Yim Physio Near Me: Ligament failure from wrist hyperextension weight bearing basic review

Ref: https://www.naasery.com/

Have you taken weight on your palm with pain? Taking weight on the palm such as push up, handstand, or hand support is a common function in daily living and sports. To do this function requires wrist extension, that is motion from carpal bones.

It is FOOSH injury which is nickname for an injury caused by fallen onto an outstretched band.

Different wrist hyperextension weight bearing direction make different ligament injury
(Ref: https://aulakinesica.com.ar/semioquirurgica/files/12389765.pdf)

Carpal bones are 8 bone components in 2 rows of wrist joint which consists of trapezium, trapezoid, capitate, and hamate in distal carpal, and scaphoid, lunate, and triquetrum in proximal carpal. However, pisiform bone which is sesamoid bone on triquetrum and is easy to palpate because it locates out of carpal line superficially.

The complex nature of carpal mechanics can be simplified by considering the distal carpal row (trapezium, trapezoid, capitate, and hamate) as securely attached to the medial 4 metacarpals through short, tight, intrinsic ligaments. The distal row moves with the hand as a single unit. The proximal carpal row (scaphoid, lunate, and triquetrum) can be considered a single free-body, intercalated between the hand (including the distal row) and the forearm, suspended by extrinsic radiocarpal and intrinsic intercarpal ligaments.

Carpal bone anatomy
(Ref: https://www.lecturio.com/)

As the hand forearm unit moves the wrist, the position of the intercalary proximal row shifts at the radiocarpal joint (relative to the forearm) and at the midcarpal joint (relative to the hand), similar to a ball-and-socket joint. The carpal mechanism depends on the health and integrity of the intrinsic and extrinsic ligaments to guide bony relationships among the 7 critical carpals (pisiform excluded).

Carpal alignment at rest is maintained with considerable stored potential energy and, by definition, a predisposition of the carpus to collapse into a more stable but less physiologic attitude. Ligamentous struts and guy wire mechanisms maintain the longitudinal axis of the scaphoid at about 47 relative to the longitudinal axis of the hand forearm unit. A neutral position of the lunate is maintained through its secure attachment to the proximal scaphoid pole by the scapholunate (SL) interosseous ligament. Separated from the palmar - flexing influence of the scaphoid, the lunate is predisposed to collapse into extension

Wrist joint component: Radius, Ulnar, Carpals, Metatarsal, and Carpal ligaments
(Ref: https://www.ncbi.nlm.nih.gov/)

Wrist extension pain is related to carpal instability that can develop to hyperextension.

Carpal instability can occur after trauma, remotely after trauma, and sometimes without trauma. The 3 most important conditions are scapholunate instability, lunotriquetral instability, and perilunate instability complex. The carpus is considered unstable if it exhibits symptomatic malalignment, is not able to bear loads, and does not have normal kinematics during any portion of its arc of motion.

There are 4 patterns of instability that have been described by various investigators and are widely accepted Carpal instability dissociative (CID) refers to instability within a row of carpal bones, such as scaphoid fractures or scapholunate dissociation in the proximal row. Carpal instability nondissociative (CIND) is instability between rows either at the radiocarpal joint (eg, radiocarpal fracture dislocations) or midcarpal joint (eg, midcarpal instability). Carpal instability combined/complex (CIC) is a combination of CID and CIND, such as Perilunate dislocations (PLDs). Carpal instability adaptive (CIA) refers to carpal malalignment in adaptation to extra carpal changes (eg, carpal collapse in malunited distal radius fractures).

Scapholunate instability

Scapholunate ligament
(Ref: http://rehabforbetterlife.com/)

Scapholunate instability is the most common form of carpal instability. Scapholunate ligament tears wrist instability commonly occurs in a spectrum of severity in hyperextension injuries. Contact sports such as football or rugby commonly place the athlete in a position of impact with hyperextension, ulnar deviation, and supination of the wrist that can lead to these injuries. This may be preceded by a fall. Pain is typically over the dorsum and dorsoradial aspect of the wrist, aggravated by loading the extended wrist or strenuous activity. Pain in a loaded, extended wrist with tenderness in the dorsal wrist at the interval between the third and fourth extensor compartments suggests possible scapholunate interosseous ligament injury. Lab investigations including x - ray and MRI are needed.

Forward wrist weight bearing (hyperextension, ulnar deviation, and supination)
Ref: https://www.amazon.com/)

Stage 1 of 6 which is initial treatment consists of splinting to allow healing in acute and subacute injuries with subsequent proprioception training of the flexor carpi radialis and extensor carpi radialis muscles. Surgery for recalcitrant pain includes arthroscopic interventions, such as de´ bridement alone or with thermal shrinkage and/or pinning, and has 80% to 90% success rates. Left untreated, it may progress to arthritis.

Lunotriquetral instability

Lunotriquetral ligament injury develop Lunotriquetral instability
(Ref: https://www.3pointproducts.com/blog/)

Lunotriquetral instability remains frequently underdiagnosed. It may occur in isolation as an acute traumatic tear or in association with degenerative causes, such as ulnocarpal abutment and central TFCC tears, and as part of the perilunate complex injury, to name a few conditions. Acute isolated injuries typically result from a backward fall with the hypothenar eminence striking the ground. Tenderness is localized to the lunotriquetral interval with the appearance of a volar sag, and the Reagan ballottement and Kleinman shear tests may be positive. Stage 1 of 3 which is acute partial injuries, above-elbow casting or splinting with a pad under the pisiform to boost the triquetrum into correct alignment is prescribed. Even in chronic situations, this should be the first line of treatment. Patients who remain symptomatic may benefit from arthroscopic de´ bridement with or without pinning of the lunotriquetral joint.

