Chapter 87 - Angular limb deformitites Flashcards
What is a conformation deviation of the limb in the FRONTAL plane?
is defined as angular limb deformity (ALD)
angular deformities can be classified in 2 types accodringly to the etiology
acquired
perinatal
A lateral deviation of the limb distal to the point of origin is referred to as
valgus deformity
Is each lateral or medial deviation associated with a certain degree of axial rotation?
yeas each deviaty is associated with axial rotation
In foals with valgus deformities, this is displayed as an
outward rotation called
splay foot
when a medial deviation occurs is named
varus deformity
In foals with cases of varus deformities,
as an inward rotation of the feet caleed
pigeon toed
Diagnosis of angluar deformity is made with (4 things)
static exam
dynamic exam
palpation
radiography
Foals with a toed-out posture, with
or without ALD, therefore are evaluated from a ____________________(1w) position
craniolateral position
It is very important that
the toe be aligned in the same direction as the _________________(1)
It is very important that
the toe be aligned in the same direction as the carpus/tarsus. Postpone surgery
if the carpus points outward but the toes point straight
forward, a __________(1w) deformity of the distal limb is present (see
Figure 87-1, B)
if the carpus points outward but the toes point straight
forward, a varus deformity of the distal limb is present (see
Figure 87-1, B). Surgery is indicated
Figure 87-1. (A) A valgus deformity of the carpal region is evaluated perpendicular to the frontal plane
of the outward-rotated carpus. If the toe points in the same direction, the entire limb is rotated out and
surgery can possibly be postponed. (B) If the carpus points outward and the toe points forward, surgical
intervention is indicated to prevent the development of a fetlock varus deformity.
Figure 87-2. Manual pressure to the medial aspect of the carpal region of a foal suffering from valgus deformity corrects the deformity temporarily, indicating that the ALD is caused either by incomplete ossification of the cuboidal carpal bones or periarticular laxity and conservative treatment is possible. Counterpressure is applied to the metacarpophalangeal region of the same limb.
pigeon-toed foals frequently rotate their ________________joints outward while advancing the li
pigeon-toed foals frequently rotate their metacarpophalangeal/metatarsophalangeal (MCP/MTP) joints outward while advancing the li
The only diagnostic aid that allows determination of the exact location and provides objective evaluation of the degree of the deformity is
radiography
In the hind limbs, dorsoplantar views are less helpful because the ______and the ___________ bone are not in alignment (an angle of 5–7 degrees is recognized as normal).
In the hind limbs, dorsoplantar views are less helpful because the tibia and the third metatarsal bone (MTIII) are not in alignment (an angle of 5–7 degrees is recognized as normal).
during radiography the foal should stand
foal should stand “square.”
____________ (1w) views are the most important in the forelimbs. Here lateromedial views should additionally be obtained.
Dorsopalmar views are the most important in the forelimbs. In the hind limbs, dorsoplantar views are less helpful because the tibia and the third metatarsal bone (MTIII) are not in alignment (an angle of 5–7 degrees is recognized as normal). Here lateromedial views should additionally be obtained.
The radiographs should be taken at a right angle relative to the ________plane of the carpus and the __________plane of the tarsus.
The radiographs should be taken at a right angle relative to the _frontal plane of the carpus and the _sagittal plane of the tarsus.
The third metacarpal/metatarsal (MCIII/MTIII) and phalangeal region should be aligned in ____plane for the radiographs, allowing interpretation of the articular orientation and differentiation of deformities.
The third metacarpal/metatarsal (MCIII/MTIII) and phalangeal region should be aligned in one plane for the radiographs, allowing interpretation of the articular orientation and differentiation of deformities.
Two lines are drawn through the axis of the long bones and the bisection of the lines (also known as the _________ represents the origin of the deformity
Two lines are drawn through the axis of the long bones and the bisection of the lines (also known as the pivot point) represents the origin of the deformity.
the pivot point helps determinate whether the deviation originates in the _____or at the ________
it can be determined whether the deviation originates in the joint or at the physis.
What are the main places that ALD occur?
- cuboidal bones of the carpus or tarsus,
- in the epiphyseal region of the long bones (epiphyses, physes, and metaphyses), 3. diaphyses of the long bones
- +++ frequently disproportionate growth at the level of the metaphyseal growth plates.
At what time the bones of carpus and tarsus are visible in radiography?
at 300 days
what can be the cause of incomplete ossification at the time of birth (Figure 87-4)?
