EDITOR ' S CHOICE

Intrarater Keandalan dari Rentang Pengukuran

Gerak dari terluka Wrist Perempuan Setelah
Distal Radius Fraktur
Geoffrey HF Johnston, MD, MBA, * Samuel A. Stewart, PhD †

Tujuan Untuk menentukan keandalan intrarater pergelangan tangan serial dan berbagai lengan gerak (ROM) pengukuran
anggota tubuh terluka, dengan 1 evaluator menggunakan teknik standar pengukuran, pada wanita yang telah menderita
patah tulang radius distal.

metode Dari Desember 2007 sampai Desember 2014, wanita skeletally dewasa yang telah mengalami fraktur radius
distal terisolasi secara rutin memiliki pengukuran berurutan ekstensi pergelangan tangan dan fl exion serta lengan
supinasi dan pronasi di kedua dan anggota badan mereka terluka mereka tidak terluka, minimal interval 3 minggu.
Penulis senior (GHFJ) menggunakan teknik standar pengukuran ROM selama periode ini, dan data ini terkait
dengan pergelangan tangan terluka dan lengan secara retrospektif Ulasan.

hasil Dari 508 wanita yang mengalami patah tulang radius distal, 506 telah pengukuran terbuat dari uninjuredwrist dan
forearmon 2, 300 pada 3, dan 128 pada 4 kesempatan terpisah. Usia rata-rata perempuan adalah 61 tahun, dengan kisaran
16-94 tahun. The intraclass korelasi koefisien fi koefisien antara pengukuran dari waktu ke waktu untuk perpanjangan, fl exion,
dan pengukuran supinasi adalah 0,71,
0,63, 0,68, masing-masing, dan 0,47 untuk pronasi. The intraclass korelasi koefisien fi sien bervariasi sesuai dengan usia pasien, tetapi tanpa
spesi fi perkembangan c dalam setiap kelompok usia untuk anyROM. Perpanjangan,
fl exion, dan supinasi menurun signifikan fi cantly usia meningkat, sedangkan forearmpronation tidak.

kesimpulan Pengukuran pergelangan tangan dan gerakan lengan ekstremitas terluka dapat diandalkan direproduksi oleh penilai
tunggal, yang paling jadi untuk ekstensi, fl exion, dan supinasi, dan kurang begitu untuk pronasi. penilaian reliabilitas antar penilai
masih harus dievaluasi.

relevansi klinis Mengingat keandalan intrarater pergelangan tangan dan pengukuran gerak lengan, kebalikan (terluka) pergelangan
tangan mungkin merupakan metrik referensi yang berguna untuk pemulihan gerak untuk pemulihan dari cedera pada anggota
tubuh yang berlawanan. ( J Tangan Surg Am. 2018; 43 (1): 1 e 7. Hak Cipta 2018 oleh American Society for Bedah Tangan.
Seluruh hak cipta.)

kata kunci Gerak, kehandalan, terluka, wanita, pergelangan tangan.

D
Dari * Divisi Bedah Ortopedi, Royal University Hospital; dan † Departemen Kedokteran, Universitas

Saskatchewan, Saskatoon, Saskatchewan, Kanada.

di antara wanita dewasa, dan evolusi pengobatan telah
melihatISTAL
pergeseran (DRFS) yang cor
dari manajemen
RADIUS FRAKTUR umumnon-bedah mendukung
Diterima untuk publikasi September 21, 2016; diterima dalam bentuk direvisi 29 Agustus 2017. Tidak ada bene fi ts

dalam bentuk apapun telah diterima atau akan diterima terkait langsung atau tidak langsung dengan topik artikel ini.
perawatan bedah. Debat, bagaimanapun, terus untuk yang dari
banyak perawatan yang paling tepat untuk setiap pasien.

