- Email: [email protected]
Normal range-of-motion of trapeziometacarpal joint
Chirurgie de la main 28 (2009) 297–300
Original article
Normal range-of-motion of trapeziometacarpal joint Détermination des amplitudes normales de l’articulation trapézométacarpienne J.-N. Goubier a,b,*, L. Devun a, D. Mitton a, F. Lavaste a, E. Papadogeorgou b a
Laboratoire de biomécanique, École nationale des arts et métiers (Ensam), 151, boulevard de l’Hôpital, 75013 Paris, France Clinique du Parc-Monceau, centre international de chirurgie de la main (CICM), 21, rue de Chazelles, 75017 Paris, France
b
Received 4 January 2009; received in revised form 4 June 2009; accepted 19 July 2009
Abstract Purpose. – The range-of-motion of the trapeziometacarpal joint is difficult to assess clinically. The purpose of our study was to constitute a rangeof-motion database from normal active trapeziometacarpal joints. Material and methods. – Two hundred hands from 101 healthy subjects (50 female and 51 male) with a mean age of 23.1 years (range: 22 to 35 years) have been evaluated. An optoelectronic device (Polaris1) was used to analyse the thumbs range-of-motion. Splints were fitted so as to isolate the trapeziometacarpal joint and retroreflective markers were placed both on the splints and on the thumb. After active flexion–extension, abduction–adduction, axial rotation and circumduction, the different range-of-motion parameters were calculated. Results. – The mean range-of-motion of the trapeziometacarpal joint was 418 for flexion–extension, 518 for abduction–adduction and 218 for axial rotation. Comparisons between female and male subjects showed significant differences concerning flexion–extension, abduction–adduction axial rotation and circumduction. No significant differences were noted between right and left hands except for the abduction–adduction movement. Discussion and conclusion. – One hundred and one healthy subjects were analysed for the development of a database of normal active range-ofmotion parameters of the trapeziometacarpal joint, with an in vivo protocol. This database should allow comparing the range-of-motion of patients with osteoarthritic trapeziometacarpal joint and assessing surgical outcome. # 2009 Elsevier Masson SAS. All rights reserved. Keywords: Trapeziometacarpal joint; Kinematics; In vivo; Range-of-motion; Optoelectronic; Biomechanics
Résumé Objectifs. – L’évaluation des amplitudes articulaires de l’articulation trapézométacarpienne est difficile en pratique clinique courante. L’objectif de notre étude était de réaliser une base de données à partir de sujets sains, concernant les amplitudes de l’articulation trapézométacarpienne in vivo. Matériels et méthodes. – L’analyse cinématique de 101 sujets sains (50 femmes, 51 hommes), soit 200 mains, a été réalisée à l’aide d’un système optoélectronique. Des attelles ont été placées sur la main et le poignet afin de ne mesurer que les mobilités trapézométacarpiennes. Les mouvements de flexion–extension, d’abduction–adduction, et de circumduction ont été étudiés. Résultats. – Les mobilités moyennes de l’articulation trapézométacarpienne étaient de 418 en flexion–extension, de 518 en abduction–adduction, et de 218 en rotation axiale. La comparaison des sujets masculins et féminins montre une différence significative concernant les mobilités de flexion–extension, d’abduction–adduction, de rotation axiale et de circumduction. Aucune différence significative n’était notée entre les mains droites et gauches en dehors du mouvement d’abduction–adduction. Discussion et conclusion. – L’analyse de 101 sujets sains a permis d’élaborer une base de données concernant les paramètres cinématiques de l’articulation trapézométacarpienne. Cette base de données permettra de comparer les mobilités de sujets atteints d’arthrose afin d’évaluer une éventuelle modification. De plus, la comparaison de patients ayant subi une intervention chirurgicale et des sujets sains pourra être réalisée, afin d’évaluer un éventuel bénéfice. # 2009 Elsevier Masson SAS. Tous droits réservés. Mots clés : Articulation trapézométacarpienne ; Cinématique ; In vivo ; Optoélectronique ; Biomécanique
* Corresponding author. E-mail address: [email protected] (J.N. Goubier). 1297-3203/$ – see front matter # 2009 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.main.2009.07.003
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J.-N. Goubier et al. / Chirurgie de la main 28 (2009) 297–300
