Joints Flashcards
Arthropathy
any joint disease
Arthrosis
“wear and tear” degeneration
Arthritis
Inflammation within a joint
Polyarthritis
inflammation in several joints simultaneously
Osteophyte
forms at synovial or articular margins
Enthesiophyte
forms at tendon/ligament attachment
Joint Mouse
mobile fragment within a joint
Joint Capsule
the sac that encloses a joint
-rrhaphy
“to suture in place”; to close
imbrication
surgical tightening
-plasty
surgical repair or shaping of
arthro
joint
rhino
nose
trochleo-
groovelike area on a bone
Ankylosis
spontaneous fusion of joint - end stage of joint disease
Arthrodesis
surgical fusion of a joint
Arthrotomy
incision into joint
Types of Joints
Synovial
Fibrous
Cartilaginous
How do you differentiate between an inflammatory and noninflammatory arthritis?
Do a Joint Tap
Infectious Causes of Arthritis?
Bacterial Fungal Mycoplasmal Erosive Non-erosive
What is the most common cause of Osteoarthritis in cats?
Primary Idiopathic Osteoarthritis
What are the types of secondary osteoarthritis?
Developmental
Acquired
What are the radiographic signs of Osteoarthritis?
Osteophytes Effusion Increased joint space Decreased joint space Soft tissue swelling Subchondral sclerosis
What is the treatment for Osteoarthritis?
NSAIDs
salvage procedures: Joint replacement/arthroplasty, arthrodesis, amputation
How do you treat septic osteoarthritis?
open up the joint and flush it out completely and debride it
What are some symptom modifying agents for Osteoarthritis?
NSAIDs Tramadol Gabapentin Amantadine Corticosteroids
What are some disease modifying agents for Osteoarthritis?
Polysulfated glycosaminoglycan
Pentosan polysulfate
Hyaluronic acid
Autologous platelet therapy
Platelets collected and injected into involved joint
What are surgical salvage treatments for Osteoarthritis?
Joint replacement arthroplasty
Partial joint exision arthroplasty
Arthodesis
Amputation
Partial Excision Arthroplasty
Remodeling of joint without replacement
What are common examples of Partial Excision Arthroplasty?
Femoral Head and Neck exicision (FHO)
Glenoid Excision
What are the postoperative management options for Arthrodesis?
Coaptation (6-8 weeks)
Activity Restriction until bony fusion
Prolonged healing common - 3 months +
Osteochondrosis
a defect in endochondral ossification
What is the pathophysiology of Osteochondrosis?
Disruptions in anastomoses lead to cartilage necrosis
Where is the most common place on the shoulder for Osteochondrosis dissecans?
caudolateral humeral head
Where is the most common place on the elbow for Osteochondrosis dissecans?
medial humeral condyle
Where is the most common place on the Hock for Osteochondrosis dissecans?
Medial or lateral talar ridge
Where is the most common place on the Stifle for Osteochondrosis dissecans?
Medial or lateral femoral condyle
What are the treatments for Osteochondrosis dissecans?
Preventative measures - diet, energy, calcium, vitamin D restriction
Conservative
Surgical
What are the surgical treatments for Osteochondrosis dissecans?
Fragment removal and subchondral bone debridement
Replacement of articular cartilage with fibrocartilage
Osteochondral transplants (OATS)
What is conservative management for Shoulder OCD Treatment?
Rest
NSAIDs
Diet
What is the standard of care for shoulder OCD?
Surgical treatment
What is the surgical treatment for Shoulder OCD?
Flap removal and joint lavage
Debridement of bone with curette or shaver
Defect heals with fibrocartilage
Arthroscopy
What is the treatment for Acute Biceps Brachii Tendinopathy?
Confinement for 4-6 weeks
NSAIDs
Physical therapy
What is the treatment for Moderate Biceps Brachii Tendinopathy?
Intraarticular corticosteroid injection
Strict confinement 4-6 weeks
Physical therapy
What is seen on physical exam for Shoulder Instability?
Muscle Atrophy
Pain on manipulation of Joint
Medial instability: Increased abduction angle
What is the treatment for mild shoulder instability?
