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. 2026 Oct 19;13(1):1–12. doi: 10.1080/23335432.2026.2747911

Total wrist fusions alter scapular kinematics during functional task performance

Hannah Verity a, Alexander Waslen a, Laura Sims b, Angelica E Lang a,c,✉
PMCID: PMC13686183  PMID: 42897935

ABSTRACT

Total wrist fusion is a surgical procedure used to manage pain in late-stage arthritis, though it results in a complete loss of wrist mobility. This loss can lead to compensatory movement patterns in other upper limb joints, which may increase the risk of secondary musculoskeletal disorders. This study investigated scapular kinematics in wrist fusion patients compared to healthy controls. Eighteen participants (nine wrist fusion patients, nine age- and sex-matched controls) were recruited. Scapular motion was tracked using motion capture during seven functional tasks. Bilateral scapular kinematics (upward rotation, internal rotation and anterior tilt) were analyzed at 30° increments of humeral elevation. Kinematic outcomes were assessed using linear mixed models with group and side (fusion or non-fusion) as independent factors. Participants with wrist fusion demonstrated greater scapular internal rotation, upward rotation, and anterior tilt for both arms as compared with the control group. Upward rotation was greater on the fusion side than the non-fusion side in the surgery group. These findings suggest that scapular kinematics are altered to compensate for wrist immobility during daily living and functional tasks. Understanding these compensatory patterns is important to guide post-surgical rehabilitation strategies and help prevent secondary upper limb injuries.

KEYWORDS: Arthritis, biomechanics, orthopedic surgery, shoulder

Introduction

Arthritis is a common chronic condition that affects up to 20% of the Canadian population (Badley et al. 2019). Wrist involvement is highly prevalent in certain types of arthritis, such as rheumatoid arthritis, occurring in about 70% of affected patients based on radiographic findings (Anderson et al. 2023). A commonly used treatment option for late-stage arthritis of the wrist is a total wrist fusion, a procedure that involves surgically attaching the radius to the carpal bones, often with fixation that extends to the metacarpals (Jimenez and Anand 2025).

Total wrist fusions have both beneficial and adverse consequences. Total wrist fusions are associated with reliable pain relief, increases in grip strength, and a high patient satisfaction rate (Field et al. 1996; Rauhaniemi et al. 2005). However, this procedure sacrifices wrist mobility. Cadaver studies have shown that wrist fusions significantly limit wrist range of motion in all directions (Meyerdierks et al. 1987; Berkhout et al. 2010). While some patients may return to their previous occupation following the procedure, many experience ongoing difficulties with activities of daily living (ADLs), such as reaching high shelves, lifting saucepans, and perineal hygiene (Field et al. 1996). In addition to experiencing difficulties with ADLs, wrist fusion patients also report performing these tasks in a modified fashion compared with pre-surgery (Weiss et al. 1995). Surgeons must therefore weigh the advantages and drawbacks of this procedure with patients. Considering the complexity of the wrist joint and its role in intricate upper limb movements, restricting or eliminating range of motion at the wrist can lead to compensatory changes in other joints, such as the shoulder.

Restricting wrist motion can lead to greater demands on the proximal joints of the upper limb. For example, bracing the wrist affects global shoulder movement, with immobilized sides demonstrating exaggerated shoulder motion during functional tasks (Mell et al. 2005). Alterations in scapular kinematics have also been observed in individuals with distal arm injuries, such as radius fractures (Ayhan et al. 2015) and congenital radioulnar synostosis (Kasten et al. 2009). In addition to kinematic alterations, wrist immobilization is associated with increased activation of the shoulder girdle muscles during functional tasks (Bulthaup et al. 1999; Jung et al. 2013), further supporting the concept of compensatory movement adaptations at the shoulder.

Many patients with hand or forearm injuries present with concurrent musculoskeletal complaints of the shoulder, neck, or elbow. Up to 40% of patients with distal musculoskeletal issues report proximal arm complaints, most commonly involving the shoulder (62%), and more than one quarter of these cases develop diagnosed secondary upperlimb injuries (Winiarski et al. 2021). This pattern suggests that proximal compensations are not evenly distributed across the upper limb, but instead disproportionately affect the shoulder and may predispose individuals to shoulder impingement and future injury (Kibler et al. 2013). Investigating how wrist fusion surgery alters shoulder kinematics may help explain why secondary shoulder injuries develop in this population, further enabling patients and healthcare providers to make informed decisions about the procedure and develop rehabilitation strategies that minimize the risk of secondary injury. Despite evidence of upperlimb kinematic changes that occur when the wrist is temporarily restricted with a brace (Bulthaup et al. 1999; King et al. 2003; Mell et al. 2005; May-Lisowski and King 2008; Pereira et al. 2012; Jung et al. 2013), there is a relative lack of research examining how permanent surgical wrist fusion alters scapular kinematics compared with healthy controls.

The purpose of this study was to investigate the differences in shoulder kinematics between wrist‑fusion patients and healthy controls. We hypothesized that the surgical limb of the wrist‑fusion group would demonstrate altered scapular kinematics compared with the non-surgical limb and healthy controls. Specifically, we expected greater scapular upward rotation, internal rotation and anterior tilt (Ayhan et al. 2015), reflecting compensatory movement adaptions to preserve upper limb functionality despite limited wrist mobility.

