Sporting Hand and Wrist - What to Consider When Measuring Range of Motion

Bony Anatomy

The hand and wrist have a total of 27 bones arranged to roll, spin and slide[Maitland, G.D. Maitland's Peripheral Manipulations. 3rd Edition Edinburg: Elsevier Butterworth-Heinemann, 1999]; allowing the hand to explore and control the environment and objects.

The carpus is formed from eight small bones collectively referred to as the carpal bones. The carpal bones are bound in two groups of four bones:

• the pisiform, triquetrum, lunate and scaphoid on the upper end of the wrist
• the hamate, capitate, trapezoid and trapezium on the lower side of the hand.

Other bones of the hand are:

• the metacarpals – the five bones that comprise the middle part of the hand
• the phalanges (singular phalanx) – the 14 narrow bones that make up the fingers of each hand. Each finger has three phalanges (the distal, middle, and proximal); the thumb has two.

The hand is divided into three regions[Physical Examination of the Spine and Extremities. Hoppenfield, S. New York: Appleton-Century-Crofts, 1976.]

• Proximal region of the hand is the carpus (wrist)
• The middle region the metacarpus (palm)
• The distal region the phalanges (fingers)

Joints in the wrist and hand

Joint	Proximal articulation	Distal Articulation	Type	Movement
Radiocarpal joint	Radius and articular disc/ concave	Scaphoid, lunate, triquetrum / – convex	Ellipsoid	Flexion-extension; Abduction-adduction
Midcarpal joint	Scaphoid. Lunate, Triquetrum	Trapezium, Trapezoid, Capitate, Hamate	Gliding	Flexion-extension; Abduction-adduction
Carpometacarpal joint (thumb)	1st metacarpal	trapezium	Saddle	Flexion-extension; Abduction-adduction; circumduction; opposition
Carpometacarpal joint (fingers)	2nd metacarpal 3rd metacarpal 4th metacarpal 5th metacarpal	trapezoid, trapezium capitate capitate, hamate hamate	Ellipsoidal	Flexion-extension
Metacarpophalangeal joints	Metacarpals	phalangeal	Ellipsoidal	Flexion, extension, abduction, adduction, circumduction
Interphalangeal	Distal phlangeal	Proximal phalangeal	Hinge	Flexion (lots) Extension (minimal)

Range of motion in the wrist and hand

1. Flexion

When looking at flexion, roughly about 90 degrees. 60% of it is coming from that midcarpal joint that we discussed, the more distal joint versus 40% coming from the radiocarpal joint. So you can see if there's more movement happening from the midcarpal joint, or even not to get confused, that there's a big percentage, you know, almost half, but more than half happening from that midcarpal joint, we need to know how to measure it. And so that's where it comes when we talk about the how, to try and make sure we incorporate that.

2. Extension

Extension tends to be a bit less. Depends obviously, what type of sport you do? You always have these exceptions, but tends to be a bit less, 80 degrees. But now it's reversed. So you have more movement that tends to occur at your radiocarpal joint than your midcarpal joint. And that's really is occurring because of the mechanics of the scaphoid, which I'm not going to dwell into detail over here because we're trying to keep it uncomplicated rather than complicated, but just an understanding that obviously, if you're doing flexion and extension, you have a component of radiocarpal and midcarpal joint.

3. Radial deviation

The same can be said then for your radial deviation and also your ulnar deviation. So to go back to radial deviation, you can see like flexion, you have a bit more of that midcarpal joint occurring versus radial and the movements are about up to 20 degrees. Ulnar deviation tends to be more. It tends to be double. So almost a ratio of twos to one, ulnar deviation versus radial deviation. But again, that's if it's from a normative population, you have to see the type of athletes they are, what are they doing? You tend to have compensations, but obviously, it's good understanding of knowing you're left to right. So again, you can see like flexion and radial deviation, a bit more midcarpal joint. So really what we need to take away from here to try to keep it simple, movements are happening from both the midcarpal joint and the radiocarpal joint. So it's an understanding that when we're measuring, we need to measure that.

4. Ulnar deviation

5. Distal interphalangeal

6. Proximal Interphalangeal

7. Pronation

not directly because it's pertained to the wrist, although you can see with external forces, you are going to get that additional 10% or additional movement and torsion happening over there. But it is important because pathology is like, your TFCCs. Pathologies, which involve these sort of pronation supination movements, which is very big in sports, you know, think about golf. Think about, you know, your rugby's, your movements. Think about your tennis. So what other movements you're doing and whether they have obviously that external force or not, you need that movement and if that is obviously limited, it can require more movements to occur, more distally

8. Supination

Tools used to measure range of motion in the wrist and hand

• 

  Goniometer position for wrist flexion and extension

• 

  Inclinometer

• 

  Cellphone Inclinometer

	Goniometer	Inclinometer	Cellphone Inclinometer
Pros	Compact, easy to use and portable	Accurate and measures multiple planes	Accurate, measures multiple planes, free downloadable appconvenient
Limitations	Only one plane of movement	Bulky and expensive

Considerations when measuring wrist flexion and extension

• 

  Extension/radial deviation

• 

  Neutral

• 

  Flexion/Ulnar deviation

Coupling

Open versus closed hand

Open vs closed hand

Flexion

• Open hand = joint
• Closed hand = soft tissue

Extension

• Open hand = soft tissue
• Closed hand = joint

Reason to measure

Baseline

Gupta and Moosawy 2005, talking about that free movement and external forces and the difference about those, how the impact on the radiocarpal joint