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Ulnar Extension Coupling in Functional Wrist Kinematics During Hand Activities of Daily Living

      Purpose

      Wrist circumduction is increasingly used as a functional motion assessment for patients. Thus, increasing our understanding of its relation to the functional motion envelope is valuable. Previous studies have shown that the wrist is preferentially extended during hand activities of daily living (ADLs), with greater ulnar than radial deviation. The purpose of this study was to characterize the functional wrist motions of 22 modern ADLs in healthy subjects. We hypothesized that the subjects would perform ADLs predominantly in ulnar extension.

      Methods

      Ten right-handed, healthy subjects performed flexion-extension, radioulnar deviation, maximal circumduction, and 22 modern ADLs. Angular wrist positions were obtained by tracking retroreflective markers on the hand and forearm. Angular motion data were analyzed with a custom program for peak/trough angles in flexion extension and radioulnar deviation, ellipse area of circumduction data, and ellipse area of combined motion data.

      Results

      The required ranges of motion for ADLs were from 46.6° ± 16.5° of flexion (stirring task) to 63.8° ± 14.2° of extension (combing) in flexion-extension and from 15.6° ± 8.9° of radial deviation (opening a jar) to 32.5° ± 8.3° of ulnar deviation (picking up smartphone) in radioulnar deviation. Ellipse area of combined motion data of the 22 ADLs were, on average, 58.2% ± 14.3% of the ellipse area of maximal circumduction. A motion data quadrantal analysis revealed that 54.9% of all ADL wrist motion occurred in ulnar extension. Among the average wrist positions for 22 ADLs, 16 were located in the ulnar extension quadrant.

      Conclusions

      This study revealed a functional wrist motion envelope that was less than 60% of wrist maximal motion capacity on average. Our results also showed that the majority of ADLs are performed in ulnar extension of the wrist.

      Clinical relevance

      Baseline values for healthy subjects performing 22 wrist ADLs can inform future studies assessing dysfunction, postsurgical changes, and rehabilitation progress.

      Key words

      Wrist function in humans has evolved through a complex relationship between carpal bones, supportive musculature and connective tissues, enabling us to write, dress ourselves, mix ingredients, twist doorknobs, and more. Motion of the wrist required for daily activities may be disrupted by pathology and/or trauma. Understanding wrist kinematics during modern activities of daily living (ADLs) is important for monitoring progress in rehabilitation, assessing functional impacts after surgical correction, providing guidance on functional requirements for implant design, and more.
      Movement at the radiocarpal and midcarpal joints allows for simultaneous rotation in anatomic planes. Wrist motion occurs in the sagittal plane (flexion-extension [FE]) and the coronal plane (radioulnar deviation [RUD]), with a relatively small range of rotation in the axial plane.
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      A biomechanical study of normal functional wrist motion.
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      Electrogoniometer measurement and directional analysis of wrist angles and movements during the Sollerman hand function test.
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      Electrogoniometer measurement and directional analysis of wrist angles and movements during the Sollerman hand function test.
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      The mechanical axes of the wrist are oriented obliquely to the anatomical axes.
      Given that ulnar deviation has the highest ROM in the coronal plane and that wrist extension is important to wrist function, it would be expected that manual ADLs predominately occur in the coupled wrist position of extension with ulnar deviation.
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      • Lieb M.
      • Benjamin J.
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      ,
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      • Azen S.P.
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      • Crisco J.J.
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      • Rich R.R.
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      The mechanical axes of the wrist are oriented obliquely to the anatomical axes.
      Wrist circumduction, the elliptical motion that includes all extreme positions of the wrist, may better dynamically assess global wrist functionality than assessments in each anatomical plane separately. Clinically, the senior author (W.S.) has found circumduction assessment to be more relevant than biplanar motion when monitoring functional competence in the wrist. The characterization of circumduction in normal, healthy subjects has been evaluated for changes in velocity, range, and smoothness throughout the motion.
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      Assessment of velocity, range, and smoothness of wrist circumduction using flexible electrogoniometry.
      A functional envelope of wrist motion has also been described to be approximately 20% of circumduction motion capacity, based on electrogoniometer data.
      • Dauncey T.
      • Singh H.P.
      • Dias J.J.
      Electrogoniometer measurement and directional analysis of wrist angles and movements during the Sollerman hand function test.
      Our study sought to reassess functional task space in relation to maximal circumduction with previously examined ADLs and modern ADLs using more advanced technology.
      The primary purpose of this study was to reexamine functional wrist kinematics using a motion tracking system while performing an updated list of 22 common ADLs. The secondary aim of this study was to identify preferred wrist positioning with respect to the maximal circumduction envelope. We quantified the functional arcs of motion in the FE and RUD motion planes for manual tasks of ADLs and maximal circumduction and described preferred wrist positions in relationship to the envelope of circumduction. We hypothesized that the preference of wrist position for functional manual tasks would be biased to ulnar extension.