Methods

Participants

Wrist fusion group

Patients who underwent a total wrist fusion by one of the authors, a fellowship‑trained upper extremity surgeon, were retrospectively identified. Eligibility criteria included adults who had undergone wristfusion surgery on one or both of their wrists at least 6 months prior to enrollment. Individuals were excluded if they had significant pain upon use of their upper limbs for functional tasks, could not raise their arms overhead, had allergies to adhesives, or had other health-related disorders such as multiple sclerosis, heart disease, or heartrhythm disorders.

Control group

Control participants were matched to the wristfusion group based on age (±2 years) and sex. Participants were recruited using university electronic bulletin boards, social media, and posters displayed in local community centers. Eligibility criteria included healthy adults with no current upper limb pain, injuries, or discomfort. Individuals were excluded if they had a history or current diagnosis of arthritis or non-arthritis shoulder disorders, such as cervical radiculopathy, other health-related disorders, such as heart disease, multiple sclerosis, or heart rhythm disorders, or an allergy to adhesives.

The study protocol was approved by the institutional research ethics board, and all participants provided informed written consent.

Procedures

All participants who met inclusion criteria underwent a single laboratory visit. Upon arrival to the lab, participants provided demographic data (age, height, weight, handedness) and completed the QuickDASH (Disabilities of the Arm, Shoulder and Hand) to evaluate perceived disability (Gummesson et al. 2006). The wrist fusion group also completed the Patient‑Rated Wrist Evaluation (PRWE) questionnaire (MacDermid 2007).

Motion of the upper body was tracked with a 10-camera passive optical motion capture system (Vicon Motion Systems, Oxford, UK). Twenty-two individual passive reflective markers were placed (bilateral 2nd and 5th metacarpals; bilateral radial and ulnar styloids; bilateral lateral and medial epicondyles; suprasternal notch, xiphoid process, C7 vertebrae, T8 vertebrae) or digitized (bilateral acromial angle, root of the scapular spine, and inferior angle) were placed on the anatomical landmarks of the upper limb and torso according to International Society of Biomechanics recommendations (Wu et al. 2005). An additional seven rigid body tracking clusters were affixed to each segment for motion tracking. Scapular kinematics were tracked using the acromial marker cluster (Karduna et al. 2001; MacLean et al. 2014; Warner et al. 2015). Two different researchers performed the scapular palpations for calibration to the acromial cluster (one with the fusion group and one with the control group). To minimize potential between-rater differences in landmark palpation, the single calibration procedure was used for scapular tracking, meaning only the position of the anatomical landmarks relative to the tracking cluster when the arm was in a neutral position was used to define the anatomical positions during the functional movements. Kinematic data were sampled at 100 Hz.

The experimental protocol consisted of a set of seven work-related functional tasks and activities of daily living that were chosen to test the range of arm motion, functional abilities, and the relative contributions of distal and proximal joints. This is a defined protocol that has been previously validated for shoulder kinematic measurements (Figure 1) (Friesen et al. 2023). Each task was performed three times with each arm, or three times total for bilateral movements, and trials were averaged within each person. The tasks were as follows:

  1. Comb hair: Holding a comb in one hand, move it to the forehead, and comb from the front to the back.

  2. Wash opposite axilla: Holding a washcloth in one hand, move it to the opposite axilla and implement a typical wash motion.

  3. Tie apron: Holding a ribbon with both hands, move hands to the waist and behind back, pantomiming tying an apron.

  4. Overhead reach: Reach with one hand towards a target on a shelf that is centered and 1.5 m off the ground with a 1 kg load.

  5. Forward transfer: Move a 1 kg bottle with one hand to a target placed 50 cm away in the forward direction.

  6. Floor to waist lift: Lift a standard-sized milk crate with an 8 kg load with both hands from the floor to a waist height shelf.

  7. Overhead lift: Lift a standard-sized milk crate with an 8 kg load with both hands from a waist height to a forehead height shelf.

Figure 1.

Part icipant performing comb hair and overhead lift tasks with motion capture markers.

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Participant with optical motion capture tracking markers completing the comb hair task with the right hand (left) and overhead lift task (right).

The selected tasks encompass a range of upper limb actions, enabling assessment of both distal and proximal contributions to functional movement. Activities such as combing hair, washing the opposite axilla, and tying an apron are expected to rely on wrist motion and fine motor control to achieve precise hand positioning. Following wrist fusion, these motions are restricted, necessitating compensatory increases in proximal joint motion to accomplish the same task, which may be reflected in altered scapular kinematics. In contrast, during lifting and reaching tasks, the wrist may act as more a stabilizer and remain in a relatively neutral position. This spectrum of wrist demands allows for evaluation of how reduced wrist mobility influences scapular kinematics across a range of functional activities.

Analysis

Custom MATLAB (Version 24) scripts were used to calculate the scapular and humeral joint angles. The raw marker data were filtered by a low-pass zero-lag fourth‑order Butterworth filter with a 6 Hz cut-off (Winter 2009). The filtered data were used to create local coordinate systems of each segment and create joint coordinate systems that were used to describe clinically relevant rotations. Scapular orientations of internal rotation, upward rotation and scapular tilt (Figure 2) were calculated using the YXZ rotation and extracted at minimum, 30°, 60°, and 90° humeral elevation, as relevant, during the upward portion of each task (Wu et al. 2005). As the single calibration procedure was implemented for scapular‑tracking analysis, scapular data above 90° was not analyzed due to known accuracy issues with high arm elevation (Karduna et al. 2001; Lang et al. 2022). Right scapular upward rotation and left scapular internal rotation were adjusted to be positive values. Humeral elevation was calculated as the first rotation from the XZY rotation sequence during the Comb Hair and Tie Apron and from the ZXY rotation sequence for all other tasks (Friesen et al. 2023). Humeral axial rotation was calculated using the True axial rotation method, as this method may allow for more consistent comparisons (Aliaj et al. 2021; Lang and Friesen 2023). Peak and range were extracted from humeral angles during the upward portion of the movement for analysis.

