вход по аккаунту


Movements at the carpometacarpal and metacarpophalangeal joints of the hand and their effect on the dimensions of the articular ends of the metacarpal bones.

код для вставкиСкачать
THE ANATOMICAL RECORD 213:102-110 (1985)
Movements at the Carpometacarpal and
Metacarpophalangeal Joints of the Hand and Their
Effect on the Dimensions of the Articular Ends of
the Metacarpal Bones
Department of Anatomy, Medical School, University of Calabar, Calabar, Nigeria
A detailed study was undertaken to quantify the range of various
movements at the carpometacarpal and metacarpophalangeal joints of the hand in
cadavers and compare the values so obtained with those in the living, measured
with the help of skiagrams. Longitudinal sections of hand were also prepared to
bring out the nature of articulations at the carpometacarpal joints. Based on the
data available, metacarpal mobility formulae of 1 > 5 > 4 > 2 > 3 for the
carpometacarpal, and 5 > 4 > 3 > 2 > 1 and 5 > 2 > 4 > 3 > 1 for metacarpophalangeal joints are being proposed with the hope that these formulae will find
their application in the clinical practice to assess the extent of functional damage t o
these joints as well as to evaluate the rate of progress or deterioration, in course of
time. As a n extension of our earlier study (Batmanabane, 1982),osteometric analysis
of the metacarpus was also carried out and it is confirmed that it is the mobility
which determines the osteometric features of the articular ends of these miniature
long bones.
One of the important evolutionary changes that the
primates have undergone is the transformation of the
hand from an organ of progression to one of prehension,
perception, and expression. The metacarpals are designed chiefly to adapt the hands for prehension. The
performance of the hand is dependent on the movements
between the different components of the hand, taking
place a t different joints. Hence these joints, especially
the carpometacarpal and the movements occurring in
them, have attracted the attention of many workers.
Although the first carpometacarpal joint (CMJ) is the
most analysed one, a few reports are available regarding
the other joints as well. Some gliding movement is possible a t the carpometacarpal and intermetacarpal joints
of the second to fifth fingers (Gardner et al., 1975). A
small but useful range of movement a t the base of the
fourth metacarpal (MC4) and a wider range of movement
a t the base of the fifth (MC5) aid in the approximation
of the two borders of the hand, thereby deepening the
cup of the palm.
Movements of the thumb have been studied by various
authors (Backhouse, 1960; Bunnell, 1938; Haines, 1944;
Napier, 1955) and the general observations on the functional aspect of the hand have been done (Landsmeer,
1962; McFarlane. 1962; Napier, 1956).
Earlier reports (Batmanabane, 1981a,b)suggested that
the movements rather than the length may be responsible for the various dimensions of the metacarpals a t
their articular ends. Though the occurrence of movements at each of CMJs and metacarpophalangeal joints
(MPJs) was known (Harris and Joseph, 1949), the exact
range of movements available at each of these joints has
@ 1985 ALAN R. LISS, INC.
not been investigated thoroughly and the range of movements of the metacarpal bones, as measured in cadavers, has not been verified radiographically in the living.
Hence, a detailed analysis of movements at CMJs and
MPJs was considered meaningful, especially because
these movements seem to influence the osteometric features of the metacarpus. Hence this study was designed
to quantify the available movements a t CMJs and MPJs
and find a correlation between these movements, the
metacarpal lengths, and indices of various diameters of
these bones.
1) Fresh specimens of ten normal adult hands from
cadavers, aged between 26 and 42, were used for the
measurement of movements a t each of the CMJs and
MPJs. All hands were checked radiologically and found
to have had no evidence of past injury or disease of the
bones and joints.
2) For measuring the range of movements of the metacarpal in the living, radiographs of adult hands of
individuals in the same age group, all manual laborers,
irrespective of side and sex, were taken.
3) Specimens of intact hand, from both sides of six
fresh cadavers, were sectioned to bring out the details of
articulation a t CMJs.
Received April 30, 1984; accepted April 5, 1985.
4) For anthropometric study, 50 adult samples from
each of the metacarpus were selected.
The fresh adult hand specimens were dissected free of
all structures except the ligaments and capsules of the
joints of the hand; the deep transverse metacarpal ligament was well preserved.
