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SA Orthopaedic surgery > Ligaments, luxations, arthrodesis > Flashcards

Ligaments, luxations, arthrodesis Flashcards

1
Q

Ligament and tendon structure

A

Both ligaments and tendons are composites of collagen type I (98%) in a proteoglycan matrix produced by fibroblasts

Tendon blood supply is more resilient as it comes from multiple sources, not just the insertion sites

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2
Q

Tendons

A

Join muscle to bone

Tough, inelastic

Continuous sheets of fibroblasts with matrix

Fibres in dense, parallel bundles

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3
Q

Ligaments

A

Joins bone to bone

Strong, elastic

Scattered fibroblasts in matrix

Fibres not arranged in parallel fashion

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4
Q

Healing of tendons and ligaments

A

Poor blood supply

Heal by formation of scar tissue

Requires initial protection

Followed by controlled mobilisation

Regain around 60% of strength by 6 weeks

Susceptible to re-injury

Orthotics can be invaluable in managing these injuries

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5
Q

Type I ligament sprain

A

Minimal tearing with some internal haemorrhage

Rest, bandage for 2 weeks

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6
Q

Type II ligament sprain

A

Partial tearing and stretching of fibres with intrenal and peri-ligamentous haemorrhage

Surgical repair (suture ligament or protect with prosthetic)

External coaptation post op

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7
Q

Type III ligament

A

Complete rupture or avulsion of attachment

Surgical repair and prosthetic replacement
ESF or cast post op
Arthrodesis indicated in some cases

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8
Q

Common ligament injuries

A

Cruciate ligaments

Collateral ligaments

Round ligament of the femoral head

Plantar ligament injuries

Carpal ligament injuries

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9
Q

Collateral ligament injuries

A

Usually traumatic, usually severe

Seen in shoulder, elbow, carpus, stifle, hock, and interphalageal joints

May present with obvious instability or joint luxation

In the shoulder can present as lameness without obvious instability

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10
Q

Investigations of ligament injury

A

Assessment of stance and gait

Sedated exam of joint stability

Survey radiographs and stressed radiographs

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11
Q

Management of ligament injury

A

Isolated tears of the medial or lateral collateral ligaments repaired by primary repair or prosthetic replacement

Post operatively apply rigid external coaptation

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12
Q

Prostetics for ligament injury

A

Prosthetics can be placed using two screws, washers and a figure of eight wire or synthetic monofilament suture such as nylon or polypropylene.

Or alternatively by use of a suture anchor system instead of screws.

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13
Q

Open ligament injuries

A

Commonly major trauma

Usually affect the distal limb joints

Treatment must allow simultaneous management of the ligament and skin injuries

ESF can be very useful - immobilises the joint

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14
Q

Arthrodesis

A

Permanent rigid fusion of a joint

Salvage procedure

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15
Q

Indications for arthrodesis

A

Unrelenting chronic pain from DJD that is not treatable by other means

Untreatable fractures

Chronic joint luxations

Partial neurological injuries

Unreconstructable ligament injuries or instability

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16
Q

Arthrodesis as a salvage procedure

A

Allows a continuation of the function of the animal, or part of animal, wothout preservation of normal anatomy

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17
Q

Which joints can be arthrodesed?

A

Distal joints: carpus > tarsus

Elbow and stifle will lead to signifcant gait alteration -> long lever arm -> problems!

Contraindicated in the hip

Can do well after shoulder arthrodesis

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18
Q

How to achieve arthrodesis

A

Debridement of cartilage

Placement of CBG

Immobilisation of the affected joint

Stabilisation at an appropriate angle

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19
Q

Arthrodesis after plantar/palmar ligament rupture

A

If there is degeneration or rupture of the plantar or palmar ligaments or fibrocartilage of the tarsus or carpus then repair of these ligaments / fibrocartilage is not usually successful and arthrodesis is the treatment of choice.

Implants used to stabilise the joints vary according to the level of injury.

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20
Q

Calcaneoquartal joint injury (proximal intertarsal subluxations)

A

A plate applied to the lateral aspect of the tarsus – (from the os calcaneus to the metatarsal bones).

Or a pin and figure of eight tension band wire (8 TBW)

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21
Q

Tarsometatarsal luxations

A

Lateral bone plate or 2 screws or K wires placed in a cross pin fashion with a figure of 8 TBW

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22
Q

Post-operative management of arthrodesis

A

Generally some form of external coaptation (cast or splint) should be used for a period of 4-8 weeks post operatively until radiographic evidence of healing is documented.

