SCIENTIFIC ARTICLE

Accuracy and Reliability of Three Different Techniques

for Manual Goniometry for Wrist Motion:
A Cadaveric Study
Timothy I. Carter, BA, Brian Pansy, BE, Aviva L. Wolff, BS, Howard J. Hillstrom, PhD, Sherry I. Backus, BS,
Mark Lenhoff, BS, Scott W. Wolfe, MD

Purpose Despite the ubiquitous use of manual goniometry in measuring objective outcomes
of hand surgery and therapy, there are limited data concerning its accuracy or repeatability
for wrist motion. The purpose of this study was to evaluate the accuracy and reliability (both
inter- and intra-rater) in measuring wrist flexion and extension using 3 manual goniometric
alignment techniques (ulnar, radial, and dorsal–volar) in cadaveric upper extremities, using
fluoroscopic verification of posture as a gold standard. In addition, we sought to assess the
accuracy and reliability of the dorsal–volar technique for measurement of radioulnar deviation.
Methods External fixators were applied to 10 cadaveric wrists with intramedullary cannulated
rods in the radius and third metacarpal for gold-standard fluoroscopic verification of posture.
Manual goniometric measurements with each technique were captured by 2 raters (a hand
surgeon and a hand therapist) for reliability measurements and by a single rater for accuracy.
Wrists were positioned at angles of maximum flexion, extension, and radial and ulnar
deviation for reliability testing and at preselected angles across the range of motion for
accuracy testing. At each position, wrist angle was measured with a 1° increment goniom-
eter, and fluoroscopic angles were measured digitally. Intraclass correlation coefficients and
root mean square values were calculated for all combinations, and analysis of variance was
used to test differences between techniques.
Results No technique was statistically less accurate than any other (6° to 7°). Each method
was found to have high intra-rater reliability. For measurement of wrist flexion and exten-
sion, the dorsal–volar technique demonstrated the greatest inter-rater reliability, as compared
to ulnar and radial, respectively.
Conclusions Although each measurement technique demonstrated a similar degree of accuracy
and intra-rater reliability, the dorsal–volar technique demonstrates the greatest level of
inter-rater reliability for measurement of wrist flexion and extension. This information is
important clinically, as measurements are regularly exchanged between hand surgeons and
therapists as a basis for decisions regarding patient care. (J Hand Surg 2009;34A:1422–
1428. © 2009 Published by Elsevier Inc. on behalf of the American Society for Surgery of
the Hand.)
Key words Accuracy, continuity of care, manual goniometer, reliability, wrist range of motion.

From the Hospital for Special Surgery, New York, NY. Corresponding author: Scott W. Wolfe, MD, Hospital for Special Surgery, Department, 535 East
70th Street, New York, NY 10021; e-mail: wolfes@hss.edu.
SpecialthankstoMichaelSheehanandClaraHilario,withoutwhomthisprojectwouldnothavebeen
possible. Thanks to Hologics (Bedford, MA) for the use of their fluoroscopy unit and to Synthes (West 0363-5023/09/34A08-0007$36.00/0
Chester, PA) for their generous donation of 10 external fixation devices. doi:10.1016/j.jhsa.2009.06.002
Received for publication November 28, 2007; accepted in revised form June 2, 2009.
No benefits in any form have been received or will be received related directly or indirectly to the
subject of this article.

1422 䉬 ©  Published by Elsevier, Inc. on behalf of the ASSH.

