Full Download Pediatric Hand Therapy, 1e 1st Edition Joshua M. Abzug PDF

Download More ebooks [PDF]. Format PDF ebook download PDF KINDLE.
Full download ebooks at ebookmass.com
Pediatric Hand Therapy, 1e 1st Edition

Joshua M. Abzug
For dowload this book click BUTTON or LINK below
https://ebookmass.com/product/pediatric-hand-
therapy-1e-1st-edition-joshua-m-abzug/
OR CLICK BUTTON
DOWLOAD NOW
Download More ebooks from https://ebookmass.com

More products digital (pdf, epub, mobi) instant
download maybe you interests ...
2020 Nelson’s Pediatric Antimicrobial Therapy 26th

Edition Edition John S. Bradley
https://ebookmass.com/product/2020-nelsons-pediatric-
antimicrobial-therapy-26th-edition-edition-john-s-bradley/
2022 Nelson's Pediatric Antimicrobial Therapy, 28th

Edition John S. Bradley
https://ebookmass.com/product/2022-nelsons-pediatric-
antimicrobial-therapy-28th-edition-john-s-bradley/
Frames of Reference for Pediatric Occupational Therapy

4th Edition, (Ebook PDF)
https://ebookmass.com/product/frames-of-reference-for-pediatric-
occupational-therapy-4th-edition-ebook-pdf/
The Public Health Crisis Survival Guide 2nd Edition

Joshua M. Sharfstein
https://ebookmass.com/product/the-public-health-crisis-survival-
guide-2nd-edition-joshua-m-sharfstein/
Case Competencies in Orthopaedic Surgery, 1e 1 Pap/Psc
Edition Rachel M Frank Md
https://ebookmass.com/product/case-competencies-in-orthopaedic-
surgery-1e-1-pap-psc-edition-rachel-m-frank-md/
Self-System Therapy for Depression: Therapist Guide 1st

Edition Kari M. Eddington
https://ebookmass.com/product/self-system-therapy-for-depression-
therapist-guide-1st-edition-kari-m-eddington/
Nelson Pediatric Symptom-Based Diagnosis 2nd Edition

Robert M. Kliegman
https://ebookmass.com/product/nelson-pediatric-symptom-based-
diagnosis-2nd-edition-robert-m-kliegman/
Business Analytics: Communicating with Numbers, 1e 1st

Edition Sanjiv Jaggia
https://ebookmass.com/product/business-analytics-communicating-
with-numbers-1e-1st-edition-sanjiv-jaggia/
Clinical Skills for Paramedic Practice ANZ 1e 1st

Edition Dianne Inglis
https://ebookmass.com/product/clinical-skills-for-paramedic-
practice-anz-1e-1st-edition-dianne-inglis/
Pediatric Hand Therapy
Edited by
JOSHUA M. ABZUG, MD
Associate Professor
Departments of Orthopedics and Pediatrics
University of Maryland School of Medicine
Director
University of Maryland Brachial Plexus Practice
Director of Pediatric Orthopedics
University of Maryland Medical Center
Deputy Surgeon-in-Chief
University of Maryland Children's Hospital
Baltimore, MD, United States
SCOTT H. KOZIN, MD
Clinical Professor
Orthopaedic Surgery
Lewis Katz School of Medicine at Temple University
Philadelphia, PA, United States
Clinical Professor
Orthopaedic Surgery
Sidney Kimmel Medical College at Thomas Jefferson University
Chief of Staff
Shriners Hospital for Children
REBECCA NEIDUSKI, PHD, OTR/L, CHT

Dean of the School of Health Sciences
School of Health Sciences
Elon University
North Carolina
United States
]
Pediatric Hand Therapy ISBN: 978-0-323-53091-0
Copyright Ó 2020 Elsevier Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further information about the
Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance
Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher (other
than as may be noted herein).
Notices
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds or experiments described herein. Because of rapid advances
in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be
made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or
contributors for any injury and/or damage to persons or property as a matter of products liability,
negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.
Publisher: Cathleen Sether

Acquisition Editor: Kayla Wolfe
Editorial Project Manager: Sandra Harron
Production Project Manager: Sreejith Viswanathan
Cover Designer: Alan Studholme
List of Contributors
Joshua M. Abzug, MD Alexandria L. Case, BSE

Associate Professor Research Coordinator
Departments of Orthopedics and Pediatrics Department of Orthopedics
University of Maryland School of Medicine University of Maryland School of Medicine
Director Baltimore, MD, United States
University of Maryland Brachial Plexus Practice Department of Orthopaedics
Director of Pediatric Orthopedics University of Maryland
University of Maryland Medical Center Baltimore, MD, United States
Deputy Surgeon-in-Chief
University of Maryland Children's Hospital Jennifer M. Chan, OTR/L, CHT
Baltimore, MD, United States Hand Therapist
Rehabilitation Therapy
Allison Allgier, OTD, OTR/L Lucile Packard Chidren’s Hospital
Cincinnati Children’s Hospital Palo Alto, CA, United States
Cincinnati, OH, United States
Clinical Program Manager Roger Cornwall, MD
Occupational and Physical Therapy Cincinnati Children’s Hospital
Cincinnati Children’s Cincinnati, OH, United States
Cincinnati, OH, United States Professor
Orthopaedic Surgery and Developmental Biology
Sarah Ashworth, OTR/L, BS Cincinnati Children’s Hospital
Occupational Therapist Cincinnati, OH, United States
Rehabilitation Services
Shriners Hospital for Children Jenny M. Dorich, MBA, OTR/L, CHT
Philadelphia, PA, United States Occupational Therapist III
Adjunct Faculty
Jamie Berggren, OTR/L, BS Cincinnati Children’s Hospital Medical Center
Division of Pediatric Rehabilitation Medicine Univeristy of Cincinnati College of Health Sciences
Occupational Therapist Cincinnati, OH, United States
Children’s Hospital Los Angeles
Los Angeles, CA, United States Reeti R. Douglas, OTD, OTR/L
Texas Scottish Rite Hospital for Children
Matthew B. Burn, MD Dallas, TX, United States
Hand Fellow
Hand & Upper Limb Fellowship Kelly Anne Ferry, MOTR/L
Stanford University Rick Gardner FRCS (Trauma & Orthopaedics)
Redwood City, CA, United States CURE Ethiopia Children’s Hospital
Addis Ababa, Ethiopia
v
vi LIST OF CONTRIBUTORS
Theodore J. Ganley, MD Christine A. Ho, MD

Director of Sports Medicine at the Children’s Hospital Staff Orthopaedist
of Philadelphia Dept of Orthopaedics
Professor of Orthopaedic Surgery at the University of Texas Scottish Rite Hospital for Children
Pennsylvania Dallas, TX, United States
Associate Professor of Orthopaedic Surgery Division Director
Director of Sports Medicine Department of Pediatric Orthopaedics
Division of Orthopaedic Surgery Children’s Health Dallas
Children’s Hospital of Philadelphia Dallas, TX, United States
Associate Professor
Department of Orthopaedics
Richard Gardner, FRCS
University of Texas Southwestern Medical School
CURE Ethiopia Children’s Hospital
Dallas, TX, United States
Addis Ababa, Ethiopia
Danielle A. Hogarth, BS
Ritu Goel, MS, OTR/L
Occupational Therapist
University of Maryland
University of Maryland School of Medicine
Baltimore, MD, United States Research Coordinator
Orthopaedics
Donald Goldsmith, MD University of Maryland School of Medicine
Professor Batlimore, MD, United States
Pediatrics
Drexel University College of Medicine Deborah Humpl, OTR/L
Philadelphia, PA, United States Children’s Hospital of Philadelphia
Department of Occupational Therapy
Director
Section of Rheumatology
St Christopher’s Hospital for Children Clinical Specialist Outpatient Occupational Therapy
Philadelphia, PA, United States Occupational Therapy Department
Children’s Hospital of Philadelphia
Namrata Grampurohit, PhD, OTR/L Philadelphia, PA, United States
Assistant Professor
Department of Occupational Therapy Gina Kim, MA, OTR/L
Jefferson College of Rehabilitation Sciences Division of Pediatric Rehabilitation Medicine
Thomas Jefferson University Occupational Therapist
Philadelphia, PA, United States Children’s Hospital Los Angeles
Los Angeles, CA, United States
Elliot Greenberg, PT, DPT, PhD
Board Certified Specialist in Orthopaedic Physical Scott H. Kozin, MD
Therapy Clinical Professor
Sports Medicine & Performance Center Orthopaedic Surgery
The Children’s Hospital of Philadelphia Care Network, Lewis Katz School of Medicine at Temple University
Pediatric & Adolescent Specialty Care Philadelphia, PA, United States
Bucks County Clinical Professor
Clinical Specialist / Research Scientist Orthopaedic Surgery
Sports Medicine Physical Therapy Sidney Kimmel Medical College at Thomas Jefferson
Philadelphia, PA, United States University
Chief of Staff
Shriners Hospital for Children
LIST OF CONTRIBUTORS vii
Ryan Krochak, MD M.J. Mulcahey, PhD, OTR/L, FASIA

Orthopaedic Sports Medicine Fellow at the University Professor of Occupational Therapy
of Pennsylvania Director, Center for Outcomes and Measurement
Orthopedic Surgeon Jefferson College of Rehabilitation Sciences
Orthopedic Sports Medicine Thomas Jefferson University
Orlin & Cohen Orthopedics/Northwell Health Philadelphia, PA, United States
Long Island, NY, United States
Rebecca Neiduski, PhD, OTR/L, CHT
Amy L. Ladd, MD Dean of the School of Health Sciences
Elsbach-Richards Professor of Surgery Professor of Health Sciences
Orthopaedic Surgery School of Health Sciences
Stanford University School of Medicine Elon University
Stanford, CA, United States Elon, NC, United States
Amy Lake, OTR, CHT Scott Oishi, MD

Occupational Therapy Director of Hand Service
Texas Scottish Rite Hospital for Children Orthopaedics
Dallas, TX, United States Texas Scottish Rite Hospital for Children
Dallas, TX, United States
Carolyn M. Levis, MD, MSc, FRCSC
Division of Plastic Surgery Heta Parikh, OTR/L, MPH
McMaster University Occupational Therapist
St. Joseph’s Healthcare Hamilton Department of Orthopedics
Hamilton, ON, Canada University of Maryland School of Medicine
Kevin J. Little, MD
Director Meagan Pehnke, MS, OTR/L, CHT, CLT
Pediatric Hand and Upper Extremity Center Senior Occupational Therapist
Fellowship Director Occupational Therapy
Mary S. Stern Hand Surgery Fellowship The Children’s Hospital of Philadelphia
Associate Professor of Orthopaedic Surgery Philadelphia, PA, United States
Cincinnati Children’s Hospital Medical Center
University of Cincinnati School of Medicine Nicholas Pulos, MD
Cincinnati, OH, United States Texas Scottish Rite Hospital for Children
Director, Hand and Upper Extremity Surgery Pediatric Upper Extremity Fellow
Division of Pediatric Orthopaedics Dallas, TX, United States
Cincinnati Children’s Hospital Medical Center
Cincinnati, OH, United States Lydia D. Rawlins, MEd, OTR/L
Children’s Hospital of Philadelphia
Erin Meisel, MD Department of Occupational Therapy
Assistant Professor of Orthopaedic Surgery Philadelphia, PA, United States
Children’s Hospital Los Angeles
University of Southern California Roberta Ciocco, MS, OT
Los Angeles, CA, United States Senior Occupational Therapist
Out patient Occupational Therapy
Michelle Hsia, MS, OTR/L Children’s Hospital of Philadelphia
Outpatient Supervisor Philadelphia, PA, United States
Occupational Therapy
The Children’s Hospital of Philadelphia
viii LIST OF CONTRIBUTORS
Daniel W. Safford, PT, DPT Kathleen Tate, MS, OTR/L

Board Certified Orthopaedic Specialist Children’s Hospital of Philadelphia
Certified Strength & Conditioning Specialist Department of Occupational Therapy
Penn Therapy and Fitness at Arcadia University Philadelphia, PA, United States
Good Shepherd Penn Partners
Research Physical Therapist Daniel Waltho, MD
Physical Therapy Department Resident
Arcadia University Plastic Surgery
Glenside, PA, United States McMaster University
Hamilton, ON, Canada
Sandra Schmieg, MS, OTR/L, CHT
Senior Occupational Therapist Heather Weesner, OT
Occupational Therapy Occupational Therapist
The Children’s Hospital of Philadelphia University of Maryland Rehabilitation
Philadelphia, PA, United States and Orthopedic Institute
Apurva S. Shah, MD, MBA
Assistant Professor of Orthopaedic Surgery Aviva Wolff, EdD, OT, CHT
Division of Orthopaedic Surgery Clinician Investigator
The Children’s Hospital of Philadelphia Rehabilitation
Department of Orthopaedic Surgery, Perelman School Hospital for Special Surgery
of Medicine at the University of Pennsylvania New York, NY, United States
Cheryl Zalieckas, OTR/L, MBA
Francisco Soldado, MD, PhD Department of Orthopaedics
Pediatric Hand University of Maryland
Nerve and Microsurgery Institute Baltimore, MD, United States
Barcelona, Spain
Dan A. Zlotolow, MD
Milan Stevanovic, MD Hand and Upper Extremity Surgeon
Physician Shriners Hospitals for Children Philadelphia and
Professor of Orthopaedic Surgery Greenville
Department of Orthopaedic Surgery The Hospital for Special Surgery
Division of Orthopedic Surgery The Philadelphia Hand to Shoulder Center
Keck School of Medicine of USC Professor of Orthopaedics
Los Angeles, CA, United States The Sidney Kimmel Medical College of Thomas
Jefferson University
Tami Konieczny, MS, OTR/L Philadelphia, PA, United States
Supervisor Occupational Therapy Attending Physician
Occupational Therapy Shriners Hospital for Children
Children’s Hospital of Philadelphia Philadelphia, PA, United States
AcknowledgmentsdPediatric Hand
Therapy
This book is dedicated to all healthcare providers who in tandem. We work as a team to provide state-of-the
care for the child’s upper limb. Specifically, the goal of -art surgery and optimum therapy to maximize our
this book was to provide a resource for the occupa- children’s outcome. Complex procedures mandate a
tional therapist who cares for children’s upper limbs. skilled and talented therapist. We require our families
Several of the conditions and injuries are somewhat to travel back to Philadelphia to begin their rehabili-
rare to see for most providers and therefore, we have tation process. This prerequisite avoids miscommuni-
tried to make a quick, easy to read resource for these cation and initiates the rehabilitation process with a
providers and people interested in caring for the child’s therapy team accustomed to the surgical procedure.
upper extremity. The work performed to bring this Our therapists are familiar with the potential trials and
book to completion would not have been possible tribulations in the early therapy period. Addressing
without the collaboration and efforts of all of the au- these problems can avoid a suboptimal outcome,
thors of the various chapters as well as my coeditors. I which is disappointing to the family, therapist, and
must also thank my parents for their continued support surgeon. Over the last 25 years at Shriners Hospitals for
and encouragement. Most importantly, I want to thank Children, I have had the privilege to work with many
my wife, Laura, and our three boys, Noah, Benjamin, gifted therapists. They have enhanced our patient’s
and Zachary, for always loving and supporting me. outcomes and made me a better surgeon. I want to
Although I know the time necessary to do projects like thank each and every one of them for all their knowl-
this takes away some of our time together, you always edge, for all their expertise, and for all their service to
continue to support me, understand the work that I am the children at Shriners Hospitals for Children.
doing, and most importantly love meeeand for that I Scott H. Kozin, MD
thank you.
Joshua M. Abzug, MD The key to achieving excellent outcomes in upper
extremity rehabilitation is relationships. The relation-
Hand surgery and hand therapy are synergistic. The ship between hand surgeon and hand therapist creates
results of hand surgery require preoperative and post- the foundation on which communication, shared
operative communication between the surgeon and the values, trust, and collaboration are built. The relation-
therapist. Our therapists provide invaluable preopera- ship between therapists in the subspecialty of pediatric
tive input into the families and their children regarding hand provides a network of colleagues and problem
expected outcomes, cooperation, and compliance. Our solvers who share resources and opportunities. The
therapist provides critical postoperative care. This care relationships among healthcare providers, children,
requires communication as the therapist must under- caregivers, and families enable our youngest clients to
stand the procedure performed and the status of any embrace possibility and participation through surgery,
repaired structures, such as a nerve or tendon. A stout therapy, and adaptation. This text was built on
repair can be managed with early mobilization. In invaluable relationships between therapist and sur-
contrast, a weaker repair must be treated with gentle geons, and we hope it adds an impactful resource to
mobilization. At Shriners Hospitals for Children- your pediatric hand therapy practice.
Philadelphia, hand surgeon and hand therapist work Rebecca Neiduski, PhD, OTR/L, CHT
ix
Preface
Caring for the child’s upper extremity is challenging key points of the examination are discussed along with
due to the rarity of various injuries and/or conditions details of various outcome measures. In addition,
as well as the child’s inability to cooperate and un- splinting and taping techniques as well as prosthetic
derstand instructions. Despite these obstacles, occu- use are emphasized. The remainder of the book is
pational therapy is a critical component of caring for organized into various sections to permit the reader
the child’s upper limb. Whether the therapist is helping easy access to specific diagnoses. Although the book
a child with a congenital limb difference learn how to provides a concise, yet thorough discussion regarding
perform activities of daily living or rehabilitating a these topics, we envision that the treater will keep the
child following a traumatic injury, the occupational book at “arm’s length” as a resource for caring for
therapist is maximizing the function of the child. children with an upper extremity condition. Many of
Despite this critical role, few resources exist to aid the the chapters provide protocols to use during rehabili-
occupational therapist in caring for the child’s upper tation as well as specific splints that are necessary to
limb. The purpose of this book is to provide a improve function or during the postoperative course.
comprehensive, easy to read and use reference for the The goal of this book is to provide the reader with the
healthcare provider who is caring for pediatric and knowledge to perform a thorough examination,
adolescent upper extremities. The book details the establish an accurate diagnosis, refer for timely treat-
formation and functional development of the child’s ment, and perform specific rehabilitation including
upper limb. Subsequently, the necessary details and therapy and splinting to maximize the child’s outcome.
xi
SECTION I BACKGROUND
CHAPTER 1
Embryology and Intrauterine Diagnosis

