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The range of motion of the metacarpophalangeal joint of the thumb and its relationship to injury
THE RANGE OF MOTION OF THE METACARPOPHALANGEAL JOINT OF THE THUMB AND ITS RELATIONSHIP TO INJURY S. J.
SHAW and M. A. MORRIS
From the Stockport Infirmary
A wide variation in the range of flexion of the metacarpo-phalangeal joint of the thumb in normal individuals is described. Patients with a poor range of flexion at this joint have a signifkantly higher incidence of indirect soft-tissue injury to the joint. Journal of Hand Surgery (British- V&me, 1492) Ii ‘B : 164-166
The range of motion of the M.P. joint of the thumb is variable within any group of individuals (Wilgress, 1898) and, although attempts have been made to quantify this variability, some confusion still exists as to the total range of motion that may be expected at this joint (Brown and McGrouther, 1984). The purpose of our study was twofold: first, to investigate the distribution of range of motion at the thumb M.P. joint in a given population and, second, to ascertain whether any relationship existed between the range of motion of the joint and the type of injury to the joint. Patients and methods 10
Patients attending the orthopaedic out-patients department over a six-week period were included in the first part of the study. Children under the age of 16 years or those with active inflammatory disease were excluded. These patients had no recent injury to the thumb and were regarded as normal controls. Details of their age, sex and any previous thumb injury or operation were noted on a standard proforma specially designed for this study. The active range of motion at the M.P. and I.P. joints of both thumbs was measured using both a goniometer and a malleable wire and the average of three measurements of each was recorded. For the second part of the study, every patient attending the Accident and Emergency Department with a thumb injury over a two-week period was seen in a special clinic for review. Active thumb movements of the uninjured thumb were recorded as before.
20
30
40
50
60
70
60
90
100
R.O.M. IN DEGREES
Fig. 1 Distribution of I.P. joint motion.
Table l-Means
and standard deviations of angles of flexion of I.P. joints
Sex
Male Female
Number 199 199 149 149
Side Left Right Left Right
Mean
S.D.
63.21 64.16 66.91 65.32
11.85 12.52 12.54 12.02
The means and standard deviations may be seen in Table 1. There was no significant difference in the values obtained between males and females or between right and left sides. Moreover, there was a high coefficient of correlation between the results obtained from opposite thumbs in both males and females (r=0.67 and 0.61 respectively).
Results Uninjured thumbs 348 patients were included in the first part of the study, with an age range of 16 to 86 years (mean 54 years). There were 199 males and 149 females.
joints. There was again considerable variation between individuals and the amount of flexion to be expected at the M.P. joint (Fig. 2). The greatest angle recorded was 86” and the smallest was 6”. The distribution was symmetrical and the means and standard variations of the right and left sides in both males and females are shown in Table 2. Metacarpo-phalangeal
There was a fairly symmetrical distribution of the range of motion at the interphalangeal joints (Fig. l), although considerable variability existed between individuals. The smallest angle was 28” and the greatest 95”. Znterphalangeal joints.
164
RANGE OF MOTION OF THE METACARPO-PHALANGEAL 120
There was no correlation between the angle of flexion at the I.P. joints and the maximum flexion of the M.P. joints. There was no evidence that limitation of flexion of the M.P. joint led to increased flexion at the I.P. joint.
100 u) g
165
JOINT OF THE THUMB
80
Injured thumbs
t ;m b *
40
P 20
0
10
20
30
40
50 R.O.M.
Fig. 2
Distribution
Table 2-Means joints
60
70
80
90
100
IN DEGREES
of M.P. joint motion.
and standard deviations of angles of Bexion of M.P.
Sex
Number
Male
199 199 149 149
Female
Side Left Right Left Right
Mean
S.D.
50.07 49.64 51.27 52.43
15.87 14.70 14.87 15.15
As was the case for the I.P. joints, there was no significant difference between the means of the males and females; nor was there a significant difference between the means of the right and left sides in both males and females. In both males and females there was a high correlation between the range of motion achieved in right and left thumbs (r = 0.81 and r = 0.77).
