A musculoskeletal model to estimate the relative changes in wrist strength due to interacting wrist and forearm postures

Wrist rotations about one wrist axis (e.g. flexion/extension) can affect the strength about another wrist axis (e.g. radial/ulnar deviation). This study used a musculoskeletal model of the distal upper extremity, and an optimization approach, to quantify the interaction effects of wrist flexion/extension (FE), radial/ulnar deviation (RUD) and forearm pronation/supination (PS) on wrist strength. Regression equations were developed to predict the relative changes in strength from the neutral posture, so that the changes in strength, due to complex and interacting wrist and forearm rotation postures, can be incorporated within future ergonomics assessments of wrist strength.     

Comparison of measurement accuracy between two wrist goniometer systems during pronation and supination.

Pronation and supination have been shown to affect wrist goniometer measurement accuracy. The purpose of this study was to compare differences in measurement accuracy between a commonly used biaxial, single transducer wrist goniometer (System A) and a biaxial, two-transducer wrist goniometer (System B) over a wide range of pronation and supination (P/S) positions. Eight subjects moved their wrist between -40 and 40 degrees of flexion/extension (F/E) and -10 and 20 degrees of radial/ulnar (R/U) deviation in four different P/S positions: 90 degrees pronation; 45 degrees pronation; 0 degrees neutral and 45 degrees supination. System A was prone to more R/U crosstalk than System B and the amount of crosstalk was dependent on the P/S position. F/E crosstalk was present with both goniometer systems and was also shown to be dependent on P/S. When moving from pronation to supination, both systems experienced a similar extension offset error; however R/U offset errors were roughly equal in magnitude but opposite in direction. The calibration position will affect wrist angle measurements and the magnitude and direction of measurement errors. To minimize offset errors, the goniometer systems should be calibrated in the P/S posture most likely to be encountered during measurement. Differences in goniometer design and application accounted for the performance differences.     

Muscle moment arm and normalized moment contributions as reference data for musculoskeletal elbow and wrist joint models

A geometric musculoskeletal model of the elbow and wrist joints was developed to calculate muscle moment arms throughout elbow flexion/extension, forearm pronation/supination, wrist flexion/extension and radial/ulnar deviation. Model moment arms were verified with data from cadaver specimen studies and geometric models available in the literature. Coefficients of polynomial equations were calculated for all moment arms as functions of joint angle, with special consideration to coupled muscles as a function of two joint angles. Additionally, a “normalized potential moment (NPM)” contribution index for each muscle across the elbow and wrist joints in four degrees-of-freedom was determined using each muscle's normalized physiological cross-sectional area (PCSA) and peak moment arm (MA). We hypothesize that (a) a geometric model of the elbow and wrist joints can represent the major attributes of MA versus joint angle from many literature sources of cadaver and model data and (b) an index can represent each muscle's normalized moment contribution to each degree-of-freedom at the elbow and wrist. We believe these data serve as a simple, yet comprehensive, reference for how the primary 16 muscles across the elbow and wrist contribute to joint moment and overall joint performance.     

Experimental investigation of the scaphoid strain during wrist motion

The scaphoid is the most frequently fractured of the carpal bones [Taleisnik, J., The Wrist, Churchill Livingstone, New York (1985)]. This project was undertaken to qualitatively evaluate the strain in the scaphoid during wrist motion using a newly developed strain gage method. Strain gage resettes were mounted within the scaphoid and the range of motion of the hand was monitored using a custom designed electrogoniometer and data acquisition system. Ten specimens were utilized for this study. Results indicated that supination/pronation (S/P) of the forearm did not affect the strain in the scaphoid. A map of the strain in the waist of the scaphoid, as a function of flexion/extension (F/E) and radial/ulnar deviation (R/U), was generated. The contour plot of scaphoid strain vs range of motion (ROM) shows a valley where strains are low. Minimum scaphoid strain was found near neutral F/E and 15° of ulnar deviation.     