      Materials and Methods

      Subjects

      Ten healthy, right-handed laboratory personnel (26.9 ± 2.0 years; 5 women and 5 men) participated as a sample of convenience. Subjects with a history of musculoskeletal or neuromuscular disorders associated with the hand and upper extremity were excluded. The experimental procedures were approved by the Institutional Review Board of Cleveland Clinic, and each participant signed an approved informed consent form.

      Marker placement

      Two clusters of retroreflective markers attached to planar rigid bodies, each consisting of 3 noncollinear, 11.5-mm markers, were affixed to the hand and forearm (Fig. 1A ) to measure the 3-dimensional kinematics of the wrist using a 7-camera motion capture system (Vicon Motion Systems Ltd). The hand rigid body with markers H1, H2, and H3 was affixed to the dorsal aspect of the metacarpals via a contoured foam base, and the forearm rigid body with markers F1, F2, and F3 was affixed proximal to the distal wrist extensor crease in longitudinal alignment with the middle-finger metacarpal, such that maximal extension was not limited. The rigid bodies were secured with double-sided adhesive tape and athletic underwrap. In addition, 3 noncollinear 14.5-mm retroreflective markers (J1, J2, and J3) were attached to a wooden board to establish a reference coordinate system for calibration (Fig. 1A).
      Figure thumbnail gr1
      Figure 1Calibration with the wrist at the anatomical neutral position, where the virtual forearm and hand coordinate systems, [F’] and [H’], were (1) in parallel with the jig coordinate system [J], and (2) had constantly transforming relationships with their respective marker-based coordinate systems, [F] and [H]. A Wrist in neutral position, B schematic of coordinate systems, and C wrist rotation around x and z axes for FE and RUD.

      Calibration of anatomical neutral position of the wrist

      A thermoplastic forearm orthosis and 2 wood stoppers were secured to the board to align the forearm and middle finger in parallel with the longitudinal axis defined by J1 and J2 (Fig. 1A). Subjects were asked to place their right hand in the jig while seated with the elbow flexed at 60° and the shoulder 45° abducted, slightly forward flexed to sit comfortably on the testing table. The static locations of all 9 retroreflective markers were collected for 1 second and were used to define the anatomical neutral position of the wrist.

      Experimental procedures

      After static calibration, each subject completed 3 ROM tasks: FE, RUD, and clockwise circumduction. These were performed seated in the same position as calibration with the shoulder further abducted to 60° to 70°, allowing space for the hand to move. For FE and RUD, subjects started in neutral and were asked to move the wrist to the endpoint in each direction. For circumduction, subjects started in maximal wrist extension and proceeded clockwise in only 1 revolution spread across 7–10 seconds for 3 trials. Three 10-second trials of FE and RUD were collected, each of which captured at least 5 cycles of motion. Then, each subject performed 22 ADLs in a randomized order. Each task was performed cyclically for 45 seconds so that 3 trials of 15 seconds were recorded by the cluster markers at 100 Hz. Each ADL trial captured 3–5 cycles of motion. Tasks were selected based on previous studies, with the addition of more contemporary tasks, including answering a smartphone in 2 ways and opening or closing a laptop.
      • Palmer A.K.
      • Werner F.W.
      • Murphy D.
      • Glisson R.
      Functional wrist motion: a biomechanical study.
      ,
      • Murgia A.
      • Kyberd P.J.
      • Chappell P.H.
      • Light C.M.
      Marker placement to describe the wrist movements during activities of daily living in cyclical tasks.
      Directions and body positioning were standardized for tasks, as described in Table E1 (available online on the Journal’s website at www.jhandsurg.org). All subjects completed practice trials before data were collected. Activities requiring an object had respective props fixed to wooden platforms and further clamped to the experiment table.

      Data processing

      For calibration, the jig’s coordinate system (defined by J1, J2, and J3) was translated to the hand and forearm to establish virtual coordinate systems affiliated with the hand and forearm ([H’] and [F’]; Fig. 1B). The coordinate system ([H] or [F]) defined by each marker cluster formed a constant relationship with the corresponding virtual coordinate system via a transformation matrix (THH’ or TFF’). For angular motion data, the coordinates for each marker cluster at every time point were used to form a local coordinate system ([H] or [F]) and then transformed to the respective virtual coordinate system ([H’] and [F’]). Only rotational motion was considered in this study; therefore, the origins of these coordinate systems were arbitrarily chosen (eg, 1 of the marker locations). The transformation matrix from coordinate system H’ to coordinate system F’ (TH’F’) was used to derive Euler angles using an x-z-y rotation sequence. The first 2 rotation angles represented FE (+) and radial (+)/ulnar deviation (Fig. 1C). Supination (+) and pronation of the wrist were not analyzed, given their minimal role in global wrist functions.

