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Surgery > Distal Joints > Flashcards

Distal Joints Flashcards

1
Q

which side is medial and which is lateral?

A
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2
Q

Carpal Collaterals – Anatomy

A

All carpal ligaments are short ligaments

Connect adjacent bones only
Do not bridge more than one joint

Radial
Straight and oblique parts
Division significant when discussing treatment

Ulnar: straight part only

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3
Q

Tarsal Collaterals – Anatomy

A

Long portion
Spans entire tarsus
Taut in extension but NOT in flexion

Short portion
Taut in BOTH flexion and extension Cross joint obliquely – rotational stability Anatomically divided into two parts Anatomic division not clinically relevant

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4
Q

Collateral Injury Principles

A

Concepts apply to BOTH carpus and tarsus

Typically arise from HBC or other trauma Treat life-threatening trauma FIRST
Always assess thorax in major trauma Frequent loss of soft tissue, bone – “road rash”

(but not always)
Usually on medial side of joint and accompanied by shear injuries!

Assess by physical exam and radiographs

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5
Q

How do you examine collateral injuries on PE?

A

Position limb in extension

Apply valgus and varus stress to joint

VaLgus stress – Laterally deviates distal limb

Varus stress – medially deviates distal limb

Tarsus: examine in flexion and extension Different from carpus due to long collaterals In flexion, valgus/varus motion is rotational

Abnormal motion indicates injury

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6
Q

Valgus stress engages which collateral ligament?

A

Medial colateral because you are pressing from the medial side

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7
Q

What is the purpose of rads in a collateral injury?

What views do you want?

A

Rule out fractures

Standard dorsopalmar and lateral views

Dorsopalmar stress views
Dorsopalmar views with valgus/varus stress Documents injury

Necessary even when collateral injury is obvious

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8
Q

Is conservative managenment frequently used in collateral injury?

A

Conservative management
Splinting + rest unhelpful as sole treatment May be necessary if surgery is delayed ESF in the presence of soft tissue trauma

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9
Q

What is the recommended treatment for surgical management?

A

Surgical management recommended Reconstruct/replace collateral
Take ligament anatomy into account

Salvage necessary with excessive trauma

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10
Q

What is the collateral ligament replacement?

A

Bone tunnel or screw with heavy suture placed between them

Understand that the prosthetic ligaments are placed to mimic the original ligament

Screws are placed at the origin and insertion of the original ligament

Know that these screws are proximal and distal to the joint

It is not critical that you know specific anatomic landmarks for the

collateral ligaments (at least not at this stage)

Know that in the tarsus both the short and long ligaments must be replaced

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11
Q

What is an example of the suture you would use for collateral ligament replacement?

A

Non-absorable, #2

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12
Q

Hyperextension Injury has damaged what structure?

A

Damage to palmar/plantar support ligaments

Allows abnormal motion (hyperextension) between rows of carpal/tarsal bones

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13
Q

What does flexor retinaculum mean?

A

Flexor retinaculum encloses DDF tendon

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14
Q

Palmar fibrocartilage

A

Palmar fibrocartilage extends from the distal aspect of the proximal carpal bones (radial, ulnar) to the proximal aspect of the metacarpals

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15
Q

Hyperextension Injury – Etiology

A

Trauma (fall/jump)

Immune-mediated arthropathy
Disease weakens palmar/plantar stabilizers Corticosteroids also tend to weaken ligaments

Breed-related: middle-aged Shelties/Collies Chronic, progressive breakdown
Genetic weakness suspected
May be bilateral

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16
Q

What breeds have a genetic prediposition for bilateral hyperextension injury?

A

Shelties and collies

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17
Q

What is this injury and how would you dx it on PE?

A

Swollen, painful joint
Trauma: very swollen, painful
Chronic breakdown: less swelling, less pain

Hallmark: hyperextended stance
Tarsus: “dropped hock”
Tarsus touches but calcaneus tilted proximally “dropped hock” ≠ “plantigrade stance” Plantigrade: calcanean tuberosity touches

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18
Q

What are the articulations of the tarsal joint?

A
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19
Q

Where does all the motion of the tarsus occur?

A

ibiotarsal (talocrural) joint

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20
Q

What are the articulations of the carpus?

A

Hinge joint (ginglymus)

Antebrachiocarpal joint
Between radius/ulna and proximal row Almost all motion occurs here

Middle carpal joint – between first and second row

Carpometacarpal – between second row and metacarpal bones

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21
Q

What rads do you get for hyperextension injuries?

A

Standard dorsopalmar/plantar, lateral view Provide basis for comparison
Rule out fractures

Stress views – determine level of injury Use lateral views for hyperextension injury Stabilize limb proximal to carpus/tarsus Simulate weightbearing to detect instability

22
Q

What are the treatment options for hyperextension injury?

