Shrikant J. Chinchalkar

Reliability of range-of-motion measurement in the elbow and forearm***

The purpose of this study was to examine intratester, intertester, and interdevice reliability of range of motion measurements of the elbow and forearm. Elbow flexion and extension and forearm pronation and supination were measured on 38 subjects with elbow, forearm, or wrist disease by 5 testers. Standardized test methods and a randomized order of testing were used to test groups of patients with universal standard goniometers, a computerized goniometer, and a mechanical rotation measuring device. Intratester reliability was high for all 3 measuring devices. Meaningful changes in intratester range of motion measurements taken with a universal goniometer occur with 95% confidence if they are greater than 6 degrees for flexion, 7 degrees for extension, 8 degrees for pronation, and 8 degrees for supination. Intertester reliability was high for flexion and extension measurements with the computerized goniometer and moderate for flexion and extension measurements with the universal goniometer. Meaningful change in interobserver range of motion measurements was expected if the change was greater than 4 degrees for flexion and 6 degrees for extension with the computerized goniometer compared with 10 degrees and 10 degrees, respectively, if the universal goniometer was used. Intertester reliability was high for pronation and supination with all 3 devices. Meaningful change in forearm rotation is characterized by a minimum of 10 degrees for pronation and 11 degrees for supination with the universal goniometer. Reliable measurements of elbow and forearm arm movement are obtainable regardless of the level of experience when standardized methods are used. Measurement error was least for repeated measurements taken by the same tester with the same instrument and most when different instruments were used.

Load relaxation and forces with activity in hoffman external fixators: A clinical study in patients with Colles' fractures

A small-frame Hoffman external fixation bar instrumented with strain gauges to quantify bending and torsional forces was applied to 4 patients with a displaced metaphyseal fracture of the distal radius. Measurements were taken during surgery as well as at 1, 3, and 6 weeks after surgery during activities of daily living and hand therapy mobilization. Radiographs also were taken before and after reduction and at each subsequent visit. Force decay occurred after reduction of the fracture, averaging only 26% of the initial distraction forces by 5 minutes. These forces plateaued and did not significantly change over the subsequent 40-minute observation period. There was no correlation between carpal height index and the forces measured in the external fixator. Significant changes in external fixator forces were measured during activities of daily living and hand therapy mobilization, but these returned to baseline after the activities were performed. The most provocative activities studied were twisting a doorknob and lifting heavy objects. These activities should be performed with caution by patients with unstable distal radial fractures.

Optimizing elbow rehabilitation after instability.

Elbow instability is a common clinical problem that requires careful assessment and treatment to achieve a successful outcome. Rehabilitation is a key element in achieving a stable mobile elbow. Careful communication between the treating therapist and surgeon is essential so that an optimal rehabilitation program can be developed and implemented. By understanding the patterns of injury and the biomechanics of the elbow, a good outcome can be achieved in most patients who have elbow instability.

Rehabilitation considerations in the management of terrible triad injury to the elbow.

An elbow dislocation associated with a radial head and coronoid fractures is termed a terrible triad. This injury almost always renders the elbow unstable requiring surgical intervention. The primary goal of surgery is to stabilize the elbow to permit early motion to prevent stiffness. Recent literature has improved our understanding of elbow anatomy and biomechanics as well as the pathoanatomy of this injury. This article reviews key concepts that will allow the surgeon and therapist to apply an systematic rehabilitation approach when managing such injuries.

Therapeutic implications of the radiographic "drop sign" following elbow dislocation.

A radiographic drop sign following elbow trauma is an abnormality that is controversial with limited information describing optimal management. The consequences of this complex clinical situation includes limited motion, pain, and joint impingement, which may lead to joint stiffness and contracture formation. These authors describe the therapeutic implications of this radiographic finding and present a treatment approach in order to enhance patient outcomes.—V ictoria P riganc , PhD, OTR, CHT, CLT, Practice Forum Editor

Swan Neck Deformity after Distal Interphalangeal Joint Flexion Contractures: A Biomechanical Analysis

The relationship between the flexor and extensor systems of the digits is both intricate and balanced, such that disruption of one system can affect the entire dynamics of the finger. The imbalance may be obvious, whereas the precipitating factor may be less obvious. These authors describe a case and provide a detailed biomechanical analysis of how a flexion contracture of the distal interphalangeal joint led to a swan neck deformity in one of their patients.