These include: prematurity related to shortened gestation (<320 days);
abnormal uterine positioning;
dysmaturity related to placentitis;
placental insufficiency;
severe prolonged metabolic diseases (maternal malnutrition);
heavy parasite infestation;
colic and shock, which can alter the blood supply to the uterus;
chemical insults (vaccinations and anthelmintics), which can influence fetal development;
and thyroid abnormalities, which can influence ossification
Figure 87-3. Normal ossification of the carpus and tarsus at the time of birth. (A) DP radiograph of the carpus. All the bones are ossified adequately, and the ulnar styloid process (a) is visible. The rough surface at the medial distal metaphysis of the radius (b) represents active endochondral ossification and is normal at that age. (B) LM radiograph of the tarsus showing adequate ossification of the central and third tarsal bones (arrows). It is important that the ossification process proceed to the level of the proximal aspect of MTIII. These two radiographic views are the most relevant to evaluate ossification at the time of birth.
Figure 87-4. (A) DP radiograph of a carpal region and LM radiograph of a tarsal region of a 2-day-old premature foal. The DP view of the carpus shows incomplete ossification of the carpal bones. (B) The LM view of the tarsus shows inadequate ossification especially of the third and the central tarsal bones. RF, Right front; RH, right hind.
Mention the 4 classifications of cuboidal ossification
Grade 1: Some cuboidal bones of the carpus and tarsus have no evidence of ossification.
Grade 2: All cuboidal bones (carpus and tarsus) have some evidence of ossification. The proximal physes of the MCIII/MTIII are open.
Grade 3: All cuboidal bones (carpus and tarsus) are ossified, but small and rounded edges are present. Joint spaces are wide and the lateral styloid process and malleoli are distinctly visible. Proximal physes of MCIII/MTIII are closed.
Grade 4: All criteria of grade 3 are met. Cuboidal bones are shaped like corresponding adult bones and joint spaces have the expected width.
Foals with incomplete ossification of the tarsal bones and greater than ___% collapse of the third and central tarsal bones have been shown to have a poorer outcome
Foals with incomplete ossification of the tarsal bones and greater than 30% collapse of the third and central tarsal bones have been shown to have a poorer outcome
Foals with straight limbs and incomplete ossification should be managed with
stall res and exercise restriction until complete ossification has occured
In case of incomplete ossification and stall rest the radiographs should be repeated every ___ weeks
2 weeks
If the foal has incomplete ossification and not straight limb the treatment should be
stall rest and restricted exercise along with external coaptation to ensure axial alignement of the joint
if you have to apply splint or casts it is important that they end at the
fetlock whenever possible to abvoid that flexor and extenor units are waken resulting in a dropped fetlock and osteopeni
when should be the splints and casts changed in foals?
splints every 3 to 4 days and casts every 10 to 14 dyas with radiographs obtained every 2 weeks to check the progress of the ossification
whcich two muscle when immobilized with casts or splint become flacid?
flexor carpi ulnaris
ulnaris lateralis muscle
“bakc-at-knee” may result from what?
While the limb is under a cast or splint, the flexor carpi ulnaris and the ulnaris lateralis muscles are immobilized and always become flaccid. This results in a temporary “back-at-the-knee” conformation immediately after splints or casts are removed
if radiographs demonstrate tha the deformity is lobated within the distal raidus or tibia and not cause by laxity of periarticular supporing sructures the splint or casts are indicated?
no, they are contra-indicated
what is the deifinition of windstep?
foals that suffer of one limb with varus deformity and other with valgus deformity (Fig 87-6)
periarticular laxity is treated how?
Such foals should be managed with controlled exercised daily for 10 to 20 minutes by walking the mare, to stimulate strengthening of the muscles and involved soft tissue structures.
Figure 87-6. (A) Image of a 1-week-old foal with a marked valgus deformity of the right tarsus (white arrow) and a varus deformity of the left tarsal region (black arrow). The degree of ossification was normal. (B) After 2 weeks of light hand-walking and no treatment, the deviations had corrected.
are periarticular laxity a very bad issue?
Cases with periarticular laxity are usually self-limiting and growth of the foal usually resolves the problem.
Figure 87-7. (A) DP radiograph of the distal limb in a 2-day-old Warmblood foal suffering from a marked varus deformity in the distal MTIII. Note the triangular shape of the epiphysis. (B) The same foal after 2 weeks of stall rest. The deformity is partially corrected because of the development of a compensatory deformity in the proximal phalanx. (C) DP radiographic view of severely deformed MTIII in a 1-week-old Thoroughbred foal. Note the rotational deformity of the distal half relative to the proximal half of the bone.
What is the rapid growth of proximal P1?
0-2 months
when does the physis closure in the proximal P1
12 months
when does the distal metacarpus metatarsus rapid growth period?