      Data analysis

      Angular positions of the wrist in FE and RUD were taken from the middle trial for every ADL, while an ROM task (FE, RUD, circumduction) analysis used all 3 trials of data. These central data were extracted to limit confounding factors, such as choppy movements in the first trial and fatigue associated with movements in the third trial, during each task. Extracted data represented 3–5 cycles of the task, with 1.8% of instances only capturing 2 cycles. For the tailbone reach task, data from 1 subject were not included as accurate tracking of markers could not be achieved. A custom MATLAB (MathWorks) program was used to process and analyze data. Initially, all motion data were plotted in Lissajous figures (x axis: RUD; y axis: FE) to categorize motion into quadrants (ulnar extension, ulnar flexion, radial extension, or radial flexion) of the wrist position. Data were analyzed for peak (maximum [+]; extension and radial deviation) and trough (minimum [−]; flexion and ulnar deviation) angles. Three real values of peak/trough angles were averaged to describe the motion required in both degrees of freedom. Peak angles were used to calculate arcs of motion in each plane required for tasks, and these arcs were compared with the maximal ROM arcs. Centroids representing the average angular wrist position separately in each plane were also calculated for each task. Best-fit ellipses were applied to middle trial data for all 22 ADLs (ADLs ellipse) and to the combined 3 trials of circumduction data (circumduction ellipse) using least-squares estimation. Ellipse areas were calculated with the formula πab (where a = long axis length and b the short axis length) and were compared between the 2 ellipses, both quantitatively and graphically. Upon review of our pilot subject’s Lissajous figures, it was decided to reverse RUD angle signs to allow for the presentation of motion on plots that mimicked right hand positioning in space.

      Results

      Wrist ROM in isolated FE and RUD

      In isolated FE, wrist motions ranged from 74.1° ± 6.4° of flexion to 80.2° ± 7.7° of extension (Table 1). During isolated RUD, wrist motions ranged from 20.4° ± 3.0° of radial deviation to 30.7° ± 4.7° of ulnar deviation.
      Table 1Functional Ranges of Motion in FE, RUD, and ADL Tasks
      TasksFlexion(−)/Extension(+) °Radial(+)/Ulnar(−) Deviation °Centroid °
      MinimumMaximumRangeMinimumMaximumRangeFERUD
      FE−74.1 ± 6.480.2 ± 7.7154.3 ± 7.8
      RUD20.4 ± 3.0−30.7 ± 4.751.5 ± 4.3
      Grooming Behaviors
       Comb0.7 ± 21.163.8 ± 14.263.3 ± 26.5−4.6 ± 16.4−30.7 ± 4.726.2 ± 15.433.6−20.2
       Tailbone reach−11.7 ± 11.236.2 ± 21.348.3 ± 18.41.7 ± 7.9−22.8 ± 12.024.6 ± 11.012.0−10.8
       Tie shoe−17.7 ± 16.334.0 ± 10.552.3 ± 10.74.9 ± 5.1−24.0 ± 8.429.0 ± 8.67.0−8.9
       Zip−20.1 ± 26.7−0.8 ± 19.720.5 ± 9.36.6 ± 10.7−7.4 ± 8.214.0 ± 7.9−9.6
      One of the 6 tasks that did not on average occur in ulnar extension.
      −0.5
      One of the 6 tasks that did not on average occur in ulnar extension.
       Button−3.5 ± 14.032.7 ± 8.937.1 ± 12.010.1 ± 4.3−8.0 ± 9.918.2 ± 9.111.2
      One of the 6 tasks that did not on average occur in ulnar extension.
      0.3
      One of the 6 tasks that did not on average occur in ulnar extension.
       Wash face26.1 ± 17.259.6 ± 7.133.7 ± 16.2−1.9 ± 6.2−15.9 ± 10.214.0 ± 7.042.2−9.1
      Kitchen and Eating
       Cut with knife−35.7 ± 25.48.7 ± 17.444.6 ± 23.9−6.6 ± 7.3−16.7 ± 6.910.1 ± 5.7−12.2
      One of the 6 tasks that did not on average occur in ulnar extension.
      −11.5
      One of the 6 tasks that did not on average occur in ulnar extension.
       Pierce with fork−18.1 ± 23.317.9 ± 17.536.2 ± 22.24.8 ± 3.8−15.7 ± 7.920.5 ± 9.42.8−5.6
       Flip spatula−8.0 ± 14.638.7 ± 17.547.4 ± 7.74.5 ± 7.7−22.7 ± 9.527.2 ± 9.014.3−9.5
       Drink9.7 ± 8.227.5 ± 8.718.1 ± 11.4−2.9 ± 8.6−12.4 ± 9.89.4 ± 4.317.6−7.7
       Pour22.3 ± 12.248.1 ± 7.526.4 ± 7.7−11.8 ± 9.0−21.9 ± 8.810.1 ± 3.936.7−17.2
       Stir−46.6 ± 16.5−13.5 ± 19.133.3 ± 16.71.0 ± 8.0−10.6 ± 8.111.6 ± 3.4−30.2
      One of the 6 tasks that did not on average occur in ulnar extension.
      −4.8
      One of the 6 tasks that did not on average occur in ulnar extension.
       Open jar−34.8 ± 20.7−3.4 ± 21.631.7 ± 15.715.6 ± 8.9−16.2 ± 13.331.8 ± 12.5−17.9
      One of the 6 tasks that did not on average occur in ulnar extension.
      −0.3
      One of the 6 tasks that did not on average occur in ulnar extension.
      Productivity
       Type5.4 ± 14.629.6 ± 13.524.6 ± 6.0−2.7 ± 6.3−21.4 ± 6.018.7 ± 4.217.8−12.5
       Write27.0 ± 5.236.9 ± 4.99.9 ± 4.2−4.2 ± 6.7−13.9 ± 6.49.7 ± 5.431.8−9.1
       Open laptop8.5 ± 18.158.1 ± 12.450.6 ± 21.311.1 ± 7.5−12.8 ± 9.323.9 ± 12.232.5
      One of the 6 tasks that did not on average occur in ulnar extension.
      0.2
      One of the 6 tasks that did not on average occur in ulnar extension.
       Flip pages−10.8 ± 20.334.5 ± 13.546.3 ± 19.511.7 ± 10.9−24.0 ± 10.435.6 ± 10.711.2−5.5
      Miscellaneous
       Turn doorknob−12.0 ± 22.026.7 ± 27.239.2 ± 26.6−4.2 ± 6.7−21.4 ± 5.617.3 ± 9.08.2−12.6
       Turn key0.0 ± 15.835.8 ± 12.936.6 ± 16.65.7 ± 8.8−20.8 ± 8.226.5 ± 7.715.6−6.7
       Pull smartphone out of back pocket−29.9 ± 15.448.6 ± 11.680.5 ± 17.67.8 ± 13.4−28.0 ± 7.535.8 ± 10.27.2−10.1
       Screw drive−6.7 ± 18.225.9 ± 18.133.0 ± 9.4−3.5 ± 11.6−21.0 ± 9.017.6 ± 8.29.4−12.9
       Answer call on smartphone−18.1 ± 14.649.3 ± 10.368.1 ± 15.8−0.9 ± 7.0−32.5 ± 8.331.6 ± 8.622.0−17.5
      Minimum and maximum angular positions are shown in addition to functional arcs of motion for each ADL. In the furthest right column are centroids for tasks in each plane.
      One of the 6 tasks that did not on average occur in ulnar extension.