For measuring the angular movements in cadavers,
the following simple devices were made: to a n inflexible
thick copper wire two sharp short pins were soldered a t
right angles to the wire at convenient points, depending
upon the bone for which this particular device is intended one set was made with the pins positioned in
such a way that they could be driven into the head and
the base of the metacarpals-one each for the long (second, third, and fourth) and short metacarpals (first and
fifth). A second set was prepared to fit the length of the
distal row of carpal bones and a third, the proximal
The metacarpal wire was fixed strongly along the
length of MC1 and the carpal wire into the trapezium,
both on the palmar aspect. The two pins were arranged
in such a way that the wires were nearly at the same
level but exactly parallel to each other, the joint being
in the neutral position. The movement of maximum
flexion was performed a t the CMJ and the angle between the wires was measured. This was followed by
taking the measurement of the maximum extension
movement at the same joint from the neutral position.
MC1 was then fully adducted and the wires were adjusted. Bringing it to a fully abducted position, the angle
between the wires was measured. This reading gave the
full range of abduction (FRA; FRA is taken as the maximum amount of abduction that can be produced from
the initial position of complete adduction). For measuring the rotation at the first CMJ, two wires were fixed
vertically a t the same level and parallel to each otherone each on the dorsal aspect of MC1 and trapezium, the
joint being in full extension. MC1 was then fully flexed
and the angle measured. This gave the range of rotation.
For measuring the range of movements at MPJ of
MC1, one wire was fixed to the metacarpal and another
to the corresponding proximal phalanx, both on the dorsal aspect. Observing the same precautions, the range
of flexion, extension, and FRA were measured from the
neutral position. Movements at other CMJs (FRF (vide
infra) and FRA) and MPJs (flexion, extension and FRA)
were also recorded in the same way as for the first,
except that the wires were fixed on the dorsal aspect of
the bones for all the measurements.
Since the movements at CMJs of the medial four metacarpals are of limited range, it was decided to measure
FRA and the full range of flexion (FRF), which is taken
as the maximum amount of flexion that can be produced
from the initial position of complete extension.
The readings (a mean of three) were taken, avoiding
errors of parallax (Tables 1, 2). A transparent plastic
protractor was used for the purpose throughout the
Skiagrams of the hand of 30 individuals in all were
taken in the following positions:
a) All fingers and the thumb in full adduction,
b) the fingers in full abduction and the thumb partially extended at its CMJ,
c) the thumb in neutral position,
d) the thumb fully extended a t its CMJ and MPJ, and
el MPJs of fingers and the thumb in the neutral, fully
flexed, and extended positions.
Since abduction at the pollicial MPJ is practically nil,
no separate skiagram was taken.
The following axes were drawn on the exposed x-ray
In “a” the long axes for the medial four metacarpals,
their proximal phalanges, and for the hamate were
drawn. The angles between i) the long axis of MC5 and
hamate and ii) the long axis of the metacarpal and its
corresponding proximal phalanx were measured (resting angles). A fixed point of 7 mm was taken from the
distal end of the axis of each of the four medial metacarpals. The adjacent points were joined (Fig. 1).
The distance between the adjacent points were also
measured in mm.
In “b”, the same procedure was followed as in “a” and
the new sets of readings were taken (Fig. 2). Differences
between corresponding readings as in “a” and “b” were
taken as i) the amount of FRA occurring at the CMJ of
the little finger and ii) MPJs of the medial four digits.
Any increase in the intermetacarpal distance will offer
a rough indication of the degree of movement of abduction a t other CMJs. For this purpose, during the exposures of “a” and “b”, a constant position of the middle
finger (the axis for the movements of the hand) and the
wrist was maintained.
In “c” the long axes of MC1 and the trapezium were
drawn and the angle between these was measured (resting angle) (Fig. 3).
In “8’
the same procedure was followed as in “a” and
a new set of readings was taken (Fig. 4). Difference
between corresponding readings in “c” and “d” was
calculated (angle of extension).
To measure the movements at MPJs, the long axes of
the metacarpal and its phalanx in the neutral, flexed,
extended, and abducted positions were drawn and the
angles were recorded.
The procedure for the anthropometric study was the
same as described elsewhere (Batmanabane, 1982). The
axial ratios were determined and the data statistically
Movements at CMJs-As Measured in Cadavers
The mean values of the degree of mobility of the metacarpal bones at their respective CMJs are shown in
Tables 1 and 2. There is a comparatively greater amount
of extension at the CMJ of the thumb than flexion and
the amount of rotation exceeds that of flexion and extension taken individually. Among the medial four metacarpals, MC5 displayed a maximum amount of FRF and
FRA followed by MC4, MC2, and MC3, in that order.