FRANCISCO SOLDADO, MD PHD • SCOTT H. KOZIN, MD
INTRODUCTION The requirements are not the same with all upper-
Someone’s first-ever sip of coffee is often an unpleasant limb congenital anomalies. For example, transverse de-
experience that renders them pondering how they could ficiencies are usually sporadic and carry no appreciable
ever learn to like such a foul-flavored drink. Similarly, hereditary risk. As such, subsequent pregnancies require
many health professionals’ first exposure to embry- no more monitoring than standard care,1 and there is
ology, and the basic science that is so integral to it, is no need to refer this family to a clinical geneticist. How-
often a bitter experience. However, over time, dedicated ever, concerns about the risks of teratogen exposure
professionals learn how interesting the field is and how elevate when multiple limbs are affected and deficient.
essential the knowledge gleamed is pertinent to patient This clinical finding suggests some widespread insult
care. This fundamental principle is particularly true for to all the developing limb buds and potential teratogen
those who choose to enter a field that evaluates and or bleeding abnormality.
treats newborns with congenital defects. Conversely, many other upper-limb anomalies
Congenital anomalies affect somewhere between (e.g., radial deficiency) are associated with concomi-
1% and 3% of newborns. Among these infants, roughly tant, systemic defects (Fig. 1.1).6 At the same time dur-
1 in 10 has one or more abnormalities that affect their ing embryogenesis when upper-limb anomalies are in
upper extremities.1,2 In prevalence, upper-extremity their formative stage, other organ systems are devel-
anomalies rank second only to congenital heart defects oping at the same time. These organ systems can be
among malformations present at birth.3 Most limb affected and require evaluation. It is essential that the
anomalies manifest spontaneously or are inherited, clinician recognizes those anomalies that typically
with congenital anomalies secondary to teratogens occur in isolation versus those anomalies that are asso-
decidedly rare.4,5 ciated with concomitant anomalies; many of these
For those clinicians that evaluate newborns with anomalies may initially be unapparent with dire con-
hand anomalies as patients, or counsel parents who sequences. This principle is especially crucial when
have already born such a child, a basic understanding the concomitant anomalies of other organ systems
of embryogenesis, limb formation, and genetics is ut- are of greater clinical importance than the limb anom-
terly essential. Also crucial is understanding how these alies. Hand surgeons assessing such patients must
anomalies may relate to more systemic conditions, as focus on the infant’s general health before addressing
these healthcare providers often are required to hand malformations.
counsel parents about the potential effect on future Some congenital hand anomalies are linked to other
pregnancies and what intervention can and should musculoskeletal problems, such as ulnar deficiency.7
be done. Understanding genetic criteria and their asso- Some anomalies can even be associated with more
ciated anomalies affords such healthcare providers the than one musculoskeletal disorder. For example, central
capacity to make appropriate recommendations to deficiency may be linked to the triad of ectrodactyly
families and/or referral to clinical geneticist and/or ge- ectodermal dysplasia and facial clefts (the so-called
netic counseling. EEC syndrome) or lower-limb hemimelia (in which
Pediatric Hand Therapy. https://doi.org/10.1016/B978-0-323-53091-0.00001-4

Copyright © 2020 Elsevier Inc. All rights reserved. 1
2 SECTION I Background
extremity congenital anomalies occur. The sequence

of events that determines upper-limb development is
as follows:
• Day 26 after fertilization: The limb buds initially
become visible. The embryo is only about the size of
a single grain of rice, roughly 4 mm in length.9,10
• Days 27e47: Over the next 3 weeks, limb buds
develop rapidly, but the fingers and toes are not yet
identifiable. Even at the end of this period of time,
the entire embryo is still only about the size of a lima
bean, roughly 20 mm in length.
• Days 48e53: Over the next five or so days, the fin-
gers and toes separate, so that hands and feet
become clearly recognizable.
FIG. 1.1 Nine-month-old boy with an inherited radial • Day 56: By the end of the eighth week after fertil-
deficiency associated with HolteOram syndrome. Mother ization, all the essential limb structures are present.
and child’s heart anomalies were surgically treated. Embryogenesis is complete and the next stage of
development, the fetal period, has begun.
either the tibia or fibula is absent or inadequately
formed) (Fig. 1.2). Fetal Period
Upon the completion of embryogenesis, the fetal period
begins. During this stage of development existing structures
HOW LIMBS DEVELOP IN UTERO differentiate, mature, and grow.3e13 In the limbs, part of
Embryogenesis the differentiation and maturation process involves the
After an egg is fertilized, the first stage of growth is creation of articulations. Joints form as chondrogen con-
called embryogenesis. During this period of time, a denses into dense plates between limb structures that
sequence of events occurs that will determine the will ossify to become bones.14 Joint cavitation develops
number of limbs, their location, and their orienta- the articulation further, though each joint’s development
tion.8 In addition, during this time, between the ultimately requires fetal movement to ensure the joint sur-
fourth and eighth week of gestation, most upper- face is modeled into its final prenatal form.
FIG. 1.2 Ulnar longitudinal deficiency associating a proximal femoral focal deficiency.
CHAPTER 1 Embryology and Intrauterine Diagnosis 3
At a cellular level, limb buds are an outgrowth of each bone. Joints ossify and fuse, resulting in synosto-
mesoderm into overlying ectoderm. Cells from two sis, when the process mentioned earlier fails. Two joints
mesodermal sourcesdlateral plate mesoderm and so- commonly effected by are the proximal radioulnar and
matic mesoderm. These cell lines migrate from their or- ulnohumeral joints (Fig. 1.3). Another component of
igins into the limb bud.3,14 The lateral plate cells fetal development that is required for the formation
eventually become bone, cartilage, and tendon. The so- of a functional mobile joint is movement. When fetuses
matic cells form muscles, nerves, and vascular elements. fail to move adequately, as in arthrogryposis, joint
Blastemas are clusters of cells that all are destined to spaces become infiltrated by fibrous tissue resulting in
differentiate into the same type of tissue. In the fetus’s contracted and immobile joints (Fig. 1.4).
developing limbs, muscular and chondrogenic blas-
tema, derived from lateral plate mesoderm differentiate
into muscles and bones, respectively.15 The level of ox- Signaling Centers
ygen tension appears to play a part in this differentia- Three growth signaling centersdthe apical ectodermal
tion process. Chondrogenic blastema is located more ridge (AER), the zone of polarizing activity (ZPA) and
centrally within the limb bud where oxygen tension is the Wnt (Wingless type)dcentral to limb patterning
relatively low. Muscular blastema is more peripheral align the three spatial axes of limb development. The
in location where oxygen tension is greater. Both mus- axes are labeled proximodistal, anteroposterior, and
cles and the cartilaginous structures that ultimately dorsoventral, respectively (Table 1.1).14e17 As demon-
will ossify to become bones develop sequentially, start- strated later, our understanding of embryogenesis has
ing proximal and progressing in a distal direction. been advanced by ingenious experiments performed
Joints form between the ends of adjacent blastemas, by embryologists. In these experiments, animal
a joint capsule surrounding the interzone and the inter- models with limb patterning have been manipulated
vening blastemas cavitating within the interzone’s cen- to permit the dissection and alteration of crucial
ter to create the articular space. Joint fluid is produced signaling centers that effect limb development and
within this space, while cartilage caps the two ends of orientation.12,13,18
FIG. 1.4 Eleven-month-old girl with arthrogryposis

involving predominantly the shoulder girdles. Absence of
FIG. 1.3 Ulnohumeral fusion or synostosis associated with
elbow creases revealing intrauterine poor motion.
ulnar longitudinal deficiency.
TABLE 1.1
Spatial Axes of Limb Development, their Signaling Centers and Malformation Associated.
Signaling Center Signaling molecule Limb Axis Malformation
Apical ectodermal ridge Fibroblast growth factors Proximal to distal Transverse deficiency
Zone of polarizing activity Sonic hedgehog protein Radioulnar Mirror hand
Wnt pathway Transcription factor, Lmx-1 Ventral and dorsal Abnormal nail and pulp arrangement
Nail-patella syndrome
Proximodistal limb development

Limbs develop in a proximal to distal direction, from
shoulder / arm / forearm / hand. The proximodis-
tal signaling center, called the apical ectodermal ridge
(AER), is a thickened layer of ectoderm that condenses
over each limb bud14 and secretes proteins that create
this effect.19,20 Experimental models have been devel-
oped to mimic proximodistal limb development. They
include removing the AER, which results in limb trunca-
tion. Conversely, ectopic implantation of the AER in-
duces the formation of additional limbs.10,12,14
Interestingly, however, removing the AER can be over-
ridden by administering certain fibroblast growth fac-
tors that are released by the AER. Moreover, mice
deficient in these fibroblast growth factors exhibit com-
plete transverse limb defects.21,22
Given these results, transverse deficiencies are now
attributed to deficits in the AER or certain signaling mol-
ecules, such as fibroblast growth factors, that it produces
(Fig. 1.5).
Anteroposterior limb development

FIG. 1.5 Adactylous form of symbrachydactyly a
In animal models, both transplantation of the anteropos-
manifestation of transverse deficiencies. “Nubbins” are the
terior (i.e., radioulnar or preaxialepostaxial) signaling vestiges of digits and are the hallmark of symbrachydactyly.
center, called the zone of polarizing activity (ZPA), and The nubbins are comprised of the remaining ectodermal
transplanting the sonic hedgehog protein that the ZPA se- structures of the distal finger (the pulp, nail fold, and nail).
cretes have been demonstrated to cause mirror duplica-
tion of the ulnar aspect of the limb.23 Mutant mice with
sonic hedgehog protein in their anterior limb bud with its abundant pulp tissue are differentiated and
develop polydactyly.24 Also in models, triphalangeal developed is not well understood.11 The pathway
thumbs (thumbs with three phalanges, instead of the responsible for this differentiation produces one tran-
usual two) have been found to arise secondary to point scription factor, Lmx-1, that induces the mesoderm to
mutations that generate ectopic sonic hedgehog com- adopt dorsal characteristics.26 In the ventral ectoderm,
pound at the anterior margin of the limb bud.25 In the Wnt pathway is blocked by a product of a gene
humans, therefore, both mirror hand and certain forms called engrailed-1 (En-1). Mice lacking the anteroposte-
of polydactyly are now attributed to deficits in the ZPA rior Wnt signaling pathway, which resides in dorsal
or sonic hedgehog protein (Fig. 1.6).3,18 ectoderm and secretes Lmx-1, exhibit ventralization of
the dorsal surface of their limbs, such that they manifest
Dorsoventral limb development palmar pads on both sides of their hand: front and
The mechanism behind the development of the dorsum back.27 Conversely, mice lacking the engrailed-1 protein
of the finger with its fingernail and the volar surface exhibit dorsalization of their limbs’ volar surfaces
FIG. 1.6 Mirror hand attributed to abnormal anteroposterior limb patterning. The result is duplication of the
ulnar field but absence of the radial field.
(so-called bidorsal limbs).28 Alterations in this latter

pathway are relatively rare. Loss of Lmx-1 is associated
with a condition called nail-patella syndrome, in which
affected individuals have small, poorly developed nails
and kneecaps. Affected individuals also have musculo-
skeletal defects in other areas of the body including
their elbows, hips, and chest.29 Other children may pre-
sent with anomalies that include extraneous nail or
abnormal pulp development, both linked to an altered
Wnt signaling pathway.30 In humans, dorsal dimelia
with the nails may present on the palmar surface of fin-
gers, is explained by alterations in the Wnt signaling
pathway or Lmx-1 (Fig. 1.7).23
Programmed Cell Death

