 78 degrees of flexion (a 138 degree arc of motion) and 21 degrees of radial deviation to 38 degrees of ulnar deviation (59 degree arc of motion). Comparison of these data and those previously published’, 2.‘. ’ showed general agreement, although our recording of full extension measurement was slightly smaller (Table II). Flexion and extension were measured with the forearm in neutral rotation, while radial and ulnar deviation were measured with the forearm pronated and the palm placed on a flat surface, thus limiting flexion and extension.
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Palm placement activities. The mean and standard deviations of the wrist positions during seven palm placement activities were obtained (Table III) (Fig. 5). During placement of the palm of the hand on the back of the neck, chest, waist, sacrum, and foot, the wrist was in slight flexion (0 to 24 degrees of flexion) (Table III). There was a wide range of wrist flexion and extension required to do these daily activities. In general most of the activities were done with the wrist in between neutral and 20 degrees of flexion, while more extension-oriented ranges were seen in the other ADL that required continuous motion. This finding agrees with the study by Brumfield and associates.’ Hand palm placement activities also required from 5 degrees of radial to 15 degrees of ulnar deviation. Placing the hand on the sacrum required the largest range of motion, 48 degrees of ulnar deviation. Functional wrist motion activities Twenty-four ADL require continuous motion of the wrist. These can be divided into the following three major categories: personal care and hygiene, diet and food preparation, and miscellaneous ADLs. Personal care and hygiene. Seven activities in this category included combing hair, perineal care, dental care, buttoning and unbuttoning, neck tie/scarf, and tying and untying shoe laces (Fig. 6). Wrist motion from 42 degrees of extension to 54 degrees of flexion and from 40 degrees of ulnar deviation to 15 degrees of radial deviation were required to perform all seven activities. A significantly larger amount of flexion was necessary for perineal care and tying and untying a neck tie/ scarf (54 degrees and 5 1 degrees, respectively) than for other personal care functions. The latter activity (scarf tying) also required the largest arc of radioulnar deviation of 55 degrees, including both extreme radial (15 degrees) and ulnar deviation (40 degrees). Diet and food preparation. A more limited ROM of the wrist was required for diet and food preparation. Wrist motion from 42 degrees of extension to 37 degrees of flexion and 40 degrees of ulnar deviation to 12 degrees of radial deviation was needed to perform six activities in this group (Fig. 7). Turning a spatula (73 degrees flexion-extension arc and 39 degrees ulnar deviation) and opening a jar lid (47 degrees radioulnar deviation) represented the extremes of motion in this category. Manipulating faucet or spatula required more extension (42 degrees and 37 degrees, respectively) than other activities. Miscellaneous ADLs. This category included frequently performed activities associated with work functions that require various levels of wrist motion (Fig.
Functional ranges of motion of wrist joint
-50
A
I
I
I
Back TOP head
Neck
I
I Chest
Waist
I Sacrum
415
I Foot
Palm placements l
Average
A Avg. - S.D. V Avg. + SD.
i ! I A
A
I
I
Back Top .head
I A I Neck Palm
I
I
i
i
Chest
4 Waist
A I Sacrum
I Fool
placements
Fig. 5. Category one: Seven activities requiring positioning of the wrist for personal care and hygiene. A, Extensionflexion. B, Ulnar-radial deviation. 8) such as hammering, using a screw driver in different positions, turning a doorknob, key, and steering wheel, bringing a telephone to the ear, and rising from and sitting on a chair. For comparison we included writing because it is such an important task, even though it requires minimal motion of the wrist. Subjects were requested to use an arm rest for support when rising from a chair, and this required the most extreme extension of 60 degrees and radial deviation of 17 degrees among all 24 activities. Three different turning activities, hammering, and telephoning required extension of slightly more than 40 degrees. Inserting vertical screws while the subject was sitting required a large amount of flexion, 43 degrees, while inserting horizontal screws needed more ulnar deviation, 3 1 degrees. Hand writing required the least arc of motion, 14 degrees of extension-flexion and 12 degrees of radioulnar deviation.
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Ryu et al.
Personal Care/ Hygiene Flexion -60
Extension
-20
-40
20
0
40
60
Comb hair Tie & untiit;t$ Peroneal care Dental care (outside) Dental care (inside) Tie and untie neck tie/ scarf Tie & untie shoe
laces
Personal Care/ Hygiene Ulnar Deviation
Radial -20
-10
0
10
20
30
40
50
Comb hair Tie 8 urHi;,ti;;; Peroneal care Dental care (outside) Dental care (inside) Tie and untie neck tie/ scarf Tie & untie shoe laces bB
Fig. 6. Range of wrist motion required during personal care and hygiene activities. A, Extensionflexion. B, Ulnar-radial deviation. The grey striped area represents 70% of the maximum motion (40” extension, 40” flexion, 10” radial deviation, and 30” ulnar deviation).
Minimal motion requirements To perform all 24 activities in a normal, comfortable manner, a total of 60 degrees of wrist extension, 54 degrees of wrist flexion, 40 degrees of ulnar deviation, and 17 degrees of radial deviation were necessary. However, with 40 degrees each of wrist extension and wrist flexion (70% of the maximum range of motion required), most, but not all, of the studied activities could be performed. Thirteen activities could be performed normally, and another nine activities could be done with complimentary motion of the forearm. Two activities, raising from a chair (60 degrees of extension) and perineal care (54 degrees of flexion) could be performed satisfactorily, with 40 degrees each of flexion and extension, as splinting the wrist in these positions in our test subjects demonstrated. In addition we found that 30 degrees of ulnar deviation and 10 degrees of radial
deviation (70% of the extreme range) could also satisfy most of the activities studied. Fourteen activities could be done normally, while each of the other 10 activities required only slightly greater motion. We concluded that 40 degrees of extension, 40 degrees of flexion, and a combined 40 degrees of radial-ulnar deviation permitted a minimal functional range of motion in the normal population.