Effect of 12 weeks of wrist and forearm training on high school baseball players

This study examined the effect of 12 weeks of wrist and forearm training on male high school baseball players (mean age = 15.3 +/- 1.1 years). Participants (N = 43) were tested for 10 repetition maximum (RM) wrist barbell flexion, wrist barbell extension, dominant (D) and nondominant (ND) hand-forearm supination, D and ND forearm pronation, D and ND wrist radial deviation, D and ND wrist ulnar deviation, D and ND grip strength, and a 3RM parallel squat (PS) and bench press (BP). Group 1 (n = 23) and group 2 (n = 20), randomly assigned by a stratified sampling technique, performed the same resistance exercises while training 3 days a week for 12 weeks according to a stepwise periodized model. Group 2 also performed wrist and forearm exercises 3 days a week for 12 weeks to determine if additional wrist and forearm training provided further wrist and forearm strength improvements. All wrist and forearm strength variables were measured before and after 12 weeks of training. The 3RM PS and BP were measured at 0 and after 4, 8, and 12 weeks of training. Both groups significantly increased wrist and forearm strength (kg +/- SD) except 10RM D and ND forearm supination for group 1 (p < 0.05). Group 2 showed statistically greater improvements (p < 0.05) in all wrist and forearm strength variables than did group 1 except for D and ND grip strength. Predicted 1RM (kg +/- SD) PS and BP increased significantly (p < 0.05) after weeks 4, 8, and 12 for both groups. These data indicate that a 12-week stepwise periodized training program can significantly increase wrist, forearm, PS, and BP strength for both groups. Additionally, group 2 had further wrist and forearm strength gains.     

In vivo kinematic behavior of the radio-capitate joint during wrist flexion-extension and radio-ulnar deviation.

The capitate is often considered the "keystone" of the carpus, not simply because of its central and prominent position in the wrist, but also because of its mechanical interactions with neighboring bones. The purpose of this study was to determine in vivo three-dimensional capitate kinematics. Twenty uninjured wrists were investigated using a recently developed, non-invasive markerless bone registration (MBR) technique. Surface contours of the capitate, third metacarpal and radius were extracted from computed tomography images of seven wrist positions and the three-dimensional motions of the capitate and third metacarpal were calculated with respect to the radius in wrist flexion-extension and radio-ulnar deviation. We found that in vivo capitate motion does not simply occur about a single pivot point like a universal joint, as demonstrated by non-intersecting rotation axes for different capitate motions. The distance between flexion and ulnar deviation axes was 3.9+/-2.0 mm, and the distance between extension and ulnar deviation axes was 3.9+/-1.4 mm. Furthermore, capitate axes for males tended to be located more distally than axes for females. However, we believe that this result is related to subject size and not to gender. We also found that there is minimal relative motion between the capitate and third metacarpal during these in vivo wrist motions. These findings demonstrate the complexity of capitate kinematics, as well as the different mechanisms through which wrist flexion, extension, radial deviation and ulnar deviation occur.     

Automated objective robot-assisted assessment of wrist passive ranges of motion

The measurement of wrist passive ranges of motion (ROMs) can provide insight into improvements and allow for effective monitoring during a rehabilitation program. Compared with conventional methods, this study proposed a new robotic assessment technique for measuring passive ROMs of the wrist. The robotic system has a reconfigurable handle structure that allows for multi-dimensional applications of wrist motions. The assessment reliability of this robotic system was analysed on 11 subjects for measuring wrist extension/flexion and radial/ulnar deviation. Preliminary data demonstrated its potential with intraclass correlation coefficient (ICC_2,1) all greater than 0.857 and standard error of measurement (SEM) less than 3.38°. Future work will focus on the standardization of the assessment protocol of this robotic system for assessment purposes, paving the way for its clinical application.     

Surgical strategy for improving forearm and hand function in late obstetric brachial plexus palsy

