Ch 50 the shoulder Flashcards

Question

What percentage of OCD cases will have a nonmineralised cartilage flap trapped within the tendon sheath of the biceps?

Answer 1

Approx 10%

Answer 2

Caudal - requires assistant for retraction - results in less loss of RoM and improve weight bearing in first month Caudolateral interdeltoideus approach - Craniodorsal retraction of infraspinatus and teres minor - Better protection og caudal circumflex humeral artery and axillary nerve Craniolateral - Included tenotomy of infraspinatus tendon - Greater exposure of caudal aspect of humeral head but limits access to caudal joint pouch modified cheli articular access between the supraspinatus muscle and the infraspinatus tendon. Cheli modification > forced hyperflexion. caudal displacement of the acromial deltoid and infraspinatus muscles, further modified by Vezzoni to limited open approach without humeral head luxation

Answer 3

Glenoid dysplasia is hypoplasia or aplasia of the glenoid resulting in grossly abnormal articulation Toy breeds (Toy and Min poodle, Chihuahua, Pom, Sheltieetc) Results in medial luxation of the shoulder Tx: Arthrodesis or excision arthroplasty with an acceptable return to function | generally diagnosed in dogs between 3 and 10 months

Answer 4

A rare defect in the ossification of the epiphyses of long bones, vertebrae, cuboidal bones and apophyses Severe lameness, resembles bony changes seen with congenital hypothyroidism Tx: euthanasia

Answer 5

Boerboel (Arthrodesis)

Answer 6

“Double physis” - irregular radiolucent line in the metaphysis, parallel to and seperate from the physis

Answer 7

- Chondrocalcinosis is deposition of hydroxyapatite in the articular cratilage, “pseudogout” - Overrepresented in the Greyhound and GSD - Gross lesions: small pits in cartilage surface, scarring, scoring and cracking, often unilateral - Often found incidentally at necropsy, clinical significance unknown

Answer 8

Incomplete ossification of the caudal glenoid - Often asymptomatic but can be a cause of lameness if mobile - Arthroscopy to comfirm if mobile and can remove the fragment

Answer 9

primary or secondary Primary inflammation of the tendon of origin dt overuse or chronic repetitive injury. area of relative hypovascularity may predispose to mechanical failure (fraying or rupture) Secondary in response to other intra-articular disease or trauma to other tendons of shoulder

Answer 10

middle-aged to older, medium- to large-breed dogs. chronic intermittent or progressive weight-bearing thoracic limb lameness, which becomes worse with exercise

Answer 11

- Biceps tendon test direct digital pressure against the tendon of origin while the shoulder joint is flexed and the elbow extended - Drawer test Places direct pressure against the tendon and associated sheath (doe not test for tearing/rupture) humerus is translated cranially - Biceps retraction test Grasping the tendon of insertion at cranial elbow and pulling caudally whilst weight-bearing **All tests are assessing for a pain response**

Answer 12

Rads standard orthogonal flexed craniodistal-cranioproximal (skyline) (view intertubercular groove, mineralization of the tendon + distinguishing mineralization in the tendon of the supraspinatus muscle Contrast arthrography ultrasonographic more sensitive, earlier diagnostic tool, however diseased BT can look normal ID changes within tendon sonolucent line around the tendon; hypoechoic tendon with fiber disruption; proliferative synovium; irregularities of bicipital groove MRI evaluation of all other soft tissue structures of the shoulder joint i.e. Concurrent displacement of the tendon arthrography > tendon avulsions and tears, impingement of the suprapinatus tendon on biceps

Answer 13

1. long-acting CCS - methylprednisolone acetate (10 to 40 mg), strict cage rest and a gradual return to activity - intratendon injection vs intraarticular: question the need, anecdotally intra-articular associated with tendon weakening and rupture in human and rabbit - systemic effects of long-acting steroids? - potenital effects on articular tissues to use triamcinolone (5 mg per joint) > no published reports - need for prolonged (4 to 6 weeks) strict confinement - Concurrent physical rehabilitation therapy 2. nonsteroidal antiinflammatory drugs,rest, physio 3. prp, stem cells, no objective studies have been published | corticosteroids reduce the inflammation