 RELIABILITY IN MEASURING WRIST RANGE OF MOTION 1423

(ROM) is regarded as a univer-

R
ANGE OF MOTION
sal barometer of success for surgical and non-
surgical treatment of wrist injuries. These mea-
surements, most often captured by manual goniometry,
serve as a common language between surgeons, pa-
tients, and therapists. To facilitate the successful treat-
ment of wrist injuries and to improve effective com-
munication between physicians and therapists, it is
important that measurements be both accurate and re-
liable between examiners. These parameters were eval-
uated in cadaveric specimens for 3 goniometric tech-
niques and between 2 experienced hand professionals.
There are currently 3 popular methods of measuring
wrist flexion and extension with a manual goniometer:
placement of the device along the ulnar, radial, or
dorsal–volar surfaces of the wrist. For radial and ulnar
deviation, the American Society for Hand Therapists
recommends placement of the goniometer on the dorsal
surface; the authors could find no other suggested
method in the literature.1 LaStayo et al. examined the
inter- and intra-rater reliability of these 3 techniques for
measurement of flexion and extension.2 Their study
compared measurements taken by physical therapists
with varying backgrounds and found the dorsal–volar
technique of measurement to be the most reliable. Re-
liability of passive and active measurements of ROM
between therapists was also assessed by Horger et al.3
This study, which compared therapists with different
levels of experience and specialization, found that more
specialized raters demonstrated a higher degree of intra-
rater reliability; however, no measurement technique
was specified. Several other studies of wrist ROM and
measurement tools have been conducted, dating back to
1928.4 – 6 To our knowledge, no study has examined the
accuracy of these techniques as compared to a gold FIGURE 1: Cadaveric wrist with external fixator positioned
standard of skeletal alignment. In addition, no compar- obliquely to the frontal and sagittal planes.
ison has been made of the reliability of each goniomet-
ric technique between a surgeon and a therapist, and
there is no published standard among hand surgeons METHODS
concerning use of either technique. Finally, the validity Ten above-elbow cadaveric wrists (Anatomy Gifts
and accuracy of manual goniometric measurements as a Registry, Glen Burnie, MD, and Science Care, Phoenix,
gold standard for evaluation of electronic methods of AZ) were used to determine the accuracy and reliability
wrist position (electrogoniometer, motion analysis, of each manual goniometric technique. Specimens were
data gloves) have not been established. The purpose positioned in neutral forearm rotation (in reference to
of this study was to determine the accuracy and the medial and lateral epicondyles of the humerus) and
reliability of manual goniometry for measurements pinned with a 2.0-mm (0.079-in) K-wire, driven
of static wrist position. Our primary hypothesis was through the proximal radius and ulna. We applied a
that the dorsal–volar technique would be the most bridging single-bar external fixator (Synthes USA, Pa-
accurate method to determine wrist flexion and ex- oli, PA) across the wrist in an oblique plane (45° with
tension. Our secondary hypothesis was that this tech- respect to the sagittal and frontal planes, with pin clus-
nique would exhibit the highest degree of inter- and ters in the index metacarpal and mid-diaphysis of the
intra-rater reliability. radius (Fig. 1). To detect the central axis of the radius

