Eur J Trauma Emerg Surg (2016) 42:11–14 DOI 10.1007/s00068-016-0640-2
REVIEW ARTICLE
Wrist motion analysis in scaphoid nonunion S. Gehrmann1 · T. Roeger1 · R. Kaufmann3 · A. Schaedle2 · T. Lögters1 · J. Windolf1
Received: 27 September 2015 / Accepted: 15 January 2016 / Published online: 27 January 2016 © Springer-Verlag Berlin Heidelberg 2016
Abstract Introduction The motion of human wrist is a complex and multidirectional process. The aim of this study was to develop a reliable and practicable method to measure motion impairment of the wrist in patients who incurred a scaphoid nonunion. A scaphoid nonunion in computed tomography as well as the consent in this study was required. Methods A total of nine patients with unilateral scaphoid nonunion accomplished maximal circumferential wrist movements. The wrist movements were measured with an electrogoniometer (Biometrics Ltd.). To quantify maximal wrist motion we constructed the maximal boundaries of the wrist motion from angular plots in flexion–extension (FE) and radio-ulnar deviation (RUD). We calculated the area of the circumduction envelope, the ranges of motion in FE and RUD and the main axis in wrist motion (dart-throwinmotion). The collected data were reconstructed with a custom-made MatLab program. We compared the impaired with the unimpaired side of each patient and analyzed with student’s t test. Results A scaphoid nonunion significantly reduced motion ranges in flexion/extension but not in ulnar and radial deviation. The overall mobility as quantified by the area of the circumduction envelope, decreased significantly.
* S. Gehrmann [email protected]‑duesseldorf.de 1
Department of Trauma and Hand Surgery, University Clinic Düsseldorf, Düsseldorf, Germany
2
Applied Mathematics Group of the Mathematical Institute of the Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
3
Department of Orthopedic Surgery, UPMC, Pittsburgh, USA
The circumduction boundaries of the wrists showed a kidney-shaped configuration with an oblique axis from radial/ extension to ulnar/flexion. Conclusion Our results demonstrate that scaphoid nonunion without pain has motion deficits and may be poorly quantified with conventional manual goniometers. Keywords Wrist motion · Scaphoid nonunion · Fracture · Motion analysis
Introduction The active range of wrist motion that is comfortably achieved is often used to quantify hand and wrist function after trauma. After having sustained a scaphoid nonunion, pre-intervention wrist function and post-intervention recovery may be characterized through a variety of methods. The SF-36 or the Katz-Index may be employed as well as upper extremity specific measurement scores such as the DASH or PRWE [3, 8]. The degree of discomfort that remains, as well as the subject’s overall happiness and ability to perform activities of daily living are, therein, quantified. Objective parameters such as wrist function, range of motion, grip strength and radiographic appearance are also employed. Some scoring systems, such as the Mayo wrist score [1], Gartland and Werley [5], Stewart [10], Castaing [4] and the Demerit-point system [9] include both subjective and objective parameters. As scaphoid nonunion leads to significant impairment of wrist function, most of the scores detect detrimental effects on daily living activities. So far, multidirectional wrist motion has not yet been quantified in patients with scaphoid nonunion. A central theme for the characterization of wrist function resides in the active range of motion that is comfortably
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achieved. Clinical studies, therefore, reliably measure this active range of motion and usually do so with a handheld goniometer, which can be rather imprecise, however. Noninvasive position registration using this technique can reproducibly quantify wrist range of motion status posttrauma or surgical intervention. The full motion potential is quantified and a circumduction envelope created. The goal of this study was to accurately characterize wrist range of motion in patients who were status preoperative with unilateral scaphoid nonunion. These measurements have been compared to the uninjured contralateral wrist.
Materials and methods In a prospective cohort study, range of motion was quantified in patients with unilateral scaphoid nonunion. The diagnosis of scaphoid nonunion was provided by clinical examination, conventional radiograph and computed tomography (Fig. 1). The participants in this study signed informed consent and required to be between the ages of 18 and 85 years. Exclusion criteria were any prior limitation in range of motion in hand or wrist as well as sources of pain unrelated to the scaphoid nonunion. The multidirectional motion of wrist was measured with the assistance of a noninvasive biaxial electrogoniometer (Biometrics Ltd., UK) which is superior to the use of conventional goniometer due to its ability to continuously quantifying wrist motion. This method allowed quantification of the full circumduction envelope, maximal flexion/extension and radio-ulnar deviation and to calculate the dart-throwing motion.