Rest
Physical Therapy
Hobbles
What is the treatment for moderate shoulder instability?
arthroscopic thermal “capsulorrhaphy”
Rest
Physical Therapy
Hobbles
What is the treatment for Severe shoulder instability?
Medial glenohumeral ligament reconstruction
Velpeau sling instead of hobbles
Contracture
muscle shortening not caused by active contraction
Infraspinatus Contracture
traumatic disruption of muscle fibers causing muscle shortening not caused by active contraction
What is the treatment for Infraspinatus Contracture?
Tenetomy of infraspinatus tendon
Incongruity
mismatch of articular surfaces
What is the characteristic posture for Medial Coronoid Dysplasia?
“Toed Out”
Elbow abducted
External rotation of limb
What is the incongruity associated with Ununited Anconeal Process?
Short Ulna/ Long radius
What is the incongruity associated with Fragmented Coronoid Process
short radius/ long ulna
Radioulnar incongruity
Shortened ulna displaces humerus proximally
Excess force on developing anconeal process
At what age does the normal ulna fuse?
16-20 weeks
What is the gold standard for diagnosing Fragmented Coronoid Process and OCD?
Arthroscopy
Long portion of the Tarsal Collaterals
Spans the entire tarsus
Taut in extension but not in flexion
Short portion of the Tarsal Collaterals
Taut in both flexion and extension
Which way does Valgus stress deviate the limb?
Laterally
Which ligament is stressed when valgus stress is applies?
Medial Collateral Ligament
Which ligament is stressed when varus stress is applied?
Lateral Collateral ligament
Which way does the limb deviate when varus stress is applied?
medially
What is conservative treatment for collateral ligament injury?
Splinting + rest
ESF
What is the surgical treatment for collateral ligament injury?
Reconstruct/Replace
Salvage with excessive trauma
Collateral Ligament Replacement
Screw or bone tunnel in origin and insertion of each ligament
Nonabsorbable large diameter suture placed in figure 8 pattern
What type of suture is used for Collater Ligament Replacement?
40 to 80 lb test monofilament nylon
What ligaments are damaged with a hyperextension injury?
Palmar/plantar support ligaments
What is the treatment for a hyperextension injury?
Salvage surgery
Palmar fibrocartilage
the confluence of joint capsule and ligaments on the palmar surface of the carpus
Ginglymus
Hinge Joint
What is the etiology of a Hyperextension injury?
Trauma (jump/fall)
Immune mediated
Breed related breakdown or weakness
How does a hyperextension injury present?
Swollen
Painful
“dropped hock”
plantigrade stance
What is the conservative treatment for Hyperextension injury?
Splint application and rest
What is the surgical treatment for Hyperextension injury?
Arthrodesis of the affected joint + joint distal
Post op for Arthrodesis
Coaptation for 4-8 weeks
Activity restriction until bony fusion
Explantation may be required
Carpal laxity Syndrome
Hyperextension, hyperflexion, flexural deformity with palpable laxity of puppies ages 5-27 weeks that spontaneously recovered in 1-4 weeks
What is the physical exam finding for a Common calcanean tendon rupture?
plantigrade stance
What tendon is usually preserved in a partial rupture of the common calcanean tendon?
Superficial Digital Flexor
What are the physical exam findings of a partial rupture of the common calcanean tendon?
Partial hyperflexion of hock
Flexion of digits
What is the treatment for a common calcanean tendon rupture?
Debride tendon ends
Primary Tendon repair
Immobilize tarsus in extension
Hip Dysplasia
Abnormal development of the coxofemoral joint resulting in hip laxity
What is the manifestation of Hip Dysplasia in young patients?
Subluxation
What is the manifestation of Hip Dysplasia in older patients?
Remodeling and OA
What is the etiology for Hip Dysplasia?
Genetics and Environmental
What are some nongenetic factors that contribute to Hip Dysplasia?
Pelvic Muscle Mass
Body weight
Nutrition
What is seen in the History of an animal with Hip Dysplasia?
Exercise intolerance Bunny hopping gait Difficulty rising/stiff after rest Reluctant to climb stairs or jump Bilateral Hip Lameness Sits to the side to avoid hip flexion
Ortolani test
Push stifle proximally to subluxate then slowly abduct the stifle to hear the audible clunk
How do you treat Hip Dysplasia?