Penulis yang sesuai: Geoffrey HF Johnston, MD, MBA, Universitas Rumah Sakit Royal, 103 Rumah Sakit Dr.,
Pemulihan pergelangan tangan dan berbagai lengan gerak
Saskatoon, Saskatchewan, Kanada S7N 0W8; e-mail: geoff.johnston @ saskatoonhealthregion.ca . 0363-5023 / 18 / (ROM) diantisipasi dari intervensi adalah suatu pertimbangan
4301-0001 $ 36.00 / 0 penting dalam perdebatan ini, namun metode dan keandalan
pengukuran umumnya tidak dikutip,
http://dx.doi.org/10.1016/j.jhsa.2017.08.030

2018 ASSH Diterbitkan oleh Elsevier, Inc All rights reserved. 1

r r
2 KEANDALAN terluka WRIST ROM PADA WANITA
meningkatkan ketidakpastian validitas penulis '
kesimpulan 1 e 7 - banyak fitur bisa di fl pengaruh pengukuran
termasuk pemeriksa terkait dan
Faktor-faktor yang berhubungan dengan pasien, yang pada gilirannya mungkin
menempatkan pada risiko penafsiran bagaimana ROM telah dipulihkan setelah DRF a.
Selanjutnya untuk mengetahui sejauh mana pemulihan pergelangan tangan
dan lengan bawah ROM, pembaca harus memiliki referensi untuk apa
pergelangan tangan terluka ' s gerak seharusnya. Dengan tidak adanya patologi
diketahui, pergelangan tangan terluka berlawanan dan lengan bawah harus
meminjamkan dirinya untuk fungsi ini.
With these concerns over method and reliability of
measurement and reference ROM in mind, the principal purpose
of this study was to evaluate the reliability of 1 examiner ’ s
(G.H.F.J.) measurement of active wrist extension and fl exion, as
well as forearm supination and pronation, using a standardized
measurement technique, of only the uninjured wrist and forearm in
a cohort of women who had sustained a DRF. Secondary
outcomes were to quantity the limits and changes of wrist and
forearm ROM associated with age and hand dominance.
MATERIALS AND METHODS
Institutional research ethics board approval was obtained to
review measurements of ROM of the uninjured wrists of women
treated in the DRF clinic before the review was conducted.
Dari Desember 2007 sampai Desember 2014, wanita
skeletally dewasa yang telah mengalami sebuah DRF terisolasi
terlihat di klinik rawat jalan DRF berdedikasi, umumnya dalam 1
sampai 2 minggu fraktur dan pengobatan awal, terlepas dari
apakah mereka telah menjalani manajemen bedah atau
non-bedah. Selama perawatan fraktur berikutnya mereka, seri
radiografi radial distal diambil, dan pemeriksaan klinis fi Temuan
(ekstensi pergelangan tangan bilateral dan
fl exion, bilateral lengan supinasi dan pronasi, dan kekuatan
pegangan) dan Evaluasi Wrist Pasien Nilai 8 Skor dicatat. dominasi
tangan tercatat.
Patient-related features that might contribute to inconsistent
serial ROM measurements in the uninjured limb, such as pain
from injury or arthritis, excluded patients from the study. Although
scaphotrapeziotrapezoid and thumb basal joint arthrosis were
observed frequently in the injured wrist radiographs in the older
patients, screening radiographs of the uninjured wrists to exclude
these, and any other unidenti fi ed abnormalities, were not
performed. Presence of asymptomatic clinical features of these
J Tangan Surg Am. Vol. 43, Januari 2018
r
conditions, especially related to the thumb basal joint, did not
disqualify patients from the study. No congenital deformities of the
bones of the wrist or forearms were identi fi ed in the radiographs of
the injured limbs.
Serial wrist and forearm ROM measurements were made at a
minimum of 3-week intervals. Having observed substantial
variation in ROM measurements between examiners, the senior
author (G.H.F.J.) sought to fi rst evaluate his own measurement
reliability. For this study, only those measurements made by the
senior author (G.H.F.J.), an upper extremity subspecialist
orthopedic surgeon, were included. Measurement of the uninjured
wrist ROMwas started while the patient ’ s opposite wrist and
forearm were immobilized in a cast (during the fi rst 5 e 6 weeks
postreduction), and then at 9 weeks and beyond, concurrent with
measurement of the ROM of the injured wrist.
All measurements were made with a 12-inch transparent plastic
goniometer (Model G300; Whitehall Manufacturing, City of Industry,