0-2 months
when does the metacarpus/metatarsus physis is closed?
6 months
when does the distal radius rapid growth period?
0-6 months
when does the distal radius is closed?
22-36 months
when does the distal tibia physis is closed?
17-24 months
when does the distal tibial rapid growth period?
0-4 months
whe does the ossificiation of foals starts and when does it stops?
it starts approximately 2 months before birth and stops 1 months after birth
5 to 7 degree deformity can be normal until ____ months of age in carpus
4 months
The vast majority of longitudinal growth in the long bones occurs in the ____________(bone) region of the physis
The vast majority of longitudinal growth in the long bones occurs in the metaphyseal region of the physis
Developmental factors, which are strongly associated with ALDs include
genetic predisposition,
dietary imbalances,
trauma,
exercise,
physeal dysplasia,
physeal overload,
and heavy birth weight
Fracture of the physes that can cause local retardation of growth at the medial or lateral aspect of the bone are classified as Salter-Harris type ____
This type of injury has been classified as a Salter-Harris type V fracture
Carpal deviations up to ___degrees are considered normal
Carpal deviations up to 4 degrees are considered normal
Long pasterns increased the odds of a fracture in the forelimb and a certain degree of carpal ________ deformity exhibited a protective mechanism
and a certain degree of carpal valgus deformity exhibited a protective mechanism
The more heavily loaded side of a bone (concave side) will grow ____ and the less heavily loaded side will grow slower (convex side).
the more heavily loaded side of a bone (concave side) will grow faster and the less heavily loaded side will grow slower (convex side).
Foals with ALDs because of disproportionate growth at the level of the physis (greater than 10 degrees) treatment
should be stall rested and exercised in a controlled fashion. Stall rest may be continued for 4 to 6 weeks. If correction does not occur during that time, a more aggressive approach should be implemented.
The solar surface should be enlarged by carefully rasping the ____
The solar surface should be enlarged by carefully rasping the heel
In valgus deformities, the ________hoof wall is lowered and in varus deformities and pigeon-toe conformation, the _______ hoof wall is lowered.
In valgus deformities, the outside hoof wall is lowered and in varus deformities and pigeon-toe conformation, the inside hoof wall is lowered.
For valgus deformities, extensions are placed on the _______ side and for varus deformities, on the_______side.
For valgus deformities, extensions are placed on the medial side and for varus deformities, on the lateral side.
Growth acceleration surgery should be performed when the foal has not corrected spontaneously by itself by
4week os age - unless >10 degrees
periosteal transection has its effect for approximately ____ months
2 monhts
A prolonged effect is achieved through surgical excision of ____________ triangular flaps
Does overcorrection of the deformity occur with hemicircumeferential periosteal transection and elevation (HCPTE)?
Overcorrection of the deformity does not occur.
What is the prognosis for HCPTE?
Good
HCPTE is performed on the concave aspect of the limb which is _________ side in a valgus deformity and ________ side in a varus deformity).
HCPTE is performed on the concave aspect of the limb (lateral side in a valgus deformity and medial side in a varus deformity).
what is the principle behind HCPTE?
The initial principle behind the procedure was reducing the static compression in the area of the physis allowing cells to accelerate their growth.
Mention in detail the surgical proceedure for correction of valgus deformity in the distal radius
a 3-cm vertical skin incision, continued through the periosteum between the common and lateral digital extensor tendons, is made 4 to 5 cm proximal to the distal radial physis and continued proximally (Figure 87-9, A). (Note: for correction of a varus deformity, the procedure is performed at the medial aspect of the bone.) The subcutaneous tissues and tendons are separated from the periosteum at the distal aspect of the incision parallel to the physis using curved hemostatic forceps. Using a curved scalpel blade (No. 12), an inverted T-shaped incision is made into the periosteum, whereby the horizontal bar of the inverted T is made 2 to 4 cm proximal to and parallel to the physis. The rudimentary ulna is transected. Once the inverted T is made The periosteal elevator is advanced at a 45-degree angle to the periosteal incisions underneath the periosteum to elevate two triangular flaps. Subxtu simple continuous USP 2-. absorbable followed by simple continuous
Figure 87-8. Foal with a varus deformity of the MMTP region with a lateral extension (Dallmer Shoe) view from the lateral (A) and from the plantar (B) aspect.
Figure 87-9. Locations at which growth acceleration may be carried out. In each location, the T incision together with the elevated triangular flaps is shown. (A) Anatomical landmarks for the surgical approach at the distal carpus. a, common digital extensor tendon; b, lateral digital extensor tendon; c, abductor pollicis longus; d, distal radial physis; e, transected rudimentary ulna.
