UPPER EXTREMITY RANGE OF MOTION

Range of motion of many upper extremity joints appears to differ in infants and young children compared with adults (Table 16-1). Measurements reported in a study of more than 300 Japanese infants and children from birth to 2 years of age demonstrated an increased range of shoulder extension and lateral rotation, forearm pronation, and wrist flexion, along with a decreased range of elbow extension, in this age group compared with adults.¹⁹ The amount of shoulder lateral rotation present in the neonate appears to decrease as the child ages, with the range of shoulder rotation approaching adult levels by the age of 2 years (Table 16-2). As a child ages, elbow extension range of motion also changes to approach adult levels, but more quickly than does the range of shoulder lateral rotation.

The limitation in elbow extension seen in the neonate appears to resolve by the age of 3 to 8 months (see Table 16-2),^11,19 progresses to hyperextension in many children by the age of 2 to 3 years,^5,19,21 (Fig. 16-1) and then gradually resolves to adult levels. A limitation in shoulder abduction also has been reported in neonates, but by only one investigator on a fairly small sample of subjects.¹¹ The limitation in shoulder abduction had disappeared in these infants by 3 months of age.

TECHNIQUES OF MEASUREMENT: UPPER EXTREMITY

We have not included techniques for every joint of the upper extremity, because the focus of the chapter is to examine changes in the pediatric population compared with the adult. The techniques that are included focus on joints with an increased or decreased range of motion and alternative positions that are used compared with those used for the adult. Please reference the adult chapters for alternative positioning or joints or movements that have not been included. As in the adult, follow standard procedures for measuring range of motion that have been outlined in Chapter 1.

Shoulder Flexion

Patient position:

Supine with shoulder in 0 degrees flexion, elbow fully extended, forearm in neutral rotation with palm facing trunk or pronated (Fig. 16-2).

Fig. 16-2 Starting position for measurement of shoulder flexion. Bony landmarks for goniometer alignment (lateral aspect of acromion process, lateral midline of thorax, lateral humeral epicondyle) indicated by red line and dots.

Stabilization:

Proximal to humeral head and distal to elbow (Fig. 16-3).

Fig. 16-3 End of shoulder flexion ROM, showing proper hand placement for stabilizing and flexing shoulder. Bony landmarks for goniometer alignment (lateral aspect of acromion process, lateral midline of thorax, lateral humeral epicondyle) indicated by red line and dots.

Examiner action:

Flex patient’s shoulder through available range of motion (ROM), avoiding extension of spine. Return limb to starting position. Performing passive movement provides an estimate of ROM (see Fig. 16-3).

Goniometer alignment:

Palpate following bony landmarks (see Fig. 16-2), and align goniometer accordingly.

Stationary arm:

Lateral midline of thorax.

Axis:

Midpoint of lateral aspect of acromion process.

Moving arm:

Lateral midline of humerus toward lateral humeral epicondyle.

Read scale of goniometer.

Patient/Examiner action:

Perform passive shoulder flexion (Fig. 16-4).

Fig. 16-4 End of shoulder flexion ROM, demonstrating proper alignment of goniometer at end of range.

Confirmation of alignment:

Repalpate landmarks and confirm proper goniometric alignment at end of ROM, correcting alignment as necessary (see Note). Read scale of goniometer (see Fig. 16-4).

Documentation:

Record patient’s ROM.

Note:

No extension of spine should be allowed during measurement of shoulder flexion, to prevent artificial inflation of ROM measurements.

Alternative patient position:

Side-lying; goniometer alignment remains the same.

Owing to decreased ability to stabilize trunk in these positions, great care must be taken to ensure that stationary arm of goniometer remains aligned with lateral midline of thorax, and that extension of spine does not occur. Failure to exercise such care will result in errors in measurement.

Shoulder Lateral Rotation

Patient position:

Supine with shoulder abducted to 90 degrees, elbow flexed to 90 degrees, forearm pronated, and folded towel under humerus (optional) (Fig. 16-5).

Fig. 16-5 Starting position for measurement of shoulder lateral rotation. Landmarks for goniometer alignment (olecranon and styloid processes of ulna) indicated by red dots.

Stabilization:

At infant’s elbow to maintain alignment (Fig. 16-6).

Fig. 16-6 End of shoulder lateral rotation ROM, showing proper hand placement for stabilizing and laterally rotating shoulder. Landmarks for goniometer alignment (olecranon and styloid processes of ulna) indicated by red dots.

Examiner action:

Laterally rotate patient’s shoulder through available ROM. Return limb to starting position. Performing passive movement provides an estimate of ROM (see Fig. 16-6).

Goniometer alignment:

Palpate following bony landmarks (shown in Fig. 16-5), and align goniometer accordingly (Fig. 16-7).

Fig. 16-7 Starting position for measurement of shoulder lateral rotation, demonstrating proper initial alignment of goniometer.

Stationary arm:

Perpendicular to floor.

Axis:

Olecranon process of ulna.

Moving arm:

Ulnar border of forearm toward ulnar styloid process.

Read scale of goniometer.

Patient/Examiner action:

Perform passive lateral rotation of the shoulder, stopping at the point of elevation of the scapula off the table.