1. Introduction The trapeziometacarpal (TMC) joint is important for the thumb’s range-of-motion [1]. However, its anatomy is very complicated. The shape of the trapezium and the first metacarpal articular surfaces is described as a double saddle with concave and convex surfaces. Moreover, many ligaments have been described to be present in the TMC joint [2], but their function remains unclear. Nevertheless, tendons, muscles action and capsular laxity may change the kinematics of the TMC joint. The range-of–motion of the TMC joint is clinically difficult to assess accurately. The Kapandji score measures the entire thumb motion and gives no accurate data on TMC joint rangeof-motion [1]. Goniometers can not be easily used in this joint. Many studies have described ex vivo kinematics of the TMC joint [3–12], which are definitely helpful for the understanding of TMC joint kinematics. However, these analyses did not include the active function of muscles and tendons in the study of joint kinematics. In vivo studies are currently developed and various systems have been produced to analyse in vivo kinematics. X-rays analysis may be considered dangerous for the patients because of radiation exposure [8]. MRI analysis allows static study in different positions. Some studies have analysed the TMC joint using optoelectronic or electromagnetic devices [13,14]. These studies validated a kinematics protocol but no publication to our knowledge has ever presented a database of TMC joint rangeof-motion in healthy subjects. The purpose of our study was to validate an active TMC kinematics analysis and to collect data from TMC joint rangeof-motion, in different specific patterns of movements, so as to obtain a panel of values for normal TMC joint.
Fig. 1. Splints with retroreflective markers to immobilize all joints except the TMC joint.
2. Material and methods One hundred and one healthy subjects, 50 females and 51 males, were evaluated, with a mean age of 23.1 (range 22–35) years. Both hands were studied in 99 subjects and one hand in two. Two hundred hands were finally analysed. All subjects underwent a medical query in order to exclude those with a previous hand injury or any other kind of hand pathology. Each examined hand was placed into a splint in order to immobilize the wrist. A small splint was used to fix the IP and MCP joints, so as to isolate the TMC joint for individual examination (Fig. 1). An optoelectronic system (Polaris1, Northern Digital Inc, Ontario) was used to analyse the movements of the thumb with two fixed infrared cameras and retroreflective markers. Retroreflective markers were placed on the two splints (Fig. 1). A pen with markers was used to localize bony landmarks on the first metacarpal bone. Four movements of the thumb were analysed: abduction– adduction, flexion–extension, axial rotation and circumduction. Circumduction, which is defined as the spatial motion of the first metacarpal of the thumb, was described by three parameters: ua, ub and b [13] (Fig. 2). The palm of the hand
Fig. 2. a: circumduction is defined with the ua and ub parameters. ua is the angle between the higher and lower position of the first metacarpal in abduction–adduction (movement in the same plane as the thumb nail plane). Qb is the angle between the higher and lower position of the first metacarpal in flexion– extension (movement in the perpendicular plane to the thumb nail plane); b: the angle between the surface of circumduction (oval) and plane of the palm (square) is defined with the b parameter.
J.-N. Goubier et al. / Chirurgie de la main 28 (2009) 297–300
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was defined as the reference plane. ua is the angle between the higher and lower position of the first metacarpal in abduction– adduction. Qb is the angle between the higher and lower position of the first metacarpal in flexion–extension. b is the angle between the reference plane (plane of the palm) and the plane defined by ellipse of the circumduction. 2.1. Repeatability protocol Twenty asymptomatic subjects underwent two analyses with the same splints position in order to assess the motion repeatability. Then, the same 20 subjects were evaluated after one week to study the global repeatability.
Fig. 3. Comparison between male and female subjects (F–E: flexion–extension; Abd–Add: abduction–adduction; AR: axial rotation; Circ: circumduction with the three parameters ua a, ub and ß).