For the purpose of treatment, obstetric brachial plexus palsy can be subdivided into two distinct phases: initial obstetric brachial plexus palsy, and late obstetric brachial plexus palsy. In the latter, nerve surgery is no longer practical, and treatment often requires palliative surgery to improve function of the shoulder, elbow, forearm, and hand. Late obstetric brachial plexus palsy in the forearm and hand includes weakness or absence of wrist or metacarpophalangeal or interphalangeal joint extension; weakness or absence of finger flexion; forearm supination, or less commonly pronation contracture; ulnar deviation of the wrist; dislocation of the radial or ulnar head; thumb instability; or sensory disturbance of the hand. Palliative reconstruction for these forearm and hand manifestations is more difficult than for the shoulder or elbow because of the lack of powerful regional muscles for transfer. This report reviews the authors' experience performing more than 100 surgical procedures in 54 patients over a 9-year period (between 1988 and 1997) with a minimum of 2 years' follow-up. Surgical treatment is highly individualized, but the optimal age for forearm and hand reconstruction is usually later than for shoulder and elbow reconstruction because of the requirement for a preoperative exercise program. Multiple procedures for forearm and hand function were often performed on any given patient. Frequently, these were done simultaneously with reconstructive procedures for improving shoulder and/or elbow function. Traditional tendon transfer techniques do not provide satisfactory reconstruction for those deformities. Many of the authors' patients required more complex techniques such as nerve transfer and functioning free-muscle transplantation to augment traditional techniques of tendon and/or bone management. Sensory disturbance of the forearm and hand in late obstetric brachial plexus palsy seems a minor problem and further sensory reconstruction is unnecessary.     

Measurements of wrist and finger postures: a comparison of goniometric and motion capture techniques

A marker-based kinematic hand model to quantify finger postures was developed and compared to manual goniometric measurements. The model was implemented with data collected from static postures of five subjects. The metacarpal phalangeal (MCP) and proximal interphalangeal (PIP) joints were positioned in flexion of approximately 30, 60, and 90 degrees for 5 subjects. Wrist flexion/extension and ulnar/radial deviations were also examined. The model-based angles for the MCP and PIP joints were not statistically equivalent to the goniometric measurements, with differences of -1.8 degrees and +3.5 degrees, respectively. Differences between the two measurement methods for the MCP and PIP were found to be a function of the posture (i.e., 150, 120, or 90 degree blocks) used. Wrist measurements differed by -4.0 degrees for ulnar/radial deviation and +5.2 degrees for flexion/extension. Much of the difference between the model and goniometric measurements is believed due to inaccuracies in the goniometric measurements. The proposed model is useful for future investigations of finger-intensive activities by supplying accurate and unbiased measures of joint angles.     

Distal, dorsal superior extremity plasty

Multiple deep wrinkles and redundant skin over the dorsal hand, wrist, and forearm develop and become of cosmetic importance to some patients as they age. Distal, dorsal superior extremity plasty was performed in selected patients by excising redundant skin and wrinkles from the dorsal hands, wrists, and forearms. The area of skin to be excised is elliptical, with the long axis of the ellipse centered over the wrinkles on the dorsal wrist. The amount of skin to be excised (i.e., the short axis of the ellipse) is determined by grasping the dorsal wrist skin, hence advancing the dorsal forearm and hand skin, while the patient flexes the wrist. This maneuver is performed to avoid excessive excision of dorsal wrist skin, which would cause decreased wrist flexion. The surgical procedure is performed with use of magnification to avoid sensory nerve injury. A relatively large volume of lidocaine is injected subcutaneously to increase the distance between the skin and nerves and therefore decrease the risk of nerve injury. The skin edges are undermined for 1 to 1(1/2) cm, and the wound is closed in two layers. The wrist is splinted in 30 to 45 degrees of extension to decrease wound tension. The procedure produces long-lasting, good to excellent cosmetic improvement and patient satisfaction. The dorsal wrist, hand, and forearm appear smoother and more youthful, and scars are relatively inconspicuous. Potential significant complications include injury to the superficial branch of the radial nerve and dorsal branch of the ulnar nerve, wound dehiscence, and decreased range of motion of the wrist. Use of magnification, a bloodless field, injection of a relatively large volume of local anesthetic (10 to 12 cc), knowledge of regional anatomy, and careful surgical technique decrease the risk of nerve injury. Avoidance of injury to the superficial sensory branches of the radial and ulnar nerves is absolutely necessary for patient satisfaction. Avoidance of injury to the wound edges with good surgical technique, postoperative immobilization with the wrist in an extended position, and subsequent advancement of the wrist to a neutral position for several weeks decrease the risk of wound dehiscence. Avoidance of excessive skin excision and prolonged wrist immobilization lowers the risk of decreasing range of motion. There have been no complications in patients who underwent this procedure.     