      Functional ADL motion

      Maximal angular positions in each direction for each functional task are shown in Table 1. The maximal ROMs required to perform all 22 tasks were 46.6° ± 16.5° flexion (stirring task) to 63.8° ± 14.2° extension (combing task). These requirements corresponded to 62.9% of maximal flexion and 79.6% of maximal extension. In RUD, the maximal required ROMs were 15.6° ± 8.9° radial deviation (opening jar task) to 32.5° ± 8.3° ulnar deviation (picking up smartphone task). These requirements corresponded to 76.5% of maximal radial deviation and 100% of maximal ulnar deviation.
      The percentages of maximal arc of motion in FE and RUD used for each task are shown in Figure 2. The percentage of the RUD arc used for tasks (41.3% ± 16.9%) was greater than that of the FE arc required to perform tasks (25.6% ± 10.7%). The RUD ROM required to perform ADLs was greater than the FE ROM in all tasks except for 1 (cutting with a knife). Only 1 ADL required >50% of the maximal FE arc (answering a phone from the back pocket), whereas 7 ADLs required >50% of the RUD arc. These tasks included combing, tying/untying shoelaces, flipping a spatula, opening/closing a jar, turning pages in a magazine, and answering a phone from both the table and from the back pocket.
      Figure thumbnail gr2
      Figure 2FE and RUD arc of motion requirements. The percentages of maximal arcs of motion in both planes (FE and RUD) used for each task are shown in this bar graph. A higher percentage of maximal RUD relative to the percentage of maximal FE was required for all tasks except 1 (task 7, cutting with a knife). In only 1 task >50% of maximal FE was required (task 20, answer phone from back pocket). In contrast, >50% of maximal RUD was required for 7 tasks (tasks 1, 3, 9, 13, 17, 20, and 22).

