Upper Extremity Range of Motion Deformity/Deviation Amputation and Sensation DOI: Worker’s name: WCD #: Range of motion: Report active range of motion in degrees of any joints applicable and the corresponding contralateral joint, if contralateral has no history of injury or disease. The values in parentheses are the norms established by the Department of Consumer and Business Services. Right elbow Left elbow extension (0°) -0- flexion (150°) extension (0°) -0- flexion (150°) pronation (80°) -0- supination (80°) pronation (80°) -0- supination (80°) Right wrist Left wrist dorsiflexion (60°) -0- palmar flexion (70°) dorsiflexion (60°) -0- palmar flexion (70°) radial deviation (20°) -0- ulnar deviation (30°) radial deviation (20°) -0- ulnar deviation (30°) Identify any rotational deformity or lateral deviation Right hand (digits) Carpometacarpal joint of the thumb Thumb ROM MP (0-60°) -0- IP (0-80°) -0- Rotational deformity yes digit: Ext. (Abd.) (30°) Flex. (Add.) (15°) Index finger Ext. Flex. Middle finger Ext. Flex. Ring finger Ext. Flex. no Little finger Ext. Flex. MP (0-90°) -0- -0- -0- -0- Lateral deviation PIP (0-100°) -0- -0- -0- -0- DIP (0-70°) -0- -0- -0- -0- yes digit: no Identify any rotational deformity or lateral deviation Left hand (digits) Thumb ROM Carpometacarpal joint of the thumb MP (0-60°) -0-0- yes digit: Ext. (Abd.) (30°) IP (0-80°) Rotational deformity Flex. (Add.) (15°) Index finger Ext. Flex. Middle finger Ext. Flex. Ext. Ring finger Flex. no Little finger Ext. Flex. MP (0-90°) -0- -0- -0- -0- Lateral deviation PIP (0-100°) -0- -0- -0- -0- DIP (0-70°) -0- -0- -0- -0- yes digit: no Examining physician name and title (please print or type): Signature: 440-2279 (6/10/DCBS/WCD/WEB) Date of examination: See reverse: Amputation / Sensation American LegalNet, Inc. www.FormsWorkFlow.com Amputation and Sensation Of the Upper Extremity (side 2) Amputation or resection (without reattachment) N/A For the thumb: check the box that applies and, on the illustrations, indicate the most proximal level of amputation as specified below: skin (dermis) only significant flesh or tissue loss only (no bone) bone involvement to mid-shaft of the distal phalanx proximal to/including mid-shaft of the distal phalanx to/including the head of the proximal phalanx proximal to the head of the proximal phalanx R For the fingers: check the box that applies and, on the illustrations, indicate the most proximal level of amputation as specified below: skin (dermis) only significant flesh or tissue loss only (no bone) bone involvement to mid-shaft of the distal phalanx proximal to/including mid-shaft of distal phalanx to the distal epiphysis of the middle phalanx proximal to the distal epiphysis (head) of the middle phalanx to mid-shaft of the middle phalanx proximal to the mid-shaft of middle phalanx to/including the distal epiphysis of the proximal phalanx proximal to the distal epiphysis (head) of the proximal phalanx L For reattached digits, indicate any loss of overall length. For amputations, proximal to the carpometacarpal joints, indicate the most distal bony landmark involved in the amputation. Sensation N/A On the illustrations, mark and grade palmar surface (volar) sensation. Grade 1: normal (two-point discrimination six millimeters or less) Grade 2: less than normal (two-point discrimination 7-10 millimeters) Grade 3: protective (two-point discrimination 11-15 millimeters) Grade 4: total loss (two-point discrimination >15 millimeters) R 440-2279 (6/10/DCBS/WCD/WEB) L American LegalNet, Inc. www.FormsWorkFlow.com