Ulnar Lengthening Using a Half-Ring Sulcated External Fixator for Ulnar Longitudinal Deficiency: A Case Report

Ulnar longitudinal deficiency (ULD) is a rare condition of the upper limbs. Although radius lengthening for radial longitudinal deficiencies (RLD) was found to be successful, no ulnar lengthening for ULD without RLD and hand deformities has been reported. Herein, we present a Bayne type II ULD case report of the ulnar lengthening and gradual reduction of the dislocated radial head in an 11-year-old boy using a half-ring sulcated external fixator. For ulnar lengthening/radial longitudinal traction for radial head reduction, transverse osteotomy in mid ulna was performed and half-ring sulcated external fixator was used for ulnar distraction lengthening. Radial longitudinal traction and stabilization of external fixator were achieved by transverse pins through ulna and radius. Distraction (1 mm/day) began at 5th day and was completed at 95th postoperative day. External fixator was applied for 7 months. Successful ulnar lengthening (81 mm; 62 % gain) was achieved 1-year after the surgery and the range of elbow motion at 2 years was >40°. Forearm rotation and wrist extension/flexion were also preserved with no complaints of pain. We concluded that ulnar distraction lengthening and gradual reduction of radial head could improve appearance of the arm and were of significant benefit to the patient.     

In-vivo three-dimensional carpal bone kinematics during flexion–extension and radio–ulnar deviation of the wrist: Dynamic motion versus step-wise static wrist positions

An in-vivo approach to the measurement of three-dimensional motion patterns of carpal bones in the wrist may have future diagnostic applications, particularly for ligament injuries of the wrist. Static methods to measure carpal kinematics in-vivo only provide an approximation of the true kinematics of the carpal bones. This study is aimed at finding the difference between dynamically and statically acquired carpal kinematics.For eight healthy subjects, static and a dynamic measurements of the carpal kinematics were performed for a flexion–extension and a radio–ulnar deviation movement. Dynamic scans were acquired by using a four-dimensional X-ray imaging system during an imposed cyclic motion. To assess static kinematics of the wrists, three-dimensional rotational X-ray scans were acquired during step-wise flexion–extension and radio–ulnar deviation. The helical axis rotations and the rotation components. i.e. flexion–extension, radio–ulnar deviation and pro–supination were the primary parameters. Linear mixed model statistical analysis was used to determine the significance of the difference between the dynamically and statically acquired rotations of the carpal bones.Small and in most cases negligible differences were observed between the dynamic motion and the step-wise static motion of the carpal bones. The conclusion is that in the case of individuals without any pathology of the wrist, carpal kinematics can be studied either dynamically or statically. Further research is required to investigate the dynamic in-vivo carpal kinematics in patients with dynamic wrist problems.     

Sarcomere length varies with wrist ulnar deviation but not forearm pronation in the extensor carpi radialis brevis muscle

Extensor carpi radialis brevis (ECRB) sarcomere length was measured in seven patients using intraoperative laser diffraction. Sarcomere length was measured with the forearm in one of four positions: wrist in neutral with regard to radial-ulnar deviation and forearm in neutral rotation, wrist in ulnar deviation and forearm in neutral rotation, wrist in neutral and forearm in pronation, and wrist in ulnar deviation and forearm in pronation. Two-way ANOVA comparing sarcomere length between the four positions revealed a significant effect of ulnar deviation (p < 0.05), no significant effect of pronation (p > 0.7) and no significant interaction (p > 0.9). These results demonstrate that the axes of forearm rotation and wrist radial-ulnar deviation act independently, at least with regard to the ECRB and have implications regarding the etiology of tennis elbow.     

Quantitative assessment of the accuracy for three interpolation techniques in kinematic analysis of human movement

Marker obstruction during human movement analyses requires interpolation to reconstruct missing kinematic data. This investigation quantifies errors associated with three interpolation techniques and varying interpolated durations. Right ulnar styloid kinematics from 13 participants performing manual wheelchair ramp ascent were reconstructed using linear, cubic spline and local coordinate system (LCS) interpolation from 11-90% of one propulsive cycle. Elbow angles (flexion/extension and pronation/supination) were calculated using real and reconstructed kinematics. Reconstructed kinematics produced maximum elbow flexion/extension errors of 37.1 (linear), 23.4 (spline) and 9.3 (LCS) degrees. Reconstruction errors are unavoidable [minimum errors of 6.7?mm (LCS); 0.29?mm (spline); 0.42?mm (linear)], emphasising careful motion capture system setup must be performed to minimise data interpolation. For the observed movement, LCS-based interpolation (average error of 14.3?mm; correlation of 0.976 for elbow flexion/extension) was most suitable for reconstructing durations longer than 200?ms. Spline interpolation was superior for shorter durations.     