JHS 䉬 Vol A, October 

1424 RELIABILITY IN MEASURING WRIST RANGE OF MOTION
FIGURE 2: Fluoroscopic images of the intramedullary rods in position. A Posteroanterior view. B True scaphopisocapitate lateral
projection.
and third metacarpal under fluoroscopy (GE Medical
Systems, Fairfield, CT), a cannulated rod was inserted
in both intramedullary canals by the following proce-
dure. The long finger of each specimen was removed at
the metacarpophalangeal joint and a 1.6-mm (0.063-in)
guidewire was advanced under fluoroscopic guidance
through the third metacarpal, the capitate, and into the
radius, with the wrist in neutral position. A cannulated
rod was then advanced over the guidewire to contact the
radial pin cluster of the external fixator (verified with
fluoroscopy). The radial articular surface was identified
under fluoroscopy to measure its distance from the
radial pin cluster. With the guidewire left in place, the
cannulated rod was removed and cut to fit the measured
distance between the radial articular surface and the
distal-most external fixator pin of the radial cluster. The 2
segments of the rod were again advanced over the
guidewire sequentially, seating the proximal rod in
the distal radius and then withdrawing the distal
portion into the capitate (Figs. 2A, 2B).
Manual goniometric measurements of wrist exten-
sion, flexion, radial deviation, and ulnar deviation were
performed by a hand surgeon and a hand therapist,
using previous references for guidance with regard to
positioning of the goniometer.7,8 A prestudy power
analysis indicated power ⬎0.8 to detect differences in
both reliability and accuracy between techniques. A 1°
resolution manual goniometer (Orthologic, Tempe, AZ)
was used for all measurements. After familiarizing
themselves with published techniques for measurement,
the therapist and surgeon reached consensus to stan-
dardize the alignment procedures of each technique and
were allowed to practice each technique repeatedly over
a 10-minute period before data collection.1–3 During
JHS 䉬 Vol A, October 
each measurement, the axis of the goniometer was
centered over the axis of wrist rotation—the center of
the capitate.7,8 To determine this point, we used the tip
of the radial and ulnar styloid as surface landmarks and
determined that the center of the capitate in the coronal
plane was positioned at the midpoint of the line con-
necting the 2 styloid tips, as verified under fluoroscopy.
For each measurement technique, the axis of the goni-
ometer was aligned with this midpoint. In the radial and
ulnar techniques, the proximal arm of the goniometer
was aligned in parallel with the radius or ulna along its
outer border, and the distal arm of the goniometer was
aligned in parallel with the third metacarpal (Figs. 3C, 3D).
For the dorsal–volar technique, the distal arm was
aligned with the third metacarpal, and the proximal arm
was aligned centrally on the forearm. With this tech-
nique, the goniometer was placed on the dorsal surface for
flexion, radial deviation, and ulnar deviation and on
the volar surface for extension (Figs. 3A–D, 4A–B).
Measurements of flexion and extension were cap-
tured with all 3 goniometric techniques, and mea-
surements of radial and ulnar deviation were mea-
sured exclusively with the dorsal–volar technique.1
Fluoroscopy was used as a gold standard for deter-
mination of actual wrist position. Images were captured
digitally, and the angle created by the intramedullary
rods was measured using the Adobe Photoshop (Adobe
Systems Inc, San Jose, CA) angle measurement tool
(Fig. 5).9 For any measurement in one plane, it was
important that the wrist be aligned at a neutral angle in
the unmeasured plane. To remain consistent between
specimens and between measurements, 2 radiographic
alignment techniques were used. When measuring ra-
dioulnar deviation in the coronal plane, the wrist was set
 RELIABILITY IN MEASURING WRIST RANGE OF MOTION 1425

FIGURE 3: Demonstration of the A dorsal, B volar, C radial, and D ulnar measurement techniques as used on a cadaveric
specimen instrumented with a bridging single-bar external fixator.

in neutral posture in the sagittal plane by aligning the
intramedullary rods under fluoroscopic control. Images
were taken and verified using Adobe Photoshop. The
specimen was then rotated into a coronal projection
until the radioulnar joint space was maximized, ensur-
ing a consistent posteroanterior (PA) view. Similarly,
when measuring in the sagittal plane, the intramedullary
rods were aligned in the coronal plane under fluoros-
copy and verified using Adobe Photoshop. The speci-
men was then rotated along the longitudinal (Z) axis
until the scaphoid tubercle and pisiform were maxi-
mally overlapped, assuring a consistent true scapho-
pisocapitate lateral projection as described by Yang et al.10
To evaluate accuracy, wrists were each positioned at
approximately 0°, 15°, 30°, and 45° of extension and
flexion; 0° and 10° of radial deviation; and 0°, 10°, 20°,
and 30° of ulnar deviation, as measured by the manual
goniometer, allowing a 5° range at each position to
confound any attempt by the raters to guess wrist po-
sition. The wrist was then imaged with fluoroscopy at
each set position, with both PA and lateral exposures of
the wrist, to ensure neutral rotation in the unmeasured

JHS 䉬 Vol A, October 

1426 RELIABILITY IN MEASURING WRIST RANGE OF MOTION

FIGURE 4: Demonstration of the dorsal technique for measurement of A ulnar and B radial deviation as used on a cadaveric
specimen instrumented with a bridging single-bar external fixator.