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23
Q

Prognosis of arthrodesis

A

With arthrodesis of any of the joints distal to the talocrural (tibiotarsal joint) then the prognosis is good.

Implants may occasionally need removal because of the limited soft tissue coverage in this area.

Arthrodesis after plantar tarsal ligament rupture necessitates a PARTIAL tarsal arthrodesis.

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24
Q

Carpal hyperextansion injuries

A

Little support from bony integrity.

Ligaments and palmar carpal fibrocartilage are the main supporting structures.

Hyperextension is usually secondary to trauma but can also occur secondary to immune mediated diseases such as rheumatoid arthritis.

The palmar LIGAMENTS and fibrocartilage are the structures most commonly damaged.

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25
Q

Diagnosis of carpal hyperextension injuries

A

Survey radiographs may show soft tissue swelling, and avulsion fractures.

In chronic injuries evidence of osteoarthritis may be present.

Stressed radiographs are needed in most cases to determine the level of injury.

Radiographs are taken with the carpus stressed in a hyperextended position.

Compare with the opposite limb.

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26
Q

Incidence of carpal joint hyperflexion injuries

A

ntebrachiocarpal joint – least common

middle carpal joint

carpometacarpal joint - commonest

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27
Q

Treatment for carpal hyperflexion injuries

A

Arthrodesis
- partial (fusion of middle carpal joint and carpometacarpal joint)
- pan (fusion of all three joint levels)

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28
Q

Plantar ligament rupture

A

Sometimes traumatic

Also seen in Shetland sheepdogs with no history of trauma, often bilaterally

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29
Q

Treatment of plantar ligament rupture

A

Tarsal arthrodesis
- partial
- pan

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30
Q

Congenital shoulder luxation

A

This is an uncommon condition seen only sporadically in

Small breed dogs - toy poodles and shelties

The luxation is commonly medial

The condition may be bilateral.

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31
Q

Clinical signs of congenital shoulder luxation

A

Present with an abnormal gait when they are several months of age

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32
Q

Diagnosis of congenital shoulder luxation

A

Mediolateral and craniocaudal radiographs necessary to confirm

In advanced cases the glenoid may be flattened or even convex in shape

33
Q

Treatment of congenital shoulder luxations

A

In early cases attempts to reduce the luxation and place a small temporary transarticular pin may be successful.

In more advanced cases then either arthrodesis or excision of part of the glenoid and part of the humeral head to allow a pseudoarthrosis to develop is generally successful.

Some cases can be treated conservatively

34
Q

Congenital elbow luxation

A

Uncommon

Campbells classification

Surgical reduction is sometimes possible

35
Q

Type I elbow luxation

A

Caudolateral dislocation of the radial head

Probably developmental

Most common in chondrodystrophic breeds

First seen at 4-6months

Usually premature closure of the distal ulna growth plate

36
Q

Treatment of type I elbow luxation

A

Three options
○ osteotomy of the ulna,
○ ostectomy of the radius,
○ radial head excision.

Sometimes deformity can be severe, osteotomys of both bones are required; and the prognosis is guarded.

37
Q

Type II elbow luxation

A

Lateral dislocation of the ulna

Congenital

Recognised within several weeks of birth

Lateral displacement results in an inability to extend the elbow

38
Q

Treatment of type II elbow luxation

A

Reducing the ulna manually and placing a transarticular pin across the joint for 10 to 14 days,

using pins and elastic bands to dynamically reduce the luxation.

The prognosis is guarded for formation of a normal joint but function is usually adequate after treatment.

39
Q

Type III elbow luxation

A

Dislocation of both radius and ulna laterally

A more severe luxation and treatment is similar as for type II although the prognosis is more guarded

40
Q

Acquired luxations

A

Usually occur after significant trauma

Significant soft tissue damage has to occur to allow a joint to dislocate

There will be ligament ruptures (collaterals) and in severe cases there may be muscle or tendon ruptures as well

41
Q

Acquired shoulder luxation - breeds affected

A

Any

Whippets may be over-represented

42
Q

Acquired shoulder luxation - cause

A

Fall, knock, dog fight, RTA

43
Q

Acquired shoulder luxation - presenting signs

A

Often acute onset severe non weight bearing lameness

44
Q

Acquired shoulder luxation - physical examination

A

Limb carried in a flexed position, pain, and crepitation on manipulation

45
Q

Acquired shoulder luxation - diagnosis

A

2 orthogonal x-ray views

Check for concurrent trauma e.g. pneumothorax, fractures

46
Q

Treatment of Acquired shoulder luxation

A

Closed reduction or surgical reduction

47
Q

Closed reduction of Acquired shoulder luxation

A

dog anaesthetised

attempt prior to surgery

Lateral luxations: with leg extended apply medial pressure to humerus and lateral pressure to scapula, if reduction stable through a normal ROM then support with a spica splint for 10 -14 days.