A

Conservative management
Consists of splint application and rest
May be applied regardless of the injury location Temporary prior to surgery only
NOT USEFUL as sole management

Surgical management
Arthrodesis of affected joint + joints distal Required for definitive treatment

23
Q

pancarpal arthodesis

A

Antebrachiocarpal involved: pancarpal

24
Q

Pantarsal arthrodesis

A

Pantarsal arthrodesis rarely necessary

Tibiotarsal joint rarely injured by hyperextension

Joint simply flexes in direction of injury
Other tarsal/carpal joints do not flex in this way

25
Q

Partial Carpal Arthrodesis

A

Indicated if antebrachiocarpal joint is healthy

Middle and carpometacarpal joints are fused using a T-plate or pins

Function of carpus is almost unaffected – almost all motion at antebrachiocarpal joint

26
Q

Pancarpal Arthrodesis

A

Antebrachiocarpal joint is abnormal

All 3 carpal joints fused

DCP applied – specialized plates Dorsal application is typical
Lateral application is described

27
Q

Tarsus – Partial Arthrodesis

A

Proximal intertarsal

Calcaneoquartal (lateral half) Lag screw or pin/tension band Applicable for most situations

Entire proximal intertarsal – lateral plate Tarsometatarsal – lateral plate
Good to excellent function expected Negligible effect on ROM of the hock

28
Q

Proximal Intertarsal Arthrodesis

A

Partial tarsal arthrodesis

Plate engages calcaneus

No effect on tibiotarsal articulation

Full ROM is maintained

29
Q

Tarsometatarsal arthrodesis

A

Partial tarsal arthrodesis

No effect on tibiotarsal articulation

Full ROM is maintained

30
Q

Arthrodesis – Postop

A

Principles apply regardless of location

Coaptation
4-8 weeks
Splint or external skeletal fixator (ESF)

Activity restriction until bony fusion Expect 3 months minimum
Radiographs q4 weeks to assess healing

Explantation occasionally required

31
Q

Carpal Laxity Syndrome

A

Many different breeds described

5-27 weeks of age
Males predisposed

32
Q

Carpal Laxity presentation

A

Hyperextension, hyperflexion, flexural deformity with palpable laxity

33
Q

Treatment for carpal laxity

A

Spontaneous recovery in 1-4 weeks

Energy-restricted diet
Controlled exercise
Flooring with good traction

34
Q

What is the most likely cause of this?

What’s the prognosis?

A

Carpal Laxity

Excellent prognosis

35
Q

What are the components of the calcean tendon?

A

Gastrocnemius tendons

Combined tendon of the gracillis, semitendinosus, biceps femoris

Tendon of the superficial digital flexor

36
Q

What is the difference in presentation between complete and partial rupture of the calcanean tendon?

A

Complete rupture: plantigrade stance

Partial rupture: SDF usually preserved

Partial hyperflexion
Flexion of digits

37
Q

What is this?

A

Calcanean tendon rupture- complete

38
Q

What kind of a rupture is this?

A

partial calcanean rupture

39
Q

What do you see on a PE with calcanean rupture?

A

Presentation/PE

Acute – Usually trauma, complete rupture

Chronic – Usually partial rupture
Minimal or no trauma
Medium- and large-breeds (Lab, Doberman) Older female cats
Cause unknown, repetitive trauma suspected

PE: loss of tendon substance

40
Q

What component is preserved in a parital calcanean rupture?

A

SDF

41
Q

Calcanean Rupture – Treatment

A

Calcanean Rupture – Treatment

Debride tendon ends

Primary tendon repair
3-loop pulley > locking loop

Monofilament nonabsorbable suture

Slow (poor) tendon healing

Immobilize tarsus in extension

Allows for poor (slow) tendon healing

6-8 weeks

42
Q

Calcanean Tendon – Prognosis

A

Generally good
Most (>75%) dogs and cats return to function Working dogs more guarded

Immobilization postop is VERY important External fixator
Splint
Giant lag screw

Complications related to coaptation method

43
Q

What bred is predisposed to OCD of the tarsus

A

Rottweiler

44
Q

Is medial or lateral OCD of the tarsus more common?

bilateral or unilateral

A

Frequently bilateral

Lesion is located on the ridge of the talus Medial – most common
Lateral – predominantly seen in Rottweilers

45
Q

Tarsus – OCD

Clinical signs/Physical Exam

A

Mild to moderate lameness
Lameness worsens after rest Hock-extended stance
Joint effusion/fibrosis
Pain/crepitus on manipulation of the joint

Pain at limits of hock flexion indicates DJD (not necessarily OCD)

46
Q

What rads are used for tarsal OCD?

A

Imaging

Tarsus – OCD

Radiographs – articular flattening, lucency Standard lateral and craniocaudal views Flexed lateral – expose proximal talus
Flexed craniocaudal – cranial trochlear ridges

47
Q

What is the treatment for OCD of the tarsus?

A

Treatment

Surgical therapy

Tarsus – OCD

Medical therapy – older dog, established OA

Fragment excision/debridement Young dog, no OA
Heals with fibrocartilage Arthroscopy vs. arthrotomy

Tibiotarsal (aka tarsocrural) arthrodesis

48
Q

What’s the prognosis of tarsal OCD?

A

Guarded to poor

Surgical intervention

Arthrotomy and fragment removal may be no better than medical management

Arthroscopy is considered ideal
Surgery does not prevent development of OA

Current wisdom
Surgery improves function somewhat Does not eliminate lameness

49
Q

Tarsocrural Arthrodesis Indications

A

Severe injury to tibiotarsal joint

Fracture – comminuted articular fractures

Luxation – persistent instability Failed collateral injury repair Failed partial arthrodesis

Failed calcanean tendon repair

OA not responsive to medical management End-stage OCD
Previous trauma

50
Q

What does a tarsocrucal athrodensis mean?

A

Fuse tibiotarsal joint at standing angle

Remove articular cartilage
Sagittal saw – distal tibia/proximal talus Burr – small joints

Pack with bone graft

Rigid fixation
Plate – dorsal, lateral, or medial Type 2 external skeletal fixator

51
Q

What’s the prognosis of tarsocrural arthodesis?

A

Tarsocrural Arthrodesis - Outcome

Loss of hock ROM
Mechanical lameness
Most dogs have acceptable function

Pet: good
Working dog: guarded to poor

Surgery (11 decks)

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