3. Results 3.1. Results of the repeatability study The average difference between the two observations for movement repeatability was not significant ( p = 0.11). Concerning the global repeatability, the average difference between the two analyses was not significant as well ( p = 0.22). 3.2. Results of the total healthy subjects (Table 1) The mean abduction–adduction range of motion was 518. The mean flexion–extension range of motion was 448. The mean parameters of circumduction ua, ub, and b were respectively 50, 64 and 578. The mean angle of axial rotation of the thumb was 218. 3.3. Comparison between male and female subjects (Fig. 3)
Fig. 4. Comparison between right and left hands (F–E: flexion–extension; Abd–Add: abduction–adduction; AR: axial rotation; Circ: circumduction with the three parameters ua, ub and ß).
average ub angle was also wider in female subjects (688) when compared to male subjects (618). This difference was significant with p = 0.01 and p < 0.0001 respectively. The average b angle was wider in female subjects (588) than in male subjects (578) with no significant differences. 3.4. Comparison between right and left hands (Fig. 4)
The average flexion–extension range of motion in female subjects (488) was wider than in male subjects (418). The average abduction–adduction range of motion in females (538) was larger than in males (498). The average axial rotation was wider in male subjects (248) than in female subjects (198). The differences between male and female subjects were significant for flexion–extension ( p = 0.003), for abduction–adduction ( p = 0.006) and for axial rotation ( p < 0.0001). Concerning the circumduction, the average ua angle was wider in female subjects (528) than in male subjects (498). The Table 1 Parameters calculated from 200 healthy hands (in degrees for angles and millimetres for distances).
The average flexion–extension range of motion was 438 for right hands and 458 for left hands. The average abduction– adduction range-of-motion was 498 for right hands and 538 for left hands. The average axial rotation was 228 for right hands and 218 for left hands. The difference between right and left hands was not significant except for abduction–adduction ( p = 0.002). Concerning the circumduction, the average ua angle was the same between right hands and left hands (508). The average ub angle was 648 in right hands and 658 in left hands. The average b angle was smaller in right hands (578) than in left hands (588). No significant differences were found concerning circumduction. 4. Discussion
Total results Movement parameters
Mean (8)
Std
ua angle ub angle b angle Flexion–extension Abduction–adduction Axial rotation
50 64 57 44 51 21
10 12 5 12 10 9
Std: standard.
The clinical assessment of the TMC joint is difficult. Ex vivo studies are unable to evaluate the joint’s range of motion which is produced by the contribution of muscles and tendons action. They are able only to quantify the theoretic mobility of bone and ligament segments [1]. Therefore, the study of in vivo kinematics of the thumb becomes a necessity, since it is the only method that could provide a precise measurement protocol for the TMC joint’s range of motion.
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A few studies concerning in vivo kinematics have been developed using X-ray techniques [3,15]. These accurate protocols provide skin and bone movements. However, because of radiation exposure, X-ray cannot be routinely used in clinical practice. Moreover, axial rotation of the thumb is not easily calculated [15]. Non-invasive procedures are currently used to analyse joint kinematics. Regarding TMC joint, Kuo et al. used an electromagnetic tracking device to measure the thumb’s movement by placing skin markers [14]. The correlation between the skin markers and bone segments has been previously verified [15]. This study allowed the calculation of the circumduction by the use of a mathematical model based on the length of the first metacarpal. The thumb’s range of motion values were represented with a spherical area. However, the distance between the axes of rotation cannot be calculated with this method. Cheze et al. proposed an in vivo protocol with an optoelectronic device [13]. The wrist was immobilized with a splint and markers were placed on the thumb. Abduction– adduction, flexion–extension and circumduction and axial rotation were measured according standardized axes [16]. The results of range of motion calculations were similar to ours (Fig. 3). However, only 24 hands were studied. Coert et al. proposed a method to quantify the thumb’s circumduction with an electronic device [17]. However, the interphalangeal and metacarpophalangeal joints were not stabilized. Therefore, in this study, the TMC joint range-of-motion cannot be precisely calculated. The total range of motion found in our series is wider than in ex vivo kinematics studies [3,5]. Even though passive movements are performed in studies using ex vivo analysis, the joint mobility of frozen cadavers is most probably less because of plasticity tissue modifications. The range of motion was wider in female subjects for flexion–extension and abduction adduction except for axial rotation. These data may be explained by the greater joint laxity generally found in the female population. In clinical practice, the TMC joint range-of-motion may be measured with standard finger goniometer according to the same protocol even though precision is lower without optolectronic device. Abduction–adduction is the maximal range-of-motion of the first metacarpal in the plane of the nail thumb. Flexion–extension is the maximal range-of-motion of the first metacarpal in the perpendicular plane of the nail thumb. The first part of the finger goniometer must be placed on the palm plane (or the table plane if the hand rests on a table). The second part must be placed on the first metacarpal plane. In conclusion, the database of in vivo TMC joint range-ofmotion measures presented in this study will permit the comparison between a pathologic and a healthy basal joint. Moreover, it should help comparing the thumb’s range of
motion before and after trapeziectomy or TMC arthroplasty when assessing the outcome of different methods of treatment of TMC joint in osteoarthritis.