Figure 87-9. Locations at which growth acceleration may be carried out. In each location, the T incision together with the elevated triangular flaps is shown. (B) Anatomical landmarks for the surgical approach at the distal MCIII/MTIII (A), and proximal phalanx (P1) (B). a, common digital extensor tendon and lateral to it the lateral digital extensor tendon; b, distal end of MCII/MTII; c, distal physis of MCIII/MTIII; d, extensor branch of suspensory ligament; e, proximal epiphysis of the P1; f, oblique distal sesamoidean ligaments. (
Figure 87-9. Locations at which growth acceleration may be carried out. In each location, the T incision together with the elevated triangular flaps is shown. (C) Anatomical landmarks for the surgical approach at the distal tibia. a, distal physis of the tibia; b, long digital extensor tendon; c, lateral digital extensor tendon; d, vertical periosteal incision caudal to the lateral digital extensor tendon is an alternate site (dotted line).
Figure 87-9. Locations at which growth acceleration may be carried out. In each location, the T incision together with the elevated triangular flaps is shown. (D) Location of the procedure carried out over the total length of the MCIII/MTIII. a, common/long digital extensor tendon; b, proximal aspect of the MCII/MTII. The procedure was performed and the two periosteal (barn-door) flaps were elevated.
Figure 87-10. Dorsoplantar radiograph of the MTP region of a foal with a relatively straight limb. The proximal phalanx and distal MTIII have opposing deformities, resulting in an oblique orientation of the joint surface relative to the ground.
Figure 87-11. (A) Craniocaudal/dorsopalmar radiographic view of a 2-month-old Warmblood foal with bench-knee conformation. The bisecting lines drawn along the bone axes show the composition of the different deformities, distal radial valgus and MCIII varus deformity. (B) Composite radiographic view 2 months following HCPTE at the lateral aspect of the distal radius and medial aspect of the distal MCIII. A slight compensatory deformity developed in the proximal phalanx.
Figure 87-12. Transcutaneous periosteal transection technique. The skin over the distal medial MCIII is rolled with the thumb palmarly. The pointed scalpel blade is inserted through the skin down onto the bone surface, and both the scalpel and skin are pulled in a dorsal direction. This technique allows a horizontal transection of the metaphyseal periosteum and afferent physeal vessels through a 1- to 2-mm skin incision that does not have to be sutured.
Figure 87-13. Growth retardation. (A) A stab incision to the bone is carried out at the convex aspect of the epiphysis and the distal metaphysis. (B) The soft tissue between the two incisions is elevated. (C) A 4.5-mm cortex screw is implanted through each incision but not tightened. (D) A cerclage wire loop is introduced through the proximal incision, hooked over the distal screw head, and tightened in figure-of-eight fashion over the proximal screw (E). The screws are subsequently completely inserted, which increases wire tension as the wires ride up on the shoulder of the screw heads.
Figure 87-16. (A) Foal with a severe carpus valgus deformity of the right forelimb. (B) Preoperative DP radiograph of the right carpus showing the valgus deformity. (C) Immediate postoperative radiograph showing a single transphyseal screw inserted on the medial aspect of the distal radius in an oblique proximodistal direction across the distal radial physis. (
Figure 87-17. (A) Foal with a bilateral valgus deformity of the tarsus. (B) Preoperative DP radiograph of the right tarsus showing the valgus deformity. (C) Postoperative radiograph of the right tarsus showing a four-hole 3.5-mm plate applied to the medial aspect of the distal tibia with two 3.5-mm cortex screws to retard growth. When using the bone plate technique at the distal radius, the distal screw does not cross the physis but only at the distal tibia to prevent intraarticular screw insertion secondary to the undulating shape of the distal tibial epiphysis.
Figure 87-19. (A) A 5-month-old Miniature Horse with severe tarsal valgus deformities in both hind limbs. A DP radiograph of the left carpus shows a completely developed ulna (B), and a DP view of the left tibia shows a completely developed fibula (C). Note the acute angle of the lateral trochlear ridge of talus, representing early degenerative changes (arrow).
Figure 87-20. (A) Closing wedge ostectomy. The bone wedge is removed from the horizontal plane near the physeal region. (B) Step ostectomy. The wedge is removed from the center of MCIII in the sagittal plane. (C) Derotational step ostectomy. By removing a vertical wedge with its wide aspect located either dorsally or palmarly, a rotational deformity can be corrected. (D) Step osteotomy. The Z-plasty is performed in the frontal plane, and the fragments are rotated into alignment.
