Role Of Active Range Of Motion İn Hand And Wrist Joint Photography: A Preliminary Analysis

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Role of Active Range of Motion in Hand and

Wrist Joint Photography

A Preliminary Analysis

Gokce Yildiran, MD, Mustafa Sutcu, MD, Osman Akdag, MD, Cemil Isik, MD, and Zekeriya Tosun, MD

Introduction: Hand photography is effective and advantageous for assessing functional deficits and improvements related to surgery. In this study, it is aimed to investigate whether the correct active range of motion (ROM) is masked by the passive ROM in a wrist joint.

Method:Eleven patients who were treated for unilateral wrist fractures were

in-cluded in the study. Photography was performed in all patients by the same sur-geon according to the conventional hand surgery photography approach and the active ROM photography approach. Differences between the noninjured side and injured side were assessed.

Results:No differences were found between the active ROM and passive ROM

during the extension and flexion movements in the noninjured side group. How-ever, in the injured side group, the results from the photographs obtained with the conventional method were significantly better than the results from the photo-graphs obtained when the wrist was actively moved.

Conclusion:These findings suggest that photographs of wrists during passive

motion may affect the results of a treatment or study by showing false positivity. We propose obtaining images of active ROM instead of passive ROM in hand photography.

Key Words: hand surgery, medical photography (Ann Plast Surg 2019;82: 636–638)

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n hand surgery, preoperative and postoperative photography is effec-tive and advantageous for presenting functional deficits or develop-ments and improvedevelop-ments related to surgery.1_{In 1984, Zarem}2_argued

that hand photography should be performed for hand movements di-rectly associated with the issue being assessed. In standardized photog-raphy for wrist flexion and extension movements, the patient is seated in front of a camera with the shoulders perpendicular to the sagittal plane, the palms joined with the fingertips pointing upward for exten-sion, and the hand dorsums joined with the fingertips pointing down-ward for flexion.2

Patients usually complain about the limitation of the wrist by flexing and extending their injured wrist. However, despite the com-plaints of limitations, it is observed that many of our patients have very good range of motion (ROM) degrees in standardized photographs. This led us to think that we may not be able to photograph the correct ROM degrees.

The aim of this study was to investigate whether the correct ac-tive ROM is masked by the passive ROM in a damaged wrist joint.

MATERIALS AND METHODS

Between 2014 and 2016, 11 patients who were treated for unilat-eral wrist fractures at least 24 months previously were considered for enrollment in this study. The included patients were contacted via tele-phone and called to our center for hand photography.

Camera

Photography was performed in all patients by the same surgeon under consistent conditions (same camera, lens, photo studio, lighting, and distance from the camera).

Views

Photography was performed according to the classic hand sur-gery and active ROM photography approaches with the palms facing each other in extension without touching and the hand dorsums facing each other in flexion without touching. Thus, the following 4 photo-graphs were obtained from each patient: active extension, active flexion, passive extension, and passive flexion (Fig. 1).

Photographing

All views were obtained while the patient sits in the upright po-sition and shoulders were perpendicular to the sagittal plan.

Passive extension photography: Palms and palmar sides of the fingers are in full contact. Both hands push each other, and the wrists are extended.

Passive flexion photography: Hand dorsum are in full contact. Both hands push each other, and the wrists are flexed.

Active extension photography: The palms are facing each other but not in contact. Both wrists are actively extended as far as possible. Affective flexion photography: Hand dorsum looks toward each other, but not in contact. Both wrists are actively flexed as far as possible.

Evaluation

Using the photographs, the angles between the ulna and the fifth metacarpal bone on both sides were measured in each patient with an imaging software (Image J, National Institutes of Health, Bethesda, Maryland) (Fig. 2). Differences between the noninjured side (NIS) and the injured side (IS), using the passive range, and the corrected an-gle of the pushed joint were evaluated for the flexion and extension motions (Table 1).

The Mann-Whitney U test was used to assess whether the active and passive ROM values significantly differed between the NIS and IS groups.

RESULTS

The study included 11 patients treated for damaged wrists. Of these, 5 had scaphoid fractures, 2 had scaphoid avascular necrosis, 3 had lunate fractures, and 1 had lunate avascular necrosis. All patients had unilateral injury to their IS wrist, and none of them have any history of trauma to their NIS.

Received October 17, 2018, and accepted for publication, after revision December 26, 2018.

From the Hand Surgery Division, Plastic, Reconstructive and Aesthetic Surgery Department, Faculty of Medicine, Selcuk University, Selcuklu, Konya, Turkey. Conflict of interest and sources of funding: none declared.