Figure 2.

Diagram of scapular movements: anterior tilt, internal rotation, upward rotation.

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Visual representation of the three scapular angles assessed.

All shoulders from all participants were included in the analysis. For the fusion group, shoulders were defined as ‘fusion surgery’ (surgical side) or ‘non-fusion’ (contralateral side). Two participants had bilateral fusions. For the control group, shoulders were defined as ‘control fusion match’ or ‘control non-fusion match’ based on the corresponding side of their matched fusion participant. Control participants were matched to fusion participants by limb dominance, i.e. if the fusion participant had the procedure on their dominant side, the matched control’s dominant side was deemed the ‘fusion match’. Group demographic variables (age, height, weight, QuickDASH) were compared with independent t-tests (p < .05). All kinematic outcomes were assessed with linear mixed models using SPSS Version 26, with participant as random effects and group (fusion, control) and side (fusion/fusion match, non-fusion/non-fusion match) as fixed effects. Post-hoc Tukey analyses were used to assess differences between levels for significant interactions and main effects (p < .05).

Results

Participants

A total of 18 participants were recruited. Nine participants with wrist fusion were matched to nine control participants based on age (±2 years) and sex (Table 1). The wrist fusion group had a significantly higher mean body weight than the control group. In the wrist fusion group, fusion was performed on both wrists in two participants, on the dominant wrist in five participants, and on the non-dominant wrist in two participants. QuickDASH scores were significantly higher in the wrist fusion group (38.4 ± 26.9) compared with the control group (4.0 ± 5.2; p = 0.002), with higher scores corresponding with greater disability.

Table 1.

Participant demographic data.

  Wrist Fusion
(n = 9)		 Control
(n = 9)		 p
Sex      
Male 7 7  
Female 2 2  
Age (yrs) 58.8 (34–83) 57.7 (33–82) 0.88
Height (cm) 173.1 (162–191) 173.3 (169–178) 0.95
Weight (kg) 110.1 (78.5–179.5) 82.8 (61.1–89.7) 0.023
Dominance 8 R, 1 L 7 R, 2 L  
Fusion Side      
Bilateral 2 –  
Dominant 5 –  
Non-Dominant 2 –  
QuickDASH Score (/100) 38.4 ± 26.9 4.0 ± 5.2 0.002
PRWE (/100) 46.72 ± 27.2 –  
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Age, height and weight are reported as mean (range). QuickDASH and PRWE (Patient Rated Wrist Evaluation) scores are reported as mean ± standard deviation (SD).

Kinematics

Scapular kinematics were different between groups for many tasks. There were minimal significant differences between sides and no significant interactions (Table 2).

Table 2.

Summary of all significant findings from the linear mixed model analyses.