Movements at MPJs-As
Measured in Cadavers
The mean values of movements occurring a t these
joints are summarized in Table 3. Concerning flexion
and extension, the order of mobility gave the picture of
MC5 being the most mobile followed by MC4, MC3, MC2,
and MC1. However, regarding FRA, the order was
slightly different, with MC5 leading followed successively by MC2, MC4, MC3, and MC1.
Fig. 1. Skiagram of the right hand showing the long axes of MC2,
MC:l, MC4, and MC5 and the hamate, the CMJs in full adduction. Note
the axis of MC5 intersecting that of hamate.
Fig. 2. Skiagram of the right hand, showing the same axes as in
Figure 1 but the CMJs in full abduction. Note the axis of MC5 lying
medial to that of hamate.
Movements at CMJs-As Measured From Skiagrams
partly mobile factor, the capitate as a factor of stability,
and the hamate as a gliding base for the fourth and
especially the fifth metacarpal. The articulation between the trapezium and MC1 is built like a saddle joint,
concave in anteroposterior plane and convex in the lateral plane a t the base of MC1 and vice versa a t the
contiguous surface of trapezium, which permits the various available movements (Fig. 5). The first CMJ is
closely packed in full adduction or abduction and freest
movements can occur when it is in the neutral position.
Although the movements of the thumb involve flexion
more often than extension, it was interesting to find
that the amount of the latter movement at the first CMJ
exceeded that of the former.
Even though the available movements in the medial
four CMJs are said to be pure translations and in reality
accessory movements of the first type, these are often
considered to be the only motion permitted. However,
even here, examination of cineradiographs reveals a
considerable degree of rotation and angular change in
the relative positions of the small bones during most
movements of the carpus (Williams and Warwick, 1980).
MC3, the middle member of the metacarpal series,
which maintains the central axis of the pentadactyle
hand, is particularly immobile and there is every reason
to expect that its immediate neighbours, MC2 and MC4
(Figs. 6, 7), will primitively display a n equally lessened
degree of mobility (Jones, 1949). But the simplest test
will convince us that the mobility of MC2 is far less than
The values for extension at the first and abduction a t
the fifth CMJs are summarized in Table 4. Since facilities for taking tomograms were not available further
analysis of movements could not be carried out.
Movements at MPJs-As Measured From Skigrams
These values are shown in Table 5. The graded range
of movements a t these joints, in the living, correlated
well with those values obtained in cadavers.
Statistical Analysis
In line with earlier findings, the side-to-side diameter
of the heads of MC2, MC3, MC4, and MC5 were greater
than the dorsopalmar diameter and the significance of
this finding has been discussed elsewhere (Batmanabane, 1982).
Table 6 summarises the mean 1 S.E.M. values of the
different parameters. Highly significant values were obtained for all the metacarpal bones when the data were
submitted to a “t” test, while the values of the coefficient of correlation were all insignificant.
If the carpal bones are taken as the foundation upon
which the hand is built, the trapezium becomes significant as a base for the mobile thumb, the trapezoid as a
Fig. 3. Skiagram of the right hand showing the long axes of MC1
and the trapezium, t h e first CMJ in the neutral position.
Fig. 4. Skiagram of the same right hand showing the same axes a s
i n Figure 3, t h e first CMJ i n full extension.
TABLE 1. Mean f S.E.M. values of movements of MCI at its CMJ, as measured in cadavers'
k 0.904
& 1.033
k 0.843
k 1.464
Abduction (FRA)
k 1.335
'Abduction and rotation movements were measured from initial positions of complete adduction and extension, respectively.
Mean values a r e in degrees.
TABLE 2. Mean f S.E.M. values of movements at the medial four CMJs, as measured in cadavers'
Flexion (FRF)
Abduction (FRA)
12.1 L- 0.9
5.8 0.359
16.9 & 0.731
26 t 1.366
11.6 k 0.718
5.1 k 0.26
14.6 & 1.316
23.7 k 1.256
2.3 & 0.213
2.1 f 0.314
5 & 0.258
13.6 5 0.286
4 k 0.258
13.3 f 0.26
'Flexion and abduction movements were measured from initial positions of complete extension (FRF) and adduction (FRA),
respectively. Mean values a r e i n degrees.