CA). A standardized technique for measurement of active ROM was
established a priori. Dengan pasien duduk, bahu di sekitar 90 elevasi
depan dan rotasi internal, dan siku fl Exed ke sudut kanan, teknik
ulnaris untuk pengukuran gerakan pergelangan tangan dipilih,
menggunakan poros ulnaris sebagai acuan lengan sumbu. 9 identifikasi
mudah fi kasi ujung olekranon dan ulnar kepala dan poros nya ' s alam
subkutan membuatnya relatif mudah untuk menyelaraskan goniometer
itu. Dalam penelitian ini, teknik ini adalah modi fi ed dengan memilih
untuk mengukur ekstensi pergelangan tangan dan fl exion dengan
pasien mempertahankan ditutup fi st - di kedua arah, referensi
metacarpal ketiga adalah lebih mudah untuk memvisualisasikan
dengan fi st dibuat ( Buah ara. 1 . 2 ). Hal itu diakui bahwa pasien dapat
terukur lebih meningkatkan pergelangan tangan mereka fl exion, tetapi
tidak ekstensi, dengan memperluas mereka
fi jari, fenomena dikaitkan dengan kunjungan terbatas fi ekstensor
jari. Untuk menghilangkan variasi ini, semua pengukuran
dilakukan di tertutup ini
fi st mode standar.
Untuk pengukuran rotasi lengan, pasien diminta untuk duduk
tegak dan mengamankan kedua siku ke sisi mereka, dengan siku fl
Exed kasar ke sudut kanan. Lipatan pergelangan tangan
proksimal digunakan sebagai titik acuan untuk supinasi, tidak
hanya untuk menghilangkan kontribusi supinasi karpal tetapi juga
untuk re baik fl dll rotasi dalam radioulnar kompleks lengan, spesifik fi
Cally sendi distal radioulnar ( Buah ara. 3 . 4 ).
Dalam semua keadaan pasien didorong untuk menggunakan
upaya maksimal dalam mencapai batas ROM.
 RELIABILITY UNINJURED WRIST ROM IN WOMEN
FIGURE 1: Measurement of maximal wrist extension using the ulnar technique and
a clenched fi st.
FIGURE 2: Measurement of maximum wrist fl exion using the ulnar technique and
a clenched fi st.
Itu fi rst measurement of ROM of the uninjured wrist was
generally started while the injured wrist was in a cast. At roughly
9, 12, 26 and 52 weeks after fracture, ROM of the injured wrist
and forearm was measured. At these same time points, ROM of
the uninjured wrist and forearm was measured, albeit less
frequently.
The mean values for each of extension, fl exion, supination,
and pronation were calculated, overall and by time period and age
group. Intraclass correlation coef fi cients (ICC) 10 were used to
assess intrarater reliability for each of the 4 ROM directions,
overall and by patient age group, using a 2-way mixed,
single-measure calculation (ICC, 3,1). The effect of age on the 4
values was measured using simple linear regression with age as a
predictor, and the comparison between dominant and
nondominant hand was done using t tests.
RESULTS
Five hundred eight women with an isolated DRF had a single
measurement, 506 had 2 serial measurements of ROM, 300 had 3,
and 128 had 4 measurements, all
J Hand Surg Am. Vol. 43, January 2018
r
3
FIGURE 3: Measurement of forearm supination, both arms tucked in at the side
and both simultaneously supinating to the maximum.
by the senior author (G.H.F.J.) alone, and all performed in the
standardized manner described. Considerable variation between
patients for each ROM was noted, exempli fi ed by the minimum
and maximum limits of ROM ( Table 1 ). There was little variation in
the means of ROM measurements over time.
The average age of the women was 61 years, ranging from 16
to 94 years. The 2 16-year-old girl ’ s growth plates were not
evident on the radiographs of the injured distal radius. As the age
of the patients increased,
extension, fl exion, and supination
decreased ( Table 2 ).
The overall ICC for each of the 4 ROM measurements were
0.71, 0.63, 0.68, and 0.47 for extension, fl exion,
supination, and pronation,
respectively. There were no statistically signi fi cant differences
when comparing the age groups ( Fig. 5 ). The dominant wrist
represented the uninjured wrist in 47% of 504 of the 508 patients.
The differences in the means of wrist extension, fl exion,
supination, and pronation were clinically small: 3 , 4 , 5 , and 0 more,
respectively, in favor of the dominant over the nondominant wrist ( Table