S. Gehrmann et al.
The measurements with the electrogoniometer are based on anatomic landmarks that are typically used during clinical examination, namely the long axis of the third metacarpal as well as the long axis of the forearm. The positioning of the end blocks of the goniometer was standardized. The end blocks were attached to the dorsal surface using double-sided tape, the distal one over the third metacarpal, the other one over the midline of the dorsal forearm, with the wrist in neutral position. The examination started always with the uninjured wrist first. The subject was asked to be seated on a height-adjustable chair with the elbow at 90° flexion with neutral pronation and supination. The forearm was placed with ulnar border in a thermal plastic splint and fixed with two Velcro fasteners. The motion of the wrist was not restricted. After control of the right position of the electrogoniometer blocks the subjects were encouraged to move their wrist through a maximal arc of motion without rotating their forearm and without any level of discomfort. Speed, direction of circumduction and finger position were freely selectable by the subject. During the first five circumductions the subject was trained to perform a maximal circumduction with the wrist without using the forearm. After that the measurement started and another five circumductions were performed with maximal range of motion. When the assessment of the uninjured arm was completed, the arm was removed from the splint and the patient turned around and placed the other arm into the splint to start the assessment of the injured wrist. The motion data were digitally recorded and then evaluated on a Matlab program that was specially designed for this study (Fig. 2). Once the data were analyzed, a graphical interface allowed the creation of motion curves that would better demonstrate the circumduction envelope of motion. The full envelope of motion allowed for excellent characterization of the range of motion in each arm. The characterized parameters were the cross-sectional area of the circumduction envelope and the maximal motion in flexion/extension and radial/ulnar abduction. After analysis of the recorded data motion curves, circumduction curves were created with a graphical interface program.
Results
Fig. 1 Scaphoid nonunion of the waist
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A total of nine patients with identified scaphoid nonunion of the waist were enrolled in this study of which one was female and nine were male with an average age of 42 years (±8 years). Subjects did not suffer from concomitant diseases as flexor or extensor tenosynovitis or complex regional pain syndrome. Mild posttraumatic arthritis was radiographically identifiable in all patients. The DASH scores averaged 33.8 ± 23.3 points.
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Wrist motion analysis in scaphoid nonunion
Fig. 2 MatLab program interface with recorded motion data while wrist circumduction
The flexion/extension motion of the wrist with scaphoid nonunion was significantly smaller when compared to the uninjured side. The motion arc in the uninjured side was 100.1° ± 21.4° of flexion and extension and 77.8° ± 19.4° on the injured side (p
REVIEW ARTICLE
Wrist motion analysis in scaphoid nonunion S. Gehrmann1 · T. Roeger1 · R. Kaufmann3 · A. Schaedle2 · T. Lögters1 · J. Windolf1
Received: 27 September 2015 / Accepted: 15 January 2016 / Published online: 27 January 2016 © Springer-Verlag Berlin Heidelberg 2016
Abstract Introduction The motion of human wrist is a complex and multidirectional process. The aim of this study was to develop a reliable and practicable method to measure motion impairment of the wrist in patients who incurred a scaphoid nonunion. A scaphoid nonunion in computed tomography as well as the consent in this study was required. Methods A total of nine patients with unilateral scaphoid nonunion accomplished maximal circumferential wrist movements. The wrist movements were measured with an electrogoniometer (Biometrics Ltd.). To quantify maximal wrist motion we constructed the maximal boundaries of the wrist motion from angular plots in flexion–extension (FE) and radio-ulnar deviation (RUD). We calculated the area of the circumduction envelope, the ranges of motion in FE and RUD and the main axis in wrist motion (dart-throwinmotion). The collected data were reconstructed with a custom-made MatLab program. We compared the impaired with the unimpaired side of each patient and analyzed with student’s t test. Results A scaphoid nonunion significantly reduced motion ranges in flexion/extension but not in ulnar and radial deviation. The overall mobility as quantified by the area of the circumduction envelope, decreased significantly.
