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

Bony Anatomy[edit | edit source]

The hand and wrist have 27 bones arranged to roll, spin and slide[1], 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. From medial to lateral, they are arranged as follows:[2]

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[3].

The hand is divided into three regions[4]

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

The forearm consists of the radius and ulna and a complex and interrelated set of joints

  • distal radioulnar joint
  • proximal radioulnar joint
  • soft tissue stabilizers between the 3 bones
  • triangular fibrocartilage complex at the wrist (The crucial stabiliser)
  • annular ligament at the elbow
  • interosseous membrane in the forearm (load transmission from radius to ulna[5])
  • palmar and dorsal radioulnar ligaments

This arrangement guarantees the stability of the joint throughout pronation and supination[6]

Disruptions in these structures may lead to forearm instability[7].

Skeletal System Phalanges - 89698643

Joints in the Wrist and Hand[edit | edit source]

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) trapezium 1st metacarpal Saddle Flexion-extension; Abduction-adduction; circumduction; opposition
Carpometacarpal joint (fingers) trapezoid, trapezium

capitate

capitate, hamate

hamate

2nd metacarpal

3rd metacarpal

4th metacarpal

5th metacarpal

Ellipsoidal Flexion-extension
Metacarpophalangeal joints Metacarpals phalangeal Ellipsoidal Flexion, extension, abduction, adduction, circumduction
Interphalangeal Proximal phalangeal Distal phalangeal Hinge Flexion (lots) Extension (minimal)

Table summarised from The Physiology of the Joints: Volume 1, The Upper Limb. 5th Ed.[8]

Range of Motion in the Wrist and Hand[edit | edit source]

Movement Muscles Range Origin Insertion Innervation Joint
Flexion Flexor carpi radialis 0-80 Medial Epicondyle of the humerus 2nd and 3rd metacarpals Median nerve (C6,7) 60% mid-carpal joint

40% radiocarpal joint

Flexor carpi ulnaris Medial epicondyle of humerus and sup.post. border of ulna Pisiform, hamate and base 5th metacarpal Ulnar nerve (C7,8)
Palmaris longus Medial epicondyle of humerus Flexor reinaculum and palmar aponeurosis Median nerve (C8)
Flexor digitorum superficialis Medial epicondyle of humerus, coronoid process of

ulna, and a ridge along the lateral margin of the anterior surface of the radius

Middle phalanges of each finger Median nerve (C7,8 T1)
Flexor digitorum profundus Anterior medial surface of the body of the ulna Base of distal phalanx of thumb Median nerve (C7,8, T1)

Ulnar nerve (C8, T1)

Flexor pollicis longus Anterior surface of radius and interosseous membrane Base of distal phalanx of thumb Median nerve (C8, T1)
Extension Extensor carpi radialis longus 0-70 Lateral supracondylar ridge of humerus 2nd metacarpal Radial nerve (C6,7) 40% mid carpal joint

60% radiocarpal joint

Extensor carpi radialis brevis Lateral epicondyle of humerus Distal and middle phalanges of each finger Radial nerve (C6,7)
Extensor carpi ulnaris Lateral epicondyle of the humerus and posterior border of ulna 5th metacarpal Radial nerve (C7,8)
Extensor digitorum Lateral epicondyle of humerus Distal and middle phalanges of each finger Radial nerve (C7,8)
Extensor indicis Posterior surface of ulna Tendon of extensor digitorum of the index finger Radial nerve (C7, 8)
Extensor digiti minimi Lateral epicondyle of humerus Tendon of extensor digitorum on 5th phalanx Radial nerve (C7,8)
Extensor pollicis longus Posterior surface of the middle of radius and ulna and interosseous membrane 1st metacarpal Radial nerve (C7,8)
Extensor pollicis brevis Posterior surface of the middle of the radius Base of proximal phalanx of thumb Radial nerve (C7,8)
Radial deviation Flexor carpi radialias 10-20 Medial Epicondyle of the humerus 2nd and 3rd metacarpals Median nerve (C6,7) Radiocarpal Jt
Ulnar deviation Flexor carpi ulnaris 30-40 Medial epicondyle of humerus and sup.post. border of ulna Pisiform, hamate and base 5th metacarpal Ulnar nerve (C7,8) Radiocarpal Jt
Supination

(of the forearm)

Supinator 60 Lateral epicondyle of humerus and ridge near radial notch of the ulna Lateral surface of proximal one-third of radius Radial nerve (C5,6) Sup. and inf.radioulnar jt
Biceps brachii Long head - supraglenoid tubercle; Short head - coracoid process of scapula Radial tuberosity and bicipital aponeurosis Musculocutaneous nerve (C5,6)
Brachioradialis Medial and lateral borders of the distal end of humerus Superior to the styloid process of the radius Radial Nerve (C5,6)
Pronation

(of the forearm)