Acknowledgement The authors wish to thank L. Cessey and J. Etchard for their help in this study.
References [1] Kapandji A. Functional anatomy of the 1st web space. Ann Chir Main 1986;5(2):158–65. [2] Bettinger PC, Smutz WP, Linscheid RL, Cooney 3rd WP, An KN. Material properties of the trapezial and trapeziometacarpal ligaments. J Hand Surg [Am] 2000;25(6):1085–95. [3] Cooney 3rd WP, Lucca MJ, Chao EY, Linscheid RL. The kinesiology of the thumb trapeziometacarpal joint. J Bone Joint Surg Am 1981;63(9): 1371–81. [4] Imaeda T, Niebur G, An KN, Cooney 3rd WP. Kinematics of the trapeziometacarpal joint after sectioning of ligaments. J Orthop Res 1994;12(2):205–10. [5] Imaeda T, Niebur G, Cooney 3rd WP, Linscheid RL, An KN. Kinematics of the normal trapeziometacarpal joint. J Orthop Res 1994;12(2):197–204. [6] Imaeda T, Cooney WP, Niebur GL, Linscheid RL, An KN. Kinematics of the trapeziometacarpal joint: a biomechanical analysis comparing tendon interposition arthroplasty and total-joint arthroplasty. J Hand Surg [Am] 1996;21(4):544–53. [7] Kauer JM. Functional anatomy of the carpometacarpal joint of the thumb. Clin Orthop 1987;(220):7–13. [8] Miura T, Ohe T, Masuko T. Comparative in vivo kinematic analysis of normal and osteoarthritic trapeziometacarpal joints. J Hand Surg [Am] 2004;29(2):252–7. [9] Zancolli EA, Ziadenberg C, Zancolli Jr E. Biomechanics of the trapeziometacarpal joint. Clin Orthop 1987;220:14–26. [10] Uchiyama S, Cooney WP, Niebur G, An KN, Linscheid RL. Biomechanical analysis of the trapeziometacarpal joint after surface replacement arthroplasty. J Hand Surg [Am] 1999;24(3):483–90. [11] Najima H, Oberlin C, Alnot JY, Cadot B. Anatomical and biomechanical studies of the pathogenesis of trapeziometacarpal degenerative arthritis. J Hand Surg [Br] 1997;22(2):183–8. [12] Momose T, Nakatsuchi Y, Saitoh S. Contact area of the trapeziometacarpal joint. J Hand Surg [Am] 1999;24(3):491–5. [13] Cheze L, Doriot N, Eckert M, Rumelhart C, Comtet JJ. In vivo cinematic study of the trapezometacarpal joint. Chir Main 2001;20(1):23–30. [14] Kuo LC, Cooney WP, Chen QS, Kaufman KR, Su FC, An KN. A kinematic method to calculate the workspace of the trapeziometacarpal joint. Proc Inst Mech Eng [H] 2004;218(2):143–9. [15] Kuo LC, Cooney 3rd WP, Oyama M, Kaufman KR, Su FC, An KN. Feasibility of using surface markers for assessing motion of the thumb trapeziometacarpal joint. Clin Biomech (Bristol Avon) 2003;18(6):558– 63. [16] Dumas R, Cheze L, Fayet M, Rumelhart C, Comtet JJ. How to define the joint movements unambiguously: proposal of standardization for the trapezometacarpal joint. Chir Main 2008;27(5):195–201. [17] Coert J, Hoek van Dijke G, Hovius S, Snijders C, Meek M. Quantifying thumb rotation during circumduction utilizing a video technique. J Orthop Res 2003;21:1151–5.