3 ).
4 RELIABILITY UNINJURED WRIST ROM IN WOMEN
FIGURE 4: Measurement of forearm pronation, both arms tucked in at the side and
both simultaneously pronating to the maximum.
DISCUSSION
The ROM is an important outcome measure of the treatment of
DRFs so it is important that its reliability be con fi rmed.
Horger 11 studied 50 wrists, fi nding that intrarater reliability
among occupational therapists was high for both active and
passive extension and fl exion. Interrater evaluation, however, was
found to have considerably less agreement. The study of 141
wrists of LaStayo and Wheeler 12 found signi fi cant differences in
measurement techniques between clinics and that, although all 3
techniques (ulnar, radial, and volar-dorsal alignment) were
reliable, the volar-dorsal technique consistently produced less
error than the other 2 techniques. In both studies, the only limbs
examined were the injured limbs, and the patient was identi fi ed as
contributing to the most variance. Carter et al, 9 in a cadaveric
study of 10 wrists, identi fi ed that the intrarater reliability of ulnar,
radial, and dorsalvolar techniques of wrist goniometric
measurements was comparably high for all 3 techniques and that
each technique was accurate to within 5 of wrist position when
compared with the gold standard of
fl uoroscopic measurement.
J Hand Surg Am. Vol. 43, January 2018
r
This study found that serial measurements by a single
measurer of active wrist extension and fl exion (with a closed fi st)
using a standardized ulnar technique, as well as forearm
supination, have substantial intrarater consistency, whereas
pronation was less consistent. Typically, an ICC in the 0.81 to 1.0
range indicates near-perfect agreement, the 0.61 to 0.80 range
substantial agreement, and the 0.41 to 0.60 range moderate
agreement. 13 Using these bounds, the measurement of extension,
fl exion, and supination all suggests strong agreement or strong
consistency in their measurement reproducibility, whereas the
lower value for pronation suggests moderate agreement.
Positioning of the elbow at the side lends itself to variation in
measurements of supination and pronation — the more anterior to
the trunk ’ s coronal plane the greater the shoulder external
rotation, which increases the degree of measured supination and
decreases pronation. The opposite is true for the elbow being
posterior to the trunk ’ s coronal plane. Evaluators should strive to
have patients securely tuck both elbows into their sides in the
trunk ’ s coronal plane.
Whereas the landmarks for wrist extension and
fl exion, and supination, offer relatively fl at and, therefore, relatively
reproducible surfaces for measurement, measurement of
pronation at the level of the distal forearm is challenged by the
distal radial contour made up of radial and ulnar slopes and by the
potential interference in measurement by the prominence of the
distal ulna. These features likely contributed to the less
consistently reliable measure of pronation.
Recent DRF studies have asserted advantages of 1 surgical
management over another on the basis of increased mobility. 1 e 4 These
authors, however, did not de fi ne the alignment technique used,
nor make any statement as to intrarater or interrater reliability of
their measurements. Surgeons need to have con-
fi dence, and con fi rmation, that measurements are reliable,
regardless who might have made them.
Means as references for ROM for individual patients have
limited utility. The mean values of ROM of active wrist extension
and fl exion and forearm supination and pronation in the women of
this study approximated 58 , 62 , 81 , and 83 , respectively, and
changed with age. These mean values differed considerably from
those cited by E-Hand.com , 14
reporting 70 , 75 , 85 , and 70 for each, respectively. The clenched fi st
in this study did limit the extent of measured fl exion; it would have
been greater had measurements been made with the fi ngers
extended. Chaudhry et al, 5 in their meta-analysis of 2 different
surgical interventions, acknowledged
 RELIABILITY UNINJURED WRIST ROM IN WOMEN 5

