Carpal Hyperextension Injury

Article Written by Dr. Daniel A. Degner, Board-certified Veterinary Surgeon (DACVS)

Key Points

Carpal hyerextension injury is due to tearing of the ligaments on the palm side of the wrist

Treatment involves fusion of the joint

Prognosis is generally good with surgical treatment

Anatomy

The carpus of the dog is similar to the wrist in man. It is made of many small bones that form 3 major joints. Normally, the top joint is very flexible, whereas the remaining joints have limited range of motion. The backside of the carpus is supported by a very strong ligamentous structure called the palmar fibrocartilage, which prevents the joints from over extending (hyperextension).

Cause of carpal hyperextension injury

The cause of a hyperextension injury is due to tearing of the palmar fibrocartilage. This type of injury can be due to a single isolated traumatic event such as jumping off a roof or out of a window. In other cases it is due to repeated injury to the palmar fibrocartilage due to jumping off a deck of out of vehicles. Once the palmar fibrocartilage tears, conservative measures such as splinting or casting the limb are consistently ineffective in nearly all cases.

Signs

Carpal hyperextension injury is most commonly seen in large active dogs; however, small breeds certainly can sustain a similar injury. Warning signs of this condition include lameness that worsens with activity. Swelling and hyperextension (paw sinks down) of the carpus also are common clinical signs.

Diagnosis

The diagnosis of a carpal hyperextension injury is based on physical examination findings and x-rays of the affected forelimb. The surgeon likely will take stress x-rays of the affected limb, with your pet under anesthesia. This involves applying a stress to the carpus to see which joints have torn ligaments (see photo right – arrow points to the unstable joints). If only the lower two rows of joints are broken down, a partial fusion of the joint will be recommended. If all of the joints are broken down or the top joint is broken down, a fusion of all of the joints will be recommended.

The day of surgery

The anesthesia and surgical team will prescribe a pain management program, both during and after surgery that will keep your companion comfortable. This will include a combination of general anesthesia, injectable analgesics, epidural analgesia, oral analgesics and anti-inflammatory medication. The surgeon will call you following surgery with a progress report.

Treatment

In order to correct this problem, it is essential to perform an arthrodesis or fusion of the carpal joints. This involves removing the cartilage from the surfaces of the bones within the joints, packing the joints with a bone graft that is collected from the humerus bone (near the shoulder) and stabilizing the bones with a plate and screws. The surgeon will have made a determination prior to surgery if a partial arthrodesis (photo right) or a full arthrodesis is necessary. The full arthrodesis will remove all movement within the carpus, whereas the partial arthrodesis retains about 50 to 75% of normal range of motion of the carpus. After surgery, a cast or splint is applied to the limb to support the repair for about four to six weeks.

Aftercare

After surgery, you can continue to give your pet a prescribed pain reliever to minimize discomfort. A splint or cast likely will be used to support the repair for four to six weeks. The splint or cast will need to be changed by your dog’s surgeon at least every other week. It’s also extremely important to limit your dog’s activity and exercise level during the post-operative period. The surgeon will monitor the healing process with a series of follow-up exams. At eight weeks after the surgery, x-rays will be made to evaluate the healing of the bone. Subsequent x-rays will be made on a monthly basis until the bones has completely healed.

Results

Surgical arthrodesis will relieve your companion’s pain once the bones have fused together. A partial arthrodesis commonly will allow your pet to have normal function of the limb with good range of motion of the carpus. A full arthrodesis of the carpus typically results in good function of the limb; however, a gait abnormality is expected, as the carpus will not have any movement. Uncommon complications following surgery include infection, failure of the bones to fuse together, breakage of the implants (metal plate and screws) and cold sensitivity. In general, about 90 to 95% of the patients will respond well to the surgery.

Frequently Asked Questions After Surgery

When should my dog have the first bowel movement after surgery?

• Many dogs will not have a bowel movement for the first 4 to 5 days after surgery
• Reasons that a dog will not have regular bowel movements after surgery include:
  • The dog has been fasted prior to surgery
  • Dogs do not eat well during the hospital stay
  • They frequently do not eat well when they go home
  • They are fed highly digestible food that produces little stool
  • Pain medication that contain narcotics (such as morphine, fentanyl patches, and tramadol) can be constipating
• If a pet does not have a bowel movement on the 5th day of being home, a stool softener such as metamucil can be fed
  • Dose of metamucil is 1 tsp per 25 Kg mixed in with each meal (canned dog food); feed immediately after mixing, as the metamucil will gel the food and may make it less palatable

My pet had surgery and will not eat.  What can be done?