      Quadrantal analysis and task centroids

      Motion data were categorized into 4 quadrants of coupled wrist positions. The distribution of data in each quadrant for every task is shown in Table 2. Of the 22 tasks, 17 predominantly occurred in the ulnar extension of the wrist, and 54.9% of all ADL activity occurred with ulnar extension. The second most frequent quadrant was the ulnar flexion, which described 20.2% of all ADL performance, and 3 tasks predominantly occurred in ulnar flexion.
      Table 2Quadrantal Analysis of Wrist Position During 22 ADLs Signifying the Percent of Total Task Data Within Each Quadrant
      Activity or ADLRadial ExtensionUlnar ExtensionRadial FlexionUlnar Flexion
      Grooming Behaviors
       Comb4.5%75.7%
      Denoted percentages correspond to the predominating quadrant for each task.
      1.3%9.6%
       Tailbone reach7.2%64.6%
      Denoted percentages correspond to the predominating quadrant for each task.
      16.2%12.0%
       Tie-untie shoe15.2%57.0%
      Denoted percentages correspond to the predominating quadrant for each task.
      3.7%23.2%
       Zip10.9%22.7%43.2%
      Denoted percentages correspond to the predominating quadrant for each task.
      22.5%
       Button59.3%
      Denoted percentages correspond to the predominating quadrant for each task.
      23.8%5.8%11.0%
       Wash face15.9%82.2%
      Denoted percentages correspond to the predominating quadrant for each task.
      0.4%1.5%
      Kitchen and Eating
       Cut with knife0.0%26.2%8.2%65.6%
      Denoted percentages correspond to the predominating quadrant for each task.
       Pierce with fork17.6%35.0%
      Denoted percentages correspond to the predominating quadrant for each task.
      13.1%34.2%
       Flip spatula8.0%60.5%
      Denoted percentages correspond to the predominating quadrant for each task.
      11.7%19.8%
       Drink24.4%75.0%
      Denoted percentages correspond to the predominating quadrant for each task.
      0.0%0.7%
       Pour4.9%95.1%
      Denoted percentages correspond to the predominating quadrant for each task.
      0.0%0.0%
       Stir0.0%3.2%22.7%74.4%
      Denoted percentages correspond to the predominating quadrant for each task.
       Open jar11.8%11.5%35.0%41.6%
      Denoted percentages correspond to the predominating quadrant for each task.
      Productivity
       Type6.0%87.7%
      Denoted percentages correspond to the predominating quadrant for each task.
      0.0%6.3%
       Write13.3%86.7%
      Denoted percentages correspond to the predominating quadrant for each task.
      0.0%0.0%
       Open laptop41.7%51.8%
      Denoted percentages correspond to the predominating quadrant for each task.
      2.7%3.8%
       Flip pages30.5%46.8%
      Denoted percentages correspond to the predominating quadrant for each task.
      13.4%12.5%
      Miscellaneous
       Turn doorknob6.3%53.4%
      Denoted percentages correspond to the predominating quadrant for each task.
      0.4%39.9%
       Turn key19.4%68.0%
      Denoted percentages correspond to the predominating quadrant for each task.
      11.4%1.2%
       Pull smartphone out of back pocket18.4%48.6%
      Denoted percentages correspond to the predominating quadrant for each task.
      10.1%22.9%
       Screw drive11.2%64.5%
      Denoted percentages correspond to the predominating quadrant for each task.
      5.0%19.2%
       Answer call on smartphone10.0%67.2%
      Denoted percentages correspond to the predominating quadrant for each task.
      0.5%22.3%
       All ADL data15.3%54.9%
      Denoted percentages correspond to the predominating quadrant for each task.
      9.3%20.2%
       No. of tasks with predominance11713
      The percentage of data in each respective coupled-position quadrant is shown for every task. Ulnar extension was the dominating quadrant for 17 tasks and described more than half of the motion data.
      Denoted percentages correspond to the predominating quadrant for each task.
      Centroids, or plotted points of average positions in each plane, for ADLs are listed in Table 1. We found that the majority (16 of 22) of ADLs had angular position centroids in ulnar extension (Fig. 3). ADLs with centroids not in ulnar extension are shown in Table 1. The second most common centroid location was ulnar flexion. The following 4 ADLs occurred, on average, in ulnar flexion: zipping, cutting with a knife, stirring, and opening a jar. Angular position centroids located in radial extension were found for the buttoning and opening laptop tasks. Zipping was the only task that did not have a centroid matching its predominant quadrant. Its data predominated in radial flexion despite its centroid being in ulnar flexion. Centroids for all tasks for each subject are also plotted in Figure 4.
      Figure thumbnail gr3
      Figure 3Centroid predominance of wrist ADLs. The proportions of centroids within each quadrant of biplanar wrist position are shown in this pie chart based on average wrist position data for tested ADLs. The majority of these ADLs were performed in ulnar extension in alignment with quadrantal analysis findings.
      Figure thumbnail gr4
      Figure 4Circumduction area versus task ellipse area. Shown are all the individual subject ellipse comparisons with plotted centroids. Ellipses fit to circumduction and all tasks performed by each subject are shown with points representing average wrist position for tasks.

      Minimum required circumductive arc of motion

      The area of the best fitting ellipse was plotted for all tasks (Fig. 4) and compared with the ellipse area of maximal wrist circumduction for each subject. Task ellipses included 80.2% ± 3.3% of task data. Our analysis revealed that to perform our study’s particular 22 ADLs, an average of 58.2% ± 14.3% of the maximal circumduction area was required.