Confirmation of alignment:

Repalpate landmarks and confirm proper goniometer alignment at end of ROM, correcting alignment as necessary. Read scale of goniometer (Fig. 16-8).

Fig. 16-8 End of shoulder lateral rotation ROM, demonstrating proper alignment of goniometer at end of range.

Documentation:

Record patient’s ROM.

Elbow Extension

Patient position:

Supine with upper extremity in anatomical position (see Note), with elbow extended as far as possible, folded towel under distal humerus, proximal to humeral condyles (optional) (Fig. 16-9).

Fig. 16-9 Starting position for measurement of elbow extension. Bony landmarks for goniometer alignment (lateral aspect of acromion process, lateral humeral epicondyle, radial styloid process) indicated by red dots.

Stabilization:

At the wrist or anterior forearm and posterior humerus.

Examiner action:

Determine whether elbow is extended as far as possible, providing pressure across the elbow in the direction of extension (Fig. 16-10).

Fig. 16-10 End of elbow extension ROM, showing proper hand placement for stabilizing humerus and extending elbow. Bony landmarks for goniometer alignment (lateral aspect of acromion process, lateral humeral epicondyle, radial styloid process) indicated by red dots.

Goniometer alignment:

Palpate following bony landmarks (see Fig. 16-9), and align goniometer accordingly (Fig. 16-11).

Fig. 16-11 Goniometer alignment for measurement of elbow extension.

Stationary arm:

Lateral midline of humerus toward acromion process.

Axis:

Lateral epicondyle of humerus.

Moving arm:

Lateral midline of radius toward radial styloid process (see Note).

Read scale of goniometer (see Fig. 16-11).

Documentation:

Record patient’s ROM.

Note:

Patient’s forearm should be completely supinated at beginning of ROM, or beginning reading of goniometer. May be compromised owing to apparent lack of elbow extension.

Alternative patient position:

Seated or side-lying; towel not needed; goniometer alignment remains the same.

Wrist Flexion

Patient position:

Supine with shoulder abducted to 90 degrees, elbow flexed to 90 degrees, forearm pronated (Fig. 16-12).

Fig. 16-12 Starting position for measurement of wrist flexion using lateral alignment technique. Bony landmarks for goniometer alignment (olecranon process of ulna, triquetrum, lateral midline of fifth metacarpal) indicated by red dots.

Stabilization:

Over dorsal surface of hand and proximal to the elbow (Fig. 16-13).

Fig. 16-13 End of wrist flexion ROM, showing proper hand placement for stabilizing forearm and flexing wrist. Bony landmarks for goniometer alignment (olecranon process of ulna, triquetrum, lateral midline of fifth metacarpal) indicated by red dots.

Examiner action:

Flex patient’s wrist through available ROM (see Note). Return wrist to neutral position. Performing passive movement provides an estimate of ROM (see Fig. 16-13).

Goniometer alignment:

Palpate following bony landmarks (shown in Fig. 16-12), and align goniometer accordingly (Fig. 16-14).

Fig. 16-14 Starting position for measurement of wrist flexion, demonstrating proper initial alignment of goniometer.

Stationary arm:

Lateral midline of ulna toward olecranon process.

Axis:

Triquetrum.

Moving arm:

Lateral midline of fifth metacarpal.

Read scale of goniometer.

Patient/Examiner action:

Perform passive wrist flexion (Fig. 16-15).

Fig. 16-15 End of wrist flexion ROM, demonstrating proper alignment of goniometer at end of range.

Confirmation of alignment:

Repalpate landmarks and confirm proper goniometric alignment at end of ROM, correcting alignment as necessary. Read scale of goniometer (see Fig. 16-15).

Documentation:

Record patient’s ROM.

Note:

Flexion of fingers should be avoided during measurement of wrist flexion to prevent limitation of motion by tension in extrinsic finger extensors.

Alternative patient position:

Supportive sitting for lateral alignment. See Chapter 5.

Lower Extremity ROM

Normal range of motion in the lower extremity joints is not static but changes across the life span, from birth until the later decades of life (Table 16-3).* Studies in the pediatric population have demonstrated increased hip flexion, abduction, and rotation range of motion in infants and young children compared with the adult population (see Table 16-3).^† Extension of the hip is decreased in neonates, resulting in a hip flexion contracture that appears to resolve by the age of 2 years.^‡ A similar flexion contracture is seen at the knee of neonates,^3,7,19,20 but this contracture appears to resolve fairly quickly, with knee extension approaching adult values by the time the infant reaches 3 to 6 months of age (Table 16-3)^3,11 and progressing to hyperextension in some children by 3 years of age. Studies of large groups of children in China, England, and Scotland revealed hyperextension of the knee in young children that disappeared at some point between the ages of 6 and 10 years.^15,21

Table 16-3

Changes in Lower Extremity Range of Motion: Birth to 84 Years of Age

^*Watanabe et al.¹⁹

^†Boone et al.²

^‡Roach and Miles.¹⁴

^§Walker et al.¹⁸

Component of pronation.

^¶Component of supination.

^**Forero et al⁸ (neonates).

^††Drews et al⁷ (neonates).

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