Pronator teres 40 Medial epicondyle of humerus and coronoid process of ulna Midlateral surface of radius Median nerve (C6,7) Sup.and inf.radioulnar jt
Pronator quadratus Distal portion of the shaft of ulna Distal portion of the shaft of radius Median nerve (C8, T1)
Brachioradialis Medial and lateral borders of the distal end of humerus Superior to the styloid process of the radius Radial nerve (C5,6)
Distal Interphalangeal
Proximal Interphalangeal

Table summarised from Anatomy and Human Movement: Structure and Function. 6th Ed.[9]

Tools Used to Measure the Range of Motion in the Wrist and Hand[edit | edit source]

[10] [11] [12]

Goniometer Inclinometer Cellphone Inclinometer[13]
Pros Compact, easy to use and portable Accurate and measures multiple planes Accurate measures multiple planes, free downloadable app, convenient
Limitations Only one plane of movement Bulky and expensive

Reason to Measure[edit | edit source]

The main reason to measure is that you have an accurate baseline on to base your rehab and progression.

Considerations When Measuring Wrist Flexion and Extension[edit | edit source]

1. Coupling[edit | edit source]

Coupling occurs in the wrist while performing flexion–extension and radial–ulnar deviation[14] movements. The maximal wrist range of motion is near the neutral position. The wrist should be placed at a neutral position in workstation design to account for the naturally coupled wrist motion[15].

2. Open versus closed hand[edit | edit source]

Open vs closed hand

Flexion

  • Open hand = joint
  • Closed hand = soft tissue

Extension

  • Open hand = soft tissue
  • Closed hand = joint


References[edit | edit source]

  1. Maitland, G.D. Maitland's Peripheral Manipulations. 3rd Edition Edinburg: Elsevier Butterworth-Heinemann, 1999
  2. Al-Khater KM, Hegazi TM, Al-Thani HF, Al-Muhanna HT, Al-Hamad BW, Alhuraysi SM, Alsfyani WA, Alessa FW, Al-Qwairi AO, Al-Qwairi AO, Bayer SB. Time of appearance of ossification centres in carpal bones: A radiological retrospective study on Saudi children. Saudi Medical Journal. 2020;41(9):938.
  3. Chim H. Hand and Wrist Anatomy and Biomechanics: A Comprehensive Guide. Plast Reconstr Surg. 2017 Oct;140(4):865.
  4. Physical Examination of the Spine and Extremities. Hoppenfield, S. New York: Appleton-Century-Crofts, 1976.
  5. Spies CK, Langer M, Müller LP, Oppermann J, Löw S, Unglaub F. Anatomy and biomechanics of the distal radioulnar joint. Der Orthopade. 2018 Aug 1;47(8):621-7.
  6. Soubeyrand M, Assabah B, Bégin M, Laemmel E, Dos Santos A, Crézé M. Pronation and supination of the hand: anatomy and biomechanics. Hand Surgery and Rehabilitation. 2017 Feb 1;36(1):2-11.
  7. Adams JE. Forearm instability: anatomy, biomechanics, and treatment options. The Journal of hand surgery. 2017 Jan 1;42(1):47-52.
  8. Kapandji IA. Upper limb. The physiology of the joints-annotated diagrams of the mechanics of the human joints. 1982;1:108-29.
  9. Palastanga N, Soames R. Anatomy and Human Movement: Structure and Function. 6th Ed. London: Churchill Livingstone, 2012
  10. Kassay AD, Daher B, Lalone EA. An wrist and forearm range of motion analysis using the Dartfish motion analysis system. Journal of Hand Therapy. 2020 Sep 21.
  11. Modest J, Clair B, DeMasi R, Meulenaere S, Howley A, Aubin M, Jones M. Self-measured wrist range of motion by wrist-injured and wrist-healthy study participants using a built-in iPhone feature as compared with a universal goniometer. Journal of Hand Therapy. 2019 Oct 1;32(4):507-14.
  12. Pourahmadi MR, Ebrahimi Takamjani I, Sarrafzadeh J, Bahramian M, Mohseni‐Bandpei MA, Rajabzadeh F, Taghipour M. Reliability and concurrent validity of a new iP hone® goniometric application for measuring active wrist range of motion: a cross‐sectional study in asymptomatic subjects. Journal of anatomy. 2017 Mar;230(3):484-95
  13. Pourahmadi MR, Ebrahimi Takamjani I, Sarrafzadeh J, Bahramian M, Mohseni‐Bandpei MA, Rajabzadeh F, Taghipour M. Reliability and concurrent validity of a new iPhone® goniometric application for measuring active wrist range of motion: a cross‐sectional study in asymptomatic subjects. Journal of anatomy. 2017 Mar;230(3):484-95.
  14. Akhbari B, Moore DC, Laidlaw DH, Weiss AC, Akelman E, Wolfe SW, Crisco JJ. Predicting Carpal Bone Kinematics Using an Expanded Digital Database of Wrist Carpal Bone Anatomy and Kinematics. J Orthop Res. 2019 Dec;37(12):2661-2670.
  15. Li ZM, Kuxhaus L, Fisk JA, Christophel TH. Coupling between wrist flexion–extension and radial–ulnar deviation. Clinical biomechanics. 2005 Feb 1;20(2):177-83.