sures of the wrist were captured under fluoroscopy to

FIGURE 5: Screen shot of digital image during measurement
of the angle created by the intramedullary rods.
plane. This enabled computerized verification of wrist
position in the plane orthogonal to the axis of the wrist
angle. All 10 wrists were measured by 1 rater with one
technique. This was then repeated for each goniometric
technique, and the sequence of wrists was randomized
for each technique to confound any potential measure-
ment recall.
To evaluate the inter- and intra-rater reliability of
each technique, wrists were positioned at angles of full
flexion, full extension, full radial deviation, and full
ulnar deviation. After positioning, PA and lateral expo-
ensure neutral alignment in the plane orthogonal to the
plane of measurement and for computerized measure-
ment of the wrist angle. At each position, the raters
measured all wrists with one technique, in a randomized
order. Each cadaver was then measured again in a
separate randomized order, using the same technique in
a second trial without repositioning the wrists. The
process was repeated for each position (full flexion,
extension, radial deviation, and ulnar deviation) and for
each technique. Measurements of radial and ulnar de-
viation were performed with the dorsal–volar technique
only.
Intraclass correlation coefficients were completed to
determine inter- and intra-rater reliability, using the
JMP6 software package (SAS, Cary, NC). To deter-
mine accuracy, the root mean squared error (RMSE)
and mean deviation were calculated between comput-
erized measurements and manual goniometric values
for each technique over the range of positions. Statisti-
cally significant differences between mean deviations
were determined using analysis of variance, using an
alpha level of p ⬍ .05.
RESULTS
When measuring the neutral position, the RMSE for
accuracy of the ulnar, radial, and dorsal–volar tech-
niques were 4°, 5°, and 4°, respectively (Table 1). No
statistically significant difference in accuracy could
be detected between techniques. For measurement of