Addressing Extensor Digitorum Communis Adherence after Metacarpal Fracture with the Use of a Circumferential Fracture Brace

Decreased gliding of the extrinsic extensor tendons after a metacarpal fracture can be challenging to treat. From a functional perspective, it is important to obtain and maintain a full glide from the extrinsic extensor tendons, as many functional activities rely on full finger motion. However, if scarring has occurred as a result of a metacarpal fracture, such tendon gliding may be compromised. These authors are presenting their protocol for addressing adherence of the extensor digitorum communis tendon after a metacarpal fracture.—Victoria Priganc, PhD, OTR, CHT, CLT, Practice Forum Editor

Extensor quadriga: Pathomechanics and treatment.

The extensor tendons to the index, long, ring and small fingers are motored by the common extensor digitorum communis muscle body. Effective function of this muscle can only occur if the gliding amplitude of each of its four extensor tendons is normal. As a corollary, limitation of the excursion of any of the individual tendons by adhesions at a fracture or tendon repair site, a fixed flexion contracture at the metacarpophalangeal joint, or by rupture, attenuation or laceration of a saggital band or juncturae tendinum, will result in reduction of the excursion of the adjacent extensor tendons. This pathological state has been termed the extensor quadriga because of its similarities to the analogous pathology affecting the flexor digitorum profundus system. Improper management of this clinical entity may lead to an abnormal pathomechanical kinematic chain imbalance. Early identification and treatment is critical to address this entity appropriately.

Contribution of the ulnar digits to grip strength

PURPOSE To determine the contribution of ulnar digits to overall grip strength. SUBJECTS Fifty individuals (25 men and 25 women; 100 hands) with a mean age of 35.6 years (range 19 to 62 years) were tested. Exclusion criteria included previous history of hand injuries, entrapment neuropathies and systemic diseases. METHODS Ethics approval was granted before testing. A calibrated Jamar dynamometer (Lafayette Instrument Company, USA) was used to test subjects in three configurations: entire hand - index, middle, ring and little fingers; index, middle and ring fingers; and index and middle fingers. Little and ring fingers were excluded using generic hand-based finger splints. The order of testing was kept constant, and subjects were tested three times on each hand for each configuration. The average of the three trials at each configuration was recorded. Subjects received 1 min of rest between each testing configuration. The data were analyzed using a 3×2 repeated measures ANOVA with hand dominance and configuration as the within-subject factors, followed by two independent sample t tests to compare flexor digitorum superficialis (FDS) independence and FDS nonindependence on right and left hand grip strength measurements in the index, middle, ring and little condition. RESULTS Univariate results demonstrated that grip strength was significantly predicted by the interaction between hand dominance and configuration, while the parsing of the interaction term demonstrated greater grip strength across all levels of configuration for the dominant and nondominant hand. There were no significant differences between FDS independence and FDS nonindependence for either hand on grip strength. DISCUSSION The results indicate a significant decrease in grip strength as ulnar fingers were excluded. Furthermore, exclusion of the little finger has differing effects on the grip strength of the dominant and nondominant hands - the dominant hand had a greater loss of strength with the little finger excluded than the nondominant hand. CONCLUSIONS The ulnar two digits play a significant role in overall grip strength of the entire hand. In the present study, exclusion of the ulnar two digits resulted in a 34% to 67% decrease in grip strength, with a mean decrease of 55%. Exclusion of the little finger from a functional grip pattern decreased the overall grip strength by 33%. Exclusion of the ring finger from a functional grip pattern decreased the overall grip strength by 21%. It is clear that limitation of one or both of the ulnar digits adversely affects the strength of the hand. In addition, there was no significant difference between grip strength of FDS-independent and FDS-nonindependent subjects for either hand.

Postoperative Management of Extensor Pollicis Longus Repairs within Close Vicinity to or within the Extensor Retinaculum

Therapists are continually modifying tendon protocols as part of the quest to create the perfect balance between tendon protection and tendon glide. Although much literature exists on the rehabilitation of the long flexor and extensor tendons to the digits, little literature exists on the rehabilitation of the extensor pollicis longus (EPL) tendon. This author used concepts related to tendon glide, tendon tethering, and early active mobilization to create a new splint and subsequent protocol for patients after an EPL laceration near the extensor retinaculum.