Co-contraction of the pronator teres and extensor carpi radialis during wrist extension movements in humans.

In order to elucidate the functional significance of excitatory spinal reflex arcs (facilitation) between musculus (M.) pronator teres (PT) and M. extensor carpi radialis (ECR, longus: ECRL, brevis: ECRB) in humans, activities of the muscles were studied with electromyography (EMG) and electrical neuromuscular stimulation (ENS). In EMG study, activities of PT, ECRL, ECRB, and M. flexor carpi radialis during repetitive static (isometric) wrist extension and a series of a dynamic motion of wrist flexion/extension in the prone, semiprone, and supine positions of the forearm were recorded in 12 healthy human subjects. In the prone, semiprone, and supine positions, PT and ECR showed parallel activities during the static extension in all, eight, and eight subjects, respectively, and at the extension phase during the dynamic motion in all, eight and five subjects, respectively. These findings suggest that co-contraction of PT and ECR occurs during wrist extension movements at least with the prone forearm. The facilitation must be active during the co-contraction. In ENS study, ENS to PT was examined in 11 out of the 12 and that to ECRL was in the 12 subjects. Before ENS, the forearm was in the prone, semiprone, and supine positions. In all the subjects, ENS to PT induced a motion of forearm pronation to the maximum pronation. ENS to ECRL induced motions of wrist extension to the maximum extension and abduction (radial flexion) to 5-20 degrees of abduction regardless of the positions of the forearm. Moreover, it induced 30-80 degrees supination of the forearm from the prone position. Consequently, combined ENS to PT and ECRL resulted in motions of the extension and abduction while keeping the maximum pronation. These findings suggest that the co-contraction of PT and ECR during wrist extension movements occurs to prevent supinating the forearm. Forearm supination from the prone position should be added to one of the actions of ECRL.     

Quantitative assessment of the accuracy for three interpolation techniques in kinematic analysis of human movement

Marker obstruction during human movement analyses requires interpolation to reconstruct missing kinematic data. This investigation quantifies errors associated with three interpolation techniques and varying interpolated durations. Right ulnar styloid kinematics from 13 participants performing manual wheelchair ramp ascent were reconstructed using linear, cubic spline and local coordinate system (LCS) interpolation from 11–90% of one propulsive cycle. Elbow angles (flexion/extension and pronation/supination) were calculated using real and reconstructed kinematics. Reconstructed kinematics produced maximum elbow flexion/extension errors of 37.1 (linear), 23.4 (spline) and 9.3 (LCS) degrees. Reconstruction errors are unavoidable [minimum errors of 6.7 mm (LCS); 0.29 mm (spline); 0.42 mm (linear)], emphasising careful motion capture system setup must be performed to minimise data interpolation. For the observed movement, LCS-based interpolation (average error of 14.3 mm; correlation of 0.976 for elbow flexion/extension) was most suitable for reconstructing durations longer than 200 ms. Spline interpolation was superior for shorter durations.     

Kinetic chain of overarm throwing in terms of joint rotations revealed by induced acceleration analysis

This study investigated how baseball players generate large angular velocity at each joint by coordinating the joint torque and velocity-dependent torque during overarm throwing. Using a four-segment model (i.e., trunk, upper arm, forearm, and hand) that has 13 degrees of freedom, we conducted the induced acceleration analysis to determine the accelerations induced by these torques by multiplying the inverse of the system inertia matrix to the torque vectors. We found that the proximal joint motions (i.e., trunk forward motion, trunk leftward rotation, and shoulder internal rotation) were mainly accelerated by the joint torques at their own joints, whereas the distal joint motions (i.e., elbow extension and wrist flexion) were mainly accelerated by the velocity-dependent torques. We further examined which segment motion is the source of the velocity-dependent torque acting on the elbow and wrist accelerations. The results showed that the angular velocities of the trunk and upper arm produced the velocity-dependent torque for initial elbow extension acceleration. As a result, the elbow joint angular velocity increased, and concurrently, the forearm angular velocity relative to the ground also increased. The forearm angular velocity subsequently accelerated the elbow extension and wrist flexion. It also accelerated the shoulder internal rotation during the short period around the ball-release time. These results indicate that baseball players accelerate the distal elbow and wrist joint rotations by utilizing the velocity-dependent torque that is originally produced by the proximal trunk and shoulder joint torques in the early phase.     