Nutritional management Exercise modulation Physical therapy NSAID Weight management
What are the surgical managements for Hip Dysplasia?
Juvenile Pubic Symphiodesis
Triple Pelvic Osteotomy
Salvage procedures: FHO, Total Hip Replacement
Juvenile Pubic Symphiodesis
Fuse pubic symphysis with cautery to tether the growth of the pelvis to roll the acetabulum ventrally (ventroversion)
What age is JPS useful in?
Less than 20 weeks
Triple Pelvic Osteotomy
Osteotomy of the pubis, ischium, ilium
Fixation of the ilium with angled plates to roll the acetabulum dorsally
What are the indications for a triple pelvic osteotomy?
Clinical signs of Hip Dysplasia Ortolani test Low angle of reduction No radiographic evidence of DJD 6-8 months of age
Total Hip Replacement
Degenerative joint replaced with prostheses: Femoral Stem and Acetabular cup
What are the two types of Total Hip Replacement?
Cemented
Cementless
What type of dog is Total Hip Replacement ideal for?
Large Active dogs
What are complications of Total Hip Replacement?
Luxation Infection Femure Fracture Loosening Failure of ingrowth Bone resorption around cement
FHO
Femoral Head and Neck Osteotomy
Femoral Head Osteotomy
Remove the entire Femoral Head and Neck of femur with a Osteotome or oscillating (sagittal) saw
What supports the hip with an FHO?
Pseudarthrosis
Muscles and tendons provide support
What is the most commonly luxated joint?
Coxofemoral joint
What causes Coxofemoral Luxation?
Trauma associated with thoracic injury or other fractures
What is the History associated with Coxofemoral Luxation?
Acute unilateral non weight bearing lameness
What are the two types of Coxofemoral Luxation?
Caudoventral
Craniodorsal
Caudoventral Coxofemoral Luxation
Luxation of the femoral head ventrally due to a fall or “splits”
Craniodorsal Coxofemoral Luxation
Pull of gluteal muscles causes the greater trochanter to displace dorsally
What is the most common Coxofemoral Luxation?
Craniodorsal Coxofemoral Luxation
How is the limb held in a Caudoventral Coxofemoral luxation?
Leg is held abducted and internally rotated
How do you treat a Caudoventral Coxofemoral luxation?
Close reduction with muscle relaxation or an epidural
Hobbles for 10-14 days
Range of Motion exercises
What is contraindicated for a Caudoventral Coxofemoral luxation?
Ehmer sling
How does the effected limb look for a Craniodorsal Coxofemoral Luxation?
Affected limb is held in relaxed extension and adducted and externally rotated
What is the treatment for Craniodorsal Coxofemoral Luxation?
Closed Reduction
Muscle Relaxation or epidural
What is contraindicated for Craniodorsal Coxofemoral Luxation?
Dysplastic hip
Fracture of the pelvis or femur
What is the treatment Post Reduction for Craniodorsal Coxofemoral Luxation?
Range of Motion
Ehmer sling
Ehmer Sling
Abduction
Internal rotation
Pushed femoral head away from damaged craniodorsal joint capsule
What are the indications for an Open reduction for a Craniodorsal Coxofemoral Luxation?
Pelvic/acetabular fracture
Femoral fractures
Unstable closed reduction
Recurrent closed reduction
What are the objectives of Hip Dysplasia Surgical Treatment?
Reconstruct joint capsule and adjacent soft tissues to hold hip in reduction
Maintain reduction temporarily with implant until soft tissues heal
What are the surgical treatment options for correction of Hip Dysplasia?
Capsulorrhaphy
Prosthetic capsule
Toggle pin
Capsulorraphy
closing the joint capsule torn by the trauma with heavy gauge suture
What is a Toggle Pin/Rod used for?
Prosthetic Capital ligament
What is the Post Op Management for the treatment of Hip Dysplasia?