• Dogs
  • Most pets will not eat their regular dog food after surgery, especially if it is kibble.
  • Offer a cooked diet having a 1:1 ratio of a protein source and carbohydrate source.  The protein source can be any meat (example: chicken breast, turkey breast, lean hamburger) that is low in fat and should be cooked (drain off all fat after the meat has been cooked).   The carbohydrate can be pasta, potato or white rice.
  • Try canned dog food; to enhance the flavor sprinkle a very small amount of garlic powder or chicken or beef broth (Chicken-in-a- Mug^TM or Beef-in-a-Mug^TM products)
  • Try Gerber strained meats for babies such as the chicken, beef, turkey, or veal
  • Try Hill's A/D diet available at most veterinary hospitals
  • Hand feeding: place a small amount of food in the mouth so that your dog gets the flavor
  • Warm the food slightly in a microwave, as the food will be more aromatic; stir the food before feeding and test the temperature on the bottom side of your wrist; it should only be luke warm.
  • Remember that most pets will not eat the first day or two after they get home from surgery
• Cats
  • Offer smelly foods that contain fish such as tuna or smelly cat foods
  • Try Gerber strained meats for babies such as the chicken, beef, turkey or veal
  • Hand feeding:  with your finger place a small amount of food on the roof of your cat's mouth; use a syringe to get soft food into the mouth
  • Warm the food slightly in a microwave as the food will be more aromatic; remember to stir the food before feeding and test the temperature; it should be only luke-warm
  • Some cats will only eat dry food, try kibble if your cat normally has been fed that food
  • Petting and stroking your cat frequently will help to stimulate appetite
  • Remember that most pets will not eat the first day or two after they get home from surgery
  • Appetite stimulants such as cyproheptadine may be helpful
  • If your cat refuses to eat anything for 7 days a stomach tube or nasogastric tube should be placed to provide nutrition so that a serious liver problem (hepatic lipidosis) does not develop

My pet is vomiting.  What can be done?

• The first thing for you to discern is whether your pet is vomiting or regurgitating.  Both will result in fluid or food being brought up.  Vomiting always will have heaving or retching of the abdomen prior to expulsion of the vomitus.  Regurgitation is not associated with heaving and the pet usually just opens the mouth and fluid or food will be expelled.  Usually the regurgited material will be clear or brown colored fluid. 
• Next is to identify the cause of the vomiting or regurgitation.
• Causes and treatment of vomiting after surgery
  • When some pets return home after a stay in the hospital they may drink excessive amounts of water at one time and then vomit; if this appears to be the case, the water should be limited to frequent smaller amounts.
  • Medications such as antibiotics, narcotics or nonsteroidal anti-inflammatory medication commonly cause vomiting after surgery.  In order to see which medication is causing the problem, the administration of each drug should be separated 2 hours apart.  Usually the pet will vomit or appear nauseated (drooling and sick look) within 1 hour of administration of the medication that they are sensitive to.  The antibiotic in some cases may be changed to a different one, or may be discontinued. 
  • Stomach upset from anesthesia is a potential cause of vomiting and will pass within a couple of days. 
  • An uncommon cause of vomiting after surgery is internal organ failure.  Blood testing will confirm this problem. For this reason vomiting should not be ignored if it persists for more than 24 hours.
  • If your pet had surgery of the bowels or stomach, vomiting is always a concern, as it may indicate that infection of the abdominal cavity, called peritonitis, is present.  Do not ignore this sign.
  • Symptomatic treatment of vomiting involves withholding food for 12 to 24 hours, then introducing small amounts of bland food such as rice and lean cooked hamburger, if your pet does not vomit after that then gradually wean him/her back onto the regular diet after 3 days.  In order to decrease the acidity of the stomach, Pepcid AC 0.5 mg/kg can be given by mouth twice daily for 5 days.  Metoclopramide and Cerenia are good anti-vomiting medications for dogs and cats.  You should always consult a veterinary healthcare professional before administering medication.
• Causes and treatment of regurgitation after surgery
  • The most common cause of regurgitation is reflux of acid from the stomach into the esophagus while your pet is under anesthesia.  Acidic fluid from the stomach can cause a chemical burn of the esophagus and result in a bad case of heart burn, called esophagitis.  This results in poor motility of the esophagus, therefore water and food will accumulate in this structure.  In most cases, esphagitis is self-eliminating and will resolve within two or three days. 
  • If the esophagitis is severe the esophagus may develop one or more strictures.  A stricture is a narrowing or stenosis of the esophagus and does not allow passage of food down the esophagus, in regurgitation that lasts longer than one week.  This problem should be brought to the attention of your pet's doctor within the first two weeks so that it can be treated by ballooning the stricture (minimally invasive procedure, as it is done with the aide of an endoscope).  If an esophageal stricture is chronic surgery is needed.
  • Symptomatic treatment of regurgitation caused by esophagitis includes feeding bland food, and administering a coating agent (sucralfate) and an acid blocker (omeprazole or other).  Consult a veterinary health care professional if the regurgitation continues for more than a couple of days.