Original article
Normal range-of-motion of trapeziometacarpal joint Détermination des amplitudes normales de l’articulation trapézométacarpienne J.-N. Goubier a,b,*, L. Devun a, D. Mitton a, F. Lavaste a, E. Papadogeorgou b a
Laboratoire de biomécanique, École nationale des arts et métiers (Ensam), 151, boulevard de l’Hôpital, 75013 Paris, France Clinique du Parc-Monceau, centre international de chirurgie de la main (CICM), 21, rue de Chazelles, 75017 Paris, France
b
Received 4 January 2009; received in revised form 4 June 2009; accepted 19 July 2009
Abstract Purpose. – The range-of-motion of the trapeziometacarpal joint is difficult to assess clinically. The purpose of our study was to constitute a rangeof-motion database from normal active trapeziometacarpal joints. Material and methods. – Two hundred hands from 101 healthy subjects (50 female and 51 male) with a mean age of 23.1 years (range: 22 to 35 years) have been evaluated. An optoelectronic device (Polaris1) was used to analyse the thumbs range-of-motion. Splints were fitted so as to isolate the trapeziometacarpal joint and retroreflective markers were placed both on the splints and on the thumb. After active flexion–extension, abduction–adduction, axial rotation and circumduction, the different range-of-motion parameters were calculated. Results. – The mean range-of-motion of the trapeziometacarpal joint was 418 for flexion–extension, 518 for abduction–adduction and 218 for axial rotation. Comparisons between female and male subjects showed significant differences concerning flexion–extension, abduction–adduction axial rotation and circumduction. No significant differences were noted between right and left hands except for the abduction–adduction movement. Discussion and conclusion. – One hundred and one healthy subjects were analysed for the development of a database of normal active range-ofmotion parameters of the trapeziometacarpal joint, with an in vivo protocol. This database should allow comparing the range-of-motion of patients with osteoarthritic trapeziometacarpal joint and assessing surgical outcome. # 2009 Elsevier Masson SAS. All rights reserved. Keywords: Trapeziometacarpal joint; Kinematics; In vivo; Range-of-motion; Optoelectronic; Biomechanics
Résumé Objectifs. – L’évaluation des amplitudes articulaires de l’articulation trapézométacarpienne est difficile en pratique clinique courante. L’objectif de notre étude était de réaliser une base de données à partir de sujets sains, concernant les amplitudes de l’articulation trapézométacarpienne in vivo. Matériels et méthodes. – L’analyse cinématique de 101 sujets sains (50 femmes, 51 hommes), soit 200 mains, a été réalisée à l’aide d’un système optoélectronique. Des attelles ont été placées sur la main et le poignet afin de ne mesurer que les mobilités trapézométacarpiennes. Les mouvements de flexion–extension, d’abduction–adduction, et de circumduction ont été étudiés. Résultats. – Les mobilités moyennes de l’articulation trapézométacarpienne étaient de 418 en flexion–extension, de 518 en abduction–adduction, et de 218 en rotation axiale. La comparaison des sujets masculins et féminins montre une différence significative concernant les mobilités de flexion–extension, d’abduction–adduction, de rotation axiale et de circumduction. Aucune différence significative n’était notée entre les mains droites et gauches en dehors du mouvement d’abduction–adduction. Discussion et conclusion. – L’analyse de 101 sujets sains a permis d’élaborer une base de données concernant les paramètres cinématiques de l’articulation trapézométacarpienne. Cette base de données permettra de comparer les mobilités de sujets atteints d’arthrose afin d’évaluer une éventuelle modification. De plus, la comparaison de patients ayant subi une intervention chirurgicale et des sujets sains pourra être réalisée, afin d’évaluer un éventuel bénéfice. # 2009 Elsevier Masson SAS. Tous droits réservés. Mots clés : Articulation trapézométacarpienne ; Cinématique ; In vivo ; Optoélectronique ; Biomécanique
* Corresponding author. E-mail address: [email protected] (J.N. Goubier). 1297-3203/$ – see front matter # 2009 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.main.2009.07.003
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J.-N. Goubier et al. / Chirurgie de la main 28 (2009) 297–300