Reprints: Gokce Yildiran, MD, Hand Surgery Division, Plastic, Reconstructive and Aesthetic Surgery Department, Faculty of Medicine, Selcuk University, Keykubat Campus, Selcuklu, Konya, Turkey 42300. E-mail: ggokceunal@gmail.com. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

ISSN: 0148-7043/19/8206–0636

DOI: 10.1097/SAP.0000000000001845

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636 www.annalsplasticsurgery.com Annals of Plastic Surgery • Volume 82, Number 6, June 2019

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In the NIS group, the active and passive extension ROM values were 111.54 and 105, respectively, and there was no statistically signif-icant difference between the extension ROM values (P > 0.05). In addi-tion, the active and passive flexion ROM values were 108 and 101.45, respectively, and there was no statistically significant difference be-tween the flexion ROM values (P > 0.05).

In the IS group, the active and passive extension ROM values were 124.45 and 115, respectively, and there was a statistically signifi-cant difference between the extension ROM values (P < 0.05). Further-more, the active and passive flexion ROM values were 127.72 and 110.18, respectively, and there was a statistically significant difference between the flexion ROM values (P < 0.05).

There were significant differences between the NIS and IS groups with regard to passive and active ROM values in both extension and flexion (all P < 0.05).

DISCUSSION

Medical photography is performed for various reasons, includ-ing avoidance of medicolegal issues, assessment of the pretreatment state of a patient, assessment of posttreatment gains or deficits, intra-operative determination of a specific condition, training, and scien-tific uses.3_{As these reasons are valid in hand surgery, photography}

is considered an essential part of hand surgery. Medical photography has been standardized, and images should be captured in full dorsal

and volar views. Oblique-view and dynamic images may be required in some patients.4

Zarem emphasized that when medical imaging is performed for the hand, the hand should not touch the background material.2

The main reason for this is to achieve the anatomical position. It has been suggested that passive motion masks some results and fails to provide a true anatomical image in wrist ROM photography. Thus, this study compared the angles of wrist ROM values in passive and active movements.

In this study, there were no differences between the active and passive ROM values during the extension and flexion movements in the NIS group, indicating that the result does not change with photogra-phy in these positions.

However, in the IS group, results from photographs obtained with the conventional method appeared significantly better than those obtained when the wrist was actively moved. Patient can push the IS to its maximum passive ROM with his or her other hand (NIS), however when performing active ROM it is clear that the ROM of the IS is not equal to the ROM of the NIS. It is not so much a false positivity as it is an exaggerated result. These findings indicate that more accurate re-sults might be obtained with photographs of wrists captured during the active motion. In addition, photographs of wrists captured during the passive motion can affect the results of a treatment or study by showing false positivity.

FIGURE 1. A, Passive extension (conventional). B, Active extension (proposed). C, Passive flexion (conventional). D, Active extension (proposed).

FIGURE 2. Obtaining the ROM value by evaluating the angle between the ulna and the fifth metacarpal bone.

Annals of Plastic Surgery • Volume 82, Number 6, June 2019 Active Movements in Hand Photography

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The limitation of this study is the limited patient population. Studies on photography of active ROM in large patient populations are needed to obtain more accurate results.

It should be emphasized that the results in conventionally photographed wrist joints that have undergone treatment are passive ROM results.

We propose photography of active ROM instead of passive ROM, which has become a standard in wrist imaging and might mask poor results in wrist extension and flexion movements.

REFERENCES

1. Wang K, Kowalski EJ, Chung KC. The art and science of photography in hand

surgery. J Hand Surg Am. 2014;39:580_–588.

2. Zarem HA. Standards of photography. Plast Reconstr Surg. 1984;74:137–146.

3. von Campe A, Strub B, Meuli-Simmen C. Photography in hand surgery. Basic

knowledge and standards. Handchir Mikrochir Plast Chir. 2012;44:272–279.

4. Neligan PC. Plastic surgery. In: Kinney BM, ed. Photography in Plastic Surgery.

3rd ed. Vol 1. Philadelphia, PA: Saunders; 2013:114.

TABLE 1. Patients' ROM Degrees During Passive and Active Extension and Flexion Movements of NIS and IS Wrists

Passive Extension IS Passive Extension NIS Active Extension IS Active Extension NIS Passive Flexion IS Passive Flexion NIS Active Flexion IS Active Flexion NIS 1 118 115 133 128 94 86 110 121 2 110 109 121 121 121 110 134 123 3 106 92 138 95 103 101 120 106 4 109 106 131 128 115 109 135 102 5 117 109 114 120 102 96 128 98 6 116 105 125 126 113 95 119 102 7 104 98 121 102 108 97 137 107 8 106 101 114 109 119 105 126 131 9 108 102 124 110 113 108 125 104 10 138 109 124 96 110 104 138 100 11 133 109 124 92 114 105 133 94

Yildiran et al Annals of Plastic Surgery • Volume 82, Number 6, June 2019