Programmed cell death (PCD) is another essential
component of proper limb development. PCD is an active
process that is genetically controlled. PCD eliminates un-
wanted cells during embryogenesis.23 Apoptotic cells un- FIG. 1.7 Dorsal dimelia with abnormal dorsoventral limb
dergo a degenerative process, associated with DNA patterning can cause duplication of the dorsal field resulting
fragmentation, and eventually are engulfed by phago- in the presence of a nail both in the dorsal and volar sides of
cytes. A clear example of this is the separation of fingers the finger.
and toes during days 48e53 of gestation. Before day 48,
all human digits are webbed. Over the next 5-day period Widely recognized for their role in chondrogenesis
of gestation, interdigital necrosis occurs with extraneous, and osteogenesis, bone morphogenetic proteins
web-like tissue between fingers and toes undergoing (BMPs) also trigger apoptotic pathways in interdigital
PCD. Failure of interdigital PCD results in syndactyly.31 mesenchyme to separate the fingers.23 Antagonists to
BMP are capable of blocking BMP signaling and pre- understanding about how limbs develop in utero.3,18
venting this process of apoptosis and interdigital necro- This research has included intense work focusing on
sis. An obvious animal example of this are bats, genotypeephenotype correlations that may have sub-
mammals whose limbs are webbed, and whose BMP stantial clinical implications.
has been shown to be blocked during limb embryogen- Online Mendelian Inheritance in Man (OMIM, www.
esis.32 Similarly, altered signaling of fibroblast growth omim.org) is a reliable and comprehensive, online
factors can negate BMP-mediated apoptosis and result compendium of human genes and genetic phenotypes
in syndactyly, which occurs in individuals with Apert that is updated daily and freely available to help clini-
syndrome (Fig. 1.8). cians, investigators, and other interested parties under-
stand the vast evolving field of genetics and countless
Genes and Molecular Abnormalities and number of different phenotypes.
www.omim.org Numerous congenital deformities have a known ge-
Research on gene misexpression and altered anatomical netic link. However, most possess variable inheritance
and functional development has enhanced general patterns and breadths of expression. Healthcare
FIG. 1.8 Syndactyly in Apert syndrome is related to altered signaling of fibroblast growth factors resulting in
abnormal BMP-mediated apoptosis.
providers who evaluate patients with hand deformities Intrauterine Diagnostics and Treating Upper-
must have basic knowledge about congenital differences Limb Anomalies
that are familial and potentially inherited versus those Diagnosing congenital anomalies in utero can lead to
differences that are not inheritable. This understanding parental counseling by a geneticist and/or by a surgeon
will justifiably recommend to families whether or not who specializes in the anomaly identified and its treat-
they should undergo evaluation by a clinical geneticist. ment. In utero diagnosis may guide parental decisions
Parents also require appropriate counseling pertaining on difficult personal and ethical questions, such as
to the spectrum of phenotypic expressions that can occur should gestation be terminated? In addition, in-utero
with a particular mutation. One misconception that procedures reevolving and may be considered based
frequently affects parents with a mild phenotype of a upon the certainty of diagnosis.37 In addition, in utero
congenital disorder is that the extent and severity of their diagnosis permits investigations to screen for associated
own disorder is a “worst-case scenario” for their child. anomalies, via further imaging studies or other proced-
This misperception can lead such parents to purse with ures such as amniocentesis and chorionic villus sam-
pregnancy and birth, naïve to the possibility that their pling for fetal karyotyping and genetic analysis.38
offspring may have a phenotypically much worse form To date, ultrasound remains the primary modality
of their difference. Their severely affected offspring ren- for fetal evaluations and/or monitor fetal development.
ders those parents devastated, ill prepared, and engulfed Ultrasound also guides prenatal care and identifies fetal
with feelings of guilt. Appropriate genetic counseling abnormalities (Fig. 1.11A).39,40 Ultrasound-based pre-
referral can mitigate the misconception of variable natal diagnosis has improved substantially over the
phenotype with similar genotype. last several decades because of technological advances,
Mutations that encode signaling proteins, receptor improved image resolution, increased standardization
molecules, and transcription factors can alter normal of prenatal ultrasound protocols, and enhanced
limb arrangement, resulting in anomalies that range training of diagnosticians.37 Prenatal ultrasound has
from almost imperceptible to complete limb absence. the potential to identify isolated musculoskeletal ab-
The number of molecularly identifiable congenital normalities, including a broad range of hand and
anomalies that practicing hand surgeons are seeing is upper-limb condition including transverse and longitu-
steadily increasing. Other anomalies, though less well dinal deficiencies, syndactyly, polydactyly, clinodactyly,
defined at a molecular level, have been mapped to spe- and clasped thumbs (Fig. 1.12).40
cific chromosomal segments.3 Table 1.2 lists examples Both the American College of Radiology and
of genes that encode transcription factors and exert American Institute of Ultrasound in Medicine recom-
some crucial level of control over upper-limb formation mend routine second-trimester screening with trans-
(Figs. 1.9 and 1.10).33e36 abdominal ultrasound, between 18 and 22 weeks of
TABLE 1.2
Consequence of Mutation of Some Genes Encoding Transcription Factors Crucial for Limb Formation.
Gen Syndrome Limb anomaly Inheritance
Hox Synpolydactyly Synpolydactyly (Fig. 1.9) A.D.
Hand-foot-genital syndrome Short great toes and
hipoplastic thumbs
Leri-Weill dyschondrosteosis Madelung’s deformity
T-Box Holt-Oram Sd (Tbx-5) Radial deficiency A.D.
Ulnar-mamary Sd (Tbx-3) Ulnar digits hipoplasia
Cartilage-derived Grebe chondrodysplasia Brachidactily A.R.
morphogenetic protein
Hunter-Thompson chondrodysplasia Brachidactily (Fig. 1.10)
FIG. 1.9 Mutation in Hox genes can result in this autosomal dominant familial synpolydactyly.
FIG. 1.10 This familial brachydactyly may be explained by an underlying mutation in cartilage-derived
morphogenetic protein gen.
gestation, to confirm the fetuses gestational age, eval- This sensitivity was lower when the anomalies were
uate their intrauterine development, and screen for limited to the upper extremities (25% vs. 55%). Sensi-
congenital anomalies. Current recommendations tivity for upper-limb anomalies was highest for condi-
only require that the ultrasonographer document tions affecting the entire upper extremity (85%) and
that all four extremities are present, although lowest for those affecting the digits alone (10%). Fe-
enhanced ultrasound imaging will likely change this tuses with limb-reduction defects, radial longitudinal
basic recommendation. Currently, even with level-2 deficiency, phocomelia, arthrogryposis, abnormal
(‘‘targeted’’) ultrasound studies, further detailed hand positioning, and cleft hand were more likely to
assessment of the extremities is ‘‘encouraged,’’ but be accurately diagnosed, because they were more likely
formalized standards are nonexistent.41 In fact, despite to have an associated anomaly.
improvements in ultrasound technology and tech- Several strategies can be utilized to enhance the
niques, its sensitivity detecting upper-limb anomalies sensitivity and accuracy of ultrasound imaging. One
remains low.42 such technique is transvaginal ultrasound, which allows
At one tertiary level hospital, the postnatally better visualization of the fetus and limbs.40 In some
confirmed sensitivity of prenatal ultrasound detecting high-risk groups, early risk assessment with ultrasound
upper-extremity anomalies was approximately 40%.42 is performed between 11 and 14 weeks of gestation.
(A) (B)
(C)
FIG. 1.11 Ultrasound showing severe leg constriction with markedly distal edema and risk of intrauterine
amputation (A) Prenatal MRI confirming the ultrasound findings (B) Fetoscopic image of the leg constriction
and longitudinal release with a Yag-Laser fiber (C).
Within this time period and by employing transvaginal often position in a clasped fist-like appearance
techniques, initial limb development can be assessed. obscuring hand anomalies. Additionally, the relative
Three-dimensional (3-D) ultrasound also improves decrease in intrauterine space and amniotic fluid in later
the modality’s diagnostic potential, allowing for the gestation limits fetal motion and the likelihood that the
identification and characterization of more-complex fetus will move into a position more suitable for
anatomical structures. Authorities have advocated detailed ultrasound assessment.
adopting 3D ultrasound as the imaging modality of Magnetic resonance imaging (MRI) has particular
choice for analyzing fetal limbs, particularly their hands advantages for evaluating neural axis, thoracic, and
(Fig. 1.13).43 head or neck abnormalities, relative to the conventional
The hand is best visualized by ultrasound during the ultrasound, because imaging the fetus with MRI is less
late part of the first and early part of the second dependent upon the presence of normal amniotic fluid
trimester. At this time, the fingers are large enough to volume, fetal position, and maternal body habitus.44
be visualized and characteristically extended and However, due to artifacts caused by moving extremities,
abducted, facilitating the examiner’s ability to discern the accuracy of MRI in evaluating the hand and remain-
anatomical alterations. Later in gestation, the hands ing upper limb remains to be determined (Fig. 1.11B).
(A) (B)
(C) (D)
FIG. 1.12 A variety of congenital differences diagnosed by ultrasound at 21 weeks of gestational age: (A)
complex syndactyly, (B) postaxial polydactyly, (C) ulnar deficiency with oligosyndactyly, and (D) radial
clubhand with absent radius.
PRENATAL TREATMENT
Fetal surgery is an emerging and established procedure.
Intrauterine surgery was initially restricted to the treat-
ment of life-threatening anomalies, given risks to both
the mother and fetus (e.g., diaphragmatic hernia, twine
twin transfusion syndrome, giant teratomas, etc.).45 As
the prerequisite of anesthesia (maternal and fetal) and
technology (fetal endoscopy) have improved, the risks
have been reduced and the indications for intrauterine
surgery have been extended to include nonlethal ortho-
pedic conditions, including myelomeningocele and
amniotic band syndrome.46
Currently, the only upper-limb indication for feto-
scopic examination and treatment is the risk of limb
amputation by an extremity amniotic band
(Fig. 1.11C). The progressive strangulation of a limb
by an intrauterine amniotic band leads to gradual wors-
FIG. 1.13 27 weeks 3D ultrasound showing an Apert’s ening of the deformity and ultimate amputation. Prena-
hand. tal band release arrests the progression of strangulation
and allows the fetal tissue’s natural healing capacity to 17. Niswander L, Jeffrey S, Martin GR, et al. A positive feed-
potentially restore the affected limb’s normal back loop coordinates growth and patterning in the verte-
morphology and function (Fig. 1.11C).36 Fetal wound brate limb. Nature. 1994;371:609.
repair also occurs without scar formation, which yields 18. Riddle RD, Johnson RL, Laufer E, et al. Sonic hedgehog
mediates the polarizing activity of the ZPA. Cell. 1993;
the potential application to treating other congenital
75:1401.
upper limb deformities (e.g., syndactyly). As future ad- 19. Mariani FV, Ahn CP, Martin GR. Genetic evidence that
vances in technology and anesthesia decrease FGFs have an instructive role in limb proximal-distal
maternalefetal risks further, the indications for prenatal patterning. Nature. 2008;453:401.
interventions to correct congenital anomalies will likely 20. Niswander L, Martin GR. FGF-4 expression during gastru-
expand. lation, myogenesis, limb and tooth development in the
mouse. Development. 1992;114:755.
21. Fallon JF, Lopez A, Ros MA, et al. FGF-2: apical ectodermal
ridge growth signal for chick limb development. Science.
REFERENCES 1994;264:104.
1. Kozin SH. Embryology of the Upper Extremity. In: Green’s 22. Niswander L, Tickle C, Vogel A, et al. FGF-4 replaces the
Operative Hand Surgeryc. 6th ed. Philadelphia: Churchill apical ectodermal ridge and directs outgrowth and
Livingstone; 2011. patterning of the limb. Cell. 1993;75:579.
2. Parker SE, Mai CT, Canfield MA, et al. Updated National 23. Chen Y, Zhao X. Shaping limbs by apoptosis. J Exp Zool.
Birth Prevalence estimates for selected birth defects in 1998;282:691.
the United States, 2004e2006. Birth Defects Res A Clin 24. Masayu H, Sagai T, Wakana S, et al. A duplicated zone of
Mol Teratol. 2010;88:1008. polarizing activity in polydactylous mouse mutants. Genes
3. Bamshad M, Watkins WS, Dixon ME, et al. Reconstructing Dev. 1995;9:1645.
the history of human limb development: lessons from 25. Lettice LA, Hill AE, Devenney PS, et al. Point mutations in
birth defects. Pediatr Res. 1999;45:291. a distant sonic hedgehog cis-regulator generate a variable
4. Taussig HB. A study of the German outbreak of phocome- regulatory output responsible for preaxial polydactyly.
lia the thalidomide syndrome. J Am Med Assoc. 1962;180: Hum Mol Genet. 2008;17:978.
1106. 26. Riddle RD, Ensini M, Nelson C, et al. Induction of the LIM
5. Temtamy SA, McKusick VA. The genetics of hand homeobox gene Lmx1 by WNT7a establishes dorsoventral
malformations. Birth Defects Orig Artic Ser. 1978;14(1). pattern in the vertebrate limb. Cell. 1995;83:631.
6. Lourie GM, Lins RE. Radial longitudinal deficiency. A re- 27. Parr BA, McMahon AP. Dorsalizing signal Wnt-7a required
view and update. Hand Clin. 1998;14:85. for normal polarity of D-V and A-P axes of mouse limb.
7. Schmidt CC, Neufeld SK. Ulnar ray deficiency. Hand Clin. Nature. 1995;374:350.
1998;14(65). 28. Loomis CA, Harris E, Michaud J, et al. The mouse
8. O’Rahilly R, Gardner E. The timing and sequence of events Engrailed-1 gene and ventral limb patterning. Nature.
in the development of the limbs in the human embryo. 1996;382:360.
Anat Embryol. 1975;148(1). 29. Dreyer SD, Zhou G, Baldini A, et al. Mutations in LMX1B
9. Uthoff HK. The Embryology of the Human Locomotor System. cause abnormal skeletal patterning and renal dysplasia in
Berlin: Springer-Verlag; 1990. nail patella syndrome. Nat Genet. 1998;19(47).
10. Zaleske DJ. Development of the upper limb. Hand Clin. 30. Al-Qattan MM. Classification of dorsal and ventral dimelia
1985;1(383). in humans. J Hand Surg Eur. 2013;38:928.
11. Moore KL. The Developing Human: Clinically Oriented 31. Zakeri Z, Quaglino D, Ahuja HS. Apoptotic cell death in
Embryology. Philadelphia: W.B. Saunders; 1988. the mouse limb and its suppression in the hammertoe
12. Riddle RD, Tabin C. How limbs develop. Sci Am. 1999; mutant. Dev Biol. 1994;165:294.
280(74). 32. Oberg KC, Feenstra JM, Manske PR, et al. Developmental
13. Shubin N, Tabin C, Carroll S. Fossils, genes and the evolu- biology and classification of congenital anomalies of the
tion of animal limbs. Nature. 1997;388:639. hand and upper extremity. J Hand Surg Am. 2010;35:2077.
14. Daluiski A, Yi SE, Lyons KM. The molecular control of up- 33. Basson CT, Bachinsky DR, Lin RC, et al. Mutations in hu-
per extremity development: implications for congenital man TBX5 cause limb and cardiac malformation in Holt-
hand anomalies. J Hand Surg Am. 2001;26(8). Oram syndrome. Nat Genet. 1997;15(30).
15. Al-Qattan MM, Yang Y, Kozin SH. Embryology of the up- 34. Goodman FR, Bacchelli C, Brady AF, et al. Novel HOXA13
per limb. J Hand Surg Am. 2009;34:1340. mutations and the phenotypic spectrum of hand-foot-gen-
16. Laufer F, Nelson CE, Johnson RL, et al. Sonic hedgehog ital syndrome. Am J Hum Genet. 2000;67:197.
and Fgf-4 act through a signaling cascade and feedback 35. Polinkovsky A, Robin NH, Thomas JT, et al. Mutations in
loop to integrate growth and patterning of the developing CDMP1 cause autosomal dominant brachydactyly type C.
limb bud. Cell. 1994;79:993. Nat Genet. 1997;17:18.
36. Ross JL, Scott Jr C, Marttila P, et al. Phenotypes associated 41. Wientroub S, Keret D, Bronshtein M. Prenatal sonographic
with SHOX deficiency. J Clin Endocrinol Metab. 2001;86: diagnosis of musculoskeletal disorders. J Pediatr Orthop.
5674. 1999;19:1e4.
37. American College of Obstetricans and Gynecologists. 42. Piper SL, Dicke JM, Wall LB, Shen TS, Goldfarb CA. Prena-
ACOG practice bulletin No. 101: ultrasonography in tal detection of upper limb differences with obstetric
pregnancy. Obstet GyneCol. 2009;113(2 Pt 1):451e461. ultrasound. J Hand Surg Am. 2015;40(7):1310e1317.
38. Drummond CL, Gomes DM, Senat MV, Audibert F, 43. Kos M, Hafner T, Funduk-Kurjak B, Bozek T, Kuriak A.
Dorion A, Ville Y. Fetal karyotyping after 28 weeks of gesta- Limb deformities and three-dimensional ultrasound.
tion for late ultrasound findings in a low risk population. J Perinat Med. 2002;30:40e4424.
Prenat Diagn. 2003;23:1068e1072. 44. Breysem L, Bosmans H, Dymarkowski S, et al. The value of
39. Chitty LS, Hunt GH, Moore J, Lobb MO. Effectiveness of fast MR imaging as an adjunct to ultrasound in prenatal
routine ultrasonography in detecting fetal structural ab- diagnosis. Eur Radiol. 2003;13:1538e1548.
normalities in a low risk 40 population. BMJ. 1991;303: 45. Cortes RA, Farmer DL. Recent advances in fetal surgery.
1165e1169. Semin Perinatol. 2004;28(3):199Y211.
40. Bronshtein M, Keret D, Deutsch M, Liberson A, Bar 46. Soldado F, Aguirre M, Peiró JL, et al. Fetoscopic release of
Chava I. Transvaginal sonographic detection of skeletal extremity amniotic bands with risk of amputation. J Pediatr
anomalies in the first and early second trimesters. Prenat Orthop. 2009;29(3):290e293. https://doi.org/10.1097/
Diagn. 1993;13:597e601. BPO.0b013e31819c405f.
CHAPTER 2
Hand Function: Typical Development

AVIVA WOLFF, EDD, OT, CHT
INTRODUCTION interaction with the environment.9,10 The develop-

Hand motor skill development begins early in utero mental process parallels the typical sequential progres-
with spontaneous movements and is fully completed sion of neuromotor maturation yet varies in timing of
during adolescence with the mastery of fine motor skills onset among children. Typical patterns of hand skill
and coordination. During the first few years of a child’s development emerge at specific stages and age ranges
life, the hand motor skills undergo rapid and remark- with a wide variation in individual development that
able developmental change to allow for exploration corresponds to maturation of the central nervous sys-
and use of objects.1e3 Early spontaneous movements tem.6,9 Influences of the environment and sensory expe-
give way to nonspecific, generalized movements. The rience on development of hand skills are believed to be
infant uses the generalized movements to explore the largely responsible for this variation.9e12 Visual, tactile,
surrounding area and gather information from the envi- and proprioceptive sensory experiences play an impor-
ronment. These critical sensory experiences are funda- tant role in the development of hand function. Sensory
mental to the development of voluntary controlled and visual stimulation provide essential feedback for
hand movements.1,4,5 Nonspecific movements further ongoing development of skills and can be manipulated
evolve into exploratory movements that begin with by caregivers and clinicians to enrich the environment
rudimentary grasp patterns and develop into precise and promote and encourage development in typically
movements that allow for dexterous manipulation of and atypically developing children.
objects. The skills required for functional hand use The purpose of this chapter is to provide clinicians
encompass multiple discreet sequential components: with an understanding of how hand skills develop
recognition of an object, accurate reach for the object, from basic crude movements to precise patterns that
proper hand orientation, proper calibration of aperture enable skilled manipulation of objects for functional
(hand opening) as it approaches the object, proper cali- use. This chapter will review the motor development
bration of forces to grasp the object, and finally, grasp of the range of skills necessary for functional use of
and manipulation of the object with one or both hands the hand for each of these skills: the reach-to-grasp
for the intended use.6 Timing and coordination for each movement, object release, object manipulation, and
of these subskills develop throughout early childhood, bimanual coordination. The first section describes the
as the reach-to-grasp movements develop from an characteristics of spontaneous movements, the second
immature feedback mechanism to a mature feedfor- section covers the development of unimanual skills
ward, anticipatory approach.6e8 In late childhood and and function, and the third section describes the devel-
early adolescence, these skills continue to develop for opment of bimanual hand skills and function. Each sec-
maximum control of speed, accuracy, and coordination explicates the specific characteristics and skills that
tion.6,7 Fig. 2.1 represents a timeline of key components emerge and mature throughout the developmental con-
of hand motor skill development from the prenatal tinuum and the important factors that influence and
period through adolescence. shape development. The components and characteris-
The development of hand skills integral for hand use tics of key hand motor skills with the corresponding
and function emerges from a complex interaction of developmental age ranges are listed in Table 2.1.
multiple systems and maturation of the central nervous
system that is further influenced by many contributing SPONTANEOUS MOVEMENTS
factors such as postural control, cognitive and percep- The earliest movements exhibited by infants are nonspe-
tual abilities, vision, sensory experiences, and cific, nonpurposeful, and seemingly random. These