1. Introduction The trapeziometacarpal (TMC) joint is important for the thumb’s range-of-motion [1]. However, its anatomy is very complicated. The shape of the trapezium and the first metacarpal articular surfaces is described as a double saddle with concave and convex surfaces. Moreover, many ligaments have been described to be present in the TMC joint [2], but their function remains unclear. Nevertheless, tendons, muscles action and capsular laxity may change the kinematics of the TMC joint. The range-of–motion of the TMC joint is clinically difficult to assess accurately. The Kapandji score measures the entire thumb motion and gives no accurate data on TMC joint rangeof-motion [1]. Goniometers can not be easily used in this joint. Many studies have described ex vivo kinematics of the TMC joint [3–12], which are definitely helpful for the understanding of TMC joint kinematics. However, these analyses did not include the active function of muscles and tendons in the study of joint kinematics. In vivo studies are currently developed and various systems have been produced to analyse in vivo kinematics. X-rays analysis may be considered dangerous for the patients because of radiation exposure [8]. MRI analysis allows static study in different positions. Some studies have analysed the TMC joint using optoelectronic or electromagnetic devices [13,14]. These studies validated a kinematics protocol but no publication to our knowledge has ever presented a database of TMC joint rangeof-motion in healthy subjects. The purpose of our study was to validate an active TMC kinematics analysis and to collect data from TMC joint rangeof-motion, in different specific patterns of movements, so as to obtain a panel of values for normal TMC joint.
Fig. 1. Splints with retroreflective markers to immobilize all joints except the TMC joint.
2. Material and methods One hundred and one healthy subjects, 50 females and 51 males, were evaluated, with a mean age of 23.1 (range 22–35) years. Both hands were studied in 99 subjects and one hand in two. Two hundred hands were finally analysed. All subjects underwent a medical query in order to exclude those with a previous hand injury or any other kind of hand pathology. Each examined hand was placed into a splint in order to immobilize the wrist. A small splint was used to fix the IP and MCP joints, so as to isolate the TMC joint for individual examination (Fig. 1). An optoelectronic system (Polaris1, Northern Digital Inc, Ontario) was used to analyse the movements of the thumb with two fixed infrared cameras and retroreflective markers. Retroreflective markers were placed on the two splints (Fig. 1). A pen with markers was used to localize bony landmarks on the first metacarpal bone. Four movements of the thumb were analysed: abduction– adduction, flexion–extension, axial rotation and circumduction. Circumduction, which is defined as the spatial motion of the first metacarpal of the thumb, was described by three parameters: ua, ub and b [13] (Fig. 2). The palm of the hand
Fig. 2. a: circumduction is defined with the ua and ub parameters. ua is the angle between the higher and lower position of the first metacarpal in abduction–adduction (movement in the same plane as the thumb nail plane). Qb is the angle between the higher and lower position of the first metacarpal in flexion– extension (movement in the perpendicular plane to the thumb nail plane); b: the angle between the surface of circumduction (oval) and plane of the palm (square) is defined with the b parameter.
J.-N. Goubier et al. / Chirurgie de la main 28 (2009) 297–300
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was defined as the reference plane. ua is the angle between the higher and lower position of the first metacarpal in abduction– adduction. Qb is the angle between the higher and lower position of the first metacarpal in flexion–extension. b is the angle between the reference plane (plane of the palm) and the plane defined by ellipse of the circumduction. 2.1. Repeatability protocol Twenty asymptomatic subjects underwent two analyses with the same splints position in order to assess the motion repeatability. Then, the same 20 subjects were evaluated after one week to study the global repeatability.
Fig. 3. Comparison between male and female subjects (F–E: flexion–extension; Abd–Add: abduction–adduction; AR: axial rotation; Circ: circumduction with the three parameters ua a, ub and ß).