'N.D., not done.
that which can be evoked in MC4. This is a specialisa- to a fair degree and MC2 practically not at all, but our
tion of the index for a n unusual degree of stability. This observation shows that MC2 can indeed be moved so
is explained by the nature of its situation where it is dorsally, though to a very limited extent, in the living.
sandwiched between the trapezium and the capitate, This is reflected in our findings in cadavers, where FRF
resting on the trapezoid. Gardner et al. (1975) remarked averaged 12.1" on the right and 11.6" on the left. Althat MC5 can be passively moved forward and backward though MC3 is the most fixed, even a t its CMJ a mini-
TABLE 3. Mean
S.E.M. values of movements of the metacarpal bones at their respective MPJs, as measured in cadavers'
47.2 f 0.611
70.1 f 1.089
79.9 k 1.089
96.6 f 1.726
102.3 f 1.366
f 0.721
f 1.164
f 2.153
f 1.662
k 1.249
16.2 f 0.997
45.5 f 1.368
55.1 f 1.32
64.3 k 1.591
69.2 f 1.356
14.8 f 0.975
41 1.316
51.8 f 1.051
60.8 f 1.576
65.5 f 1.522
2.7 k 0.226
35.8 f 0.872
7.7 f 0.336
18.3 f 0.541
38.1 f 0.921
1.8 f 0.199
31.9 i 0.743
5.6 f 0.237
14.1 f 0.499
35.9 f 0.881
'Mean values a r e in degrees.
TABLE 4. Mean 1 S.E.M. values of movements of extension of MC1 and abduction of MC5 at their
respective CMJs, as measured from skiagrdms'
Abduction (FRA)
19.3 0.238
18.8 k 0.133
12.9 0.752
10.1 k 0.314
'Extension was measured from t h e neutral position and abduction from a n initial position of complete adduction. Mean
values a r e in degrees.
'N.D., not done.
TABLE 5. Mean f S.E.M. values of movements of the metaca al bones at their respective MPJs,
as measured from skiagrams
f 0.813
i 1.093
+_ 0.7
k 1.075
f 0.845
40.9 i 0.766
60.5 i 1.035
64.1 i 1.0203
81.4 i 1.045
90.1 f 1.157
14.4 i 0.6
11.5 f 0.6006
39.6 f 1.359
36.6 L- 1.447
47 i 0.9306
43.2 i 0.696
58.1 f 0.438
53.9 i 0.448
62.3 i 1.087
60.1 f 1.069
31.4 f 0.721
5.2 f 0.198
15.7 f 0.501
33.6 f 0.799
28.1 f 0.596
3.8 k 0.122
13.5 f 0.489
29.7 0.611
'Mean values are in degrees.
TABLE 6. Mean f S.E.M. values of length and axial ratios of the metacarpals'
MC 1
f 0.026
f 0.079
f 0.073
i 0.073
f 0.053
Axial ratios
1.9 k 0.01
0.992 f 0.011
1.06 f 0.009
0.986 f 0.014
0.99 k 0.007
1.33 i 0.016
1.076 k 0.022
1.12 0.012
1.119 f 0.024
0.89 f 0.005
1.01 f 0.007
1.063 f 0.014
1.3 f 0.013
1.072 i 0.018
0.9 f 0.007
'The length values a r e in cm.
ma1 degree of flexion was found to be available (Table 2)
in the cadavers. This is easily interpretable in the light
of the postmortem changes in the ligaments of the joints
and other factors (vide infra). Certainly MC4 presented
a fair amount of movement, but compared only to MC5
which displayed the widest range of movements among
the medial four metacarpals, probably because of its
condylar type of articulations with the hamate (Fig. 8).
MC5 rotates about MC4 because of its articulation
with the latter and the saddle type of joint with the
hamate, permitting such a rotation to occur (Fig. 9).
Thus, fourth and fifth CMJs are indeed biaxial joints
rather than mere plane joints, as observed from the
available movements and the sections of hand speci-
mens. Among the movements a t CMJs, only extension
of MC1 and abduction of MCS could be verified radiologically in the living. These values were found to more or
less correspond to those obtained in cadavers, the values
in the living being slightly less, (compare Tables 1 and
2 with 4).This may be due to various factors causing
limitation of movements in the living, such as the tension of ligaments-an integral factor in producing the
close-packed position of a joint, the tension of the antagonistic muscles, and the soft tissue opposition during the
performance of these movements. The fact that there is
an increase in the intermetacarpal distance gives a
rough and yet a positive evidence of the availability of
abduction at the second and the fourth CMJs. Based on
Fig. 5. Photograph of the longitudinal section of the hand passing through MC1 and the
corresponding carpal bones. Note the articulations between MC,, the trapezium, and the
Fig. 6. Photograph of the longitudinal section of the hand passing through MC2 and the
corresponding carpal bones. Note the articulations between MC2, the scaphoid, the trapezium,
and the trapezoid.