Variable Task Level Effect df F p Control Non Control Fusion Fusion Non Fusion Surgery
Internal Rotation Comb Min Group 32 8.564 0.006 32.3 (4.9) 33.9 (3.9) 37.7 (4.9) 41.4 (3.9)
    30 Group 28 5.833 0.023 32.1 (5.6) 35.6 (4.3) 36.8 (5.6) 42.7 (4.3)
    60 Group 32 5.532 0.025 31.8 (5.7) 32.8 (4.6) 35.7 (5.7) 40.9 (4.6)
  Wash Min Group 32 8.098 0.008 32.8 (5.9) 35.7 (4.7) 41.1 (5.9) 42.3 (4.7)
    60 Group 30 17.632 <.001 38.4 (8.1) 38.1 (6.7) 52.9 (8.1) 54.1 (6.7)
  Tie 30 Group 30 4.203 0.049 27.9 (5.2) 29.3 (4.1) 32.5 (5.2) 34.3 (4.6)
  Overhead Reach Min Group 32 4.272 0.047 35.3 (5.4) 39.1 (4.3) 40.5 (5.4) 43.9 (4.3)
    60 Group 30 4.526 0.042 30.1 (5.0) 36.0 (4.4) 36.4 (5.0) 39.4 (4.0)
  Forward Transfer 60 Group 30 4.737 0.038 40.6 (6.7) 42.6 (5.6) 46.8 (6.7) 49.6 (5.6)
  Floor Lift Min Group 32 14.695 <.001 30.3 (4.4) 31.9 (3.5) 37.0 (4.4) 40.3 (3.5)
    30 Group 32 11.615 0.002 39.1 (5.3) 37.7 (4.2) 45.4 (5.3) 47.3 (4.2)
    60 Group 30 14.387 <.001 43.9 (6.4) 44.0 (5.0) 55.2 (6.0) 53.4 (4.8)
  Overhead Lift Min Group 32 8.958 0.005 38.0 (5.3) 38.2 (4.3) 43.8 (5.4) 46.8 (4.3)
    90 Group 32 11.795 0.002 34.3 (7.4) 32.6 (5.9) 44.0 (7.4) 45.5 (5.9)
Upward Rotation Comb 60 Side 32 4.586 0.04 12.1 (4.8) 14.4 (3.8) 11.7 (4.8) 18.6 (3.8)
    90 Group 30 15.382 <.001 20.1 (5.9) 20.2 (5.0) 27.4 (5.9) 34.0 (5.0)
  Overhead Reach 90 Group 31 34.205 <.001 20.4 (4.7) 19.7 (3.9) 30.9 (4.7) 33.7 (3.7)
  Forward Transfer Min Side 31 4.772 0.037 0.95 (4.7) 5.7 (3.8) −2.2 (4.7) 2.2 (3.4)
  Overhead Lift 90 Group 32 6.106 0.019 26.0 (5.8) 27.6 (4.6) 33.1 (5.8) 33.1 (4.6)
Tilt Comb 60 Group 32 5.752 0.022 −4.6 (6.6) −6.2 (5.2) −13.4 (6.6) −11.4 (5.2)
    90 Group 30 5.465 0.026 −2.9 (8.2) −4.3 (6.9) −12.3 (8.2) −12.3 (6.9)
  Wash Min Group 32 5.818 0.022 −4.3 (0.7) −5.3 (1.3) −11.7 (6.6) −8.8 (4.7)
    60 Group 30 5.468 0.026 −2.6 (3.8) −4.6 (0.8) −10.4 (4.0) −10.1 (4.9)
  Tie Min Group 32 12.448 0.001 −9.9 (3.7) −9.7 (2.9) −17.4 (3.7) −13.8 (2.9)
    30 Group 30 20.602 <.001 −9.6 (4.1) −9.9 (3.3) −19.9 (4.1) −16.6 (3.6)
    60 Group 26 27.13 <.001 −14.5 (6.8) −15.7 (5.3) −34.7 (7.5) −27.6 (5.6)
  Forward Transfer Min Group 31 5.159 0.03 −5.4 (10.1) −1.2 (8.1) −13.0 (10.1) −14.2 (8.5)
  Floor Lift Min Group 32 10.28 0.003 −7.9 (4.4) −9 (3.5) −14.9 (4.4) −11.2 (3.5)
    30 Group 30 5.517 0.026 −4.9 (5.0) −7.97 (4.0) −15.2 (5.0) −12.0 (4.0)
    60 Group 32 16.571 <.001 −5.9 (7.4) −8.0 (5.7) −17.4 (6.8) −11.2 (5.4)
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Significant differences (p < 0.05) between groups and sides for scapular internal rotation, upward rotation, and tilt. Group data are expressed as mean (95% confidence interval).

Min = starting position of the task.

Level = humeral elevation level.

df = degrees of freedom.

The fusion group demonstrated significantly greater scapular internal rotation throughout all tasks, with differences more pronounced for the fusion arm (Figure 3; Table 2). For example, at 60° of humeral elevation during the Wash Axilla, the surgical limb demonstrated the highest scapular internal rotation (54.1° ±6.7) compared with the fusion group non-surgical limb (52.9° ±8.1) and the fusion-matched and non-fusion-matched control limbs (38.1° ±6.7; 38.4° ±8.1, respectively).

Figure 3.

Four bar charts showing scapular internal rotation across humeral elevation during four tasks. Four bar charts titled Comb Hair, Wash Axilla, Floor Lift and Overhead Lift depict scapular internal rotation across humeral elevation degrees. Each chart has four bars per category with error bars and asterisk markers. Legend: Control minus non-match, Control minus fusion match, Fusion minus non, Fusion minus surgery. Comb Hair: Humeral Elevation (0, 30, 60, 90), Scapular Rotation (0-50). Values: 0 degrees (33, 34, 38, 41), 30 degrees (32, 35, 37, 42), 60 degrees (32, 34, 36, 41), 90 degrees (31, 31, 31, 39). Wash Axilla: Elevation (0, 60), Rotation (0-80). Values: 0 degrees (33, 36, 41, 43), 60 degrees (39, 38, 53, 55). Floor Lift: Elevation (0, 30, 60), Rotation (0-80). Values: 0 degrees (30, 32, 37, 40), 30 degrees (40, 38, 45, 48), 60 degrees (45, 44, 55, 53). Overhead Lift: Elevation (0, 60, 90), Rotation (0-60). Values: 0 degrees (39, 38, 44, 47), 60 degrees (39, 38, 39, 41), 90 degrees (35, 33, 44, 46).

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Scapular internal rotation: scapular internal rotation (error bar represents 95% CI) during the comb hair, wash axilla, floor lift, and overhead lift tasks. *denotes significant difference (p < 0.05).

Scapular upward rotation was greater in the fusion group at 90° of humeral elevation in all overhead movements (Comb Hair, Overhead Reach, and Overhead Lift) (Figure 4). The largest difference was observed during the Comb Hair task. At 90° of humeral elevation, upward rotation was highest in the surgical limb of the fusion group (34.0° ± 5.0) compared with the non-fusion limb (27.4° ± 5.9) and the fusion-matched (20.2° ± 5.0) and non-fusion-matched (20.1° ± 5.9) control limbs.

Figure 4.