Answer 14

1. Tenodesis to the proximal portion of the humerus through a cranial arthrotomy extrapolated from the human medical literature. Good long-term outcomes generally reported in dogs Arthroscopically assisted tenodesis decreases the incidence and severity of complications return 12 to 18 weeks after surgery 2. Tenotomy open or arthroscopically using hooded arthroscope knife or bipolar tendon provide passive restraint to the shoulder joint > Further studies needed to asses if joint stability is effected arthroscopy lateral shoulder joint portal a craniolateral instrument portal tendon is released from its origin on the supraglenoid tubercle joint can be slowly flexed, resulting in tension on the tendon | rehabilitation will maximize the speed and extent of recovery

Answer 15

Greyhounds, Afghan hounds, GSD, Border Collies Primary reconstruction of the transverse humeral retinaculum and/or augmentation with screws and PDS or staples and polydiaxonone mesh **Prognosis excellent** | displace medially from groove when joint extended and supinated or flexd

Answer 16

direct laceration, avulsion or midsubstance tear +/- traumatic shoulder joint luxation. pain, swelling, joint instability, and lameness > acute vs chronic Ultrasonographic: inhomogeneous hyperechoic area in tendon's origin on the supraglenoid tubercle Arthroscopic examination Tx: Tenodesis

Answer 17

Labs and Rottweilers pathogenesis of dystrophic calcification unknown. tendon trauma results in a disturbance of blood supply, leading to hypoxia. Hypoxia may trigger remodeling into fibrocartilage radiographic abnormality: mineral opacity in the cranial aspect of the shoulder ddx supraspinatus Tx: rest and administration of nonsteroidal antiinflammatory Tenodesis

Answer 18

dystrophic calcification vs incidental finding pathogenesis is unknown - area of hypovascularity in the tendon of the supraspinatus muscle Dx: Signalment, history, and exam similar to biceps brachii - presence of mineralization bilaterally, clinical signs may be unilateral - skyline view, ultrasonography, CT, or MRI may be necessary to confirm the diagnosis and differentiate calcification - Mineralization in the medial aspect adjacent to biceps tendon may be clinically significant > impingement or displacement of the tendon (accurately identified by MRI)

Answer 19

Excision of calcified tissue (controversial if medical vs surgical treatment is best) rest and administration of nsaid Sx: variable success rates have been reported, Hypodermic needles and C-arm fluoroscopy can be used intraoperatively Rehabilitation exercises should be performed following surgery

Answer 20

Medial instability (approx 80%)

Answer 21

small dogs the condition may occur as a congenital 3 and 10 months of age usually unilateral. Breed predispositions include Toy and Miniature Poodle, Chihuahua, Pomeranian, Pekingese, Miniature Pinscher, Lhasa Apso, and CKCS may hold the affected limb with the elbow joint flexed and adducted and with the distal part of the limb abducted. Abnormal spatial differences between the acromion and the greater tubercle are appreciated with palpation large dogs the condition is usually considered a sign of repetitive microtrauma secondary osteoarthritis are common

Answer 22

not been fully determined > extrapolation from the human literature 1. loss of concavity compression, > ball in the concavity have greater resistance to translational forces > depth of the concavity through glenoid labrum or ligaments > magnitude of the compressive force provided by periarticular muscles. 2. disruption of glenohumeral balance > net joint reaction force passes through the center of the joint, provided by mucles and capsuloligamentous restraints

Answer 23

Approx **30 degrees** (vs 50 with instability) the abduction angle test had good sensitivity but low specificity while an abduction angle > 50° may be consistent with shoulder instability, itmay also any disorder of the thoracic limb that results in significant loss in muscle strength or muscle mass.

Answer 24

hx: chronic lameness, which is often subtle and intermittent nonresponsive to nonsteroidal atrophy of the shoulder muscles ex: during sedated examination because pain and apprehension abduction angle of the shoulder > standing angle. The scapula is stabilized, the humerus is abducted, and the angle formed by the shaft of the humerus and the spine of the scapula Gray et al: variability between individual shoulders, weak to identify subtle changes one study used goniometry: 50 degrees in clinically affected dogs RADS: Subtle degenerative changes, varus and valgus stressed views may identify excessive joint capsule and collateral ligament laxity (caution advised) - Stress Radiography for the Diagnosis of Medial Glenohumeral Ligament Rupture in Canine Shoulders Livet 2019 Arthroscopic: valuable for identifying medial instability, extent and type of degenerative changes (erosion of cartilage of caudal humeral head or medial ridge of glenoid; tearing of the medial glenohumeral ligament; and synovitis) evaluation is very subjective and not reliable