Fig. 7. Photograph of the longitudinal section of the hand passing through MC3 and the
corresponding carpal bones. Note the articulations between MC,, the capitate, and the lunate.
Fig. 8. Photograph of the longitudinal section of the hand passing through MC, and the
corresponding carpal bones. Note the condylar type of articulation between MC, and the
Fig. 9. Photograph of the longitudinal section of the hand passing through MC5 and the
corresponding carpal bones. Note the saddle type of articulation between MC5 and the hamate.
these findings and in line with the logic of the metacar- and MC1 the least, leading to a metacarpal mobility
pal formula, we propose a metacarpal mobility formula f o r m u h of 5 > 4 > 3 > 2 > 1as far as flexionlextension
of 1 > 5 > 4 > 2 > 3 for CMJs.
is concerned and 5 > 2 > 4 > 3 > 1 with respect to
At MPJs, as far as FRA is concerned, MC5 emerges to abductionladduction a t MPJs. Radiological analysis of
be certainly the most mobile, and not MC2 as mentioned these movements, in the living, conformed to this
by Williams and Warwick (1980). Indeed, MC5, forming gradation.
the medial boundary of the bony framework of the penWe are of the opinion that the acceptance of these
tadactyle hand, should be expected to enjoy the highest formulae will be very useful clinically for immediate
degree of mobility in order to adapt itself to various qualitative assessment of a) the extent of damage to any
objects grasped to offer the best grip possible to the of these joints under various pathological conditions and
prehensile hand, just like its counterpart, MC1. The only b) their subsequent functional recovery or further loss
difference is MC1 is most mobile a its CMJ and MC5 a t after treatment. Thus, these observations, condensed in
its MPJ (vide infra). We consider t ‘s a very vital ar- the form of metacarpal mobility formulae, would be very
rangement which will provide a n element of stability handy in the evaluation of hand function.
without prejudice to the mobility of these joints in this
From the statistical analysis of the data obtained from
functionally specialised organ.
the measurements of the metacarpal bones, it was eviMC5 is followed by MC2, MC4, and MC3, in that order, dent that these miniature long bones are distinctively
with MC1 displaying a very negligible range.
different from each other in all parameters with the Y’
Other minor movements, consisting of rotation, dis- values found to be much higher than the tabulated valtraction, and gliding, have been omitted since these are ues a t 0.1% level of significance. Reviewing the values
really accessory movements and their values, if mea- of the coefficient of correlation, it was found that the ‘Y’
sured, may not truly reflect their exact range since these values were insignificant in all cases, confirming the
are negligible.
view (Batmanabane, 1982) that the length of the metaAlthough the extent of flexion at all MPJs is always carpal does not influence the various diameters of the
more than that of extension, in both cadavers and the articular ends of these bones.
living, it is to be remembered that a little more of extenThe metacarpal bones generally display a similar
sion can still be produced passively in the living even shape despite a glaring difference in length. The existhough this will not make the totally available range of tence of a graded range of movements in them could be
extension exceed that of flexion, as evidenced by the a factor effecting the osteometric features at their artifindings in the cadavers, where the movements were cular ends, especially in the absence of any possible role
produced passively and yet the values of extension were of the length. If mobility should influence the morpholless than those of flexion in the living. From the obser- ogy of the metacarpus the effects will be seen mainly at
vations of the available movements at MPJs, it is inter- the articular ends. The extent of the influence will deesting to note that MC5 emerges to be the most mobile pend upon the degree of mobility of the surfaces. Since
movements occur in these joints along two axes, both
dorsopalmar and side-to-side diameters of the ends will
be involved while mobility is shaping the articular terminals of these bones.’ This means, where the movements in both planes are closer to each other in their
extent, the dimensions should be affected so uniformly
and almost equally that the axial ratio of that particular
end should be nearer to one. If the ranges of movements
are wider apart, the dimensions are going to be influenced differentially and the values of the axial ratios
are going to be farther from one. This is clearly reflected
in all the metacarpals, as observed in this study, where
the mean axial ratios of the head are the ones closest to
one and those of the base farthest in all but MC1, where
the trend is reversed due to the fact that the base of
MC1 is more mobile than its head. There is thus a close
correlation between the diameters of the articular ends
of the metacarpus and their relative mobility, which
therefore appears to be a determining factor for the
distinctive osteometric characteristics of these bones.