A grouped bar chart showing scapular upward rotation during comb hair, overhead reach and overhead lift tasks. Image A: Comb Hair. Vertical axis: Scapular Upward Rotation (degrees, -10 to 50). Horizontal axis: Humeral Elevation (degrees, 0, 30, 60, 90). Data: 0 degrees (-2, 1, -3, 0), 30 degrees (4, 0, -3, 3), 60 degrees (12, 15, 12, 19), 90 degrees (20, 20, 28, 34). Asterisks at 60 degrees and 90 degrees. Image B: Overhead Reach. Vertical axis: Scapular Upward Rotation (degrees, 0 to 40). Horizontal axis: Humeral Elevation (degrees, 0, 60, 90). Data: 0 degrees (2, 5, 2, 4), 60 degrees (10, 10, 13, 15), 90 degrees (21, 20, 31, 34). Asterisk at 90 degrees. Image C: Overhead Lift. Vertical axis: Scapular Upward Rotation (degrees, 0 to 50). Horizontal axis: Humeral Elevation (degrees, 0, 60, 90). Data: 0 degrees (3, 5, 2, 4), 60 degrees (12, 13, 14, 19), 90 degrees (26, 28, 33, 33). Asterisk at 90 degrees. Legend: Control dash non-match, Control dash fusion match, Fusion dash non, Fusion dash surgery.

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Scapular upward rotation: scapular upward rotation (error bar represents 95% CI) during the comb hair, overhead reach, and overhead lift tasks. *denotes significant difference (p < 0.05).

Finally, scapular anterior tilt was also significantly greater in several tasks for the fusion group (Figure 5), with differences most pronounced during the Tie Apron and Floor Lift tasks (Table 2).

Figure 5.

A grouped bar chart showing scapular tilt across humeral elevation during four upper limb tasks. The image displays four grouped bar charts: Comb Hair, Wash Axilla, Tie Apron and Floor Lift. Each chart features a horizontal axis labeled Humeral Elevation (degree) and a vertical axis labeled Scapular Tilt (degree). The legend identifies four groups: Control minus non match, Control minus fusion match, Fusion minus non and Fusion minus surgery. Error bars and asterisks are present. Comb Hair: x-axis ticks at 0, 30, 60, 90; y-axis from 10 to -30. Bars range from -5 to -15. Wash Axilla: x-axis ticks at 0, 60; y-axis from 5 to -20. At 0, bars are -4, -5, -12, -9. At 60, bars are -2, -4, -10, -10. Tie Apron: x-axis ticks at 0, 30, 60; y-axis from 0 to -50. At 0, bars are -10, -12, -18, -15. At 30, bars are -10, -12, -20, -18. At 60, bars are -15, -18, -35, -28. Floor Lift: x-axis ticks at 0, 30, 60; y-axis from 10 to -30. At 0, bars are -8, -10, -15, -12. At 30, bars are -5, -8, -15, -12. At 60, bars are -5, -8, -18, -12.

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Scapular tilt: scapular tilt (error bar represents 95% CI) during the comb hair, wash axilla, tie apron, and overhead reach tasks. Negative values represent anterior tilt and positive values represent posterior tilt. *denotes significant difference (p < 0.05).

Humeral kinematic group differences existed for only the Overhead Lift. During the Overhead Lift, the wrist fusion group reached a lower peak humeral elevation than the control group (Figure 6). The differences were greater for the fusion side than the non-fusion side (p = 0.003).

Figure 6.

A bar graph showing humeral elevation during the overhead lift task.

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Humeral elevation: maximum humeral elevation (±95% CI) for each group and side during the overhead lift task. *denotes significant difference between groups (p < 0.05).

Discussion

The present study aimed to investigate the differences in shoulder kinematics between individuals who had undergone total wrist fusion and healthy controls during a series of functional upper limb tasks. To our knowledge, this is the first study exploring how wrist fusion influences scapular kinematics. The fusion group demonstrated consistently greater internal rotation across many tasks, with differences more pronounced on the fusion limb. The fusion group surgical limb also demonstrated greater scapular upward rotation during overhead movements (Comb Hair, Overhead Reach, and Overhead Lift) and greater anterior tilt across multiple tasks (Comb Hair, Wash Axilla, Tie Apron, Forward Transfer, and Floor Lift).

The altered scapular kinematics observed in the wrist fusion group were consistent with our hypothesis. The findings align with previous research demonstrating compensatory movement patterns and increased muscle activation at the shoulder joint following wrist immobilization or injury, likely developed to overcome limited wrist mobility. Individuals with distal radius fractures demonstrated similar increases in scapular internal rotation and upward rotation during shoulder elevation (Ayhan et al. 2015). Additionally, several studies have demonstrated increased shoulder range of motion during upper limb tasks following wrist immobilization with an orthosis in people without distal arm conditions (King et al. 2003; Mell et al. 2005; May-Lisowski and King 2008; Pereira et al. 2012). Our study demonstrates that these differences are not a temporary modification, but rather persist once wrist motion is permanently fused.

The wrist joint contributes multiple degrees of freedom (DOFs) to upper limb motion, including flexion-extension radial-ulnar deviation, and pronation-supination (Jimenez and Anand 2025), which allows for muli-planar, complex movement at the entire upper limb. Following wrist fusion, patients are unable to produce active flexion-extension or radial-ulnar deviation, as these movements rely on the midcarpal and radiocarpal joints, which are immobilized during the procedure. Consistent with previous literature demonstrating increased shoulder range of motion following wrist immobilization (King et al. 2003; Mell et al. 2005; May-Lisowski and King 2008; Pereira et al. 2012), the increased scapular upward rotation observed in the surgical limb of wrist fusion participants in the present study may reflect an exaggerated form of normal scapular motion developed to compensate for restricted wrist mobility. This adaptation is most pronounced during overhead tasks (Comb Hair, Overhead Reach, and Overhead Lift). During these tasks, the wrist is expected to primarily contribute through coupled extension and ulnar deviation, to optimize hand orientation and final upper limb position (Wei et al. 2025). When these distal degrees of freedom are lost following wrist fusion, increased scapular upward rotation may serve as a compensatory mechanism to maximize thoracohumeral elevation. Similar increases in scapular upward rotation have been reported in individuals with rotator cuff tears, where it functions to maximize arm elevation when glenohumeral function is impaired (Ludewig and Reynolds 2009). Other hand and wrist pathologies have been noted to influence temporal aspects of movement (Prodoehl et al. 2008) such as movement velocity, which may have important considerations for overall function. Future work should consider temporal or vector outcomes with kinematics in patients with full wrist fusions.