© 2020 Published by Elsevier Inc. 13
FIG. 2.1 Timeline of key components of hand motor skill development.
movements, called as generalized movements, are not iso- motor activity and identify infants at risk for develop-
lated to the upper extremity and occur in all four limbs. mental disorders.14,15,18e20 It is the most reliable clinical
They are described as spontaneous movements because assessment currently available and considered highly
they are not elicited by any cause.13 In the upper limb, predictive for cerebral palsy.21 Motion capture tech-
general movements have been identified as early as niques also provide the opportunity to detect, assess,
8 weeks of gestation and continue through early infancy and track hand and arm movements in infants over the
until purposeful and directed reach emerges by approxi- course of development. These techniques are not as
mately 16 weeks.4,14 Early fetal preterm general move- well developed but are becoming more available and
ments show large variability until 36e38 weeks of feasible for use. An extensive review of the advantages
gestation. These movements are replaced by writhing and disadvantages of various movement recognition
movements that are observed between 36 weeks of gesta- technology (video cameras, 3D motion capture, and
tion to 2 months postterm. Writhing movements are direct sensing) in assessing spontaneous general move-
proximal, and characterized by a slow-to-moderate speed ments was recently published by Marcroft et al.22 Regard-
and small-to-moderate amplitude.15 Fidgety movements less of the method used, early detection of infants at risk
appear next between 2 and 5 months old, and are more allows for early intervention with a focus on encouraging
distal, have smaller amplitude, lower speed, and varied and facilitating motor control of the hand and arm by
acceleration.15 General movements of the arms are providing opportunities that encourage increased use.
thought to be precursors to reaching and grasping move-
ment and are described in the literature as prereaching
behavior16 because they allow infants to explore their UNIMANUAL FUNCTION
own bodies and surrounding surfaces to gather informa- Unimanual Reaching
tion critical for future development of reach and Voluntary, goal-directed, functional movements begin
grasp.1,17 Absent, abnormal, and erratic spontaneous to emerge by 3 months old and replace spontaneous
movements (especially fidgety movements between 2 movements. These changes are associated with changes
and 5 months) are highly predictive of risk for later in neuromotor developmental processes and a shift
neurologic dysfunction and conversely, normal move- from subcortical to cortical processing.23,24
ments are predictive of normal development.14,18,19 The reach movement observed in early infancy
When impairment is suspected, the environment can be broadly encompasses two types of reach: reaching to-
manipulated by caregivers and clinicians to provide op- ward an object, a precursor for a reach-to-grasp move-
portunities for enriched sensory experiences to allow for ment, and reaching toward the self that is described as
early intervention and further stimulate development. bringing the hand to the face (usually mouth and
The general movement assessment is the most eye). Both movements have a directed arm movement
commonly used early screening tool to assess abnormal in common. The movements differ in the sensory
CHAPTER 2 Hand Function: Typical Development 15
TABLE 2.1
Components of Upper Limb Movements
Developmental Age
Category Movement Range Characteristics/Examples
Spontaneous Generalized movements 8e36 weeks prenatal Spontaneous, large variability, reach to
movements mouth
Writhing movements 36 weeks prenatal Proximal, slow-to-moderate speed,
e8 weeks postnatal small-to-moderate amplitude
Fidgety movements 2e4 months postnatal Distal, smaller amplitude, low speed,
varied acceleration
Reach Spontaneous reach Birth to 2 months Gross, symmetrical, swipe for objects,
predominantly bilateral
Voluntary unilateral reach 4e5 months Irregular trajectory, variable movement
patterns
Voluntary bilateral reach 4 months Attempted bilateral movements
Mature reach 1e2 years Straighter, smoother movement path,
consistent trajectory
Grasp Reflexive 1e4 months Grasp objects placed in hand,
nonpurposeful
Instinctive/Squeeze 5 months Touching, feeling, raking, beginning
anticipatory grasp
Ulnar palmar grasp 6 months Four finger grasp, no thumb
Radial palmar grasp 7 months Radial fingers and thumb press object
(superior palmar grasp) into palm
Scissors grasp 9 months Small objects picked up with thumb and
lateral border of finger
Inferior pincer 10 months Objects held between pads of thumb
and fingertip
Superior pincer 12 months Objects held between tips of thumb and
fingertip
Deft and precise grasp 15 months Adjustments for weight and size, varies
grip
Dexterity and manipulation 18 months Increased control for speed and
precision, manipulates utensils
Release Reflexive 1e4 months Response to tactile stimulation of
extensors
Accidental release 5 months Object falls out of hand
Forced withdrawal 6 months Pulling
Release to table or surface 7 months Variable, and clumsy
Intentional dropping 10e11 months Throwing/dropping food
Precision release 12 months Graded release, stacking blocks
Controlled release 18 monthse2 years Accurate, precise release, puzzle
pieces
Manipulation Premanipulation 1e4 months Object exploration, fingering, raking,
shaking objects
Transfer objects 4e6 months Transfer from hand to hand, banging,
wave and rotate objects
Finger differentiation 9e10 months Able to isolate finger movements,
pointing
In-hand manipulation 1e2 years Move items from palm to fingers
determination of the target. The reach-to-self target is variable. During early reaching, infants must learn to
determined by proprioceptive input, whereas the coordinate the movements of the shoulder, arm, and
reach-to-object target is determined by visual input.5,25 hand. They begin by using the shoulder and torso to
The earliest observation of reaching to a target has been move the hand to the target, while keeping the elbow
documented prenatally at 22 weeks of gestation in the stiff in an attempt to control the degrees of freedom.28
context of reaching toward the mouth.5 Movement trajectories of reach begin to stabilize at
the age of 1 year with straighter movement paths, and
Reach to grasp stereotypical patterns by the age of 2e3 years.29,30
Reach
The phases of a mature reach-to-grasp movement Grasp
include reach, grasp, transport, and object release. The Successful manipulation of objects is achieved through
reach component refers to the movement of the arm to- a combination of several discreet components of hand
ward a target and occurs in parallel with the hand open- motor skills: controlled grasp and release, the ability
ing and shaping in preparation to grasp the object. to transfer an object from one hand to another, and
Although these movements occur simultaneously in individuation of the fingers. Mature grasp is character-
mature reaching, each component develops sequen- ized by an anticipatory mechanism that evolves during
tially during infancy with voluntary goal-directed reach- the reach movement with the hand simultaneously
ing preceding grasp formation.26 Successful reaching opening and shaping to match the approximate size
toward a target requires integration of visual and propri- and shape of the object. The timing of hand opening
oceptive information. A mature reach is characterized and closing is critical for smooth and coordinated grasp.
by a smooth trajectory with a consistently continuous Closing the hand too early or too late results in unsuc-
straight path to the target, although the speed and tra- cessful or awkward grasp. During mature grasp, the
jectory of reach vary depending on the size and location hand opening (aperture) reaches the maximum open-
of the target and the intended action. The velocity of a ing at about 75% of the reach movement and begins
mature reach has a defined acceleration and decelera- to close as it nears the object.27,31
tion phase as the arm approaches the target and con- In infants, purposeful grasp is preceded by sponta-
cludes with a grasp phase as the hand prepares to neous opening and closing of the fingers. These nonpur-
grasp the object. These distinct phases are indicative of poseful “pregrasp” hand movements have been called as
motor planning and reflect the ability for anticipatory “vacuous hand babbling.”32 Reflexive grasp exists in in-
control27 (Fig. 2.2). fancy from birth to 4 months and is observed as infants
In infants, goal-directed reaching that is character- curl their fingers around an object in response to stimu-
ized as anticipatory and visually guided emerges by lation of the palm. Purposeful grasp control develops be-
the age of 4 months.4 Before this, infants may attempt tween 4 and 6 months through exposure to tactile and
to occasionally swipe at objects within their visual field verbal stimulation.33 During this time, infants begin to
with occasional success. Over time with repeated expo- integrate visual information to prepare the hand in antic-
sure and experience, hand and arm movements become ipation of grasping an object. The combination of tactile
more purposeful and directed toward a target. However, and visual stimulation is critical for the development of
this early reach is characterized by an irregular trajectory the ability to grasp, orient, and adjust the hand to objects
that lacks smoothness and consistency and is highly for purposeful grasp.9 Grasp patterns emerge over time
FIG. 2.2 Wrist velocity curve of mature reach-to-grasp movement over the course of time.
from experience and interaction with a variety of object a given task is determined by the size and shape of the
shapes and sizes. At 5 months, a child will touch and object, location, and intended use.9 Grasp patterns
feel an object. Voluntary grasp develops through these have been classified historically into either power or pre-
experiences and is at first accidental. Subsequently, a cision grips.39 In a power grip, the finger and thumb are
range of grasp patterns develop through stimulation directed to the palm and the force is directed at the ob-
and exposure to various objects and toys. The character- ject. Types of power grip include cylindrical grasp (hold-
istics and development of the repertoire of grasp patterns ing a cup or glass), spherical grasp (holding a round
is discussed and detailed later. The earliest anticipatory object), and a hook grasp (carrying a bag with handles).
grasp ability is seen in 5e6 month olds as they open In precision grasp, the object is held between the thumb
the hand in preparation for grasp and start to close the and fingers to allow for manipulation of the object rela-
hand before making contact with the object. tive to the hand and the force is transmitted between the
Preshaping the hand to match the object size begins thumb and fingers. Types of precision grasp include tip-
to develop by 8 months old and continues over the next to-tip pinch (picking up a marble), pad-to-pad pinch
year.26 Young children, up to age 6, overshoot when (squeezing a clothespin), three-point pinch or three-
reaching for objects and open their hands wider than jaw chuck (picking up a cube), and lateral pinch (pulling
necessary (Fig. 2.3). Older children demonstrate accu- a zipper).39
rate grip formation to the size and shape of the object In infants, early spontaneous grasp movement is
with normalization of hand shaping occurring by age governed by reflexes from birth to 4 months. The devel-
6e8.34,35 The ability to adjust and orient the grip orien- opment of purposeful grasp follows a consistent trajec-
tation to the object begins to develop at 6 months and tory that begins with a raking and scratching movement
continues to become more accurate up to the age of of the fingers in 4e5 month olds.9,40 This is important
15 months.16,26 Calibration of force control is another for tactile stimulation. At first, the fingers flex and
critical component of precision grasp that allows for ob- extend simultaneously and by 5e6 months most in-
jects to be held without being dropped or crushed. The fants exhibit individual finger differentiation and iso-
amount of force generated during grasp is dependent on lated finger movements, most notably the ability to
the size, friction, weight, and texture of the extend the index finger for pointing.41 These behaviors
object.8,36e38 The ability to anticipate force control de- are largely automatic with the occasional “accidental”
velops gradually beginning in the second year. Before grasp. Early grasp at this age (5 months) is instinctive
that, infants control force development via a feedback and resembles a squeezing motion. Voluntary grasp be-
mechanism. Fingertip force control continues to gins at age 6 months and has been studied for the last
develop throughout early childhood and reaches adult century. Although the development of grasp patterns
levels by age 6e9.39 has traditionally been described in a sequential manner,
there is recent evidence to suggest that the emergence of
Grasp patterns grasp patterns may be more dependent on the object
Mature grasp encompasses a larger repertoire of patterns and the requirements of the task.42,43 The common
utilized for the performance of an infinite number of grasp pattern development described historically is
everyday tasks. The specific grasp pattern employed for detailed later, and begins with the emergence of a
palmar grasp of the four fingers without the thumb
that is often more ulnar-based (Fig. 2.4).9,39,40
Palmar grasp is succeeded by a radial grasp (also
known as a superior palmar grasp) at 7 months. The in-
fant uses the radial fingers and thumb to press the object
into the palm when using this pattern (Fig. 2.5A). This
allows for easy access to the mouth when the forearm
is supinated (Fig. 2.5B). Infants frequently mouth objects
during this phase as a method of exploring and learning
object properties. In this position objects can also be
easily transferred from one hand to the other.
At 8e9 months, precision grasp begins to emerge,
and most infants can grasp an object with the distal as-
FIG. 2.3 Anticipatory opening of the hand in preparation for pects of the fingers without use of the palm. For small ob-
grasp. Note: the hand is opening wider than necessary to jects, a scissors grasp is used between the thumb and
grasp the cube. (Photo credit: Naomi Polatsek)
with increased precision. The ability to manipulate ob-

jects with increased dexterity continues over the next
few months and by 18 months, there is an increase in
dexterity and manipulation of tools and utensils such
as using a spoon for self-feeding.9,39,40
Object release
Object release emerges following the development of
early grasp patterns. Similar to grasp, object release is first
observed in infants as reflexive behavior in response to
stimulation of primitive reflexes. Brushing the back of
the hand elicits a spontaneous extension of the fingers.44
Purposeful release is seen at 5e6 months, at first incon-
sistently and accidentally. By 6 months, release of objects
is consistent and purposeful and mostly observed when
bringing an object to the mouth. Initially, there is a
FIG. 2.4 Palmar graspdobject is grasped with four fingers
forced withdrawal as the child uses one hand to pull
against the palm without the thumb. (Photo credit: Naomi the object out of the other hand. By 7 months, the child
Polatsek) is able to release objects on to a surface (table), and ob-
ject release occurs consistently during bilateral transfer of
lateral border of the index with the hand stabilized on a objects. Sophisticated release in the context of play is
surface (Fig. 2.6). This is an important developmental seen by 10e11 months.9 This is the time that children
step toward being able to manipulate and use objects. revel in this newfound ability and create a game out of
At 10 months, small objects can be held with the dropping items and food from their high chair.9 Graded
distal fingertip pads. This grip allows for greater control hand opening for precision release such as stacking
for release and is called as inferior pincer grasp or fore- blocks is achieved by 12 months. At first, the child will
finger grasp (Fig. 2.7A). The superior pincer grasp, tip- press hard while releasing, and lack the ability to pre-
to-tip pinch, emerges at 12 months and allows for cisely and gently release the object. Controlled release
greater accuracy and stabilization (Fig. 2.7B). continues to develop between ages 1 and 2 for more
At this stage, the child is also able to begin adjusting complex tasks that require precise release of small objects
for size and weight of the object. By 15 months, the in- with greater accuracy (placing puzzle pieces, small items
fant becomes more adept at using a variety of grasps in jar). Timing and controlling release continues to be
FIG. 2.5 (A) Radial graspdobject is grasped by radial fingers and thumb and pressed into palm, (B) Forearm
is supinated to allow easy access to the mouth. (Photo credit: Naomi Polatsek)
FIG. 2.6 Scissors graspdobject is grasped between thumb

and lateral border of the index with the hand stabilized on a
surface. (Photo credit: Naomi Polatsek)
difficult for 2e3 year olds, who often exhibit difficulty

with delicate tasks.45 This skill continues to develop by
age 5e6 for improved accuracy, speed, and dexterity.9
Manipulation
Efficient manipulation of objects requires a combina-
tion of skills and the ability to differentiate movement FIG. 2.7 (A) Inferior pincer graspdobject is grasped
between the fingers, calibrate grip force, regulate precise between pads of thumb and index finger. (B) Superior
release, and control timing and speed. Dexterous pincer graspdobject is grasped between tips of thumb and
manipulation of objects is a skill that develops from in- finger. (Photo credit: Naomi Polatsek)
fancy through adolescence.
Premanipulation behavior is observed in early in- (1992) who described in hand manipulation as the
fancy, even before voluntary grasp and reach is devel- adjustment of objects by movements of the fingers so
oped. In early infancy (1e4) months, arm movements that the objects are placed in a more appropriate posi-
are used for object exploration. When an object is tion to accomplish the task.49 Exner defines several sub-
placed in the hand of a 1e2-month-old child, the child components of this skill:
will twist the wrist to move the object when it is within 1. The ability to move an object from the palm to the
the visual field (rotation).46,47 A child will also use fingers (translation) as in moving a coin to the fin-
movements of the arm to deliberately change the loca- gers from a fistful of change.
tion of the object (translation), or to shake the object 2. The ability to rotate an object in the pads of the
(vibration). An increase in fingering and raking finger as in loosening a screw.
behavior is observed at age 4 months.48 Object explora- 3. Using the thumb to move an object in a linear di-
tion continues to develop at 5e6 months with the abil- rection on the finger (shift) as in rolling a pencil.
ity to transfer objects. By 6 months, infants are able to Finger to palm translation and simple rotation occur
rotate, wave, and bang objects as well as transfer from by 2 years old, and complex rotation movements such
one hand to the other. With the ability to differentiate as manipulating a pencil for writing use continues to
finger movements and control release at age 9e develop until age 7.49 Between ages 3 and 7 years old,
10 months, manipulation skills further develop allow- children master more complex manipulation skills
ing for poking, prodding, and picking up small objects. such as fastening buttons and manipulating writing
In-hand manipulation skills begin to develop at the and eating utensils. The ability to perform these skills
age of 1 year. The term was first described by Exner with precision is directly related to the concurrently
developing ability to properly calibrate grip forces.8 Bimanual Grasp