JHS 䉬 Vol A, October 

 RELIABILITY IN MEASURING WRIST RANGE OF MOTION
TABLE 1. In Vitro Accuracy and Reliability of
Wrist Goniometric Measurement Methods
Ulnar Radial Dorsal–Volar
RMSE overall 7° 7° 8°
RMSE neutral 4° 5° 4°
Mean deviation (p ⫽ .2) 5° 6° 6°
Intra-rater reliability
Rater 1 0.8 0.8 1 cadaveric wrists was predicated on the need to mini-
Rater 2 1 0.9 1 mize confounding variables that could jeopardize mea-
Inter-rater reliability 0.5 0.3 0.9
flexion, extension, radial deviation, and ulnar devia-
tion, the range of RMSE values was 7° to 8°; p ⫽ .3
(Table 1). The mean deviation between fluoroscopic
values and each goniometric method ranged from 5°
to 6° and was also not statistically significant; p ⫽ .2
(Table 1).
Each method demonstrated a high degree of intra-
rater reliability, with the radial technique for measure-
ment of wrist flexion and extension demonstrating the
lowest intraclass correlation coefficients values (0.8 and
0.9). Between raters (inter-rater reliability), however,
the dorsal–volar technique for measurement of wrist
flexion and extension was the most reliable as com-
pared to ulnar and radial techniques: 0.9, 0.5, and 0.3,
respectively (Table 1).
DISCUSSION
In this study, we demonstrated that hand surgeons and
therapists can attain accuracy within 7°, using the man-
ual goniometer and standardized techniques of wrist
measurement. This is important because the manual
goniometer is ubiquitous in orthopedic and hand sur-
gery. Quantifying wrist range of motion allows the
surgeon to determine patient progress and is a particu-
larly vital communication tool between hand surgeons,
hand therapists, and other health care providers. In
addition, electronic techniques to measure wrist motion
(electrogoniometry, data gloves, and external motion
analysis systems) are increasingly used in both clinical
and research arenas; verification of the accuracy and
reliability of manual goniometry is necessary as a
means to validate these instruments and techniques. To
our knowledge, no study has examined the accuracy of
manual goniometry, the repeatability of different tech-
niques of measurement, or the inter-rater reliability be-
tween surgeon and hand therapist.
The use of cadaveric specimens limited the sample
size of our study, raising the possibility of a beta error
JHS 䉬 Vol A, October 
1427
(falsely accepting the null hypothesis). It is possible that
one technique was more accurate than the others, but it
could not be statistically proven in the absence of a
great number of specimens. Nonetheless, all accuracy
measurements were within single digits, which we feel
is an appropriate margin of error; differences between
techniques of 1° or 2° would not be clinically signifi-
cant. The decision to perform these experiments in
surements of accuracy and reliability. The study re-
quired a gold standard for wrist posture, which was
achieved by the use of intramedullary alignment rods.
Furthermore, were it possible to accurately determine
wrist position with fluoroscopy on live volunteers, the
assessment would have exposed human subjects to un-
necessary radiation.
The LaStayo et al. study suggests that, among phys-
ical therapists, the dorsal–volar technique for measure-
ment of wrist flexion and extension demonstrates the
highest degree of reliability.2 The results of our study
support the reliability of the dorsal–volar technique
between a surgeon and a hand therapist who used and
practiced a standardized technique. Contrary to the lit-
erature, our data indicate that disagreement between
raters of different training backgrounds can be con-
trolled by use of a standardized dorsal–volar tech-
nique.3
We were unable to reject the null hypothesis, that
there was no difference in accuracy between the 3
techniques for measurement of wrist position. Each
technique was accurate to within 5° of wrist position
when compared to the gold standard of fluoroscopic
measurement. Although no statistically significant dif-
ference was discovered, the 5° of inaccuracy inherent to
each technique supports the use of a 1°-increment go-
niometer clinically. Often manual goniometers are
marked with 5° increments. This inaccuracy can poten-
tially compound the examiner’s error, resulting in up to
10° of inaccuracy.
We were able to prove our secondary hypothesis,
that the dorsal–volar technique demonstrates the highest
degree of reliability for measurement of wrist flexion
and extension. Based on these findings, the authors
recommend the dorsal–volar measurement technique
for assessment of wrist ROM. This method promotes
the greatest agreement between raters, as is necessary in
communication between physicians and between phy-
sician and therapist, and it is consistent with the cur-
rently accepted use of the dorsal–volar technique for
radial and ulnar deviation.
1428 RELIABILITY IN MEASURING WRIST RANGE OF MOTION

REFERENCES 6. Edgar D, Finlay V, Wu A, Wood F. Goniometry and linear assess-

1. Casanova JS. Clinical assessment recommendations. 2nd ed. Garner,
NC: American Society for Hand Therapy, 1992:62– 63.
2. LaStayo PC, Wheeler DL. Reliability of passive wrist flexion and
extension goniometric measurements: a multicenter study. Phys Ther
1994;74:162–174.
3. Horger MM. The reliability of goniometric measurements of
active and passive wrist motions. Am J Occup Ther 1990;44:342–
348.
4. Boone DC, Azen SP. Normal range of motion of joints in male
subjects. J Bone Joint Surg 1979;61A:756 –759.
5. Cobe H. The range of active motion at the wrist of white adults.
J Bone Joint Surg 1928;10:763–764.
ments to monitor movement outcomes: Are they reliable tools in
burn survivors? Burns 2009;35:58 – 62.
7. Neu CP, Crisco JJ, Wolfe SW. In vivo kinematic behavior of the
radio-capitate joint during wrist flexion-extension and radio-ulnar
deviation. J Biomech 2001;34:1429 –1438.
8. Youm Y, Flatt AE. Kinematics of the wrist. Clin Orthop Relat Res
1980;149:21–32.
9. Guyot L. Comparison between direct clinical and digital photogram-
metric measurements in patients with 22q11 microdeletion. Intl
J Oral Maxillofac Surg 2003;32:246 –252.
10. Yang Z, Mann FA, Gilula LA, Haerr C, Larsen CF. Scaphopisocapi-
tate alignment: criterion to establish a neutral lateral view of the
wrist. Radiology 1997;205:865– 869.

JHS 䉬 Vol A, October 