Answer 25

1. Transposition of the tendon of origin of the biceps or supraspinatus (84.5% good to excellent outcome) 2. Augmentation of medial collateral with suture (medial aspect of the scapular neck and humeral head > not alter joint anatomy, and more biomechanical) 3. Imbrication of tendon of subscapularis muscle via craniomedial approach for mild degrees of instability 4. Radiofrequency induced thermal modification (RITM) > Thermal energy is applied to capsule, shrinking the collagen bundles, only if if the tendon of origin of the biceps brachii muscle, articular cartilage, and lateral compartment were normal, NOT effective in mod-severe instability/tear 5. Excision arthroplasty 6. Arthrodesis (85.7% good to excellent) if OA or prior Sx fail Transposition techniques result in altered biomechanics, incongruency and OA. Placement of heavy synthetic suture preferred method in a V-shaped (at attachments of the cr.and ca. medial glenohumeral lig.) with screw and washer bone tunnels or anchours > motion with good congruency, mobility, and less alteration of normal anatomy in 9 of 10 dog

Answer 26

- incise superficial and deep pectorials - incise subscapularis and coracobrachialis tendons ->access to medial glenohumeral lig

Answer 27

**post-op** - allow adequate time for scar tissue to functionally stabilize the joint. Maintenance of the limb in a Velpeau sling for 6 weeks (bandage complications and joint stiffness) - gradual return to function and rehabilitation exercises are recommended for 4 to 6 weeks (to allow properly remodel the collagen scar tissue over time) **outcome** - Thermal damage to glenohumeral ligament during RITM may temporarily injure the proprioceptive function of the ligament - Tendon transposition: 84.5% good to excellent outcome, no long-term studies - augmentation: Clinically, functional outcomes are better - Arthrodesis reportedly yielded good to excellent results in 85.7% of 14 dogs - veterinary literature, limited information is available: Functional outcomes RITM in dogs are somewhat difficult to truly know. numerous potential pitfalls have been acknowledged in the human and veterinary literature. consistently, uniformly, and without deep tissue damage or excessive heating of the collagen, urthermore, the collagen tends to stretch back to its original length with time and use.

Answer 28

Complete tears of the lateral, All dogs had incomplete tears of the medial glenohumeral ligament. Tx: intra-articular 40 mg of methylprednisolone + rested for 4 to 6 weeks. Two of three dogs returned to normal function as reported by the owner; the third dog underwent surgery to reconstruct/augment the lateral glenohumeral ligamen

Answer 29

most frequently in a medial direction large-breed dogs often results in lateral luxation

Answer 30

dx identical to the presentation of congenital medial luxations Mediolateral and craniocaudal survey radiographic views are usually sufficient to document the luxation

Answer 31

tx Conservative treatment of traumatic medial luxation of the shoulder joint is usually successful if the luxation is reduced and stabilized with a Velpeau sling soon after injury Lateral luxation, if the injury is recent and the joint is stable following reduction, can also be treated by closed reduction, but the thoracic limb should be placed in a neutral sling or spica splint, avoiding adduction of the shoulder limited information is available regarding the management of cranial and caudal luxations ehabilitation exercises are recommended for 2 to 6 wks

Answer 32

Sx If closed reduction cannot be accomplished, or if the joint is grossly unstable following closed reduction of luxation, surgical reconstruction or augmentation of the glenohumeral ligament(s) and joint capsule is recommended. transposition of the tendon > joint incongruency and degenerative joint disease modified Campbell prosthetic suture (heavy suture passed through transverse holes in the humeral head and scapular neck to create or augment glenohumeral ligaments Treatment of severe shoulder joint derangement by temporary transarticular bridging with a locking bone plate and screw Salvage procedures such as arthrodesis and excision arthroplasty prognosis: generally good. glenoid excision or arthrodesis should be expected to have some minor degree of gait alteration and limited range

Answer 33

Grade 1 = minimal tearing of individual muscle fibres up to Grade 4 = Complete muscle rupture requiring debridement and repair Tx: grade 1 - 3: ice pack, followed by warm compresses, compressive wraps, nsaid + analgesics, relaxants, rest, and physical rehabilitation grade 4 > surgical debridement and repair of the muscle may be appropriate usually occur in mature athletic dogs and result from overstretching or overuse near the musculotendinous junction muscle is strained to 80% of failure, the strength of muscle contraction is decreased by 30% immediately after injury, by 50% after 24 hours, and by 25% after 48 hours, and recovering to 90% of original function after 1 week susceptible mm: biceps, triceps, pectoral, serratus ventralis, rhomboideus, extensor carpi radialis, flexor carpi ulnaris