Finger movements continue to become more accurate Bilateral fingering precedes bilateral grasp and is evident
in older children (ages 6e12) with demonstrated im- in 4e5 month olds. Between the ages of 6e8 months,
provements in reaction times and speed.34,50 By age objects are approached most frequently with both hands.
12, fine motor coordination and accuracy approximate During this stage, both simultaneous and sequential
adult behavior.34 bilateral reach-to-grasp patterns emerge9,53 (Fig. 2.8).
At 7 months, infants appear to use both a unilateral
and bilateral approach depending on the size and posi-
BIMANUAL FUNCTION tion of the object, and the amount of external support
Bimanual Reach to Grasp provided. They tend to use a bilateral approach to grasp
Most daily tasks require some level of bimanual func- large objects and a unilateral approach for small ob-
tion where demands are required of both hands. This jects. In an unsupported environment, they may utilize
adds a level of complexity on both a functional and a unilateral strategy while using the other arm for stabi-
neural control level for regulation of timing and coordi- lization. By 8e11 months, improved motor and
nation between the two hands. Depending on the task postural control allows for increased discriminatory
requirements, bimanual movements can be symmetri- ability of unimanual and bimanual strategies as they
cal as in throwing, lifting, pushing, and pulling, or are now unconstrained by factors that predispose a spe-
asymmetrical movements where either one hand acts cific strategy.12,54 However, a return to a predominant
to stabilize and the other manipulates, or both hands bilateral reach-to-grasp strategy emerges when postural
function independently in a differentiated role as in stability is challenged as seen with early walking.55
typing on a keyboard or playing a musical instrument.51
Bimanual function is controlled by interactions of Bimanual Manipulation
many neural structures, and the development of Transfer from hand to hand is evident as early as 4e
bimanual coordination is related to the maturation 6 months and becomes more consistent and fluid by 7e
and myelination of the corpus callosum that connects 8 months once the infant masters radial grasp.56 This is
the two hemispheres.52 In early infancy, these connec- the age when infants will begin to play with two objects
tions are incomplete and continue to develop over simultaneously by banging them together, waving them
several years. As the nervous system develops, the inter- in the air, or banging on a surface57 (Fig. 2.9).
manual control improves with the ability to regulate the
timing and spatial coordination of both hands for com-
plex tasks.52 Additionally, bimanual tasks require
mature postural and trunk control to allow for both
hands to function independently.
Bimanual Reaching
Bilateral asymmetric and symmetric arm movements
are present from early infancy, first as spontaneous gen-
eral movements. Although most spontaneous arm
movements appear to be simultaneous and symmetri-
cal, alternating arm movements are also typically pre-
sent from birth to 2 months when elicited by reflexes
and tactile input. Voluntary bimanual reach first
emerges at 2 months as gross symmetrical movements
of both hands reaching for objects, although swiping
movements tend to be predominantly unilateral.9 Sym-
metrical bilateral reaching continues to evolve and pre-
dominate by 4 months as trunk stability increases.
There is also an increased drive toward symmetrical
movements to midline. By 5 months, the bilateral
approach for reach to grasp becomes more consistent
as both hands move toward the object simultaneously.
At this age, in spite of the bilateral reach, the grasp re- FIG. 2.8 Symmetrical bilateral grasp of single object. (Photo
mains unilateral.1,6,9 credit: Naomi Polatsek)
and accuracy continue to improve with less variability

throughout early adolescence where skills approximate
those of adults.
CONCLUSION
Assessment and treatment of pediatric hand conditions
require intimate knowledge of the stages of typical devel-
opment of hand motor skills from infancy to adoles-
cence. An understanding of age appropriate function
also allows for early detection of impaired hand motor
control and delayed skill development. Early identifica-
tion of infants at risk affords early intervention so that
children are stimulated in sensory rich environments
that encourage the emergence of hand function skills. Fa-
miliarity with age appropriate skills and function enable
FIG. 2.9 Symmetrical bilateral grasp of two independent the clinician to select the appropriate assessment tools
objects. (Photo credit: Naomi Polatsek) and develop suitable treatment strategies. Proper toy se-
lection during each phase is critical to stimulate and
encourage developmentally appropriate skills.
The repertoire of symmetrical bimanual skills con-
tinues to expand to include bimanual squeezing, pull-
ing apart, and pushing together. Toys with multiple ACKNOWLEDGMENTS
parts encourage these activities and can be used in ther- Photo credits: Naomi Polatsek
apy sessions to provoke responses.54 Asymmetrical
skills develop simultaneously to allow for exploratory
behavior with one hand, while the other hand is REFERENCES
grasping the object. By 9 months, the child has acquired 1. Lobo MA, Galloway JC, Heathcock JC. Characterization and
a larger repertoire of bimanual skills and is able to po- intervention for upper extremity exploration & reaching be-
sition an object with one hand while manipulating it haviors in infancy. J Hand Ther. 2015;28(2):114e124.
with the other.58 At this time, the ability to rotate and https://doi.org/10.1016/j.jht.2014.12.003. quiz 125.
2. Lobo MA, Harbourne RT, Dusing SC, McCoy SW.
reposition objects begins to develop with the recent
Grounding early intervention: physical therapy cannot
acquisition of grip orientation ability. Between 9 and just be about motor skills anymore. Phys Ther. 2013;
12 months, coordination improves and greater inde- 93(1):94e103. https://doi.org/10.2522/ptj.20120158.
pendence between the two hands emerges allowing 3. Thelen E, Schöner G, Scheier C, Smith LB. The dynamics of
for rotation of toys with both hands. From 1 to 2 years embodiment: a field theory of infant perseverative reaching.
old, the infant continues to develop greater control over Behav Brain Sci. 2001;24(1):1e34. discussion 34-86.
bimanual skills and mastery of more difficult tasks such 4. Berthier NE, Keen R. Development of reaching in infancy.
as symmetrical bimanual drumming. Asymmetrical in- Exp Brain Res. 2006;169(4):507e518. https://doi.org/
dependent use of each hand, such as removing objects 10.1007/s00221-005-0169-9.
from inside another or stringing small beads, is also 5. Zoia S, Blason L, D’Ottavio G, et al. Evidence of early
development of action planning in the human foetus: a ki-
observed in children between the ages of 1e2.9,46,54 Be-
nematic study. Exp Brain Res. 2007;176(2):217e226.
tween the ages of 2e4, children begin to master more https://doi.org/10.1007/s00221-006-0607-3.
difficult tasks that require simultaneous efficient use 6. Charles J. Typical and atypical development of the upper
of independent movements in both hands such as limb in children. In: Eliasson A-C, Burtner PA, eds. Improving
buttoning, zippering, and opening a snack bag or candy Hand Function in Children with Cerebral Palsy:Theory, Evidence
wrapper.9,46,54 More complex bimanual coordination and Intervention. London: Mac Keith Press; 2008.
skills continue to develop along with the development 7. Shumway-Cook A, Woollacott MH. Reach, grasp, and
of cognitive and perceptual skills throughout early manipulation: changes across the life span. In: Motor Con-
childhood and adolescence, allowing for complex trol: Translating Research into Clinical Practice. Third. Phila-
two-handed tool use such as cutting food, or sequenced delphia: Lippincott; 2007.
8. Forssberg H, Eliasson AC, Kinoshita H, Johansson RS,
and complementary movements of both hands such as
Westling G. Development of human precision grip. I: basic
using scissors for cutting. The speed, efficiency, timing, coordination of force. Exp Brain Res. 1991;85(2):451e457.
9. Case-Smith J. Hand skill development in the context of in- six months postterm. Early Hum Dev. 2015;91(1):89e96.
fant’s play: birth to 2 years. In: Henderson A, Pehoski C, https://doi.org/10.1016/j.earlhumdev.2014.12.006.
eds. Hand Function in the Child: Foundations for Remediation. 24. Ouss L, Le Normand M-T, Bailly K, et al. Developmental
Second. St. Louis: Mosby; 2006:117e143. trajectories of hand movements in typical infants and
10. Thelen E. Motor development: a new synthesis. Am Psychol. those at risk of developmental disorders: an observational
1995;50(2):79e95. study of kinematics during the first year of life. Front
11. Thelen E, Corbetta D, Spencer JP. Development of reach- Psychol. 2018;9:83. https://doi.org/10.3389/fpsyg.2018.0
ing during the first year: role of movement speed. J Exp Psy- 0083.
chol Hum Percept Perform. 1996;22(5):1059e1076. 25. Zoia S, Blason L, D’Ottavio G, Biancotto M, Bulgheroni M,
12. Corbetta D, Thelen E. The developmental origins of Castiello U. The development of upper limb movements:
bimanual coordination: a dynamic perspective. J Exp Psy- from fetal to post-natal life. PLoS One. 2013;8(12):
chol Hum Percept Perform. 1996;22(2):502e522. e80876. https://doi.org/10.1371/journal.pone.0080876.
13. Ferrari F, Prechtl HF, Cioni G, et al. Posture, spontaneous 26. von Hofsten C, Rönnqvist L. Preparation for grasping an
movements, and behavioural state organisation in infants object: a developmental study. J Exp Psychol Hum Percept
affected by brain malformations. Early Hum Dev. 1997; Perform. 1988;14(4):610e621.
50(1):87e113. 27. Jeannerod M. The timing of natural prehension
14. Einspieler C, Prechtl HFR. Prechtl’s assessment of general movements. J Mot Behav. 1984;16(3):235e254.
movements: a diagnostic tool for the functional 28. Berthier NE, Clifton RK, McCall DD, Robin DJ. Proximo-
assessment of the young nervous system. Ment Retard distal structure of early reaching in human infants. Exp
Dev Disabil Res Rev. 2005;11(1):61e67. https://doi.org/ Brain Res. 1999;127(3):259e269.
10.1002/mrdd.20051. 29. Konczak J, Dichgans J. The development toward stereo-
15. Prechtl HF, Einspieler C, Cioni G, Bos AF, Ferrari F, typic arm kinematics during reaching in the first 3 years
Sontheimer D. An early marker for neurological deficits af- of life. Exp Brain Res. 1997;117(2):346e354.
ter perinatal brain lesions. Lancet Lond Engl. 1997; 30. von Hofsten C. Structuring of early reaching movements: a
349(9062):1361e1363. https://doi.org/10.1016/S0140- longitudinal study. J Mot Behav. 1991;23(4):280e292.
6736(96)10182-3. https://doi.org/10.1080/00222895.1991.9942039.
16. von Hofsten C, Fazel-Zandy S. Development of visually 31. Jakobson LS, Goodale MA. Factors affecting higher-order
guided hand orientation in reaching. J Exp Child Psychol. movement planning: a kinematic analysis of human
1984;38(2):208e219. prehension. Exp Brain Res. 1991;86(1):199e208.
17. Lobo MA, Galloway JC. Assessment and stability of early 32. Wallace PS, Whishaw IQ. Independent digit movements
learning abilities in preterm and full-term infants across and precision grip patterns in 1-5-month-old human in-
the first two years of life. Res Dev Disabil. 2013;34(5): fants: hand-babbling, including vacuous then self-
1721e1730. https://doi.org/10.1016/j.ridd.2013.02.010. directed hand and digit movements, precedes targeted
18. Prechtl HF. State of the art of a new functional assessment reaching. Neuropsychologia. 2003;41(14):1912e1918.
of the young nervous system. An early predictor of cerebral 33. Bruner JS, Koslowski B. Visually preadapted constituents
palsy. Early Hum Dev. 1997;50(1):1e11. of manipulatory action. Perception. 1972;1(1):3e14.
19. Einspieler C, Peharz R, Marschik PB. Fidgety movements - https://doi.org/10.1068/p010003.
tiny in appearance, but huge in impact. J Pediatr. 2016; 34. Kuhtz-Buschbeck JP, Stolze H, Boczek-Funcke A, Jöhnk K,
92(3 Suppl 1):S64eS70. https://doi.org/10.1016/j.jped. Heinrichs H, Illert M. Kinematic analysis of prehension
2015.12.003. movements in children. Behav Brain Res. 1998;93(1e2):
20. Kwong AKL, Fitzgerald TL, Doyle LW, Cheong JLY, 131e141.
Spittle AJ. Predictive validity of spontaneous early infant 35. Wolff AL, Raghavan P, Kaminski T, Hillstrom HJ,
movement for later cerebral palsy: a systematic review. Gordon AM. Differentiation of hand posture to object
Dev Med Child Neurol. 2018;60(5):480e489. https:// shape in children with unilateral spastic cerebral palsy.
doi.org/10.1111/dmcn.13697. Res Dev Disabil. 2015;45e46:422e430. https://doi.org/
21. Bosanquet M, Copeland L, Ware R, Boyd R. A systematic 10.1016/j.ridd.2015.07.002.
review of tests to predict cerebral palsy in young 36. Gordon AM, Forssberg H, Johansson RS, Westling G. The
children. Dev Med Child Neurol. 2013;55(5):418e426. integration of haptically acquired size information in the
https://doi.org/10.1111/dmcn.12140. programming of precision grip. Exp Brain Res. 1991;
22. Marcroft C, Khan A, Embleton ND, Trenell M, Plötz T. 83(3):483e488.
Movement recognition technology as a method of assess- 37. Forssberg H, Kinoshita H, Eliasson AC, Johansson RS,
ing spontaneous general movements in high risk infants. Westling G, Gordon AM. Development of human preci-
Front Neurol. 2014;5:284. https://doi.org/10.3389/ sion grip. II. Anticipatory control of isometric forces tar-
fneur.2014.00284. geted for object’s weight. Exp Brain Res. 1992;90(2):
23. Hitzert MM, van Geert PLC, Hunnius S, Van 393e398.
Braeckel KNJA, Bos AF, Geuze RH. Associations between 38. Eliasson AC, Gordon AM, Forssberg H. Tactile control of
developmental trajectories of movement variety and visual isometric fingertip forces during grasping in children with
attention in fullterm and preterm infants during the first cerebral palsy. Dev Med Child Neurol. 1995;37(1):72e84.
39. Napier JR. The prehensile movements of the human hand. 50. Garvey MA, Ziemann U, Bartko JJ, Denckla MB, Barker CA,
J Bone Joint Surg Br. 1956;38-B(4):902e913. Wassermann EM. Cortical correlates of neuromotor devel-
40. Halverston H. A further study of Grasping. J Gen Psychol. opment in healthy children. Clin Neurophysiol. 2003;
1932;7:34e63. 114(9):1662e1670.
41. Nagy E, Compagne H, Orvos H, et al. Index finger 51. Swinnen SP, Wenderoth N. Two hands, one brain: cogni-
movement imitation by human neonates: motivation, tive neuroscience of bimanual skill. Trends Cognit Sci.
learning, and left-hand preference. Pediatr Res. 2005; 2004;8(1):18e25.
58(4):749e753. https://doi.org/10.1203/01.PDR.000018 52. Fagard J, Hardy-Léger I, Kervella C, Marks A. Changes in
0570.28111.D9. interhemispheric transfer rate and the development of
42. Duff S. Functional development. In: Abzug J, Kozin SH, bimanual coordination during childhood. J Exp Child
Zlotolow DA, eds. The Pediatric Upper Extremity. Vol. 1. Psychol. 2001;80(1):1e22. https://doi.org/10.1006/jecp
Philadelphia: Springer; 2015. .2000.2623.
43. Lantz C, Melén K, Forssberg H. Early infant grasping in- 53. Castner B. The development of fine prehension in infancy.
volves radial fingers. Dev Med Child Neurol. 1996;38(8): Genet Psychol Monogr. 1932;12:105e193.
668e674. 54. Greaves S, Imms C, Krumlinde-Sundholm L, Dodd K,
44. Twitchell T. Reflex mechanisms and the development of Eliasson A-C. Bimanual behaviours in children aged 8e
prehension. In: Conolly K, ed. Mechanisms of Motor Skill 18 months: a literature review to select toys that elicit
Development. London: Academic Press; 1970. the use of two hands. Res Dev Disabil. 2012;33(1):
45. Gesell A, Halverston H, Thompson H, et al. The First Five 240e250. https://doi.org/10.1016/j.ridd.2011.09.012.
Years of Life. New York: Harper and Brothers; 1940. 55. Corbetta D, Bojczyk KE. Infants return to two-handed
46. Pehoski C. Object manipulation in infants and children. reaching when they are learning to walk. J Mot Behav.
In: Henderson A, Pehoski C, eds. Hand Function in the 2002;34(1):83e95. https://doi.org/10.1080/002228902
Child: Foundations for Remediation. Second. Mosby; 2006: 09601933.
143e163. 56. Pierce D, Munier V, Myers CT. Informing early interven-
47. Karniol R. The role of manual manipulative stages in the tion through an occupational science description of
infant’s acquisition of perceived control over objects. Dev infant-toddler interactions with home space. Am J Occup
Rev. 1989;9:205e233. Ther. 2009;63(3):273e287.
48. Rochat P. Object manipulation and exploration in 2 to 5 57. McCall RB. Exploratory manipulation and play in the hu-
month-old infants. Dev Psychol. 1989;25:871e884. man infant. Monogr Soc Res Child Dev. 1974;39(2):1e88.
49. Exner CE. The zone of proximal development in in-hand 58. Kimmerle M, Ferre CL, Kotwica KA, Michel GF. Develop-
manipulation skills of nondysfunctional 3- and 4- ment of role-differentiated bimanual manipulation during
year-old children. Am J Occup Ther. 1990;44(10): the infant’s first year. Dev Psychobiol. 2010;52(2):168e180.
884e891. https://doi.org/10.1002/dev.20428.
SECTION II EVALUATION AND ASSESSMENT
CHAPTER 3
Physical Examination of the Pediatric

Upper Extremity
SARAH ASHWORTH, OTR/L, BS
Physical examination of the upper extremity in the of motion (PROM) measurements can be challenging
pediatric client includes the same components pertinent with infants and young children due to pain, fearfulness,
to the adult population. However, methods of limited attention span, and small hand size. Children
assessment must be tailored to the developmental level may be afraid when they see an unfamiliar tool. When
of the patient. Infants and young children have limited possible, handing the goniometer to the child to “mea-
attention spans, less ability to follow directions, and are sure” a parent or clinician often helps to reduce fear. At
often uncooperative with unfamiliar adults. Patience, times, the goniometer will not be tolerated and the ther-
age-appropriate language, and a ready supply of toys apist is required to use his or her “ocular goniometer” to
and props will lead to a more successful evaluation. Eval- assess motion. Beginning with AROM measurements can
uations performed on the floor, at a child-sized table, or help to build trust before handling, however if the child
from a trusted caregiver’s lap can build rapport and has difficulty following instructions starting with PROM
improve participation. When working with children, can model the desired movement. For children having
including the family is imperative. Caregivers often pro- difficulty tolerating the assessment, prioritizing the
vide history; explain what the child can do and actually most important measures and completing others later
does on a daily basis; and are important to supporting is a necessary strategy.1
carryover at home. Videos or photographs of participation With young children, it is often challenging to take
in daily activities in the child’s environment provide valu- accurate goniometric measurements of active motion.
able information that may be difficult to elicit in the clinic. Small hand size can make measuring active and passive
Children will often try to “get the right answer” on digital movement difficult.2,3 Alternative play-based
the examination, especially when they know what the measurements may be necessary. For example, compos-
clinician is assessing. For example, a 6-year-old child ite flexion may be quantified by measuring the diameter
with a history of pollicization may demonstrate consis- of the smallest marker the child can grasp. Alternative
tent incorporation of her thumb when handed various measures should be objective and repeatable to track
objects by the therapist. However, in the waiting progress over time. Limited attention spans or ability
room, she demonstrates interdigital scissoring pinch to follow directions can lead to difficulty maintaining
for small objects. Her mother reports that she uses her maximum effort at end range. Having the goniometer
thumb for cups and balls, but prefers scissor pinch for in position to measure quickly and engaging a parent
small items. A combination of formal assessment, to elicit the desired motion can assist the process.
observation, and family interview provides a more accu- Games, such as Simon Says, can also help engage and
rate picture of the child’s true function. build rapport with younger clients.4 Patients who
have sustained a traumatic injury may have their effort
RANGE OF MOTION limited by pain or fear of pain. Beginning with moving
A precise assessment of range of motion is essential to unaffected adjacent joints may reduce guarding pos-
identify limitations and tracking progress with interven- tures. A functional task may produce more movement
tion. Active range of motion (AROM) and passive range than instructions to move in a particular plane.