Coaptation: Ehmer sling or Hobbles Belly Sling Avoid slippery floors Restrict activity X 4 weeks Slow gradual return to activity
Legg-Perthes Disease
“Aseptic necrosis of the femoral head”
Ischemia to femoral head causes necrosis
What is the signalment for Legg-Perthes Disease?
Cats and small/toy breed dogs
immature (4-11 months)
Some Breed disposition
What are the signs seen on radiographs for Legg-Perthes Disease?
Radiopacity of lateral femoral head
Focal bony lysis - “motheaten” “apple core”
Flattening mottling of the femoral head
Collapse thickening of femoral neck
What is the treatment for Legg-Perthes disease?
Femoral Head Osteotomy
Total Hip Replacement
What is the function of the Cranial Cruciate Ligament?
Prevents internal rotation
Prevents hyperextension
Prevents cranial tibial thrust
Cranial Tibial Thrust
Naturally occurring weight bearing compression across the joint
Angle between compression and tibial plateau results in shear
What opposes the shear force of Cranial Tibial Thrust?
Cranial Cruciate Ligament
Cranial Cruciate Ligament Tear
occurs when cranial tibial thrust exceeds breaking strength of the cranial cruciate ligament
What causes Acute Cranial Cruciate Ligament rupture?
Traumatic catastrophic overload of the ligament
What causes chronic cranial cruciate ligament rupture?
Progressive degeneration of the Cranial Cruciate Ligament due to a lower breaking strength resulting in rupture from normal weight bearing
Deranged Stifle
enough force to damage multiple ligaments in the stifle
What other injuries of the stifle is CCL rupture associated with in cats?
Injuries to Menisci
Injuries to other ligaments
Deranged stifle
What is the history of an animal with acute CCL Rupture?
Athletic injury
Traumatic hyperextension, limb loading or excessive internal rotation
Sudden onset of non or partial weight bearing lameness
What is the history of an animal with chronic CCL rupture?
Slow degeneration of CCL leads to DJD
Fraying of ligament rather than complete rupture
What do you see on physical exam of chronic CCL rupture?
Effusion Rounding of limb Muscle atrophy Medial buttress - firm medial fibrosis Crepitus - osteophyte formation Instability
What are the tests for Instability and CCL Rupture?
Cranial drawer test
Tibial compression test
What are the two bands of the Cranial Cruciate ligament?
Craniomedial
Caudolateral
When does the Craniomedial Cranial Cruciate ligament become taut?
in flexion and extension
When does the Caudolateral Cranial Cruciate ligament become taut?
in extension only
What is the function of Menisci?
Shock absorption
Reorient load transmission “hoop stress”
improve congruency/stability
What are the signs seen on Radiographs for Meniscus injury?
Effusion of the fat pad Osteophytes Subchondral sclerosis Increased medial soft tissue Tibial displacement
What is medical treatment for meniscus injury?
6 weeks confinement
pain management
Physical therapy
What is the surgical treatment for meniscus injury?
Explore joint: debride CCL, Evaluate meniscus, arthroscopy vs. arthrotomy
Stabilize the joint
What is the most common Meniscal tear?
“Bucket Handle”
Partial Meniscectomy
Removal of damaged portion of the meniscus
Minimal change in contact mechanics
What is the risk for a Partial Meniscectomy?
Postoperative meniscal injury
Meniscal Release
Cut caudal pole of medial meniscus
Allows caudal pole to move caudally
What is the advantage of Meniscal Release?
decreases risk of postoperative injury
What is the disadvantage of Meniscal Release?
Worsens contact mechanics
Long Term OA
What are the stabilization techniques for meniscal tears?
Intracapsular
Extracapsular
Tibial Osteotomies: TPLO and TTA
What are the Extracapular techniques for meniscal tear?
Lateral suture
TightRope
Lateral Suture
Heavy monofilament nylon placed in orientation similar to the native CCL
Nylon mimics function of ligament: Around lateral fabella and through hole in tibial tuberosity
What are the complications of Lateral Suture?