3. Results 3.1. Results of the repeatability study The average difference between the two observations for movement repeatability was not significant ( p = 0.11). Concerning the global repeatability, the average difference between the two analyses was not significant as well ( p = 0.22). 3.2. Results of the total healthy subjects (Table 1) The mean abduction–adduction range of motion was 518. The mean flexion–extension range of motion was 448. The mean parameters of circumduction ua, ub, and b were respectively 50, 64 and 578. The mean angle of axial rotation of the thumb was 218. 3.3. Comparison between male and female subjects (Fig. 3)
Fig. 4. Comparison between right and left hands (F–E: flexion–extension; Abd–Add: abduction–adduction; AR: axial rotation; Circ: circumduction with the three parameters ua, ub and ß).
average ub angle was also wider in female subjects (688) when compared to male subjects (618). This difference was significant with p = 0.01 and p < 0.0001 respectively. The average b angle was wider in female subjects (588) than in male subjects (578) with no significant differences. 3.4. Comparison between right and left hands (Fig. 4)
The average flexion–extension range of motion in female subjects (488) was wider than in male subjects (418). The average abduction–adduction range of motion in females (538) was larger than in males (498). The average axial rotation was wider in male subjects (248) than in female subjects (198). The differences between male and female subjects were significant for flexion–extension ( p = 0.003), for abduction–adduction ( p = 0.006) and for axial rotation ( p < 0.0001). Concerning the circumduction, the average ua angle was wider in female subjects (528) than in male subjects (498). The Table 1 Parameters calculated from 200 healthy hands (in degrees for angles and millimetres for distances).
The average flexion–extension range of motion was 438 for right hands and 458 for left hands. The average abduction– adduction range-of-motion was 498 for right hands and 538 for left hands. The average axial rotation was 228 for right hands and 218 for left hands. The difference between right and left hands was not significant except for abduction–adduction ( p = 0.002). Concerning the circumduction, the average ua angle was the same between right hands and left hands (508). The average ub angle was 648 in right hands and 658 in left hands. The average b angle was smaller in right hands (578) than in left hands (588). No significant differences were found concerning circumduction. 4. Discussion
Total results Movement parameters
Mean (8)
Std
ua angle ub angle b angle Flexion–extension Abduction–adduction Axial rotation
50 64 57 44 51 21
10 12 5 12 10 9
Std: standard.
The clinical assessment of the TMC joint is difficult. Ex vivo studies are unable to evaluate the joint’s range of motion which is produced by the contribution of muscles and tendons action. They are able only to quantify the theoretic mobility of bone and ligament segments [1]. Therefore, the study of in vivo kinematics of the thumb becomes a necessity, since it is the only method that could provide a precise measurement protocol for the TMC joint’s range of motion.
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A few studies concerning in vivo kinematics have been developed using X-ray techniques [3,15]. These accurate protocols provide skin and bone movements. However, because of radiation exposure, X-ray cannot be routinely used in clinical practice. Moreover, axial rotation of the thumb is not easily calculated [15]. Non-invasive procedures are currently used to analyse joint kinematics. Regarding TMC joint, Kuo et al. used an electromagnetic tracking device to measure the thumb’s movement by placing skin markers [14]. The correlation between the skin markers and bone segments has been previously verified [15]. This study allowed the calculation of the circumduction by the use of a mathematical model based on the length of the first metacarpal. The thumb’s range of motion values were represented with a spherical area. However, the distance between the axes of rotation cannot be calculated with this method. Cheze et al. proposed an in vivo protocol with an optoelectronic device [13]. The wrist was immobilized with a splint and markers were placed on the thumb. Abduction– adduction, flexion–extension and circumduction and axial rotation were measured according standardized axes [16]. The results of range of motion calculations were similar to ours (Fig. 3). However, only 24 hands were studied. Coert et al. proposed a method to quantify the thumb’s circumduction with an electronic device [17]. However, the interphalangeal and metacarpophalangeal joints were not stabilized. Therefore, in this study, the TMC joint range-of-motion cannot be precisely calculated. The total range of motion found in our series is wider than in ex vivo kinematics studies [3,5]. Even though passive movements are performed in studies using ex vivo analysis, the joint mobility of frozen cadavers is most probably less because of plasticity tissue modifications. The range of motion was wider in female subjects for flexion–extension and abduction adduction except for axial rotation. These data may be explained by the greater joint laxity generally found in the female population. In clinical practice, the TMC joint range-of-motion may be measured with standard finger goniometer according to the same protocol even though precision is lower without optolectronic device. Abduction–adduction is the maximal range-of-motion of the first metacarpal in the plane of the nail thumb. Flexion–extension is the maximal range-of-motion of the first metacarpal in the perpendicular plane of the nail thumb. The first part of the finger goniometer must be placed on the palm plane (or the table plane if the hand rests on a table). The second part must be placed on the first metacarpal plane. In conclusion, the database of in vivo TMC joint range-ofmotion measures presented in this study will permit the comparison between a pathologic and a healthy basal joint. Moreover, it should help comparing the thumb’s range of
motion before and after trapeziectomy or TMC arthroplasty when assessing the outcome of different methods of treatment of TMC joint in osteoarthritis.