26 SECTION II Evaluation and Assessment
The concept of scaffolding should be utilized to elicit

challenging motions.5,6 This refers to beginning in the
range where the child experiences success and gradually
building the challenge, rather than starting in a range
that is out of reach. For example, a toddler with a
brachial plexus injury with limited shoulder abduction
may not even attempt to reach for a sticker held over-
head. By presenting the sticker at chest height, the child
experiences success. From here, the stimulus can be
gradually raised higher until the AROM limit is
achieved (Fig. 3.1).
PROM assessment is often difficult for clients who
have pain or have had negative experiences with stretch-
ing over time. Other children may have limited toler-
ance for handling or being still for the assessment.
Distractions such as music or videos may help the child
relax for the exam. Patience and time may be necessary
to slowly move the affected joint and avoid eliciting
muscle guarding and discomfort. Any stretches that FIG. 3.2 A child with a congenital hand difference grasps a
are anticipated to cause discomfort should be saved toy, which was selected by the clinician to be an appropriate
for the end of the examination. One example is passive width and weight for success in play. (Courtesy Shriners
shoulder external rotation for children with brachial Hospital for Children, Philadelphia.)
plexus palsy and suspected internal rotation contrac- compensatory strategies will highlight areas that require
ture. Initiating the evaluation with this stretch in an in- further assessment. Excessive wrist flexion can be
fant or toddler may cause them to shut down, negating observed during midline function in children with
any additional assessment of arm function. brachial plexus birth palsy who demonstrate limitations
Children with range of motion deficits, especially in internal rotation limitation. Wrist flexion is also used
congenital conditions, will develop adaptations to func- as a compensatory strategy for self-feeding in a child lack-
tion within their abilities. Careful observation of these ing elbow flexion after an elbow injury. Patients with
arthrogryposis multiplex congenita (AMC) often develop
several compensatory patterns to overcome limitations
(Fig. 3.2). For clients with chronic conditions that create
limited potential for improvement in range of motion,
these patterns are encouraged. However, in conditions
where further recovery is expected, these movement pat-
terns are discouraged to eliminate ongoing and unneces-
sary compensatory movement patterns.
STRENGTH
Strength assessment in pediatric clients can be chal-
lenging for many of the reasons noted in the previous
section. Manual muscle testing (MMT) can be utilized
in older children and adolescents. Beginning with larger
joints, clear instructions and comparison to the unaf-
fected side, when possible, will allow the clinician to
assess if a child is able to participate in the exam. For pa-
tients with limited attention spans, focus on the key
muscles to test to elicit maximum effort.1 Making
strength testing a game can help to increase participa-
FIG. 3.1 Slowly raising the sticker to provide the “just right” tion. In addition to MMT, dynamometry for grip and
challenge to elicit overhead reach. (Courtesy Shriners pinch strength has established norms for children as
Hospital for Children, Philadelphia.) young as 6 years old.7
CHAPTER 3 Physical Examination of the Pediatric Upper Extremity 27
Upper extremity strength in infants and toddlers children with trunk weakness, proximal support from
should be assessed through observation of function.2,3 adaptive seating or alternative positions might be neces-
This can be objectively measured by presenting toys sary to fully assess strength in the upper extremity. In the
with different sizes and monitoring how long the child example of the teen with C5 spinal cord injury, when
can maintain grasp or lift the toy. Movement is asked to perform shoulder abduction, they may initially
compared in antigravity and gravity-eliminated planes. demonstrate very limited motion against gravity. Raising
As the child moves through developmental positions, the arm above shoulder height may cause loss of sitting
such as quadruped or pulling to stand, assess for sym- balance and passive elbow flexion causing the hand to
metrical weight bearing and inclusion of the affected fall into the client’s face. Providing appropriate support
side. The Active Movement Scale was developed for at the trunk and maintaining elbow extension will allow
measuring strength in infants with obstetrical brachial for a more accurate assessment of shoulder function. Cre-
plexus palsy.8 Although reliability studies focus on ative variations from standard testing positions may be
this population, this scale can be used clinically for in- necessary to fully assess a child’s strength.
fants with other diagnoses to obtain an objective com-
parison of strength changes.
SENSIBILITY TESTING
Compensatory movements may conceal weaknesses
and require careful scrutiny. A teenage patient with ab- Sensibility assessment requires concentration, focus, and
sent triceps from a C6 spinal cord injury may appear to participation of a patient. Different from most other as-
have 2/5 MMT strength via shoulder external rotation pects of upper extremity evaluation, occluding vision is
and supination. However, palpation, blocking external necessary for accuracy. Many of the tests require tedious
rotation, and any attempt at antigravity movement will test procedures with multiple stimuli applied in each
reveal that the triceps is not functioning. Extensor digito- area of the hand. These aspects make formal sensation
rum communis and the long finger flexors (flexor digito- testing challenging with the pediatric population.1
rum profundus and superficialis) can act upon the wrist As with the other areas of evaluation, clinical obser-
in the presence of weak wrist extension or flexion, respec- vation is valuable with regards to sensibility testing.
tively (Fig. 3.3). Proximal momentum can be utilized to Observing how the child spontaneously incorporates
augment shoulder or elbow flexion. In the absence of the affected area into play is critical information. Pro-
active elbow flexors, children may utilize the Steindler ef- vide bimanual toys such as hook and loop, food, pop
fect. This occurs when forearm protonation and wrist beads, and stickers to peel from backing paper. Bypass-
and finger flexion are paired with momentum to initiate ing digits or avoiding use of the hand is indicative of
elbow flexion. The child is able to hold the elbow in decreased sensibility. Observe for motor changes such
flexion by contracting the flexor/pronator muscles that as claw posturing or altered thumb movement patterns
originate proximal to the elbow.9 When in doubt, having indicating underlying nerve injury. Sympathetic
the child reproduce the movement slowly can often dysfunction should raise suspicion for loss of sensibility
elucidate what is powering the motion. in peripheral nerve injuries, as the sympathetic fibers are
It is also important to consider the effect of concom- more resistant to damage from traumatic injury.10 Ob-
itant weakness on distal and proximal control. For servations or parent reports of sympathetic dysfunction
may include skin color and temperature changes (cold
or bluish area, redness in the bath or summer heat);
excessive or absent sweat; and trophic changes such as
smooth, shiny, or excessively dry skin, tapered appear-
ance of digits, and nail and hair abnormalities11
(Fig. 3.4). Signs of self-mutilation from biting can be
present in young children with suspicion of abnormal
sensation (Fig. 3.5). In the clinic, this can appear to
begin with nerve regeneration, possibly as a way to
dampen neurogenic discomfort. Children often lack
the vocabulary to verbalize pain or sensory changes.
Some may describe feeling “ants crawling” or “electric
shocks,” others may react with nonverbal gestures. For
FIG. 3.3 12-year old child utilizing extensor digitorum
example, patients may react with leg twitching when
communis to aid weak wrist extensors. (Courtesy Shriners light touch stimuli or stroking is applied to a hypersen-
Hospital for Children, Philadelphia.) sitive hand.
to complete. The Weinstein Enhanced Sensory Test

(WEST) can be utilized with children as young as 6 years
old and only includes five monofilaments that are con-
nected to one handle. This allows for quickly switching
between monofilaments for more efficiency with testing.
In normal pediatric upper limbs, it has moderate to
excellent testeretest reliability.12,13
Functional sensibility assessments include static and
moving two-point discrimination, Moberg Pickup Test,
and stereognosis testing. Two-point discrimination is
commonly utilized following nerve repair to track recov-
ery. In addition, it can be used in children with cervical
spinal cord injuries to assist in determining if sensibility
will allow for spontaneous hand function without visu-
ally observing the hand during manipulation.14 Static
two-point discrimination has been found to be reliable
FIG. 3.4 A hand presenting with trophic changes following in children as young as 6 years old.15,16 The Moberg
nerve injury. (Courtesy Shriners Hospital for Children, Pickup Test presents the child with a set of objects to
Philadelphia.) pick up with each hand, with and without vision.17 In
addition to observing hand function relying on sensibil-
ity, this test allows the clinician to observe in hand
Threshold and functional sensibility tests can be
manipulation skills and which parts of the hand are
incorporated in the pediatric population. Avoid words
incorporated. Stereognosis testing involves presenting
that may elicit a fearful response before application.
familiar objects to the patient with vision occluded for
Substituting “warm” for “hot” and “pointy” for “sharp”
the child to identify with sensation only. Pictures of the
can improve participation. Allowing the child to see
objects can be incorporated when testing younger chil-
and feel the stimulus in an unaffected area before testing
dren. This test can allow the clinician to observe manip-
gives them better understanding of the exam and what to
ulation patterns and can be presented as a fun game.
expect. The Semmes Weinstein Monofilament Test may
The Wrinkle Test can be administered to assess vaso-
be utilized with older children and adolescents. The
motor function. The test is relatively simple to use and
entire exam includes 20 monofilaments and can docu-
only requires tolerance of water play. This assessment
ment small changes; however, the evaluation is lengthy
includes submerging the hand in warm water, 40 C
for 20e30 min as described by O’Riain.18 After soaking,
the hand is observed for even wrinkling throughout the
nerve distributions. Affected areas will remain smooth
while intact skin will appear wrinkled. Incorporating
toys for water play encourages bimanual submersion,
which can be helpful for comparison.1 This test is
most useful to indicate complete peripheral nerve lacer-
ations. Patients with nerve compression injuries will
often maintain sympathetic function.19
DEXTERITY
Dexterity is simply defined as using the hands to manip-
ulate objects. The developmental context of acquiring
grasp, pinch, release, and in-hand manipulation skills
is further discussed in Chapter 2. These movement pat-
terns are multifactorial. Assessment of dexterity requires
mindfulness of hand development and the impact of
FIG. 3.5 Digit injury secondary to self-mutilating behaviors strength, range of motion, muscle tone, and sensation
in a 4-year-old girl following nerve injury. (Courtesy Shriners on typical hand function.
Hospital for Children, Philadelphia.)
CHAPTER 3 Physical Examination of the Pediatric Upper Extremity 29
Assessment of dexterity can be particularly difficult 3. Ho ES. Measuring hand function in the young child.
in children under 3 years old. Developmental motor as- J Hand Ther. 2010;23:323e328.
sessments with fine motor subscales can be utilized to 4. Ashworth S, Kozin SH. Brachial plexus palsy reconstruc-
identify delays, such as the Peabody Developmental tion tendon transfers, osteotomies, capsular release and
arthrodesis. In: Skirven TM, Osterman AL, Fedorczyk JM,
Motor Scales (PDMS-2).20 Often, more specific hand
Amadio PC, eds. Rehabilitation of the Hand and Upper Ex-
function measures are desired. Ho describes a consistent tremity. 6th ed. Philadelphia: Elsevier; 2011:792e812.
developmental approach for young children.3 She rec- 5. Wood D, Bruner J, Ross G. The role of tutoring in problem
ommends preparing a consistent set of toys, carefully solving. J Child Psychol Psychiatry. 1976;17:89e100.
selected with objects of different shapes and sizes, to 6. Maybin J, Mercer N, Stierer B. “Scaffolding” learning in the
elicit a variety of grasp and manipulation patterns. classroom. In: Norman K, ed. Thinking Voices: The Work of
When possible, the unaffected limb is assessed as the the National Oracy Project. London: Hodder and Stoughton;
reference point to compare function. By utilizing the 1992:186e195.
same set of objects, serial assessments can be utilized 7. Mathiowetz V, Federman S, Wiemer D. Box and blocks test
to track progress over time.3 Safety must be considered of manual dexterity: norms for 6e19 year olds. Can J
Occup Ther. 1985;52:241e245.
when introducing small objects to assess pincer grasp.
8. Curtis C, Stephens D, Clarke HM, Andrews D. The Active
Consider utilizing individually appropriate edible Movement Scale: an evaluative tool for infants with obstet-
props, such as cereals, to avoid choking hazards. rical brachial plexus palsy. J Hand Surg Am. 2002;27(3):
Many additional assessment tools have been found 470e478.
to be reliable for children. The Functional Dexterity 9. Al-Qattan MM. Elbow flexion reconstruction by Steindler
Test (FDT), box and block test, and 9-hole peg test all flexorplasty in obstetric brachial plexus palsy. J Hand
have norms established from 3 years old through Surg. 2005;30B:424.
adulthood.7,21e23 The FDT assesses in-hand manipula- 10. Tindall A, Dawood R, Povlsen B. Case of the month: the
tion skills. The test consists of a pegboard with 16 pegs skin wrinkle test: a simple nerve injury test for paediatric
that the client picks up, turns over, and replaces into the and uncooperative patients. Emerg Med J. 2006;23:
883e886.
board. Performance is timed with penalties for dropped
11. Duff S, Estilow T. Therapist’s management of peripheral
pieces.21 The box and block test has clients pick up one nerve injuries. In: Skirven TM, Osterman AL,
inch blocks, lift over a divider, and drop into the other Fedorczyk JM, Amadio PC, eds. Rehabilitation of the Hand
side of the box. Scoring is based on how many blocks and Upper Extremity. 6th ed. Philadelphia: Elsevier; 2011:
are moved in 1 min. This assessment can be utilized 619e633.
with children with limited hand function; however, it 12. Weinstein S. Fifty years of somatosensory research: from
requires proximal function to cross over the divider.7,22 the Semmes-Weinstein monofilaments to the Weinstein
In addition to objective measures to assess progress over enhanced sensory test. J Hand Ther. 1993;6(1):11e22.
time, these tests provide observation of repeated hand 13. Thibault A, Forget R, Lambert J. Evaluation of cutaneous
movement patterns. Compensatory movements and and proprioceptive sensation in children: a reliability
study. Dev Med Child Neurol. 1994;36(9):796e812.
other concerns should be noted with results.
14. McDowell CL, Moberg EA, House JH. The second interna-
Physical examination of the pediatric upper extrem- tional conference on surgical rehabilitation of the upper
ity can present unique challenges. This population is limb in tetraplegia (quadriplegia). J Hand Surg. 1986;
very rewarding to treat, as children often heal better 11(4):604e608.
and are more resilient than older patients. Caregivers 15. Cope EB, Antony JH. Normal values for the two-point
are vital to provide an accurate picture of functional discrimination test. Pediatr Neurol. 1992;8:4.
limitations and day-to-day symptoms. Approaching 16. Dua K, Lancaster TP, Abzug JM. Age-dependent reliability
the assessment with patience, a playful attitude, and of Semmes-Weinstein and 2-point discrimination tests in
toys builds rapport to facilitate a successful evaluation. children. J Pediatr Orthop. 2016. https://doi.org/10.1097/
BPO.0000000000000892.
17. Moberg E. Objective methods for determining the func-
tional value of sensibility in the hand. J Bone Joint Surg
REFERENCES
Br. 1958;40-B:454e476.
1. Ho ES. Evaluation of pediatric upper extremity peripheral
18. O’Riain S. New and simple test of nerve function in hand.
nerve injuries. J Hand Ther. 2015;28:135e143.
Br Med J. 1973;3:615e616.
2. Aaron DH. Pediatric hand therapy. In: Henderson A,
19. Phelps PE, Walker E. Comparison of the finger wrinkling
Pehoski C, eds. Hand Function in the Child: Foundations for
test results to established sensory tests in peripheral nerve
Remediation. 2nd ed. St Louis: Mosby Elsevier; 2006:
injury. Am J Occup Ther. 1977;31(9):565e572.
367e400.
20. Exner CE. Development of hand skills. In: Case-Smith J, 22. Jongbloed-Pereboom M, Nijhuis-van der Sanden MWG,
ed. Occupational Therapy for Children. 5th ed. Philadelphia: Steenbergen B. Norm scores of the box and block test for
Elsevier; 2005:304e355. children ages 3e10 years. Am J Occup Ther. 2013;67:
21. Gorgola GR, Velleman PF, Shuai X, Morse AM, Lacy B, 312e318.
Aaron D. Hand dexterity in children: administration and 23. Wang Y, Bohannon RW, Kapellusch J, Garg A, Gershon RC.
normative values of the Functional Dexterity Test. J Hand Dexterity as measured with the 9-hole peg test (9-HPT)
Ther. 2013;38:2426e2431. across the age span. J Hand Ther. 2015;28:53e60.
CHAPTER 4
Outcome Measures
NAMRATA GRAMPUROHIT, PHD, OTR/L • M.J. MULCAHEY, PHD, OTR/L, FASIA
INTRODUCTION Spinal Cord Injury,5 and Classification of the Upper Ex-