      Discussion

      Adequate motion in the wrist is necessary to perform ADLs. Thus, the characterization of the normal ROM of the wrist required to perform important ADLs is necessary to better guide treatment modalities in the form of hand therapy or surgical intervention. In this study, we aimed to elucidate the functional wrist kinematics in healthy subjects using retroreflective marker technology, with a focus on circumduction and ulnar extension.
      The wrist ROM found in the current study showed similar values in both FE and RUD when compared with previous studies. In FE, our values closely align to those in the study by Boone and Azen
      • Boone D.C.
      • Azen S.P.
      Normal range of motion of joints in male subjects.
      (149° of FE arc ROM), though our FE range was 23° larger than that in 2 other studies.
      • Palmer A.K.
      • Werner F.W.
      • Murphy D.
      • Glisson R.
      Functional wrist motion: a biomechanical study.
      ,
      • Ryu J.Y.
      • Cooney III, W.P.
      • Askew L.J.
      • An K.N.
      • Chao E.Y.
      Functional ranges of motion of the wrist joint.
      In RUD, our study revealed a 52° arc of motion, whereas previous studies showed 56° and 59° arcs, respectively.
      • Ryu J.Y.
      • Cooney III, W.P.
      • Askew L.J.
      • An K.N.
      • Chao E.Y.
      Functional ranges of motion of the wrist joint.
      ,
      • Safaee-Rad R.
      • Shwedyk E.
      • Quanbury A.O.
      • Cooper J.E.
      Normal functional range of motion of upper limb joints during performance of three feeding activities.
      These studies captured more ulnar deviation in their subjects, at 36.0° and 37.7°, compared to our average of 30.7°.
      Our ADL FE and RUD ROM data differed minimally from those of previous studies. Palmer et al
      • Palmer A.K.
      • Werner F.W.
      • Murphy D.
      • Glisson R.
      Functional wrist motion: a biomechanical study.
      looked at patient ROMs during performance of 24 tasks. For these tasks, less flexion (32.5° vs 46.6°), less extension (58.6° vs 63.8°), greater radial deviation (23.0° vs 15.6°), and less ulnar deviation (21.5° vs 32.5°) of the wrist were required when compared to our study. These differences can be explained by stirring requiring more flexion and answering the phone from the back pocket requiring more ulnar deviation in our study. While it is unclear which task required 23° of radial deviation in the study by Palmer et al,
      • Palmer A.K.
      • Werner F.W.
      • Murphy D.
      • Glisson R.
      Functional wrist motion: a biomechanical study.
      per their data only 3 tasks required deep radial deviation in the 20° to 30° range. Furthermore, the loss of radial deviation alone was not associated with functional declines in radioscapholunate fusion patients.
      • Nagy L.
      • Büchler U.
      Long-term results of radioscapholunate fusion following fractures of the distal radius.
      Ryu et al
      • Ryu J.Y.
      • Cooney III, W.P.
      • Askew L.J.
      • An K.N.
      • Chao E.Y.
      Functional ranges of motion of the wrist joint.
      looked at wrist motion in 24 activities and showed greater flexion (54° vs 46.6°), lesser extension (60° vs 63.8°), greater radial deviation (17° vs 15.6°), and greater ulnar deviation (40° vs 32.5°) requirements compared with our findings. The tie and untie necktie task included in the study by Ryu et al,
      • Ryu J.Y.
      • Cooney III, W.P.
      • Askew L.J.
      • An K.N.
      • Chao E.Y.
      Functional ranges of motion of the wrist joint.
      which was not included in our investigation, led to the increased ulnar deviation and flexion requirements. Our study shows some expanded wrist ROM requirements with additional modern tasks but generally shows similar ROM requirements despite different chosen tasks. We recommend that future studies should test as many common ADLs as possible while carefully considering ADLs performed today to capture maximal requirements reflective of the times.
      Our study showed a strong coupled positional preference of wrist extension with ulnar deviation (Table 2). Of 22 tasks, 20 were predominated in ulnar deviation, although this was mild (<5°) in 3 of those tasks. Wrist extension was predominant in 18 of 22 tasks, with 5 of these tasks requiring <10° of wrist extension. Of 22 tasks, 17 predominated in the ulnar extension quadrant of coupled wrist position, with all but 1 also centering in that quadrant. While it is tempting to question this study’s finding of ulnar extension preference against the heavily studied dart thrower’s motion (DTM), which follows a coupled radial extension with ulnar flexion motion trajectory, it is important to remember that this study’s centroids represent an average position and not coupled motion of both planes. Even if tasks occur with the DTM, as was found primarily for the carpentry tasks investigated in the study by Palmer et al,
      • Palmer A.K.
      • Werner F.W.
      • Murphy D.
      • Glisson R.
      Functional wrist motion: a biomechanical study.
      the centroids for these tasks were predominantly (5/7) in ulnar extension. While the DTM may be required for larger energy swinging motions, as is found with hammering, it may not be a coupled motion required for modern tasks that are relatively more static in wrist positions.
      The functional motion requirement was roughly 60% of the total circumductive ROM in this study, nearly 3-fold that which has been reported previously.