Backward fall down
(Ref: https://www.jucm.com/)

Perilunate instability complex

Perilunate instability complex is the most common wrist dislocation and presents a spectrum of ligamentous and/or bony disruptions to the carpal. The mechanism of injury is wrist axial loading and hyperextension, ulnar deviation, and intercarpal supination. Purely ligamentous injuries are termed lesser arc injuries and those with a fracture greater arc injuries. These terms are synonymous with PLD and perilunate fracture dislocation (PLFD), with the most common fracture a scaphoid fracture. Aside from the acutely painful and swollen wrist, clinical findings may be subtle and there should be suspicion with a high-energy injury mechanism. Acute median neuropathy may be present and was reported in 23% of cases in Herzberg and colleagues’ series. CT scans are indicated when fractures are suspected. This instability may need surgery recommendation from doctors.

Perilunate instability or dislocation
(Ref: https://link.springer.com/chapter/10.1007/978-1-4471-6572-9_27)

Distal radioulnar joint (DRUJ) instability

Distal radioulnar joint (DRUJ) instability can occur either from a variety of causes including traumatic and nontraumatic causes. Primary stability of the DRUJ is contributed by the congruity of its articular surfaces and the TFCC. The DRUJ is further reinforced by an osseocartilaginous lip on the volar aspect of the radius. The secondary stabilizers include the joint capsule, extensor carpi ulnaris, pronator quadratus, and interosseous membrane. DRUJ instability can be due to either alterations in the bony anatomy, resulting in altered sigmoid notch architecture or abnormal radioulnar relationship, and/or disruptions to the TFCC.

TFCC injury develop instability
(Ref: https://pathologies.lexmedicus.com.au/)

DRUJ instability may accompany distal radius fractures due to TFCC disruption or basal ulnar styloid fractures. A fracture of the palmar lunate facet disrupts the buttress effect of the palmar lip and can cause instability. TFCC tears can be traumatic or degenerative. Synovitis in rheumatoid arthritis attrite the stabilizers of the DRUJ, causing instability.

Patients may present with ulnar-sided wrist pain after a fall on an outstretched hand that is usually exacerbated with loading of the wrist in extension, at the extremes of pronation or supination, or after lifting weights. Patients may report clicking and hypermobility. There may be swelling over the ulnar side of the wrist with a dorsally subluxed ulna head projections of the wrist suspending 2.27 kg of weight and always should be compared with the opposite side. MRIs can delineate foveal and peripheral tears of the TFCC as well as assess the state of cartilage in the DRUJ.

Basal ulnar styloid fracture is in red box.
(Ref: https://www.reddit.com/r/)

TFCC injuries can occur with injuries to the extensor carpi ulnaris and fractures of the radius and/or ulna bone, and these must be addressed concurrently. Nonoperative treatment of acute TFCC injury involves casting or splinting the patient in the position of stability for a period of 6 weeks. In patients with persistent DRUJ instability after fracture reduction or after a trial of nonsurgical treatment, TFCC repair is warranted. This can be done as an open procedure for arthroscopic assisted or arthroscopic capsular repairs. An open repair can be done via an approach between the fifth and sixth extensor compartments. An inverted L-shaped capsulotomy is made, preserving the dorsal radioulnar ligament. The TFCC is then anchored via bone tunnels or suture anchors.

Triangular Fibrocartilage Complex (TFCC)
(Ref: https://www.orthobullets.com/)

Scaphoid fracture

Scaphoid fracture type
(Ref: https://www.rch.org.au/)

Scaphoid fractures are the most commonly injured carpal bone with a high incidence in college football players and an increasing incidence in female athletes. This hyperextension wrist injury tends to occur in a pronated, radially deviated hand. Presentation can range from disabling wrist pain to mild swelling and decreased range of motion. It is not uncommon to find a scaphoid nonunion with a remote history of a wrist sprain. Located at the radial side of the carpus, athletes will complain of radial-sided wrist pain with exquisite tenderness in the anatomical snuff box, axial loading of the thumb, or pincer grasp. Radiographic and MRI assessment of the wrist should be involved in diagnosis.

Anatomical snuff box is represented by red triangle
(Ref: https://teachmeanatomy.info/)

Treatment decisions depend upon fracture location and displacement, with strong surgical consideration being given to scaphoid fractures which are displaced and/or proximal. Whether treatment affects the athlete’s continued participation in his or her sports within the context of the status of the season may also play a role in determining whether or not to operate. Due to retrograde blood supply, distal pole scaphoid fractures can effectively be treated nonsurgical.

There are basic wrist hyperextension injury reviews that raise during wrist extension weight bearing activities. The signs and symptoms are demonstrated on the radial side, the most. Mechanics of injury history, physical assessments, and radiography are combined in diagnosis confirmation. In case of mild damage, it needs to be immobilized by a brace. In case of more instability, it needs to be operative. However, all cases need physiotherapy to improve the quality of movement.