Upper extremity capabilities of varied prehension, tremity in Tetraplegia for children with spinal cord
reach, object transport, and sensing can challenge the injury (SCI)6 will not be discussed in this chapter as
measurement of outcomes in therapy.1 The growth they are not outcome measures, but classification sys-
and development in children along with differential op- tems. The scope of this chapter also excludes
portunities for play and education can further impact impairment-based measures for muscle strength, sensi-
functional upper extremity measurement. Multifaceted bility, joint range of motion, pain, and spasticity. Infor-
assessment by therapists of children with upper extrem- mation on these methods can be found in other
ity impairments and limitations involves the use of excellent resources.2,7e11 Impairment-based methods
standardized observation and assessment of impair- have traditionally been used during therapy and do
ment (manual muscle testing, sensation, lower motor not suffice as functional endpoints for outcomes assess-
neuron deficits, spasticity, etc.), performance-based ment in children. The scope of this chapter also excludes
measures, child-reported outcomes, and parent- assessments using mobile health technology and activ-
reported outcomes. Therapy-related objectives for ity trackers as the literature on these technology-based
assessment include screening; diagnosing functional measures is in its early stages with no consensus; how-
limitations to develop benchmark, reimbursement, ever, preliminary evidence can be found in some recent
evaluation, and goal setting; prioritization of treatment studies.12,13 Of note, the terms tests, tools, scales, in-
goals; monitoring change over time; building evidence struments, measures, and assessments will be used
to support treatment for individualized data-driven de- interchangeably in this chapter, as is the case in much
cision making; and comparing outcomes among treat- of the literature.
ments. This chapter is an update to a prior
publication that provided a description of outcome
measures and their psychometric properties.2 This chap- TYPES OF OUTCOME INSTRUMENTS
ter provides an overview of different types of tests; de- The selection of outcome instruments is guided by
tails the psychometric properties of outcome determining if the scores need to be compared to a level
instruments and their interpretation; updates the thera- of performance or criterion, or to the typical popula-
pists on the literature on outcome instruments with tion. Thus, there are two types of instruments that differ
particular focus on functional pediatric upper extremity in how scores are interpreted: criterion-referenced and
instruments; and further discusses scoring and interpre- norm-referenced tests. Criterion-referenced tests enable
tation of traditional and modern item response theory interpretation of test score in relation to a certain level
(IRT)-based measures. Finally, the chapter provides re- of benchmark performance.14,15 For example, Shriners
sources for therapists to maintain ongoing competency Hospitals Upper Extremity Evaluation (SHUEE) is a
in assessment of the pediatric upper extremity. criterion-referenced test where children with cerebral
The scope of this chapter includes functional assess- palsy are compared on predefined criteria for assess-
ments of the upper extremity. The existing classification ment of their performance. In contrast, norm-
systems such as the Manual Ability Classification Sys- referenced tests can be interpreted in the individual’s
tem for children with Cerebral Palsy (CP),3 the Mallet performance relative to performance of some known
Classification and Active Movement Scale for children typical or normative group.14 An example of commonly
with brachial plexus birth palsy (BPBP),4 the Interna- used norm-referenced tests is the developmental motor
tional Standards for Neurological Classification of scales wherein scores are interpreted against “normal”
Pediatric Hand Therapy. https://doi.org/10.1016/B978-0-323-53091-0.00004-X

