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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
Partial Carpal Arthrodesis
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
Pancarpal Arthrodesis
Antebrachiocarpal joint is abnormal All 3 carpal joints fused DCP applied – specialized plates Dorsal application is typical Lateral application is described
27
Tarsus – Partial Arthrodesis
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
Proximal Intertarsal Arthrodesis
Partial tarsal arthrodesis Plate engages calcaneus No effect on tibiotarsal articulation Full ROM is maintained
29
Tarsometatarsal arthrodesis
Partial tarsal arthrodesis No effect on tibiotarsal articulation Full ROM is maintained
30
Arthrodesis – Postop
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
Carpal Laxity Syndrome
Many different breeds described 5-27 weeks of age Males predisposed
32
Carpal Laxity presentation
Hyperextension, hyperflexion, flexural deformity with palpable laxity
33
Treatment for carpal laxity
Spontaneous recovery in 1-4 weeks Energy-restricted diet Controlled exercise Flooring with good traction
34
What is the most likely cause of this? What's the prognosis?
Carpal Laxity Excellent prognosis
35
What are the components of the calcean tendon?
Gastrocnemius tendons Combined tendon of the gracillis, semitendinosus, biceps femoris Tendon of the superficial digital flexor
36
What is the difference in presentation between complete and partial rupture of the calcanean tendon?
Complete rupture: plantigrade stance Partial rupture: SDF usually preserved Partial hyperflexion Flexion of digits
37
What is this?
Calcanean tendon rupture- complete
38
What kind of a rupture is this?
partial calcanean rupture
39
What do you see on a PE with calcanean rupture?
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
What component is preserved in a parital calcanean rupture?
SDF
41
Calcanean Rupture – Treatment
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
Calcanean Tendon – Prognosis
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
What bred is predisposed to OCD of the tarsus
Rottweiler
44
Is medial or lateral OCD of the tarsus more common? bilateral or unilateral
Frequently bilateral Lesion is located on the ridge of the talus Medial – most common Lateral – predominantly seen in Rottweilers
45
Tarsus – OCD Clinical signs/Physical Exam
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
What rads are used for tarsal OCD?
Imaging Tarsus – OCD Radiographs – articular flattening, lucency Standard lateral and craniocaudal views Flexed lateral – expose proximal talus Flexed craniocaudal – cranial trochlear ridges
47
What is the treatment for OCD of the tarsus?
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
What's the prognosis of tarsal OCD?
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
Tarsocrural Arthrodesis Indications
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
What does a tarsocrucal athrodensis mean?
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
What's the prognosis of tarsocrural arthodesis?
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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