Reliability and reproducibility The accuracy of the electrogoniometer was measured against a hand-held goniometer (Table I). The electrogoniometer measured greater extension and less flexion but an equal arc of flexion-extension and radial-ulnar deviation. The difference in flexion-extension may be a reflection of the zero (or initial) starting place. The reliability of the electrogoniometer to perform repeat measurements was determined from comparing the first
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Diet/ Food Preparation Flexion -40 -30 -20 -to
Extension 0
10
20
30
40
5‘0
Open 8 close faucet handle Pour water from pitcher Drink water from glass Cut meat with knife Open & close jar lid Turn spatula
3A Diet/ Food Preparation Radial
Ulnar Deviation
Open & close faucet handle Pour water from pitcher Drink water from glass Cut meat with knife Open 8 close jar lid Turn spatula
Fig. 7. Range of wrist motion required during diet and food preparation activities. A, Extensionflexion. B, Ulnar-radial deviation.
and last electrogoniometer recording of maximum motion (Table I, bottom) and was extremely tight (less than 1.2 degrees). The reproducibility of the electrogoniometer is demonstrated by repeat measurements of the same activity (Fig. 4, B). For each subject tested, standard deviations of three trials of each task (Fig. 4, A) were 3 degrees in extension, 4 degrees in flexion, 3 degrees in ulnar deviation, and 3 degrees in radial deviation. Discussion Although knowledge of the functional ROM of the wrist joint is extremely important, only limited, singleplane data were available until the report by Palmer et al.* In our study that analyzed wrist motion in 40 subjects we found an average total range of motion of 138 degrees of flexion-extension and 58 degrees of
radial-ulnar deviation. We studied 24 different ADL and found a minimal ROM of 60 degrees of extension, 54 degrees of flexion, 17 degrees of radial deviation, and 40 degrees of ulnar deviation was required. Seventy percent of this extreme range (40 degrees each of extension and flexion, 10 degrees of radial deviation, 30 degrees of ulnar deviation) assured completion of a majority of the 24 functional tasks studied. Two activities, rising from a chair and perineal care, could not be done using the affected wrist within this limited ROM. We believe, however, that this range provides a reasonable representation of the arcs of motion required for most ADL. The range of wrist motion for ADL required from our studies is significantly larger than that previously reported.7, * The difference between these studies may be related to different data reduction methods and the
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The Journal of HAND SURGERY
Ryu et al.
Extension
FI%xion -so
-40
-!M
-20
-10
0
10
20
30
40
50
Polmd wtul hammer
Usescrewdriver(Verll
stt)
use screwdrtver (Horv aa) use
screwdrtver(Vwtl
Stand)
Use screwdrtvff (n0rnstand)
Srtng telephona
to eer
Turn doorknob Tun key stand & dl on chat Turn steertng wheel
Radial I
Ulnar Deviation
-10
Pomd with hamier
use screwdrber (Ver!/ sit) Uss screwdriver (Horil sit) Use screwdriver (Vertl
atand)
Use screwdriver (Horil sta@ Sring teiephone to ear TufTIdoorkrob Turn key Stand & sit on chair Turn stecwing wheet Writing
Fig. 8. Range of wrist motion required during other frequently used ADLs. A, Extension-flexion. B, Ulnar-radial deviation. difference in wrist goniometer design and application.24 The goniometer used in this study was aligned with the axes of flexion-extension and radioulnar deviation with use of a parallelogram linkage design.25 We did not specifically address the question of wrist rotation since axial rotation occurs mainly in the forearm. Although supination-pronation may be present at the wrist because of the compound motion among the carpal bones, it actually is rather sma11.3’ Our main goal was to quantitate the main components of the wrist motion in flexion-extension and ulnar-radial deviation, and, as a result, we chose to ignore the minute amount of localized axial rotation within the wrist joint. Axial rotation was allowed, however, in the goniometer design to avoid binding action of the linkage during motion. From this study we would agree with others’. 4,’ that
ulnar deviation and extension are the most important positions for wrist activities. Thus when a wrist arthrodesis or prolonged immobilization is carried out, the position of the wrist should generally be in extension and ulnar deviation. Optimal wrist fusion or splinting position must be judged by the specific occupation and avocational activities of the patient.” Wrist electrogoniometer measurements could be used as an adjunctive technique to quantitate the special requirements of wrist motion in patients with specific functional demands. From a clinical standpoint this study suggested that 40 degrees of wrist extension, 40 degrees of wrist flexion, and a total of 40 degrees of radial-ulnar deviation is needed to perform a majority of the activities of daily living. Future studies are needed to determine if surgical procedures such as limited wrist fusion, wrist ligament
Vol. 16A, No. 3 May 1991
reconstruction, or wrist joint prosthetic replacements are able to provide such motion in most patients. It is our opinion that the biaxial electrogoniometer used in this study is a reliable, reproducible, and easyto-use instrument for sequential measurement of wrist motion, and that this device could be utilized to evaluate performance efficiency of sporting equipment and work tools that will require the use of the hand and wrist. In addition this technique could also provide quantitative data on wrist movement for functional impairment assessment.
Functional ranges of motion of wrist joint
16.
17.
18.
19.
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