63 patients with injuries to the thumb were seen during the study period (Fig. 3). There were 15 patients with a laceration to the thumb, usually affecting the non-dominant side and occurring in a domestic setting. 11 patients had a contusion or subungual haematoma caused by a crush injury. 13 thumbs had sustained a fracture; four of the metacarpals and nine of the phalanges. The M.P. joint was dislocated in four patients and the I.P. joint in three. 17 had sustained an indirect soft-tissue injury around the M.P. joint, defined as local swelling or tenderness around the joint as a result of a forced hyperextension or sideways strain. A symmetrical distribution of motion was again obtained (Fig. 4). The means of the range of motion of the M.P. joint of the uninjured thumb for each group of injuries is shown in Table 3. The mean of the range of motion of the M.P. joint of the thumb in subjects with a soft-tissue injury around the joint was significantly less than the means in the other groups of injuries (P < 0.005). Discussion
The M.P. joint of the thumb is almost a hinge-joint, capable of flexion and a small amount of radial and ulnar movement. The range of flexion varies considerably. One factor which may cause this is the shape of the M.P.
INJURIES Soft-tissue to MP joint
Dislocations
Lacerations
(11 .l%)
Fractures Fig. 3
Distribution
of injuries.
(n = 63)
(20.6%)
(23.8%)
THE JOURNAL
10
20
30
40
50
60
70
80
90
100
R.O.M. IN DEGREES Fig. 4
Distribution of maximum flexion of M.P. joints sustaining softtissue injuries compared to that in M.P. joints with other injuries.
Table 3-Means aad standard deviations of angles of Bexion of M.P. joints ia injuredsubjects Number
Injury Laceration Contusion Soft-tissue Fractures Dislocated
injury to M.P.J. M.P. and I.P. Joints
15 11 17 13 7
Mean
S.D.
52.52 48.57 31.65; 52.12 43.43
14.87 15.03 7.96 13.66 11.76
4PCO.005
joint: subjects possessing a relatively flat metacarpal head have a smaller range of flexion (Harris and Joseph, 1949). However, it has been shown that subjects without a flat M.P. joint may also have a poor range of motion at the joint (Joseph, 1951) and it has been assumed that this is due to capsular tightness. The amount of flexion at the M.P. joint appears to be the same on both sides in individual subjects and we have therefore assumed that the degree of flexion in the uninjured thumb correlates well with the amount of motion in the injured thumb before it was injured.
OF HAND SURGERY
VOL. 178 No. 2 APRIL 1992
We suggest that a subject with decreased flexion of the M.P. joint of the thumb, whether it be due to flattening of the metacarpal head, capsular tightness or other factors, is less able to disseminate forces acting upon it and is therefore more susceptible to sprains and tears of the soft tissues which play a role in the stability of the joint. The number of subjects with dislocations of the M.P. joint was too small for statistical analysis but as dislocation is the end result of failure of the soft-tissue stabilising structures it may be that M.P. joint dislocation is another injury that subjects with poor M.P. joint flexion are susceptible to. Repair or reconstruction of the collateral ligaments of the thumb M.P. joint may be associated with postoperative stiffness of the joint (Strandell, 1959). This may have been over-estimated in the past however, as these subjects are the very ones who may have had relatively stiff joints before injury. Arthrodesis of the M.P. joint is one method of treatment for subjects with chronic instability of the M.P. joint of the thumb (Moberg and Stener, 1955), the alternative being reconstruction of the failed collateral ligament (Smith, 1977). One criticism of arthrodesis is the loss of function which occurs, but none of our subjects with severe congenital restriction of flexion at the M.P. joint was aware of any disability. References BROWN, C. P. and McGROUTHER, D. A. (1984). The excursionof the tendon of flexor pollicis longus and its relation to dynamic splintage. Journal of Hand Surgery, 9A: 4: 787-791. HARRIS, H. and JOSEPH, J. (1949). Variation in extension of the metacarpophalangeal and interphalangeal joints of the thumb. Journal of Bone and Joint Surgery, 31B: 4: 547-559. JOSEPH, J. (1951). Further studies of the metacarpo-phalangeal and interphalangeal joints of the thumb. Journal of Anatomy, 85: 1: 221-229. MOBERG, E. and STENER, B. (1955). Injuries to the ligaments of the thumb and fingers. Acta Chirurgica Scandinavica, 114: 166186. SMITH, R. J. (1977). Post-Traumatic Instability of the Metacarpophalangeal Joint of the Thumb. Journal of Bone and Joint Surgery, 59A: 1: 14-22. STRANDELL, G. (1959). Total Rupture of the Ulnar Collateral Ligament of the Metacarpo-phalangeal Joint of the Thumb. Results of surgery in 35 cases. Acta Chirurgica Scandinavica, 1I8 : 1: 72-8 1. WILGRESS, J. H. F. (1988). A note on hereditary stiffness of the metacarpophalangeal joint of the thumb. Journal of Anatomy of London, 32: 4: 753761. Accepted: 24 January 1991 Mr S. J. Shaw, F.R.C.S., Ed., 40 Beltkid 0
1992 The British
Society
for Surgery
Road,
Didsbury,
of the Hand
Manchester,
MZO OBH
SHAW and M. A. MORRIS
From the Stockport Infirmary