Answer 34

Prominent pain with reduced shoulder flexion Tx: excision of enture muscle, excellent prognosis | Ultrasonography or MRI can be used to localize the lesion

Answer 35

Brittany spaniel, Pointers, Labs Biphasic - Acute painful pain, swelling and lameness - Chronic, static, nonpainful gait abnormality with mm atropht/prominent scapular spine Gait - elbow adduction, shoulder abduction - external rotation of antebrachium - circumdution of limb with carpal flip ultrasonographic examination reveals hyperechoic changes in the muscle +/- MRI Tx: Tenotomy of the tendon through a lateral approach, with release of adjacent capsular adhesions Contracture > fibrous connective tissue replacement of muscle secondary to degenerative changes, dt low-grade repetitive trauma from vigorous activity +/- compartment syndrome

Answer 36

Synovectomy Radiation therapy anti-TNF-a administration excision arthroplasty or arthrodesis

Answer 37

Synovial chondrometaplasia - a proliferative disorder of undiffernetiated stem cells. Fibroblast-like cells are transformed into chondroblastic cells under the influence of the extracellular chondroid matrix material Treatment - Good outcome with debridement of nodules, loos body removal and synovial stripping - Excision arthroplasty or arthrodesis

Answer 38

Infraspinatus bursal ossification has been reported in Labrador Retrievers Radiographic changes include single or multiple mineralizations (osteochondromatosis) within the infraspinatus bursa that are best observed in the craniocaudal view. These mineralizations may not be clinically significant if pain cannot be elicited when pressure is applied directly over the tendon. Treatment with rest and nonsteroidal antiinflammatory drugs or intra-articular long-acting corticosteroids Surgical excision of loose bodies, the infraspinatus bursa, and a portion of the tendon of the infraspinatus muscle

Answer 39

retrospective study 18 client-owned toy-breed dogs (20 treated limbs). CLINICAL PRESENTATION Toy-breed dogs treated with the antiluxation pin lateral to the supraspinatus muscle tendon Reluxation occurred in 3 limbs final follow-up (median, 18.5 months gait assesment only, use of force plates and kinematic studies are desirable prevented the recurrence of and maintained a good long-term function

Answer 40

limited canine research available, relevant human research, and what is known about tissue repair,formulate the following recommendations: * No surgery if BT is healthy or if the amount of fiber tearing is ≤ 20%. * BT is 75% torn, surgery approach. Conservative guarded prognosis. * tears between 20% and 75%, a case-by-case decision, ensuring best communication about advantages and disadvantages with the owners is likely the best approach. * NSAIDs only short-term pain control, protracted use may delay healing. NSAIDs are not indicated in chronic cases. * Intra-articular corticosteroids are not an appropriate long-term conservative treatment and are contraindicated * Intratendinous corticosteroid injections must not be performed. If the end goal is tendon necrosis, a biceps tenotomy should be considered instead, using the least invasive approach available. * PRP might be useful > currently a lack of evidence in the published literature * Cage rest is discouraged * Consider multimodal Tx: physio with activity restriction that returns to normal in a staged manner over several months. * Modalities such as ESWT, regenerative medicine, and photobiomodulation should be considered. * At this time, there is insufficient evidence to recommend therapeutic ultrasound, PEMF, or acupuncture.

Answer 41

the medial glenohumeral ligament could be identified with a medial ultrasonographic approach of the shoulder and a wider articular space can be a sign of a medial shoulder joint instability. Further studies are needed to confirm these preliminary findings in living dogs, with and without shoulder instability.

Answer 42

Retrospective. 12. shoulder arthrodesis with 2 locking compression plates force plate analysis, at least 6 months follow up. ALL cases > satisfactory progression of arthrodesis at 6 weeks postoperatively, defined by loss of the radiolucent line previously present No major complications 11/12 > full functional recovery complication rate favorable compared to previously published fitzpatrick; complications in 50%, 2 catastrophic amputation or euthanasia bone graft 50%, not affect healing outcome shoulder joint exposed through transection of the insertion of the acromial head of the deltoideus, allowing identification of the tendon of insertion of the infraspinatus and teres minor on the proximolateral humerus. Both tendons were transected

Answer 43

Ex-vivo Study. use of intra-articular aiming device for suture-toggle or bone-anchor techniques - both techniques reduced reduction angles - suture-toggle more reliably performed Placement of anchors were not feasible in 3 and mild violations of the articular surfaces were detected in 3 specimens overall neurovascular structures in the region > not be entrapped by the suture tape as it courses over medial side raise the question of tensioning the repair - surgeon subjective

Answer 44

modified Cheli craniolateral approach for shoulder OCD - to reduce invasiveness and post-op complications - forced hyperflexion of the shoulder and hyperextension of the elbow → caudal displacement of acromial head of deltoid and infraspinatus → exposure of caudal humeral head without myotomy/tenotomy - 97.3% complete resolution of lameness intraoperative bleeding > omobrachial vein injury. joint cannot be completely evaluated for other diseases. Cheli approach can be used to allow OATS/synthetic resurfacing implant.