Infection Implant failure Incomplete stabilization Meniscal injury Peroneal nerve deficit/entrapment Complications increase with higher body weight and younger age
TightRope
Multifilament nonabsorbable fiber tape implant that is fixated with toggle mechanism
Osteotomy Purpose
Alter angle between weight bearing and the tibial plateau to eliminate shear
Render cranial cruciate ligament unnecessary
Eliminates tibial thrust
Does not eliminate cranial drawer
TPLO Mechanics
Force of weightbearing parallel to tibial axis
Radial cut in the proximal tibia
Rotate proximal tibial fragment
Perpendicular to force of weight bearing
Tibial Tuberosity Advancement Description
Quadriceps are primary resistance to stifle flexion during weightbearing
Force of weightbearing parallel to patellar tendon
Longitudinal cut in the tibial tuberosity Advancement of tuberosity makes patellar tendon perpendicular to plateau
What are the complications of Osteotomies?
Infection Incomplete stabilization Implant failure Meniscal injury Iatrogenic angular limb deformity - TPLO Iatrogenic patellar luxation - TTA
What is the post operative Management for Osteotomy?
Physical therapy 48-72 hours post op
limit exercise until radiographic healing (8-12 weeks)
Gradual return to activity over 1–2 months
6 months of recovery
What procedures are best to perform on a small dog or cat for meniscal repair?
TPLO
TTA
Tightrope
What procedures are best to perform on everything else?
TPLO
TTA
Tightrope
What is the most common congenital joint deformity?
Patellar luxation
What is the signalment for Patellar luxation?
Small and toy breeds
What is the history for patellar luxation?
Intermittent weight-bearing lameness
Non-weight bearing when patella is luxated
What is the cause of Medial Patellar Luxation?
Medial malalignment of quadriceps
What is the result of Medial Patellar Luxation?
Lateral bowing of distal femur Lateral torsion of distal femur Medial displacement of tibial tuberosity Medial boring of proximal tibia Abnormal trochlear groove Hypoplasia of medial condylar ridge
What is the result of Medial Patellar Luxation?
Lateral bowing of distal femur Lateral torsion of distal femur Medial displacement of tibial tuberosity Medial boring of proximal tibia Abnormal trochlear groove Hypoplasia of medial condylar ridge
What do you find on physical exam of Medial patellar luxation?
Stifle in extension
Tibia internally rotated
What do you find on physical exam of Lateral patellar luxation?
Stifle in extension
Tibia externally rotated
What should you always assess for Patellar luxation?
Cranial drawer
Grade 1 patellar luxation
Patella stays in the groove
but can be manually luxated but will spontaneously reduce immediately
Grade 2 Patellar luxation
Patella more often reduced than luxated and luxated easily with manipulation
May luxate spontaneously
Once luxated will stay luxated until manually reduced or stifle is extended
Intermittent lameness
Grade 3 Patellar Luxation
patella more often luxated than reduced
Patella can be manually reduced
Reluxates when released or with flexion
“Crouched” gait - flexed stifle and internally rotated tibia
Grade 4 Patellar Luxation
Patella is fixed in luxation
Manual reduction is not possible
Anatomic abnormalities are severe - Tibia may be rotated 80-90 degrees medially, Stifle may not be able to be fully extended, or severe fibrosis and muscular contracture
What is the most common patellar luxation?
MPL
What patellar luxation is most common in large breed dogs?
LPL
What are the conformational abnormalities of Lateral Patellar Luxation?
Mirror image of medial luxation
Femoral valgus or torsion, tibial varus
“Knock-kneed” or “Cow Hocked”
What is more severe MPL or LPL?
LPL
What is the indication for surgical management?
Significant lameness regardless of grade Episodes lasting 2-3 weeks or longer 3 or more episodes in a short time Higher grade (3-4) associated with RCCL
What are the surgical procedures for patellar luxation?
Soft tissue reconstruction
Bone reconstruction/realignment
Lateral imbrication
Chronic stretching of lateral joint capsule, fascia
Imbrication prevents reluxation
Medial release
Chronic fibrosis of medial joint capsule, fascia
Free up contracted tissue
Allows reduction of patella
Trochleoplasties
Deepen femoral trochlear groove
Wedge or block recession
Tibial tuberosity transposition
Osteotomy in tibial crest
Realign quadriceps
tibial tuberosity transposition description
Tibial tuberosity cut from proximal to distal, leaving periosteum attached distally
Tibial tuberosity shifted laterally
Tibial tuberosity fixed in placed with K-wires
What are the indications for ACVS referral for large breed dogs?