      • Dauncey T.
      • Singh H.P.
      • Dias J.J.
      Electrogoniometer measurement and directional analysis of wrist angles and movements during the Sollerman hand function test.
      The increased requirement found in our study may be explained by the new set of tested ADLs; half of the 20 ADLs tested in the study by Dauncey et al
      • Dauncey T.
      • Singh H.P.
      • Dias J.J.
      Electrogoniometer measurement and directional analysis of wrist angles and movements during the Sollerman hand function test.
      were included in this study, in addition to more modern tasks involving a mobile phone and a computer. The circumduction ellipse area overall was also lower, and their study did show DTM-oriented circumduction in their ellipses similar to a previous study but unlike ours.
      • Dauncey T.
      • Singh H.P.
      • Dias J.J.
      Electrogoniometer measurement and directional analysis of wrist angles and movements during the Sollerman hand function test.
      Nearly half of ellipses fit to circumduction in this study are oriented in reflection instead of alignment, with wrist motion coupling as per the DTM. The unexpected orientation of circumduction found in our study may be related to how the motion was instructed; circumduction was performed clockwise, as has been done previously, but also slowly, across 7–10 seconds, which may have captured a wider envelope than quicker, smaller-magnitude motions.
      • Gehrmann S.V.
      • Kaufmann R.A.
      • Li Z.M.
      Wrist circumduction reduced by finger constraints.
      We allowed subjects to move their digits as was comfortable, because restraint of the digits by gripping a cylinder has been shown to decrease the circumduction envelope.
      • Gehrmann S.V.
      • Kaufmann R.A.
      • Li Z.M.
      Wrist circumduction reduced by finger constraints.
      Our findings actually seem similar to the normal volunteers’ circumduction in a study comparing ROM in patients who underwent proximal row carpectomy or 4-corner fusion.
      • Singh H.P.
      • Dias J.J.
      • Slijper H.
      • Hovius S.
      Assessment of velocity, range, and smoothness of wrist circumduction using flexible electrogoniometry.
      All subjects showed orientations in opposition to the DTM, and this study similarly tested slow, comfortable circumduction. The present study’s circumduction findings may also differ from those of previous cadaveric work due to the coordinate system definition.
      • Crisco J.J.
      • Heard W.M.
      • Rich R.R.
      • Paller D.J.
      • Wolfe S.W.
      The mechanical axes of the wrist are oriented obliquely to the anatomical axes.
      Although divergent from the standards advised by the International Society of Biomechanics for defining a joint coordinate system for global wrist motion, our methods relied on the their standard for neutral wrist position, and pilot testing confirmed accuracy against an electrogoniometer. Ultimately, the comparison of circumduction across studies is difficult because the studies may not only be performed differently, but also the investigators may not adequately describe the motions used and the instructions given to subjects.
      There are several limitations to this study. Our study’s task list is not an exhaustive representation of current daily life. The tasks are general and are not unique to special recreational or work activities. Additionally, our subjects were all of similar age and were right-handed, which does not apply to the entire population. Moreover, skin motion relative to bone may interfere with motion tracking.
      • Murgia A.
      • Kyberd P.J.
      • Chappell P.H.
      • Light C.M.
      Marker placement to describe the wrist movements during activities of daily living in cyclical tasks.
      Our methodology involved the use of rigid bodies, with the hand rigid body affixed to a foam platform to help limit additional motion from the skin. While skin motion presents considerable error when assessing the motions of individual carpal bones marked at bony prominences, we expect that such errors would be negligible when considering the motion of the entire wrist complex. Furthermore, these markers were not placed over large muscle bellies, which is what likely contributes to high skin motion artifact, such as that seen over the anterior thigh.
      • Akbarshahi M.
      • Schache A.G.
      • Fernandez J.W.
      • Baker R.
      • Banks S.
      • Pandy M.G.
      Non-invasive assessment of soft-tissue artifact and its effect on knee joint kinematics during functional activity.
      This functional wrist kinematics study provides a methodology and baseline data for future study in pathological wrists or specialized populations. Our findings show functional ROMs from previously studied tasks, as well as from new, untested tasks. Our study revealed strong predominance of ulnar extension in ADL performance, which can guide clinical management of wrist pathologies. The highly expanded functional envelope of circumduction in this study points to a need for further functional wrist kinematic studies with rigorous motion descriptions. These findings can be applied to design modern wrist implants or wrist rehabilitation protocols based on the required ROMs for specific tasks and may better inform engineers, surgeons, patients, and therapists on independent wrist functions.