Answer 45

Cross-sectional study. 20 dogs (n = 26 shoulders). surgical debridement of proximal humeral OC lesions >12 months prior Orthopedic examination, kinetic gait analysis, radiographs, (CT), and arthroscopy performed. **needle arthroscopy** may be equivalent to conventional arthroscopy for the diagnosis of some shoulder pathology no differences in peak vertical force and vertical impulse between affected and unaffected limbs. 4.4% decrease in load distributed to the operated limb OA + muscle atrophy > all shoulders treated for OC lesions. Arthroscopically > all lesions patchy, incomplete cartilaginous infilling. No more than 60% infilling mechanisms that may explain this finding. 1. Studies in horses> fibrocartilage formed after subchondral curettage is mechanically inferior 2. Studies experimentally created cartilage defects in dog demonstrated decreased bonding of natural reparative fibrocartilage to the subchondral bed most dogs exhibiting subtle lameness on the subjective gait examination. Despite this, owner-perceived mobility was satisfactory The findings underscore the need for further scientific investigation into the most effective management of proximal humeral OC. Surgical debridement > not restore the articular surface or prevent OA but appears clinically beneficial in the majority of dogs.

Answer 46

The most effective means of subchondral bone stimulation remains unexplored in the veterinary literature. Curettage: leads to local destruction of chondrocytes and inadvertent removal of healthy tissue This can lead to delayed healing and a poorer quality of fibrocartilage infilling Microfracture: result in increased fibrocartilage infilling volume with a greater percentage of type II collagen content histologic studies: demonstrated that secondary fibrocartilage stimulated by surgical debridement or forage does not have the same mechanical or structural properties of healthy hyaline cartilage

Answer 47

Retrospective. inverted V-shaped extracapsular (coated polyester) stabilisation for MSI - modification of Fitch 2001 to allow early weight-bearing without coaptation - removes need to access two sites of scapular anchorage and extensive dissection - function → full in 4/6, acceptable in 2/6 - implant loosening in 2/6 without requiring revision **The suture material must maintain joint stability until the soft tissues have healed with maturation of scar tissues**.

Answer 48

Leipzig distractor shoulder arthroscopy.ex vivo. use of a shoulder distraction device might improve the outcomes of shoulder arthroscopy by decreasing iatrogenic cartilage injury and arthroscopy time.

Answer 49

Shoulder Abduction Angles in Dogs: Ex Vivo poor inter-observer repeatability, good intra-observer - intra-observer repeatability improved with experience Shoulder flexion angle can significantly affect measured abduction angles. shoulder abduction test is not as accurate as the fluoroscopic measurement > end-point may be challenging to discern clinically may be accurate enough for detecting clinically relevant hyperabduction angles. Transection of the medial supporting structures of the shoulder joint resulted in only a limited increase in the abduction angle > inconsistent to reported increase in lit.

Answer 50

Six adult Beagle cadavers, randomly assigned Abduction angles were significantly larger in the AS group as measured by goniometer, image analysis and radiographic stress view than in the NS group. Shoulder abduction angles measured with a stress radiographspecific view provide objective data that may contribute to diagnosis of medial shoulder instability in dogs.

Answer 51

medium-to-large defects located in the caudocentral aspect limitations:retrospective nature, Incomplete follow-up was obtained at 12 weeks postsurgery in 8/24 dogs Although results are encouraging, widespread implementation would be premature without a prospective clinical trial comparing synthetic resurfacing with debridement alone. complications infection + losening

Answer 52

Feline shoulder luxation cadaveric limbs: medial injury, lateral injury or bilateral injury + bone tunnel repair 4/6 medially injured joints > clinically stable 5/6 laterally injured joints > clinically stable. All bilaterally > deemed unstable (abduction + external rotation) repaired using bone tunnel and prosthetic suture regardless if medial, lateral or bilateral injury > returns the joint to normal….