Acknowledgement The authors wish to thank L. Cessey and J. Etchard for their help in this study.
References [1] Kapandji A. Functional anatomy of the 1st web space. Ann Chir Main 1986;5(2):158–65. [2] Bettinger PC, Smutz WP, Linscheid RL, Cooney 3rd WP, An KN. Material properties of the trapezial and trapeziometacarpal ligaments. J Hand Surg [Am] 2000;25(6):1085–95. [3] Cooney 3rd WP, Lucca MJ, Chao EY, Linscheid RL. The kinesiology of the thumb trapeziometacarpal joint. J Bone Joint Surg Am 1981;63(9): 1371–81. [4] Imaeda T, Niebur G, An KN, Cooney 3rd WP. Kinematics of the trapeziometacarpal joint after sectioning of ligaments. J Orthop Res 1994;12(2):205–10. [5] Imaeda T, Niebur G, Cooney 3rd WP, Linscheid RL, An KN. Kinematics of the normal trapeziometacarpal joint. J Orthop Res 1994;12(2):197–204. [6] Imaeda T, Cooney WP, Niebur GL, Linscheid RL, An KN. Kinematics of the trapeziometacarpal joint: a biomechanical analysis comparing tendon interposition arthroplasty and total-joint arthroplasty. J Hand Surg [Am] 1996;21(4):544–53. [7] Kauer JM. Functional anatomy of the carpometacarpal joint of the thumb. Clin Orthop 1987;(220):7–13. [8] Miura T, Ohe T, Masuko T. Comparative in vivo kinematic analysis of normal and osteoarthritic trapeziometacarpal joints. J Hand Surg [Am] 2004;29(2):252–7. [9] Zancolli EA, Ziadenberg C, Zancolli Jr E. Biomechanics of the trapeziometacarpal joint. Clin Orthop 1987;220:14–26. [10] Uchiyama S, Cooney WP, Niebur G, An KN, Linscheid RL. Biomechanical analysis of the trapeziometacarpal joint after surface replacement arthroplasty. J Hand Surg [Am] 1999;24(3):483–90. [11] Najima H, Oberlin C, Alnot JY, Cadot B. Anatomical and biomechanical studies of the pathogenesis of trapeziometacarpal degenerative arthritis. J Hand Surg [Br] 1997;22(2):183–8. [12] Momose T, Nakatsuchi Y, Saitoh S. Contact area of the trapeziometacarpal joint. J Hand Surg [Am] 1999;24(3):491–5. [13] Cheze L, Doriot N, Eckert M, Rumelhart C, Comtet JJ. In vivo cinematic study of the trapezometacarpal joint. Chir Main 2001;20(1):23–30. [14] Kuo LC, Cooney WP, Chen QS, Kaufman KR, Su FC, An KN. A kinematic method to calculate the workspace of the trapeziometacarpal joint. Proc Inst Mech Eng [H] 2004;218(2):143–9. [15] Kuo LC, Cooney 3rd WP, Oyama M, Kaufman KR, Su FC, An KN. Feasibility of using surface markers for assessing motion of the thumb trapeziometacarpal joint. Clin Biomech (Bristol Avon) 2003;18(6):558– 63. [16] Dumas R, Cheze L, Fayet M, Rumelhart C, Comtet JJ. How to define the joint movements unambiguously: proposal of standardization for the trapezometacarpal joint. Chir Main 2008;27(5):195–201. [17] Coert J, Hoek van Dijke G, Hovius S, Snijders C, Meek M. Quantifying thumb rotation during circumduction utilizing a video technique. J Orthop Res 2003;21:1151–5.