Hand Surgery Source

Hyperligamentous Laxity

Test, Exam and Signs

Description

  • A small percentage of the population experiences natural hyperextension. Flute players often experience hypermobility, which can be related to reduced proprioception.1
  • Joint laxity contributes to atypical joint biomechanics. This can eventually lead to pain, disability, and osteoarthritis.2
  • Hyperligamentous laxity can be measured by the Beighton score, a standardized method of measuring joint laxity and hyperextension.2

Pathophysiology

  • More severe cases of hyperligamentous laxity may result from Marfan syndrome, Ehlers-Danlos syndrome, or osteogenesis imperfecta.
  • Prevalence of joint hypermobility varies based on age, sex and necessity. It is common in children and decreases with age. Men have less hypermobility in women.
  • Joint hypermobility syndrome, similar to Ehlers-Danlos syndrome, can be related to joint instability and chronic pain.3
  • Conditions associated with laxity can predispose a patient to midcarpal instability.4

Instructions

  1. Record the patient’s history. Ask the patient to rate on a scale from 1-10 how much pain s/he usually experiences at the affected hand, wrist, elbow, and/or forearm.
  2. Ask the patient to hyperextend the affected elbow.
  3. Stretch the thumb back on the front of the forearm.
  4. Ask the patient to hyperextend the small finger.
  5. Examine the contralateral elbow, thumb, and small finger.

Variations

  • Check for a “clunk” noise, sometimes accompanied by pain, when the wrist is moved from radial to ulnar deviation. This is a sign of midcarpal instability.4
  • Also check for skin hyperextensibility and bruising.5

Related Signs and Tests

  • ROM, active
  • ROM, passive
  • Watson scaphoid shift test
  • Collateral ligament stability
Presentation Photos and Related Diagrams
  • Hyperligamentous laxity of thumb - relatively uncommon but normal variant
    Hyperligamentous laxity of thumb - relatively uncommon but normal variant
Definition of Positive Result
  • According to the Beighton score, a positive result occurs when the patient can hyperextend the elbow >10°, bend the thumb back on the front of the forearm, or hyperextend the small finger to 90°.
Definition of Negative Result
  • A negative result occurs when the patient extends the elbow to <0°, is not able to bend the thumb back on the front of the forearm, and is not able to hyperextend the small finger to 90°. 
Comments and Pearls
  • In women, hormonal influence can contribute to joint laxity and may lead to the development of osteoarthritis in the hand.2
  • In cases of ligamentous laxity related to Ehlers-Danlos syndrome, the results of reconstructive procedures other than arthrodesis are difficult to predict.5
  • It is important to diagnose joint hypermobility syndrome or Ehlers-Danlos syndrome accurately in children, so that they are not overmedicated.6
  • When assessing joint stability always consider the degree of normal joint laxity before concluding a joint is unstable.
  • Always compare right and left upper extremities.
Diagnoses Associated with Tests, Exams and Signs
References

Cited References:

  1. Artigues-Cano I, Bird HA. Hypermobility and proprioception in the finger joints of flautists. J Clin Rheumatol 2014;20(4):203-8. PMID: 24847746
  2. Wolf JM. The influence of ligamentous laxity and gender: implications for hand surgeons. J Hand Surg Am 2009;34(1):161-3. PMID: 19121743
  3. Kumar B, Lenert P. Joint hypermobility syndrome: recognizing a commonly overlooked cause of chronic pain. Am J Med 2017;130(6):640-7. PMID: 28286166
  4. Rayan G, Akelman E. The Hand: Anatomy, Examination and Diagnosis. Philadelphia: Lippincott Williams & Wilkins, 2012.
  5. Kornberg M, Aulicino PL. Hand and wrist joint problems in patients with Ehlers-Danlos syndrome. J Hand Surg Am 1985;10(2):193-6. PMID: 3980930
  6. Tofts LJ, Elliott EJ, Munns C, et al. The differential diagnosis of children with joint hypermobility: a review of the literature. Pediatr Rheumatol Online J 2009;7:1. PMID: 19123951
  7. Andel, C., Roescher, W., Tromp, M., Ritt, M., Strackee, S., & Veeger, D. (2008). Quantification of Wrist Joint Laxity. The Journal of Hand Surgery, 33(A), 667-674.
  8. Lawrence, A. (2014). Benign joint hypermobility syndrome. Indian Journal of Rheumatology, 9, S33-S36. http://dx.doi.org/10.1016/j.injr.2014.09.009