Healthy scapulae are expected to demonstrate increasing external rotation and posterior tilt with humeral elevation (McClure et al. 2001). This is in contrast to the present study’s surgical limb wrist fusion group, which demonstrated greater internal rotation and anterior tilt across many tasks. Muscular factors may explain the altered scapular kinematics observed in the surgical limb of wrist fusion patients. Previous studies show increased activation of the upper trapezius (Bulthaup et al. 1999; Jung et al. 2013) and pectoralis major (Bulthaup et al. 1999) following wrist immobilization with an orthosis. Tightness and hyperactivity in these muscles can inhibit the lower trapezius, which can result in excessive scapular internal rotation, or ‘protraction’ (Ludewig and Reynolds 2009; Kibler et al. 2013). Additionally, anterior shoulder tightness from chronic hyperactivity, particularly in the pectoralis muscles, may further increase scapular internal rotation and anterior tilt, while limiting posterior tilt and external rotation during arm elevation (Ludewig and Reynolds 2009; Kibler et al. 2013).

Excessive scapular anterior tilt and internal rotation are generally regarded as unfavorable movement patterns. These scapular motions can compress the subacromial space, particularly during arm elevation (Hébert et al. 2002; Ludewig and Reynolds 2009). Previous research has demonstrated that similar kinematic deviations are present in individuals with shoulder impingement, supporting an association between scapular motion and glenohumeral joint pathology (Kibler et al. 2013). The present findings suggest that wrist fusion may be associated with comparable alterations in scapular kinematics during functional upper extremity tasks. While these adaptations may reflect compensatory strategies to preserve task performance in the setting of reduced wrist mobility, they may also increase mechanical demand at the ipsilateral shoulder and contribute to loading patterns associated with subacromial impingement or rotator cuff pathology (Ludewig and Reynolds 2009; Kibler et al. 2013). Emerging literature suggests that targeted scapular physiotherapy exercises may be beneficial in patients with hand, wrist, or elbow disorders by addressing maladaptive movement patterns, thereby improving functional outcomes and reducing the risk of secondary shoulder injury (Gutiérrez-Espinoza et al. 2025). Together, these findings suggest that altered scapular kinematics may represent a potentially modifiable risk factor for secondary shoulder dysfunction. Further research is warranted to evaluate whether interventions aimed at addressing and mitigating these kinematic adaptations influence clinical outcomes in patients undergoing wrist fusion.

Differences in humeral elevation were only observed during the Overhead Lift task, in which the wrist fusion group demonstrated a lower peak humeral elevation compared to the control group. This difference was most pronounced on the surgical limb. These findings contrast with those reported previously (Mell et al. 2005), which demonstrate that short-term immobilization with a wrist splint increased maximum humeral elevation angle during a similar reaching task involving object retrieval from a box. The reduced humeral elevation observed in the present study may reflect tightness or weakness in these muscles from disuse after surgery.

In the present study, main effects of group were present for most significant differences, with few within-person differences for the wrist fusion group. While the fusion side generally demonstrated more pronounced differences compared to controls, the main notable within-person findings were greater scapular upward during the Comb Hair and Forward Transfer tasks. This suggests that both the fusion limb and the non-fusion limb demonstrated altered movement patterns, particularly during bilateral tasks, to compensate for reduced wrist mobility. There may be a central component to the mechanism of altered scapular kinematics, such as prolonged muscle hyperactivity in the ipsilateral limb leading to weakness or tightness in opposing muscles (Bulthaup et al. 1999; Jung et al. 2013), necessitating increased scapular motion in the contralateral limb to complete functional tasks (Sadler and Cressman 2019). These compensatory changes would not be evident through within-person comparisons alone, highlighting the importance of including a healthy control group to accurately investigate the alterations in scapular following wrist fusion surgery.

Limitations

Several limitations should be considered when interpreting these results. The sample size was relatively small, which may reduce statistical power. However, the inclusion of patients with total wrist fusion, as opposed to artificially restraining wrist mobility enhances the significance of the findings, in spite of the smaller sample size. As this was a cross-sectional study design, it cannot establish causality or infer temporal relationships between wrist fusion surgery and the observed kinematic changes. Participants in the wrist fusion group had varying lengths of time since surgery, which may influence kinematic adaptations. More research is required to determine how scapular kinematics may change over time following wrist fusion surgery. Body weight differed between groups at baseline, with the wrist fusion group having a notably elevated mean BMI. This difference, combined with the between-groups analysis, indicates that there could be residual confounding factors that influenced the results. Future work should consider controlling for potential covariates in the statistical models instead of relying solely on group matching on select variables. Data collection was conducted by two different researche groups, and though both were trained and overseen by the same experienced investigator, potentially introducing variability in scapular landmark location. However, this was partially accounted for by the single calibration pose to reduce the error of repeated palpations. Motion at the elbow joint, an important link in the upper limb kinetic chain, was not assessed in this study. Future work will explore elbow-related adaptations to wrist fusions. Finally, the absence of pre-fusion data on the evaluated upper extremities limits our ability to account for baseline differences between dominant and non-dominant limbs within the same individual, as well as variation in typical movement patterns across participants. Longitudinal research is needed to understand how scapular kinematics may evolve over time following wrist fusion surgery and how they may contribute to the development of shoulder pathology.