TABLE 1. ROM at 4 Different Sequential Time Points

Mean ( ) SD ( ) Minimum First Quartile Median Third Maximum

Variable Time n () () () Quartile ( ) ()

Extension 1 508 58 10 21 52 58 65 83

2 506 58 9 26 51 58 64 87

3 299 58 9 23 52 59 64 83

4 128 58 9 37 52 57 65 81

Flexion 1 508 62 11 25 55 63 70 90

2 506 62 12 27 54 62 70 90

3 299 63 11 31 55 64 71 92

4 128 64 11 34 57 66 71 87

Supination 1 508 82 10 15 78 83 88 115

2 508 81 10 49 75 81 86 111

3 299 81 10 46 76 81 88 106

4 128 81 10 55 77 82 87 104

Pronation 1 508 84 7 55 80 84 89 108

2 508 83 8 35 78 83 88 130

3 298 83 8 52 79 83 88 103

4 127 83 8 48 80 83 89 105

TABLE 2. Relationship Between Age Group and the 4 ROMs

Age Mean ( ) SD ( ) Minimum First Median Third Maximum P

Variable (y) n () Quartile ( ) () Quartile ( ) () Value

Extension < 40 54 63 9 39 58 64 69 81 < . 05

40 e 50 47 60 12 33 51 60 68 83

50 e 60 145 60 8 33 54 59 64 81

60 e 70 134 57 10 21 51 58 64 79

70 e 80 78 55 9 38 50 55 61 77

80 50 54 10 35 47 53 61 82

Flexion < 40 54 65 11 41 57 67 72 90 < . 05

40 e 50 47 64 10 39 57 63 71 83

50 e 60 145 64 10 34 57 65 71 86

60 e 70 134 63 11 39 54 63 71 89

70 e 80 78 58 12 25 50 61 67 81

80 50 55 12 27 47 53 65 74

Supination < 40 54 84 9 54 80 85 89 105 < . 05

40 e 50 47 83 7 71 79 83 87 105

50 e 60 145 83 10 42 77 84 88 115

60 e 70 134 82 11 15 77 83 88 105

70 e 80 78 84 10 63 78 84 90 106

80 50 77 10 56 71 78 82 106

Pronation < 40 54 85 6 67 81 85 90 99 > . 05

40 e 50 47 83 7 62 81 83 86 102

50 e 60 145 84 8 55 79 84 90 108

60 e 70 134 85 7 65 80 85 90 105

70 e 80 78 83 7 62 79 83 88 96

80 50 84 6 65 80 83 88 100

J Hand Surg Am. Vol. 43, January 2018

r
6 RELIABILITY UNINJURED WRIST ROM IN WOMEN

FIGURE 5: ICC measurements, overall and by age group.

TABLE 3. Comparison of Measurements Between Dominant and Nondominant Hands

Dominant Nondominant
95% Con fi dence
n Mean ( ) n Mean ( ) Difference Interval P Value

Extension 239 60 265 57 3.2 (1.5 e 4.8) < . 05

Flexion 239 64 265 60 3.8 (1.9 e 5.8) < . 05

Supination 239 85 265 80 4.8 (3.1 e 6.4) < . 05

Pronation 239 84 265 84 0.5 ( 0.8 e 1.7) > . 05

converting percentages to degrees of motion by using normal
values for extension, fl exion, supination, and pronation of 80 , 85 ,
85 , and 80 , respectively. The use of a mean value, particularly in
small clinical samples, might throw into question the meaning of
their reported early advantage of 4 of fl exion and supination for
volar locked plating over K-wires in DRF management.
Authors have recently adopted the technique of expressing
ROM of the injured wrist as a percentage of the uninjured side. 6,15 Given
the wide variability of ROM of the uninjured “ normal ” wrist, the
value of reporting ROM as a percentage or ratio of the injured and
uninjured sides is self-evident, assuming that the ROMs of the 2
sides were originally very similar. Such comparison of the injured
with the uninjured side will provide practitioners real insight into
the progress of rehabilitation of the injured arm.
Small differences in mean extension, fl exion, and supination (3 ,
4 , and 5 , respectively) were identi-
fi ed in favor of the dominant wrist in 504 women; there was no
difference in mean pronation. Lauder
et al 7 found, among their 18 patients, an 11 difference in the
means of wrist extension of the uninjured dominant and
nondominant wrists. Our data suggest considerably fewer
differences in the means between dominant and nondominant
sides.
The means of ROM neither decreased nor increased as time
from the original DRF passed, dispelling concern that discomfort
of the opposite injured limb might in fl uence patients ’ ability to
perform active ROM of their uninjured limb.
A limitation of the study was that an independent observer did
not make the measurements, the treating surgeon (G.H.F.J.) did.
The surgeon, however, made the measurements at least 3 weeks
apart, unaware of the previous measurement values, thereby
minimizing potential bias.
Only intrarater reliability of the treating surgeon was evaluated.
Generally, surgeons are reliant on 1 or more allied health workers
to measure the ROM of the wrist, oblivious to the speci fi c
technique of measurement or its reliability. Future reports should
identify both the standardized measurement technique used