      Appendix A

      Table E1Activity Body Positioning and Instructions for Subjects
      TasksBody PositionOrientationActivity Instructions
      CircumductionSitWest
      • Shoulder abducted to lift arm off table, elbow approaching 90° flexion
      • Begin at wrist extension, and rotate clockwise at comfortable speed
      Flexion extensionSitWest
      • Shoulder abducted to lift arm off table, elbow approaching 90° flexion
      • Begin at neutral, and toggle comfortably between maximal extension and flexion
      Radial ulnar deviationSitWest
      • Shoulder abducted to lift arm off table, elbow approaching 90° flexion
      • Begin at neutral, and toggle comfortably between radial and ulnar deviation
      Grooming Behaviors
      CombStandSW
      • Black, disposable standard hair combs used
      • Bring comb from frontal hairline through hair to the posterior edge of the top of the head, repeat cyclically
      Tailbone reachStandWest
      • From neutral standing position with arm at side, reach back to the lowest edge of back just proximal to buttocks, and return to neutral
      Tie-untie shoeSitNorth
      • Shoe affixed to wooden platform, facing North, and clamped down to center of table
      • Tie and untie laces at a comfortable pace, using own method
      ZipSitNorth
      • Partial cutout of shirt affixed to vertical wooden block, further screwed into wooden platform clamped to table
      • Meant to simulate zipping an item like a quarter zip pullover (upper chest)
      • Reach around to zip and unzip cyclically
      ButtonSitNorth
      • Partial cutout of shirt affixed to vertical wooden block, further screwed into wooden platform clamped to table
      • Meant to simulate buttoning top half of shirt, similar to the zipping task
      • Start with all buttons closed, undoes buttons going down, and then buttons them up
      Wash faceSitNorth
      • Simulate washing of face by making circular motions over the face
      • Head sitting above shoulders and not facing down
      • Kitchen and Eating
      Cut with knifeSitNorth
      • Plastic utensil used to place knife and then cut imaginary item toward self (North → South)
      • Cutting movement limited to 6 inches
      Pierce with forkSitNorth
      • Plastic utensil used to pierce imaginary item and bring up to mouth
      Flip spatulaStandNorth
      • Plastic kitchen spatula used to flip 3 × 5-inch rubber rectangle, 0.5-cm thick
      • Flip rectangle from right marked paper with outline to left marked paper with outline, transfers it back to right square (spatula slides under it for transfer) before repeating
      • Corners of demarcated paper marked on the experimentation table so that the location is identical for all subjects
      • Arm jig wooden edge used as sturdy object against which to lean rubber square to get underneath it (as in the far edge of a pan)
      DrinkSitNorth
      • Circle drawn on paper to mark cup placement with paper corners also marked on the table
      • Bring cup up to the mouth and tip as if drinking, set back down onto circular outline, and repeat
      PourSitNorth
      • Two papers with outlines for cup (left) and pitcher (right) taped to table in standardized spots
      • Pitcher with water used to fill the cup to three-fourth full
      • Left hand used to throw water back into the pitcher to maintain identical volume
      StirStandNorth
      • Medium sized baking bowl with wooden spoon
      • Stir clockwise feeling comfortable, with the bowl supported in the left arm
      Open jarStandNorth
      • Jar affixed to wooden platform and clamped down to the testing table
      • Twist open and then closed, repeat, without twisting closed too tightly
      • Productivity
      TypeSitNorth
      • Notepad on the experimental computer used for subject to type “The quick brown fox jumps over the lazy dog.” Hit enter for new line and repeat continuously
      WriteSitNorth
      • Write “wrist kinematics” line after line continuously on a piece of paper
      Open laptopSitNorthwest
      • Primary author’s Macbook Air laptop is opened to comfortable viewing angle, closed. Repeat cyclically without hand moving from the laptop
      Flip pagesSitNorth
      • An old Orthopaedic Research Society journal (larger in size, more than standard printer paper) is used in the laboratory to flip through pages. Left hand is allowed to stabilize the magazine
      • Magazine flat on the table
      • Miscellaneous
      Turn doorknobSitNortheast
      • Set-up includes doorknob apparatus affixed to a wooden platform (4 × 6 × 1.5 inch), which is then screwed onto a wood platform, which is further clamped to the testing table
      • Twist the doorknob open repeatedly
      Turn keySitNortheast
      • Set-up includes doorknob apparatus affixed to a wooden platform (4 × 6 × 1.5 inch), which is then screwed onto a wood platform, which is further clamped to the testing table
      • Place key in lock, unlock (rightward twist), twist it back locked, take it out, and repeat cyclically
      • Left hand is used to hold the wooden platform for stability
      Pull smartphone out of back pocketStandWest
      • The primary author’s smartphone is placed in the subject’s back pocket before beginning
      • From the right arm positionally relaxed on the side of the body, reach back for the phone, look at the screen as if to imitate checking who called, and then finally bring it to the ear
      • Phone should be slipped back into the pocket directly after answering before repeating the cycle
      Screw driveSitNortheast
      • Set-up includes the wooden platform used for the doorknob apparatus (see above)
      • Pre-placed screws already fixed in horizontally (3–5 threads in to start)
      • Using the same screwdriver, screw in horizontally while using the left hand to stabilize the platform
      • Do not unscrew, only go as deep as comfortable before moving over to another screw nearby (approximately an inch apart)
      Answer call on smartphoneSitNorth
      • The primary author’s smartphone is used for this task
      • The phone is started face down on an outline-marked paper that is positioned by tape-marked corners
      • Pick up the phone and imitate checking to see who it is before bringing it to the ear to answer
      • Place the phone back face down on outline, and repeat the whole task cyclically

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