Conclusions

Scapular kinematics are altered in people who have undergone total wrist fusion surgery. The current findings highlight the importance of addressing scapular kinematics during rehabilitation programs following wrist fusion surgery to promote optimal upper limb function and reduce the risk of secondary shoulder injuries.

Acknowledgments

We would like to acknowledge the University of Saskatchewan’s College of Medicine for supporting this work.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data and code availability

Data will be available upon reasonable request to the corresponding author (AEL).

References

  1. Aliaj K, Foreman KB, Chalmers PN, Henninger HB.. 2021. Beyond Euler/Cardan analysis: true glenohumeral axial rotation during arm elevation and rotation. Gait Posture. 88:28–36. 10.1016/j.gaitpost.2021.05.004 [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Anderson RJ et al. 2023. Patterns of involvement of the hand joints in classical rheumatoid arthritis. J Clin Rheumatol. 29(5):230–234. 10.1097/RHU.0000000000001971 [DOI] [PubMed] [Google Scholar]
  3. Ayhan C, Turgut E, Baltaci G. 2015. Distal radius fractures result in alterations in scapular kinematics: a three-dimensional motion analysis. Clin Biomech. 30(3):296–301. 10.1016/j.clinbiomech.2014.12.015 [DOI] [PubMed] [Google Scholar]
  4. Badley EM, Goulart CM, Millstone DB, Perruccio AV. 2019. An update on arthritis in Canada—national and provincial data regarding the past, present, and future. J Rheumatol. 46(6):579–586. 10.3899/jrheum.180147 [DOI] [PubMed] [Google Scholar]
  5. Berkhout MJ et al. 2010. The effect of radioscapholunate fusion on wrist movement and the subsequent effects of distal scaphoidectomy and triquetrectomy. J Hand Surg Eur Vol. 35(9):740–745. 10.1177/1753193410370926 [DOI] [PubMed] [Google Scholar]
  6. Bulthaup S, Cipriani DJ, Thomas JJ. 1999. An electromyography study of wrist extension orthoses and upper-extremity function. Am J Occup Ther. 53(5):434–440. 10.5014/ajot.53.5.434 [DOI] [PubMed] [Google Scholar]
  7. Field J, Herbert TJ, Prosser R. 1996. Total wrist fusion: a functional assessment. J Hand Surg. 21(4):429–433. 10.1016/S0266-7681(96)80039-8 [DOI] [PubMed] [Google Scholar]
  8. Friesen KB, Wu LZ, Waslen A, Lang AE. 2023. Defining repeatability for scapulothoracic and thoracohumeral motion during the novel work-related activities and functional task (Wraft) protocol. J Biomech. 153:111596. 10.1016/j.jbiomech.2023.111596 [DOI] [PubMed] [Google Scholar]
  9. Gummesson C, Ward MM, Atroshi I. 2006. The shortened disabilities of the arm, shoulder and hand questionnaire (quick dash): validity and reliability based on responses within the full-length DASH. BMC Musculoskelet Disord. 7(1):44. 10.1186/1471-2474-7-44 [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Gutiérrez-Espinoza H et al. 2025. Effectiveness of a scapular exercise program on functional outcomes in patients with hand, wrist or elbow disorders: a comprehensive systematic review with meta-analysis. J Hand Ther. 38(3):450–463. 10.1016/j.jht.2024.07.006 [DOI] [PubMed] [Google Scholar]
  11. Hébert LJ, Moffet H, McFadyen BJ, Dionne CE. 2002. Scapular behavior in shoulder impingement syndrome. Archives Phys Med Rehabil. 83(1):60–69. 10.1053/apmr.2002.27471 [DOI] [PubMed] [Google Scholar]
  12. Jimenez A, Anand P. 2025. Wrist arthrodesis. StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK556015/ [PubMed] [Google Scholar]
  13. Jung H-Y et al. 2013. Effect of wrist joint restriction on forearm and shoulder movement during upper extremity functional activities. J Phys Ther Sci. 25(11):1411–1414. 10.1589/jpts.25.1411 [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Karduna AR, McClure PW, Michener LA, Sennett B. 2001. Dynamic measurements of three-dimensional scapular kinematics: a validation study. J Biomech Eng. 123(2):184–190. 10.1115/1.1351892 [DOI] [PubMed] [Google Scholar]
  15. Kasten P, Rettig O, Loew M, Wolf S, Raiss P. 2009. Three-dimensional motion analysis of compensatory movements in patients with radioulnar synostosis performing activities of daily living. J Orthopaedic Sci. 14(3):307–312. 10.1007/s00776-009-1332-0 [DOI] [PubMed] [Google Scholar]
  16. Kibler WB et al. 2013. Clinical implications of scapular dyskinesis in shoulder injury: the 2013 consensus statement from the ‘scapular summit’. Br J Sports Med. 47(14):877–885. 10.1136/bjsports-2013-092425 [DOI] [PubMed] [Google Scholar]
  17. King S, Thomas JJ, Rice MS. 2003. The immediate and short-term effects of a wrist extension orthosis on upper-extremity kinematics and range of shoulder motion. Am J Occup Ther. 57(5):517–524. 10.5014/ajot.57.5.517 [DOI] [PubMed] [Google Scholar]