Many grade 2 luxations require surgery
require distal femoral osteotomy
What is the post op care for surgery for patellar luxation?
Controlled activity
leash walking for 6 weeks
Physical therapy
Radiographs in 6 weeks
What is the Etiology of Fragmented Coronoid Process?
a previous error in endochondral ossification that experience microtrauma caused by incongruity
How do you diagnose Elbow Dysplasia?
Radiographs
What view is required for diagnosis of Ununited Anconeal process?
flexed lateral view
What view is required for the diagnosis of OCD of the elbow?
craniocaudal view
What may be the only sign of Fragmented Coronoid process seen on Radiographs?
Sclerosis
What is the gold standard for diagnosis of Elbow Dysplasia (FCP and UAP)?
Arthroscopy
What is the surgical treatment of Ununited Anconeal Process?
Fragment excision
Osteotomy + fixation
What occurs to the elbow joint if you excise the anconeal process?
destabilization
What is the signalment of a patient that should receive a Fragment excision of the Ununited Anconeal process?
Older dog
What is the goal of an Ununited Anconeal Process Osteotomy + fixation?
Osteotomy allows distraction of the ulna
Restoration of congruity through ulna lengthening
Encourages the union of the anconeal process
What is the signalment of a patient who should receive an Osteotomy + fixation for UAP?
Young dog with no DJD
What is the gold standard of treatment for FCP/OCD?
Arthroscopic treatment: Debridement and fragment removal
What will still progress even after arthroscopy of FCP/OC?
Arthritis
What is important to know about the prognosis of Elbow Dysplasia?
Early intervention is best chance
Early intervention does not prevent DJD
Treatment via arthotomy is worse than arthroscopy
Medical management is expected long-term
What is Incomplete Ossification of the Humeral Condyle?
Failure of union between the medial and lateral portions of the humeral condyle
When does the fusion of the humeral condyles take place?
12 weeks
What is important to note about Incomplete ossification of the Humeral condyle?
Bilateral
In spaniel breeds
males are predisposed
What is the presentation of Incomplete ossification of the Humeral condyle?
You to young adult dogs
no clinical signs
Mild lameness: Weightbearing lameness that is worse after activity
Acute Non-weight bearing lameness due to a pathologic fracture
How do you diagnose Incomplete ossification of the Humeral condyle?
Craniocaudal Radiographs
What is the treatment for Incomplete ossification of the Humeral condyle?
Single large lag screw
Traumatic Elbow Luxation
Rupture/avulsion of collateral ligaments
Which side do we see Traumatic Elbow Luxation to most?
Lateral
Which collateral ligament is traumatized in dogs with Traumatic Elbow Luxation?
lateral collateral
Which ligament is traumatized in cats with Traumatic Elbow Luxation?
Both collateral ligaments
How do you diagnose Traumatic Elbow Luxation?
Lateral and Craniocaudal Radiographs
What is the treatment for Traumatic Elbow Luxation?
Closed Reduction
Open Reduction
When do you perform an Open Reduction on a Traumatic Elbow Luxation?
Concurrent fractures
Unsuccessful/unstable closed reduction
Recurrent luxation
What procedure do you perform on a Traumatic Elbow Luxation with severe DJD?
Salvage procedure
What test is used to Assess collateral ligaments of the elbow?
Campbell’s Test
How do you perform the Campbell’s Test?
Elbow and carpus at 90 degrees
Supination to test the lateral collateral
Pronation to test the medial collateral
In what species do you perform an open reduction normally to treat Traumatic Elbow Luxation?
Cats
What procedure do you perform to stabilize the Lateral collateral ligament?
Suture prothesis
What do you do Post op for a Traumatic Elbow Luxation?
Maintain the leg in extension
Exercise restriction for 4-6 weeks after coaptation removal
Physical therapy
Slow gradual return to activity
What coaptation do you use for Post op treatment of Traumatic Elbow Luxation?
Spica Splint for 2-3 weeks (Closed reduction)
Flexible ESF for 3-4 weeks (open reduction)