However, it may sound very strange, a t the outset, to
state that it is movements which determine the shape of
the articular terminals of these bones. We may be
tempted to favour the common view that only shapes
dictate the type of movements that should occur in a
joint and not vice versa. In order to arrive at a conclusion to the question “Movement first or shape first?” we
should take into serious consideration the fact that, in
the course of a long, arduous process of evolution, attempts of living organisms to adapt to a different habitat, from aquatic to terrestrial, to cite a n example, would
put a lot of stress and strain on the joints during movements, and such initially difficult-to-perform movements will mould the joint surfaces in the course of time
to make it easy for the animals to make a successful
adaptation. Thus, only movement is the factor which
appears to have a direct access or influence over the
joint surfaces and hence will shape them over the long
years (of evolution) depending on the need of the animals concerned. Is it not true that, in the case of the
bones of the skull, where movement is not necessary or
even desired, bones which come together are firmly connected with one another to form sutures? Are not
“squatting facets” examples of structural modifications
consequent to the peculiar posture of a particular type
of DoDulation? In the words of Walter and Savles (1959).
“Climbing, digging, flying, striking, standing, running:
gasping and lifting are Only a few Of the many
that make necessary structural adaptations.” Hence it
is logical to believe that only movements dictated the
design of the shapes of the articular ends of the bones,
especially in the hand, which has evolved from having
been a n organ of progression to one of prehension, perception, and expression.
The author wishes to thank the head of the Department of Anatomy for making the facilities available for
this study and the Committee of Deans, University of
Calabar, for providing funds to attend the Winter Meeting of the Anatomical Society of Great Britain & Ireland, December, 1980, where a part of this work was
Batmanahane, M. (1981a) Mobility-a major factor in the determination of the morphology of the human metacarpal hones. J.Anat.,
Batmanahane, M. (1981h) A further study on the role of mobility as
the determining factor for the morphology of metacarpal bones.
J.Anat., 132(3):458(Abstract).
Batmanahane, M. (1982) Whether mobility influences the osteometric
features at the articular ends of the metacarpal bones. Acta Morphol. NeerlScand., 20(2):111-115.
Backhouse, K.M. (1960)Digital rotation. J.Anat., 94.453.
Bunnell, S.E. (1938) Opposition of the thumb. J. Bone Jt. Surg.,
Gardner, E., D.J. Gray, and R. O’Rahilly (1975) The hand. In: Anatomy-A Regional Study of Human Structure. Saunders, Philadelphia, pp. 152-156.
Haines, R.W. (1944)The mechanism of rotation at the first carpometacarpal joint. J.Anat., 78.44-46.
Harris, H., and J. Joseph (1949) Variation in extension of metacarpophalangeal and interphalangeal joints of the thumb. J.Bone Jt.
Surg. 31B547-559.
Jones, F.W. (1949)The metacarpal formula. In: The Principles of Anatomy as Seen in the Hand. Bailliers, Tindall and Cox, London, pp.
Landsmeer, J.M.F. (1962) Power grip and precision handling. Ann.
Rheum.Dis., 21:164-170.
McFarlane, J.M. (1962) Observations on the functional anatomy of the
intrinsic muscles of the thumb. J.Bone Jt. Surg., 444:1073-1088.
Napier, J.R. (1955)The form and function of the carpometacarpal joint
of the thumb. J.Anat., 89:362-369.
Napier, J.R. (1956)The prehensile movements of human hand. J.Bone
Jt. Surg., 38B:902-913.
Walter, H.E., and L.P. Sayles (1959) The skeleton. In: Biology of the
Vertebrates. The Macmillan Company, New York, pp, 606-607,
Williams, L.P. and R. Warwick (1980) Kinesiology: Arthrology. In:
Gray’s Anatomy. Churchill Livingstone, Edinburgh, pp. 431-438,
‘A study to map out and analyse the configurations of these joints
is currently in progress.
Без категории
Размер файла
1 017 Кб
effect, dimensions, ends, hands, metacarpophalangeal, movement, joint, carpometacarpal, metacarpal, articular, bones
Пожаловаться на содержимое документа