How do I know that my dog is in pain following surgery?

• Signs of pain include
  • crying
  • biting if you get near the surgical site
  • grimacing (lips are pulled back and the the dog looks anxious)
  • tragic facial expression
  • panting
  • restlessness and unable to sleep; pacing
  • if abdominal surgery was done the pet will not lie down on the incision, or will continually sit up in spite of appearing very tired
  • the worst pain will be for the first 2 to 3 days after surgery

What can I do to control my dog's pain?

• Narcotic medications that control pain: tramadol, butorphanol, Duragesic (fentanyl patch)
• Anti-inflammatories used to control pain: Deramaxx, Rimadyl, Previcox, or Etogesic
• If an orthopedic surgery has been done cold packing the surgical site may be helpful
  • A cold pack may be a pack of frozen peas, crushed ice in a Ziploc bag, or a cold gel pack; place a thin barrier between the skin and the cold pack.  An alternative to a cold pack is to freeze water in a styrofoam cup; after frozen cut the bottom of the styrofoam cup out. Cool the surgical site around the incision by rubbing the exposed ice directly on the skin in a circular pattern.  Cooling the surgical site helps to numb the area.

How do I know that my cat is in pain following surgery?

• Pain is more difficult to assess in cats versus dogs, as signs can be more subtle and they usually do not vocalize when in pain
• Signs of pain in a cat include the following:
  • biting if you get near the surgical site
  • growling or deep cry
  • not wanting to eat
  • hiding and not wanting to be near owner (remember that this could also be caused by the cat just being upset about leaving home and coming back)

What can be done for pain at home for my cat?

• Pain medication such as buprenorphine or a Duragesic (fentanyl) patch
• Tylenol will kill a cat as they lack abundant glutathione enzyme in the liver
• Anti-inflammatories can be used, but the dose is much less than dogs

Is it okay for my pet to lick the incision?

• If a dog licks the incision, the healing process may be delayed.
• Licking can remove stitches and cause the incision to open
• Licking can become a severe habit that is difficult to break
• Licking can cause infection as the mouth has many bacteria
• Dogs will frequently lick the incision when the owner is not watching such as at night time; if the skin looks red or excoriated the most common cause is from licking.
• To stop your pet from licking the following can be tried:
  • Elizabethan collar can be placed on the neck; this will not help stop your pet from scratching at the region
  • Cervical collar (bite not collar) is a less awkward device and can be effective at stopping a pet from licking the surgical site
  • A tee shirt can be used to cover an incision on the chest or front part of the abdomen; gather the waist of the shirt up over the dog's back and wrap an elastic band around this part of the shirt.
  • A bandage or sock can be used to cover an incision on a limb; fasten the top of the sock to the dog's limb with tape.
  • Bitter apple can be applied around the incision; many dogs will continue to lick  after application of this topical
  • Bitter Apple and Liquid Heet^TM (obtain this from a drugstore...it is used for sore muscles) mixed in a 2:1 ratio can be applied around the skin incision
  • Antipsychotic medication in some cases is needed

Board-certification by the American College of Veterinary Surgeons

What does it mean?

• Four years of advanced training in surgery beyond the Doctor of Veterinary Medicine Degree

• Experience in the development of new surgical treatments

• Rigorous examination by the American College of Veterinary Surgeons to ensure competency in advanced surgical techniques

• Assurance that a veterinarian is a surgical specialist