Simulation of extension,radial and ulnar deviation of the wrist with a rigid body spring model

A novel computational model of the wrist that predicts carpal bone motion was developed in order to investigate the complex kinematics of the human wrist.This rigid body spring model (RBSM) of the wrist was built using surface models of the eight carpal bones, the bases of the five metacarpal bones, and the distal parts of the ulna and radius, all obtained from computed tomography (CT) scans of a cadaver upper limb. Elastic contact conditions between the rigid bodies modeled the influence of the cartilage layers, and ligamentous structures were constructed using nonlinear, tension-only spring elements. Motion of the wrist was simulated by applying forces to the tendons of the five main wrist muscles modeled.Three wrist motions were simulated: extension, ulnar deviation and radial deviation. The model was tested and tuned by comparing the simulated displacement and orientation of the carpal bones with previously obtained CT-scans of the same cadaver arm in deviated (45°ulnar and 15°radial), and extended (57°) wrist positions. Simulation results for the scaphoid, lunate, capitate, hamate and triquetrum are presented here and provide credible prediction of carpal bone movement. These are the first reported results of such a model. They indicate promise that this model will assist in future wrist kinematics investigations. However, further optimization and validation are required to define and guarantee the validity of results.     

Precision of measurements of physical workload during standardised manual handling. Part II: Inclinometry of head, upper back, neck and upper arms.

For measuring the physical exposure/workload in studies of work-related musculoskeletal disorders, direct measurements are valuable. However, the between-days and between-subjects variability, as well as the precision of the method per se, are not well known. In a laboratory, six women performed three standardised assembly tasks, all of them repeated on three different days. Triaxial inclinometers were applied to the head, upper back and upper arms. Between-days (within subjects) and between-subjects (within tasks) variance components were derived for the 10th, 50th and 90th percentiles of the angular and the angular velocity distributions, and for the proportion of time spent in predefined angular sectors. For percentiles of the angular distributions, the average between-days variability was 3.4 degrees , and the between-subjects variability 4.0 degrees . For proportion of time spent in angular sectors, the variability depended on the percentage of time spent in the sector; the relative variability was scattered and large, on average 103% between days and 56% between subjects. For the angular velocity percentiles, the average between-days variability was 7.9%, and the average between-subjects variability was 22%. The contribution of the measurement procedure per se to the between-days variability, i.e., the imprecision of the method, was small: less than 2 degrees for angles and 3% for angular velocity.     

Measurement of the screw-home motion of the knee is sensitive to errors in axis alignment

Measurements of joint angles during motion analysis are subject to error caused by kinematic crosstalk, that is, one joint rotation (e. g., flexion) being interpreted as another (e.g., abduction). Kinematic crosstalk results from the chosen joint coordinate system being misaligned with the axes about which rotations are assumed to occur. The aim of this paper is to demonstrate that measurement of the so-called "screw-home" motion of the human knee, in which axial rotation and extension are coupled, is especially prone to errors due to crosstalk. The motions of two different two-segment mechanical linkages were examined to study the effects of crosstalk. The segments of the first linkage (NSH) were connected by a revolute joint, but the second linkage (SH) incorporated gearing that caused 15 degrees of screw-home rotation to occur with 90 degrees knee flexion. It was found that rotating the flexion axis (inducing crosstalk) could make linkage NSH appear to exhibit a screw-home motion and that a different rotation of the flexion axis could make linkage SH apparently exhibit pure flexion. These findings suggest that the measurement of screw-home rotation may be strongly influenced by errors in the location of the flexion axis. The magnitudes of these displacements of the flexion axis were consistent with the inter-observer variability seen when five experienced observers defined the flexion axis by palpating the medial and lateral femoral epicondyles. Care should be taken when interpreting small internal-external rotations and abduction-adduction angles to ensure that they are not the products of kinematic crosstalk.