A wide variation in the range of flexion of the metacarpo-phalangeal joint of the thumb in normal individuals is described. Patients with a poor range of flexion at this joint have a signifkantly higher incidence of indirect soft-tissue injury to the joint. Journal of Hand Surgery (British- V&me, 1492) Ii ‘B : 164-166
The range of motion of the M.P. joint of the thumb is variable within any group of individuals (Wilgress, 1898) and, although attempts have been made to quantify this variability, some confusion still exists as to the total range of motion that may be expected at this joint (Brown and McGrouther, 1984). The purpose of our study was twofold: first, to investigate the distribution of range of motion at the thumb M.P. joint in a given population and, second, to ascertain whether any relationship existed between the range of motion of the joint and the type of injury to the joint. Patients and methods 10
Patients attending the orthopaedic out-patients department over a six-week period were included in the first part of the study. Children under the age of 16 years or those with active inflammatory disease were excluded. These patients had no recent injury to the thumb and were regarded as normal controls. Details of their age, sex and any previous thumb injury or operation were noted on a standard proforma specially designed for this study. The active range of motion at the M.P. and I.P. joints of both thumbs was measured using both a goniometer and a malleable wire and the average of three measurements of each was recorded. For the second part of the study, every patient attending the Accident and Emergency Department with a thumb injury over a two-week period was seen in a special clinic for review. Active thumb movements of the uninjured thumb were recorded as before.
20
30
40
50
60
70
60
90
100
R.O.M. IN DEGREES
Fig. 1 Distribution of I.P. joint motion.
Table l-Means
and standard deviations of angles of flexion of I.P. joints
Sex
Male Female
Number 199 199 149 149
Side Left Right Left Right
Mean
S.D.
63.21 64.16 66.91 65.32
11.85 12.52 12.54 12.02
The means and standard deviations may be seen in Table 1. There was no significant difference in the values obtained between males and females or between right and left sides. Moreover, there was a high coefficient of correlation between the results obtained from opposite thumbs in both males and females (r=0.67 and 0.61 respectively).
Results Uninjured thumbs 348 patients were included in the first part of the study, with an age range of 16 to 86 years (mean 54 years). There were 199 males and 149 females.
joints. There was again considerable variation between individuals and the amount of flexion to be expected at the M.P. joint (Fig. 2). The greatest angle recorded was 86” and the smallest was 6”. The distribution was symmetrical and the means and standard variations of the right and left sides in both males and females are shown in Table 2. Metacarpo-phalangeal
There was a fairly symmetrical distribution of the range of motion at the interphalangeal joints (Fig. l), although considerable variability existed between individuals. The smallest angle was 28” and the greatest 95”. Znterphalangeal joints.
164
RANGE OF MOTION OF THE METACARPO-PHALANGEAL 120
There was no correlation between the angle of flexion at the I.P. joints and the maximum flexion of the M.P. joints. There was no evidence that limitation of flexion of the M.P. joint led to increased flexion at the I.P. joint.
100 u) g
165
JOINT OF THE THUMB
80
Injured thumbs
t ;m b *
40
P 20
0
10
20
30
40
50 R.O.M.
Fig. 2
Distribution
Table 2-Means joints
60
70
80
90
100
IN DEGREES
of M.P. joint motion.
and standard deviations of angles of Bexion of M.P.
Sex
Number
Male
199 199 149 149
Female
Side Left Right Left Right
Mean
S.D.
50.07 49.64 51.27 52.43
15.87 14.70 14.87 15.15
As was the case for the I.P. joints, there was no significant difference between the means of the males and females; nor was there a significant difference between the means of the right and left sides in both males and females. In both males and females there was a high correlation between the range of motion achieved in right and left thumbs (r = 0.81 and r = 0.77).
63 patients with injuries to the thumb were seen during the study period (Fig. 3). There were 15 patients with a laceration to the thumb, usually affecting the non-dominant side and occurring in a domestic setting. 11 patients had a contusion or subungual haematoma caused by a crush injury. 13 thumbs had sustained a fracture; four of the metacarpals and nine of the phalanges. The M.P. joint was dislocated in four patients and the I.P. joint in three. 17 had sustained an indirect soft-tissue injury around the M.P. joint, defined as local swelling or tenderness around the joint as a result of a forced hyperextension or sideways strain. A symmetrical distribution of motion was again obtained (Fig. 4). The means of the range of motion of the M.P. joint of the uninjured thumb for each group of injuries is shown in Table 3. The mean of the range of motion of the M.P. joint of the thumb in subjects with a soft-tissue injury around the joint was significantly less than the means in the other groups of injuries (P < 0.005). Discussion
The M.P. joint of the thumb is almost a hinge-joint, capable of flexion and a small amount of radial and ulnar movement. The range of flexion varies considerably. One factor which may cause this is the shape of the M.P.