development. For norm-referenced instruments, the better at detecting change than a generic measure.19
mean scores from the reference sample provide a stan- For example, the PUFI has items probing the usefulness
dard and variability is used to determine how an indi- of the prothesis for the activity and items that have
vidual performs relative to the reference sample.15 response options that take into consideration the use
Norm-referenced tests are usually used for diagnosing, of prosthetic hand actively and passively.20
while criterion-referenced tests are used to examine pro- The International Classification of Functioning,
ficiency of performance along a continuum. An example Disability, and Health (ICF) has also been used to catego-
of a criterion-referenced test continuum is the range rize outcome instruments into body structure and func-
from inability to do a task to ability to complete the tion, activity, or participation level of measurement.
task and is felt to be more useful for developing and Although measurement of performance in each of these
evaluating rehabilitation outcomes.15 domains is important for a comprehensive assessment
There are two types of assessments based on the use of functioning, the currently available measures lack
of scores: formative and summative assessments. An adequate coverage of all three domains, particularly those
assessment that provides information to guide ongoing related to participation. Hao et al.21 described the expert
planning of treatment is called as a formative assess- consensus on musculoskeletal pediatric upper extremity
ment. The criterion-referenced instruments provide the outcome instruments according to ICF domains. For the
ability to examine ongoing performance and are used activity domain, the bilateral tasks were highly valued
as formative assessments. In contrast, a summative by experts along with the instruments Assisting Hand
assessment enables initial or discharge assessment of Assessment (AHA), Pediatric Evaluation of Disability
function and typically is a norm-referenced test.16 The Inventory (PEDI), SHUEE, and Jebsen Hand Function
knowledge of the original purpose of the test as Test. For the participation domain, the Canadian Occu-
described by the test author can help identify the recom- pational Performance Measure (COPM), Pediatric Out-
mended use of the instrument as a formative or summa- comes Data Collection Instrument (PODCI), and
tive assessment. Therapists need to be aware of the Disabilities of the Arm, Shoulder, and Hand (DASH)
author-intended use of the instrument and to avoid were highly valued by experts. Other sources have
inaccurate representation of the scores. provided detailed ICF classification of outcome instru-
The assessments can also be categorized as generic ments for children with CP22 and linking of individual
versus disease specific. Generic measures are used across outcome measures such as the PEDI.
diagnostic conditions but need to be validated for their There are different types of assessments based on the
use in the population of interest. The disease-specific individual completing the items, that is, performance-
measures are only used with certain diagnoses with based measures, parent/teacher/proxy-reported mea-
their items customized for the symptoms, features, or sures, and child-reported measures. Therapists typically
functional implications of the diagnosis. For example, use performance-based measures wherein the items are
the Jebsen Test of Hand Function17 and the Box and scored based on observed performance of the tasks for
Block Test18 are generic performance measures for the the test and used to be the data collection method
upper extremity that assess function and dexterity, preferred within the clinical setting. However, in the
respectively. Although these measures have been origi- changing healthcare environment, to adhere to patient-
nally developed for adults, their measurement proper- centered clinical practice, there is also a need to collect
ties have been studied in children. In contrast, the patient-reported outcomes23 and a battery of outcome
Prosthetic Upper Extremity Functional Index (PUFI) measures may be needed to fully assess the client’s func-
and the Child Amputee Prosthetics Project-Functional tioning. Child-reported outcomes are equally important
Status Inventory (CAPP-FSI) are disease-specific instru- to collect within pediatric therapy practice and children
ments developed for children with limb deficiency. as young as 3 years old could participate in reporting
The selection between generic and disease-specific in- their experiences on appropriately designed measures.24
struments is determined by the purpose of assessment.
The generic measures enable comparison of outcomes
across diagnostic conditions; whereas, the specialized PSYCHOMETRIC PROPERTIES OF
therapy centers prefer to use disease-specific instru- OUTCOME INSTRUMENTS
ments as they typically work for most patients seen The measurement or psychometric properties of an in-
within the clinic. Disease-specific instruments have the strument provide the therapist with evidence on the ac-
advantage of highly relevant items and response scales curacy and appropriateness of the tool for the intended
to the diagnostic population and may also function purpose. The properties should be considered during
Another random document with
no related content on Scribd:
Exeter, Henry Holland third Duke of, 65 n.
John Holland, second Duke of, 65 n.
Expeditions under Edward IV, 31.
Henry VIII, 74, 77.
Elizabeth, 117, 136, 137, 140, 160, 164.
James I, 187.
Charles I, 219-222, 228, 231, 233, 251, 277, 278.
Expenditure, dockyard. See Dockyard.
naval, under Henry VI, 22, 23, 24.
Henry VII, 35.
Henry VIII, 93, 94.
Edward VI, 102, 103, 108.
Mary, 111, 112, 113.
Elizabeth, 117, 160-165.
James I, 195, 197 and n.
Charles I, 293-295.
during Interregnum, 303, 304, 368-370.
F
Fauconberg, Bastard of, 32.
Ferrers, Walter Devereux, Lord, 77.
Figure heads, 61, 131, 341.
Fisheries, 42, 89, 92, 107, 108, 167, 200.
Fitzwalter, Lord, 27.
Fitzwilliam, Wm., Earl of Southampton, 52, 61, 66.
Flags, 15, 41, 62 and n., 182, 183, 213, 214, 300, 370, 377.
Fleming, Denis, 282, 283 n.
Fleet, of 1588, cost of, 163.
epidemic in, 137, 138.
formations, 59, 307 n.
regulations, 3, 63, 64.
Fleets, armament of, 155.
Cinque Ports, 2, 26.
contracted for, 24, 27, 28, 31.
cost of, 26, 163, 164, 197 and n., 198, 225, 295.
disease in, 77, 114, 136, 137, 183, 219, 220, 228, 231, 235,
237, 321, 323.
division of, 64, 183, 307 n.
during Civil war, 264, 295.
during Commonwealth, 302, 303, 307, 323, 341, 342.
maintenance of, 5.
manning of, 74, 242, 311, 314.
merchantmen in, 35, 118, 163, 251, 295, 342.
of Richard I, 3.
John, 3.
Edward III, 6.
Edward VI, 101.
Mary, 110, 111.
Elizabeth, 164.
James I, 188.
Charles I, 219, 222, 225, 231, 233, 235, 237, 238, 239,
251, 252, 276, 277.
Foresight (of Elizabeth), 120, 122, 166 and n., 206.
Forests, 288, 367.
Foster, Edward, 79.
France, Navy of, 9, 21, 264-266, 304.
Freight, cost of, 343.
from Spain to America, 398.
Frigates, 255 n., 338.
Furring, 187 and n.
G
Gabriel Royal, 49 and n., 70, 77.
Galleasses, 57, 58, 128 and n.
Galley Blancherd, 78.
Galley oarsmen, 5, 78, 126.
Galley Subtylle, 51 and n., 59, 78, 100.
Galleys, English, 5 and n., 12, 41, 57-60, 78, 101, 121, 123, 125
and n., 126, 207.
foreign, 5, 9, 60, 78, 126.
Garland (of Elizabeth), 121, 129, 131, 205, 206, 210.
(of James I), 188, 202, 208, 344.
Gibbs, Stephen, 274.
Gibson, Richard, 307 n., 308.
Gillingham. See Dockyards, Chatham.
Girdling, 187 and n., 258.
Gloucester, Richard, Duke of, 65 n.
Golden Hind. See Pelican.
Golden Lion. See Lion (of Elizabeth).
Gonson, Benjamin, 85, 86, 104, 108, 112, 144, 145.
Junior, 149.
William, 81, 84, 85, 93.
Grace Dieu (of Henry V), 12 n., 13, 14, 15, 19, 23, 29.
(of Edward IV), 33, 36.
(merchantman), 19, 37.
Grand Mistress, 51 and n., 55, 58, 59, 101, 109.
Great Barbara, 49 and n., 55.
Great Christopher, 51 and n., 122, 123.
Great Elizabeth, 49 and n., 54, 66.
Great Michael, 47.
Great Nicholas, 49 and n., 71.
Green, Mrs J. R., referred to, 11.
Grenades, 361.
Grent, Thomas, 274.
Grevill, Sir Fulke, 149, 189.
Greyhound (of Henry VIII), 51, 55, 58, 59, 110, 123.
Greyle, Richard, 21.
Gromets, 314 and n.
Guldeford, Sir Richard, 35, 36.
Gun carriages, 96, 157, 361.
Gun founders, 96, 159, 213, 289, 360 and n., 361.
Gunners, 56, 57, 157-159, 290, 358.
Gunpowder, 33, 56, 97 and n., 155, 158, 159, 160, 239 and n.,
240, 288, 289, 361, 362.
H
‘H.M.S.,’ its equivalents, 9 n.
Hamble, the river, 14, 23.
Hammocks, 134, 235, 300.
Hansa League, 11.
Steelyard, 150.
Happy Entrance, 202, 207, 208, 228, 237, 344.
Harbours, 92.
Hart (of Henry VIII), 51, 58.
(of Mary), 110.
(of Commonwealth), 310 n.
Hatsell, Henry, 349.
Hawkyns, Sir John, 91, 129, 134, 135, 144, 145-148, 150, 162-
164, 167, 173, 392-397.
Sir Richard, 136.
William, 91.
Henrietta Maria, 254, 269, 344.
Henry III, 4.
IV, 10, 11.
V, naval policy of, 11.
ships of, 12.
will of, 16.
VI, naval policy under, 24, 25.
VII, commercial policy of, 42.
general policy of, 37.
VIII, as designer, 48, 59.
as naval organiser, 98, 99.
causes of increase of navy under, 45-48.
embarkation of, at Dover, 57.
personal interest of, in artillery, 56.
in shipping, 48, 60, 62.
Henry Grace à Dieu, 47, 49, 53, 55, 61, 62, 69, 70, 73, 75, 80,
91, 109.
inventory of, 372-381.
Heron, John, 26, 81.
Heywood, Thomas, 260.
Hoggekyns, John, 15.
Holborn, Robert, 73.
Holigost, 12, 13, 15, 22, 23.
Holland, Navy of, 219, 253, 305, 307.
Holland, Edmund, Earl of Kent, 65 n.
Henry. See Exeter, Duke of.
John. See Exeter, Duke of.
261, 284, 286, 347 and n., 348 n.
Holstock, William, 85, 104, 105, 140, 149.
Hopton, John, 70, 71, 83, 84, 372.
Hospitals, 321.
Hospital ships, 188.
Howard, Lord Thomas, 65.
Sir Edward, 61, 63, 64, 65, 74, 76, 81.
Sir John, 32.
of Effingham, Charles, Lord, 117, 135, 137, 138, 148, 166,
189, 190, 193, 194, 204, 209, 216, 383, 397.
William, Lord, 111.
Howlett, Richard, 85, 149.
Hull, Sir William, 26.
Hutchinson, Richard, 296 n., 351, 352.
I
Impressment, 164, 197, 234, 241, 311 and n.
Improvements and inventions, 128, 274, 367. See also
Shipbuilding, improvements in.
J
James, 237, 254, 257.
James I, Navy at accession of, 184, 185.
retrogression of navy under, 215.
Duke of York, xi, 27, 283 and n.
Jennet (of Henry VIII), 50, 58, 59.
Jermyn, Thomas, 84.
Jesus of the Tower, 12 and n., 14, 23.
Jesus of Lubeck, 51, 107, 139, 183 n.
John, 3.
Johnson, Peter, 23.
K
Kateryn Fortileza, 49 and n., 61.
Keeper of King’s ships, 316. See also Ships, Clerk of.
Kent, Earl of. See Holland, Edmund.
Kent, William Neville, Earl of, 65 n.
King’s spears, 77.
Knight, Richard, 93.
Knight, Dr William, 79.
Knyvet, Sir Thomas, 81.
L
Langford, Roger, 148, 189, 246.
Last, of tonnage, 293 and n.
Laughton, Professor J. K., referred to, ix, 154 n., 265.
Legge, Robert, 85, 93, 94, 104.
Libel of English Policie, 6, 7, 15, 23.
Lieutenants, 154, 225 and n., 226, 359.
Lighthouses, 199, 201.
Lindsey, Robert Bertie, Earl of, 236, 251, 279 n., 291.
Lion (of Henry VIII), 50, 58, 59, 101.
(of Elizabeth), 120, 128, 132, 382-391.
(of James I), 202, 206, 220.
Lisle, John Dudley, Lord. See Dudley, John.
Loans to the crown, 27.
Logbooks, 354.
Lopez, Dr Roderigo, 398.
M
Madre de Dios, 125, 138, 165 and n., 166, 167.
Mansell, Sir Robert, 189-192, 195, 196, 202, 204, 209, 215,
260, 397.
Manwayring, Sir Henry, 208, 258 n.
Maravedis, value of, 37 n.
Margaret of Anjou, 26, 31.
Marsden, R. G., referred to, 4 n.
Marshmen, 70 and n., 72.
Mary, maintenance of Navy under, 109, 110.
Mary Guildford, 50 and n., 68, 91.
Mary Rose (of Henry VIII), 5 n., 49, 52 n., 55, 61, 66, 67, 70, 72,
73, 76, 80.
(of Edward VI), 109.
(of Elizabeth), 121, 128, 131, 206, 210.
(of James I), 202, 208, 344.
Masts, 4, 13, 14, 40, 53, 58, 126, 208, 299, 363, 374 n.
Maydman, Henry, 350.
Medals, 278 n., 328.
Medium, the, 309 n.
Medway chain. See Upnor.
ships moored in, 151, 284 and n.
Men-of-war, lists of. See Ships, Lists of.
Mennes, Sir John, 287.
Merchant Shipping. See Shipping, merchant.
Merhonour, 121, 129, 131, 181, 182, 187, 196, 201, 202 and n.,
205, 344.
Mervyn, Sir Henry, 231, 235, 239, 267, 282, 287.
Midshipmen, 226, 314 and n.
Minion (of Henry VIII), 50, 68, 91, 101, 106.
(of Elizabeth), 120, 123, 139.
Moleyns, Adam de, 16 n., 22.
Monk, George, 321, 328.
Monson, Sir William, 165, 184 n., 292, 397.
More, Edmund, 84.
Morfote, William, 18.
Morley, Thomas, 85.
Murderers, 54 and n.
Mutinies, 152, 224, 228, 230, 233, 234, 235, 236, 248-250, 310
n., 315, 382-391.
N
Navigation Acts, 10, 34, 42, 167.
Navy, a personal possession of the King, 17.
a subsidiary force in early reigns, 6.
Board, 104, 111, 189-194, 264, 280-284, 287 n., 292, 394.
duties of, 190.
formation of, 86.
salaries of members of, 85, 280, 394.
Burgundian, 32.
Commissioners of, and Customs, 287, 346.
(of Civil War and Commonwealth), 287, 288, 306, 311,
326, 327, 329, 347 and n., 358, 359.
(James I and Charles I), 187, 191, 195 and n., 205,
206, 209, 215, 222, 224, 227, 228, 237, 275, 279,
282, 298.
Committees of Long Parliament, 241, 287, 346, 351.
Comptroller of, 85, 126, 129, 149, 167, 189, 191, 282.
expenses of. See Expenditure.
French. See France, Navy of.
government of, in thirteenth and fourteenth centuries, 4.
under Mary, 111-113.
growing sense of importance of, 45.
increase in, at certain periods, 11, 52, 110, 112.
influence of, on Wars of Roses, 27.
lists. See Ships, lists of.
Master of Ordnance of, 85, 104, 111, 149.
of fourteenth and fifteenth centuries underrated, 9, 20, 21.
Office, 283, 349, 350.
Seal, 300 n.
origin of, 1, 2.
modern, 1.
sale of, 15, 17, 22.
Saxon, 2.
ships purchased into, 33, 34, 52, 53, 120, 123, 255, 330
and n.
Surveyor of, 85, 104, 149, 189, 191, 258, 281, 288, 347 n.
Treasurer of, 85, 86, 104, 112, 144, 145-148, 149, 162, 164,
167, 173, 189, 191, 192, 195, 240, 245, 280, 287, 295,
349, 351, 352, 392-397.
Necessary money, 83, 141.
Nettings, 182 and n.
Nicholas, Edward, 231, 232, 259, 280, 285.
Nicholas of the Tower, 12, 13, 25.
Nicolas, Sir N. H., referred to, 2, 15 and n., 62 n.
Nomenclator Navalis referred to, 29, 187, 208 and n., 339 n.
Norreys, Thomas, 192, 195 and n.
Northumberland, Algernon Percy, tenth Earl of, 238, 239, 240,
278 n., 283, 286, 292.
Nottingham, Charles Howard, Earl of, see Howard of Effingham,
Charles, Lord.
Nuestra Señora del Rosario, 121 and n., 210.
O
Officers, dishonesty of, 82, 146, 187, 191-194, 220, 283-286,
316, 353-355.
incapacity of, 221, 287.
pay of, 26, 41, 42, 75, 152-154, 226, 360.
professional feeling among, 229, 232, 352, 355.
see also captains.
Oleron, 98 and n.
Ordnance, improvements in, 288.
office, 85, 86, 158, 289, 290, 361.
price of, 159, 212, 262, 288, 360 n., 361.
recovery of, 345.
secret exportation of, 159, 213.
stores, 96, 97, 155-160, 289, 301. See also, Ships,
ordnance stores of.
want of, 360, 361.
Orlop, 129, 130 n., 205.
Oxford, John de Vere, twelfth Earl of, 27.
thirteenth ——, 65.
P
Paget, Sir William, 93.
Painting, see Ships, painting of.
Palmer, Sir Henry, 149, 189.
Jr., 227, 266, 282, 283 n.
Parliament Joan, see Alkin, Elizabeth.
Partriche, Nicholas, 70.
Pavesses, 41, 61.
Paymaster of Marine Causes, 149.
the sea, 85.
Pelican, 168 and n., 210.
Pennington, John, 223-225, 229, 239, 240, 253, 257, 258 and
n., 261 n.
Pensions, 25, 247, 322, 324.
Peppercorn, 201.
Peter Pomegranate, 49, 55, 62, 68, 70, 72, 73, 75, 76.
Petitions, 235, 317, 318, 340.
Pett, John, 74.
Joseph, 152.
Peter (died 1589), 74, 113, 151, 162, 163, 395, 396.
(son of above), 255.
(nephew of Phineas Pett), 255, 288, 338.
(son of —— ——), 338, 347.
Phineas, 152, 186, 192, 203, 204, 208, 209, 255, 260, 261,
282, 283 n., 288.
Thomas, 74.
Phœnix, 345.
Philip and Mary, 109, 120 n., 122.
Pierriers, see Stone guns.
Pilgrimage, over-sea, 18.
Pilot, Chief, of England, 149.
Major, of Spain, 149.
Piracy, supporters of, on shore, 95, 96, 178, 198.
under Henry IV, 10.
Henry VI, 17, 18.
Edward IV, 32.
Henry VIII, 94, 95, 96.
Edward VI, 104, 105.
Mary, 114.
Elizabeth, 177-180.
James I, 198, 199.
Charles I, 252, 272, 274-276.
Commonwealth, 345, 346.
Pirates, Turkish, 198, 199, 252, 274, 275, 345.
Plantagenet, Arthur, 66.
Plymouth, 219, 223, 231, 235, 363.
Poldavies, 98 and n., 103, 182.
Pole, William de la, Duke of Suffolk, 17, 26, 65 n.
Pond at Deptford, 70.
Portholes, 40, 41, 206, 257, 258, 259, 261 n., 268.
Ports, condition of, under Charles I, 271, 272.
Portsmouth, town of, 69, 297, 321.
Poundage, 192.
Pride, Thomas, 324 and n.
Primrose (of Edward VI), 101 and n., 109 and n.
(of Elizabeth), 120, 123, 139.
Prince Royal, 186, 202, 203, 204, 207, 247, 257 n., 261, 338.
Prisoners, in Sallee, 275, 277.
ransom of, 95.
treatment of, 63, 78, 322, 323 n.
Privateering, English, 104, 105, 106, 114, 140, 180, 181, 343,
344, 398-400.
French, 94, 179.
Scotch, 179.
Prize money, 26, 165, 166, 273, 292, 293, 308, 309.
Commissioners of, 309 n., 316, 317.
Prizes, 12, 13, 61, 78, 88, 101, 107, 120, 121, 123, 165, 166,
185, 254, 305, 307, 330-337, 399. See also Ships, lists of.
Provisions, price of, 82. See also Victualling.
want of, 81, 82, 83, 142, 143, 220-224, 233, 236, 326-328.
Pumps, 15, 127.
Punishments, 79, 188, 221, 228, 229, 239, 244, 312, 349, 352,
353, 357, 358.
Purchases of ships. See Navy, ships purchased into.
Pursers, 41, 42, 82, 146, 194, 285, 286, 356, 357.
Purveyance, abolition of, 140, 141.
Q
Quarles, James, 142 and n.
Quintal, 398 and n.
R
Rainsborow, Thomas, 248-50.
William, 258, 277 n.
Ralegh, Sir Walter, 66, 156, 184 n., 186, 187.
Ramsay, David, 274.
Redynge, John, 81.
Regent, 35, 36, 40, 41, 66, 68, 74.
Revenge, 120, 130, 135, 178, 183 n.
Revenue, English national, 17, 21, 25, 27, 219, 223, 303, 368
and n.
French ——, 219.
Richard II, 10.
Richelieu, Cardinal de, 264, 265.
Richmond, Henry Fitzroy, Duke of, 66.
Roger, Thomas, 32, 36.
Ropehouses, 150.
Roses, wars of, 21, 27.
Round robin, 230.
Rupert, Prince, 303, 309, 353.
Russell, Sir William, 195, 240, 245, 281, 293.
William, Lord, 66.
S
Sails, 4, 13, 14, 40, 53, 54, 127, 208, 257, 299, 338, 377.
St Andrew (of Elizabeth), 121, 123, 206.
(of James I), 202, 208, 259, 335.
St George, 202, 208, 220, 259, 338.
St John, William Paulet, Lord, 81, 93.
St Mary’s Creek, 151, 211.
St Matthew, 121, 123, 206.
Salisbury, Richard Neville, Earl of, 27.
Sallee, expedition to, 277 and n.
Saltpetre, 97.
Salute, claim to the, 106, 183, 291, 292, 307.
Saluting, 111, 213, 290, 291, 370.
Sandwich, sack of, 27.
Sapphire, 319 and n.
Scotland, Navy of, 47.
Seamanship, English, 19, 154.
Spanish, 154.
Seamen and Commonwealth, 318, 322.
Long Parliament, 240, 242, 250, 308, 314.
clothes of, 34, 41, 68, 76, 113, 138, 139, 223, 229, 230,
234, 286, 329.
condition of, 21, 42, 74, 79, 138, 187, 222, 238, 318.
English, foreign opinion of, 133, 187.
foreign, 23, 78, 87.
in Wars of Roses, 27.
merchant, 79, 243, 244, 314, 350.
numbers of, available, 74, 176, 242, 244, 314.
pay of, 25, 26, 28, 34, 41, 75, 106, 113, 134, 197, 225, 232,
241, 314.
delayed, 187 n., 226, 228, 231, 240, 316, 320, 368 n.,
369.
rewards to, 106, 135, 136, 245, 328; see also Medals.
sick and wounded, 76, 77, 135, 137, 188, 221, 223, 224,
231, 235, 237, 238, 320, 323.
Commissioners of, 322.
unwillingness of, to serve, 187, 188, 237, 316.
Search, right of, 80.
Serpentines, 41, 54 and n., 96, 379, 380.
Seymour, Sir Thomas, 101, 104, 105.
Sheathing, 103, 110, 126, 187.
Sheerness, 150.
Shipbuilding abroad, 14.
criticism of (under James I), 185-187.
(under Charles I), 258.
effects of Crusades on, 3.
improvements in, 14, 40, 41, 53, 54, 126, 127, 128 and n.,
129, 130, 185, 205, 206, 253, 287, 338.
Norman superiority in, 3.
Shipkeepers, 23, 188, 191, 284.
Ship-money, 218, 236, 237, 238.
Shipping, merchant, destruction of, 7, 271, 272.
lists of, 19, 20, 90, 172-175, 269-271.
under Edward III, 7, 8.
Henry IV, 11.
Henry VI, 18, 19, 20, 21.
Henry VII, 37.
Henry VIII, 88, 89, 90.
Edward VI, 107.
Elizabeth, 167-176.
James I, 199.
Charles I, 269-271.
Commonwealth, 343.
Ships, appearance of, 263.
armament of, 13, 29, 33, 41, 54 and n., 55, 124, 125, 155-
157, 212, 229, 256, 262, 341, 379, 380 and n.
arrest of, 2, 3.
build of, 4, 14, 40, 41, 53, 58, 59, 60, 124, 125, 185, 186,
205, 253, 254, 259, 267, 268, 307, 338.
Clerk Comptroller of, 70, 84.
Clerk of, 3, 4, 12, 13, 14, 16, 18, 22, 24, 31, 32, 33, 36, 53,
83, 84-87, 144, 149, 282.
cost of, 128, 129, 195, 196, 204, 208, 256, 257, 260, 261,
339.
decoration of, 15, 41, 57, 60, 130, 131, 204, 205, 261, 340.
early fighting, 4.
English, foreign opinion of, 133.
hired by the crown, 8, 10, 17, 21, 32, 35, 38, 39, 74,
87, 88, 169, 171, 201, 229, 273, 343.
size of, 4, 13, 124, 270, 271.
equipment of, 13, 14, 29, 40, 41, 53, 54, 124, 257.
foreign, hired by the crown, 12, 13, 27, 38, 39, 87, 88, 164.
size of, 13, 265 and n.
hiring, difficulty in, 88, 252, 273.
lists of:—
under Henry V, 12.
Edward IV, 32, 33.
Henry VII, 34.
Henry VIII, 49-51.
Edward VI, 100, 101.
Mary, 109.
Elizabeth, 120, 121, 124.
James I, 202, 207.
Charles I, 254, 255.
Commonwealth, 329-337.
lost during Interregnum, 330, 337, 344, 345.
Master of Ordnance of, 85, 86, 149.
merchant, bought. See Navy, ships purchased into.
names of. See Ships, lists of.
names of, changed, 338.
number of, commissioned each year under Elizabeth, 118.
fighting, under Edward III, 9.
under Commonwealth, 338.
Elizabeth, 115, 119.
Henry VIII, 52.
office expenses in moving, 70.
on seals and coins, 7 and n.
ordnance stores of, 33, 56, 124, 155, 213, 289, 341.
painting of, 41, 62, 130, 340.
royal, hired out, 4, 22, 34, 42, 67, 68, 107, 139, 140, 293 n.

Full Download Pediatric Hand Therapy, 1e 1st Edition Joshua M. Abzug PDF

Uploaded by

Copyright:

Available Formats

Full Download Pediatric Hand Therapy, 1e 1st Edition Joshua M. Abzug PDF

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Full Download Pediatric Hand Therapy, 1e 1st Edition Joshua M. Abzug PDF

Uploaded by

Copyright:

Available Formats

Download More ebooks [PDF]. Format PDF ebook download PDF KINDLE.

Full download ebooks at ebookmass.com

Pediatric Hand Therapy, 1e 1st Edition

For dowload this book click BUTTON or LINK below

Download More ebooks from https://ebookmass.com

2020 Nelson’s Pediatric Antimicrobial Therapy 26th

2022 Nelson's Pediatric Antimicrobial Therapy, 28th

Frames of Reference for Pediatric Occupational Therapy

The Public Health Crisis Survival Guide 2nd Edition

Self-System Therapy for Depression: Therapist Guide 1st

Nelson Pediatric Symptom-Based Diagnosis 2nd Edition

Business Analytics: Communicating with Numbers, 1e 1st

Clinical Skills for Paramedic Practice ANZ 1e 1st

REBECCA NEIDUSKI, PHD, OTR/L, CHT

Publisher: Cathleen Sether

Joshua M. Abzug, MD Alexandria L. Case, BSE

Theodore J. Ganley, MD Christine A. Ho, MD

Ryan Krochak, MD M.J. Mulcahey, PhD, OTR/L, FASIA

Amy Lake, OTR, CHT Scott Oishi, MD

Daniel W. Safford, PT, DPT Kathleen Tate, MS, OTR/L

Embryology and Intrauterine Diagnosis

Pediatric Hand Therapy. https://doi.org/10.1016/B978-0-323-53091-0.00001-4

extremity congenital anomalies occur. The sequence

FIG. 1.4 Eleven-month-old girl with arthrogryposis

Proximodistal limb development

Anteroposterior limb development

(so-called bidorsal limbs).28 Alterations in this latter

Programmed Cell Death

Hand Function: Typical Development

INTRODUCTION interaction with the environment.9,10 The develop-

Pediatric Hand Therapy. https://doi.org/10.1016/B978-0-323-53091-0.00002-6

FIG. 2.1 Timeline of key components of hand motor skill development.

with increased precision. The ability to manipulate ob-

FIG. 2.6 Scissors graspdobject is grasped between thumb

difﬁcult for 2e3 year olds, who often exhibit difﬁculty

developing ability to properly calibrate grip forces.8 Bimanual Grasp

and accuracy continue to improve with less variability

Physical Examination of the Pediatric

Pediatric Hand Therapy. https://doi.org/10.1016/B978-0-323-53091-0.00003-8

The concept of scaffolding should be utilized to elicit

to complete. The Weinstein Enhanced Sensory Test

INTRODUCTION Spinal Cord Injury,5 and Classiﬁcation of the Upper Ex-

Pediatric Hand Therapy. https://doi.org/10.1016/B978-0-323-53091-0.00004-X

You might also like