J Hand Surg Am. Vol. 43, January 2018

r
 RELIABILITY UNINJURED WRIST ROM IN WOMEN
and a summary of intra- and interrater reliability of ROM
measurement.
Restoration of wrist and forearm ROM of the injured limb is an
important objective of management of DRFs and, indeed, for any
wrist disorder. Only tools that measure ROM of the wrist and
forearm in a manner that has strong intrarater and interrater
reliability can validate reported ROM outcomes of treatment. As a fi
rst step to this objective, this study of 508 adult women
established that a modi fi ed standardized ulnar technique,
performed conscientiously with attention to detail, has substantial
intrarater reliability for wrist extension, fl exion, and forearm
supination, and moderate intrarater reliability for pronation.
REFERENCES
1. Brehmer JL, Husband JB. Accelerated rehabilitation compared with a
standard protocol after distal radial fractures treated with volar open reduction and
internal fi xation: a prospective, randomized, controlled study. J Bone Joint Surg Am. 2014;96(19):1621
e 1630 .
2. Plate JF, Gaffney DL, Emory CL, et al. Randomized comparison of
volar locking plates and intramedullary nails for unstable distal radius fractures. J Hand
Surg Am. 2015;40(6):1095 e 1101 .
3. Williksen JH, Husby T, Hellund JC, Kvernmo HD, Rosales C,
Frihagen F. External fi xation and adjuvant pins versus volar locking plate fi xation in
unstable distal radius fractures: a randomized, controlled study with a 5-year follow-up. J
Hand Surg Am.
2015;40(7):1333 e 1340 .
J Hand Surg Am. Vol. 43, January 2018
r
7
4. Zong S, Kan S, Su L, Wang B. Meta-analysis for dorsally displaced
distal radius fracture fi xation: volar locking plate versus percutaneous Kirschner wires. J
Orthop Surg. 2015;10(1):10 e 19 .
5. Chaudhry H, Kleinlugtenbelt YV, Mundi R, Ristevski B,
Goslings JC, Bhandari M. Are volar locking plates superior to percutaneous K-wires for
distal radius fractures? A meta-analysis.
Clin Orthop Relat Res. 2015;473:3017 e 3027 .
6. Roh YH, Lee BK, Baek JR, Noh JH, Gong HS, Baek GH.
A randomized comparison of volar plate and external fi xation for intra-articular distal
radius fractures. J Hand Surg Am. 2015;40(1): 34 e 41 .
7. Lauder A, Agnew S, Bakri K, Allan CH, Hanel DP, Huang JI.
Functional outcomes following bridge plate fi xation for distal radius fractures. J Hand
Surg Am. 2015;40(8):1554 e 1562 .
8. MacDermid JC, Turgeon T, Richards RS, Beadle M, Roth JH. Patient
rating of wrist pain and disability: a reliable and valid measurement tool. J Orthop
Trauma. 1998;12(8):577 e 586 .
9. Carter TI, Pansy B, Wolff AL, et al. Accuracy and reliability of three
different techniques for manual goniometry. J Hand Surg Am.
2009;34(8):1422 e 1428 .
10. Shrout PE, Fleiss JL. Intraclass correlations: uses in assessing rater
reliability. Psychol Bull. 1979;86(2):420 e 428 .
11. Horger MH. The reliability of goniometric measurements of
active and passive wrist motions. Am J Occup Ther. 1990;44(4): 342 e 348 .
12. LaStayo PC, Wheeler DL. Reliability of passive wrist fl exion and
extension goniometric measurements: a multicenter study. Phys Ther.
1994;74(2):162 e 174 .
13. Landis JR, Koch GG. Measurement of observer agreement for cat-
egorical data. Biometrics. 1977;33(1):159 e 175 .
14. E-Hand.com. The Electronic Textbook of Hand Surgery. Available at:
http://www.eatonhand.com/nor/nor002.htm . AccessedOctober 6, 2017.
15. Strassmair MK, Jonas M, Schäfer W, Palmer A. Distal radial fracture
management with an intramedullary cage and fragment fi xation.
J Hand Surg Am. 2016;41(8):833 e 840 .