INJURIES Soft-tissue to MP joint
Dislocations
Lacerations
(11 .l%)
Fractures Fig. 3
Distribution
of injuries.
(n = 63)
(20.6%)
(23.8%)
THE JOURNAL
10
20
30
40
50
60
70
80
90
100
R.O.M. IN DEGREES Fig. 4
Distribution of maximum flexion of M.P. joints sustaining softtissue injuries compared to that in M.P. joints with other injuries.
Table 3-Means aad standard deviations of angles of Bexion of M.P. joints ia injuredsubjects Number
Injury Laceration Contusion Soft-tissue Fractures Dislocated
injury to M.P.J. M.P. and I.P. Joints
15 11 17 13 7
Mean
S.D.
52.52 48.57 31.65; 52.12 43.43
14.87 15.03 7.96 13.66 11.76
4PCO.005
joint: subjects possessing a relatively flat metacarpal head have a smaller range of flexion (Harris and Joseph, 1949). However, it has been shown that subjects without a flat M.P. joint may also have a poor range of motion at the joint (Joseph, 1951) and it has been assumed that this is due to capsular tightness. The amount of flexion at the M.P. joint appears to be the same on both sides in individual subjects and we have therefore assumed that the degree of flexion in the uninjured thumb correlates well with the amount of motion in the injured thumb before it was injured.
OF HAND SURGERY
VOL. 178 No. 2 APRIL 1992
We suggest that a subject with decreased flexion of the M.P. joint of the thumb, whether it be due to flattening of the metacarpal head, capsular tightness or other factors, is less able to disseminate forces acting upon it and is therefore more susceptible to sprains and tears of the soft tissues which play a role in the stability of the joint. The number of subjects with dislocations of the M.P. joint was too small for statistical analysis but as dislocation is the end result of failure of the soft-tissue stabilising structures it may be that M.P. joint dislocation is another injury that subjects with poor M.P. joint flexion are susceptible to. Repair or reconstruction of the collateral ligaments of the thumb M.P. joint may be associated with postoperative stiffness of the joint (Strandell, 1959). This may have been over-estimated in the past however, as these subjects are the very ones who may have had relatively stiff joints before injury. Arthrodesis of the M.P. joint is one method of treatment for subjects with chronic instability of the M.P. joint of the thumb (Moberg and Stener, 1955), the alternative being reconstruction of the failed collateral ligament (Smith, 1977). One criticism of arthrodesis is the loss of function which occurs, but none of our subjects with severe congenital restriction of flexion at the M.P. joint was aware of any disability. References BROWN, C. P. and McGROUTHER, D. A. (1984). The excursionof the tendon of flexor pollicis longus and its relation to dynamic splintage. Journal of Hand Surgery, 9A: 4: 787-791. HARRIS, H. and JOSEPH, J. (1949). Variation in extension of the metacarpophalangeal and interphalangeal joints of the thumb. Journal of Bone and Joint Surgery, 31B: 4: 547-559. JOSEPH, J. (1951). Further studies of the metacarpo-phalangeal and interphalangeal joints of the thumb. Journal of Anatomy, 85: 1: 221-229. MOBERG, E. and STENER, B. (1955). Injuries to the ligaments of the thumb and fingers. Acta Chirurgica Scandinavica, 114: 166186. SMITH, R. J. (1977). Post-Traumatic Instability of the Metacarpophalangeal Joint of the Thumb. Journal of Bone and Joint Surgery, 59A: 1: 14-22. STRANDELL, G. (1959). Total Rupture of the Ulnar Collateral Ligament of the Metacarpo-phalangeal Joint of the Thumb. Results of surgery in 35 cases. Acta Chirurgica Scandinavica, 1I8 : 1: 72-8 1. WILGRESS, J. H. F. (1988). A note on hereditary stiffness of the metacarpophalangeal joint of the thumb. Journal of Anatomy of London, 32: 4: 753761. Accepted: 24 January 1991 Mr S. J. Shaw, F.R.C.S., Ed., 40 Beltkid 0
1992 The British
Society
for Surgery
Road,
Didsbury,
of the Hand
Manchester,
MZO OBH