  18. Lang AE, Friesen KB. 2023. Defining humeral axial rotation with optical motion capture and inertial measurement units during functional task assessment. Med Biol Eng Comput. 61(11):2963–2970. 10.1007/s11517-023-02894-z [DOI] [PubMed] [Google Scholar]
  19. Lang AE, Kim SY, Milosavljevic S, Dickerson CR. 2022. The utility of the acromion marker cluster (AMC) in a clinical population. J Electromyogr Kines. 62:102298. 10.1016/j.jelekin.2019.04.002 [DOI] [PubMed] [Google Scholar]
  20. Ludewig PM, Reynolds JF. 2009. The association of scapular kinematics and glenohumeral joint pathologies. J Orthop Sports Phys Ther. 39(2):90–104. 10.2519/jospt.2009.2808 [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. MacDermid JC. 2007. The patient-rated wrist evaluation (Prwe)© user manual. McMaster University. [Google Scholar]
  22. MacLean KFE, Chopp JN, Grewal T-J, Picco BR, Dickerson CR. 2014. Three-dimensional comparison of static and dynamic scapular motion tracking techniques. J Electromyogr Kines. 24(1):65–71. 10.1016/j.jelekin.2013.09.011 [DOI] [PubMed] [Google Scholar]
  23. May-Lisowski TL, King PM. 2008. Effect of wearing a static wrist orthosis on shoulder movement during feeding. Am J Occup Ther. 62(4):438–445. 10.5014/ajot.62.4.438 [DOI] [PubMed] [Google Scholar]
  24. McClure PW, Michener LA, Sennett BJ, Karduna AR. 2001. Direct 3-dimensional measurement of scapular kinematics during dynamic movements in vivo. J Shoulder Elb Surg. 10(3):269–277. 10.1067/mse.2001.112954 [DOI] [PubMed] [Google Scholar]
  25. Mell AG, Childress BL, Hughes RE. 2005. The effect of wearing a wrist splint on shoulder kinematics during object manipulation. Archives Phys Med Rehabil. 86(8):1661–1664. 10.1016/j.apmr.2005.02.008 [DOI] [PubMed] [Google Scholar]
  26. Meyerdierks EM, Mosher JF, Werner FW. 1987. Limited wrist arthrodesis: a laboratory study. J Hand Surg. 12(4):526–529. 10.1016/S0363-5023(87)80201-0 [DOI] [PubMed] [Google Scholar]
  27. Pereira BP, Thambyah A, Lee T. 2012. Limited forearm motion compensated by thoracohumeral kinematics when performing tasks requiring pronation and supination. J Appl Biomech. 28(2):127–138. 10.1123/jab.28.2.127 [DOI] [PubMed] [Google Scholar]
  28. Prodoehl J et al. 2008. Changes in the relationship between movement velocity and movement distance in primary focal hand dystonia. J Mot Behav. 40(4):301–314. 10.3200/JMBR.40.4.301-314 [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Rauhaniemi J, Tiusanen H, Sipola E. 2005. Total wrist fusion: a study of 115 patients. J Hand Surg. 30(2):217–219. 10.1016/J.JHSB.2004.11.008 [DOI] [PubMed] [Google Scholar]
  30. Sadler CM, Cressman EK. 2019. Central fatigue mechanisms are responsible for decreases in hand proprioceptive acuity following shoulder muscle fatigue. Hum Mov Sci. 66:220–230. 10.1016/j.humov.2019.04.016 [DOI] [PubMed] [Google Scholar]
  31. Warner MB, Chappell PH, Stokes MJ. 2015. 96. Measurement of dynamic scapular kinematics using an acromion marker cluster to minimize skin movement artifact. JoVE. (96):51717. 10.3791/51717 [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Wei Q et al. 2025. An analysis of wrist motions during daily activities from a directional perspective: the significance of directions beyond the Dart-throwing motion. Orthop Surg. 17(5):1486–1502. 10.1111/os.70024 [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Weiss A-P et al. 1995. Upper extremity function after wrist arthrodesis. J Hand Surg. 20(5):813–817. 10.1016/S0363-5023(05)80437-X [DOI] [PubMed] [Google Scholar]
  34. Winiarski LM, Livoni JD, Madsen PV, Rathleff MS, Larsen P. 2021. Concurrent musculoskeletal complaints in elbows, shoulders, and necks after common hand and forearm injuries or conditions: a cross-sectional study among 600 patients. J Hand Ther. 34(4):543–548. 10.1016/j.jht.2020.05.002 [DOI] [PubMed] [Google Scholar]
  35. Winter DA. 2009. Biomechanics and motor control of human movement. 1st ed. Wiley. https://onlinelibrary.wiley.com/doi/book/10.1002/9780470549148 [Google Scholar]
  36. Wu G et al. 2005. ISB recommendation on definitions of joint coordinate systems of various joints for the reporting of human joint motion—part ii: shoulder, elbow, wrist and hand. J Biomech. 38(5):981–992. 10.1016/j.jbiomech.2004.05.042 [DOI] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

Data will be available upon reasonable request to the corresponding author (AEL).

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