* S. Gehrmann [email protected]‑duesseldorf.de 1
Department of Trauma and Hand Surgery, University Clinic Düsseldorf, Düsseldorf, Germany
2
Applied Mathematics Group of the Mathematical Institute of the Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
3
Department of Orthopedic Surgery, UPMC, Pittsburgh, USA
The circumduction boundaries of the wrists showed a kidney-shaped configuration with an oblique axis from radial/ extension to ulnar/flexion. Conclusion Our results demonstrate that scaphoid nonunion without pain has motion deficits and may be poorly quantified with conventional manual goniometers. Keywords Wrist motion · Scaphoid nonunion · Fracture · Motion analysis
Introduction The active range of wrist motion that is comfortably achieved is often used to quantify hand and wrist function after trauma. After having sustained a scaphoid nonunion, pre-intervention wrist function and post-intervention recovery may be characterized through a variety of methods. The SF-36 or the Katz-Index may be employed as well as upper extremity specific measurement scores such as the DASH or PRWE [3, 8]. The degree of discomfort that remains, as well as the subject’s overall happiness and ability to perform activities of daily living are, therein, quantified. Objective parameters such as wrist function, range of motion, grip strength and radiographic appearance are also employed. Some scoring systems, such as the Mayo wrist score [1], Gartland and Werley [5], Stewart [10], Castaing [4] and the Demerit-point system [9] include both subjective and objective parameters. As scaphoid nonunion leads to significant impairment of wrist function, most of the scores detect detrimental effects on daily living activities. So far, multidirectional wrist motion has not yet been quantified in patients with scaphoid nonunion. A central theme for the characterization of wrist function resides in the active range of motion that is comfortably
13
12
achieved. Clinical studies, therefore, reliably measure this active range of motion and usually do so with a handheld goniometer, which can be rather imprecise, however. Noninvasive position registration using this technique can reproducibly quantify wrist range of motion status posttrauma or surgical intervention. The full motion potential is quantified and a circumduction envelope created. The goal of this study was to accurately characterize wrist range of motion in patients who were status preoperative with unilateral scaphoid nonunion. These measurements have been compared to the uninjured contralateral wrist.
Materials and methods In a prospective cohort study, range of motion was quantified in patients with unilateral scaphoid nonunion. The diagnosis of scaphoid nonunion was provided by clinical examination, conventional radiograph and computed tomography (Fig. 1). The participants in this study signed informed consent and required to be between the ages of 18 and 85 years. Exclusion criteria were any prior limitation in range of motion in hand or wrist as well as sources of pain unrelated to the scaphoid nonunion. The multidirectional motion of wrist was measured with the assistance of a noninvasive biaxial electrogoniometer (Biometrics Ltd., UK) which is superior to the use of conventional goniometer due to its ability to continuously quantifying wrist motion. This method allowed quantification of the full circumduction envelope, maximal flexion/extension and radio-ulnar deviation and to calculate the dart-throwing motion.
S. Gehrmann et al.
The measurements with the electrogoniometer are based on anatomic landmarks that are typically used during clinical examination, namely the long axis of the third metacarpal as well as the long axis of the forearm. The positioning of the end blocks of the goniometer was standardized. The end blocks were attached to the dorsal surface using double-sided tape, the distal one over the third metacarpal, the other one over the midline of the dorsal forearm, with the wrist in neutral position. The examination started always with the uninjured wrist first. The subject was asked to be seated on a height-adjustable chair with the elbow at 90° flexion with neutral pronation and supination. The forearm was placed with ulnar border in a thermal plastic splint and fixed with two Velcro fasteners. The motion of the wrist was not restricted. After control of the right position of the electrogoniometer blocks the subjects were encouraged to move their wrist through a maximal arc of motion without rotating their forearm and without any level of discomfort. Speed, direction of circumduction and finger position were freely selectable by the subject. During the first five circumductions the subject was trained to perform a maximal circumduction with the wrist without using the forearm. After that the measurement started and another five circumductions were performed with maximal range of motion. When the assessment of the uninjured arm was completed, the arm was removed from the splint and the patient turned around and placed the other arm into the splint to start the assessment of the injured wrist. The motion data were digitally recorded and then evaluated on a Matlab program that was specially designed for this study (Fig. 2). Once the data were analyzed, a graphical interface allowed the creation of motion curves that would better demonstrate the circumduction envelope of motion. The full envelope of motion allowed for excellent characterization of the range of motion in each arm. The characterized parameters were the cross-sectional area of the circumduction envelope and the maximal motion in flexion/extension and radial/ulnar abduction. After analysis of the recorded data motion curves, circumduction curves were created with a graphical interface program.
Results
Fig. 1 Scaphoid nonunion of the waist
13
A total of nine patients with identified scaphoid nonunion of the waist were enrolled in this study of which one was female and nine were male with an average age of 42 years (±8 years). Subjects did not suffer from concomitant diseases as flexor or extensor tenosynovitis or complex regional pain syndrome. Mild posttraumatic arthritis was radiographically identifiable in all patients. The DASH scores averaged 33.8 ± 23.3 points.
13
Wrist motion analysis in scaphoid nonunion
Fig. 2 MatLab program interface with recorded motion data while wrist circumduction
The flexion/extension motion of the wrist with scaphoid nonunion was significantly smaller when compared to the uninjured side. The motion arc in the uninjured side was 100.1° ± 21.4° of flexion and extension and 77.8° ± 19.4° on the injured side (p