Medial luxations - reduce by extending leg and apply lateral pressure to the proximal humerus and medial pressure to the distal scapula, if reduction stable through a normal ROM then support with a velpeau sling for 10-14 days.

48
Q

Surgical treatment of acquired shoulder luxation

A

if closed reduction is unsuccessful then open reduction and stabilisation with capsulorrhaphy or tendon transposition is required

In severe cases with dysplasia or DJD then salvage procedures such as glenoid excision or arthrodesis must be performed.

A surgical approach is made to the joint and the articular surfaces are inspected.

*If the labrum is worn then the prognosis for successful stabilisation is poor.

49
Q

Prognosis for acquired shoulder luxation

A

fair, DJD may develop.

50
Q

Dislocation of the scapula

A

Very rare

Occurs secondary to severe trauma

Disrupts the attachment of the scapula to the thoracic wall

May be commoner in cats than dogs

Relocated using a heavy gauge wire placed through a small hole in the caudal border of the scapula

51
Q

Aquired elbow luxation

A

Traumatic luxation of the elbow is not common.

However when it occurs the direction of the luxation is usually lateral as the medial aspect of the condyle is larger and slopes distally making medial luxation very unlikely.

52
Q

Acquired elbow luxation - signalment

A

Any

53
Q

Acquired elbow luxation - cause

A

Often trauma e.g. RTA

54
Q

Acquired elbow luxation - clinical presentation

A

Non-weight bearing lameness with adduction of the elbow, abduction of the foot and pronation of the foot

Elbow swelling usually present and ROM severely limited

55
Q

Acquired elbow luxation - investigation

A

radiography (orthogonal views)

check for the presence of fractures

56
Q

Acquired elbow luxation - treatment

A

Attempt closed reduction

If closed reduction successful assess collateral ligament inetgrity

If not successful then attempt surgical repair - primarily using a suture technique like the locking loop pattern

57
Q

Acquired elbow luxation - post op

A

Leg should be supported in an extended position using either a bandage up to the axilla or preferably a body bandage or spica splint

External coaptation should not be used for more than 2 weeks or severe stiffness of the elbow joint will result

58
Q

Acquired elbow luxation - prognosis

A

after closed reduction alone the prognosis is good with 90% of dogs returning to normal.

The prognosis is worse after surgical reduction (usually the chronic or more severe cases) with only 50% returning to normal and the other 50% staying intermittently or permanently lame.

59
Q

Monteggia fractures

A

These are elbow luxations that occur concurrent to fractures of the ulna.

The annular ligament AND interosseous ligament may both be damaged.

The ulna fracture must be repaired.

Reluxation is a common complication secondary to the ligament instability.

It is important to repair/replace the annular ligament or fixate the radius to the ulna (either temporarily or permanently) to minimise the likelihood of reluxation.

60
Q

Hip luxations

A

Hip luxations most commonly occur in a cranio-dorsal direction, ventral or caudal luxation is much less common.

Medial luxation may occur in combination with an acetabular fracture.

61
Q

Diagnosis of hip luxation

A

Gait: affected animals will be non-weight bearing or markedly lame on the affected limb

Thumb displacement test negative - the thumb will not be displaced if the hip is dislocated craniodorsally

Radiography

62
Q

Closed reduction for hip luxations

A

animals should preferably be anaesthetised (or very heavily sedated).

Reduction is achieved by extension of the hip followed by internal rotation of the hip.

A palpable or audible click should be felt when the hip is reduced.

Reduction should be confirmed with further radiography.

Cage confinement or placement of an Ehmer sling should then be used to prevent reluxation.

63
Q

Why might closed reduction of a hip luxation fail?

A

Hip dysplasia

Femoral head fracture fragments

Blood clot, fibrous tissue, or infolding of the joint capsule in the acetabulum

Inadequate restriction of exercise post reduction

64
Q

Indications for surgical reduction of hip luxation

A

Articular fractures are present

The luxation is chronic

There are other injuries present

Closed reduction is unsuccessful

The joint reluxates

65
Q

Salvage surgery of hip luxation

A

(femoral head and neck excision or total hip replacement) should be considered if there is underlying hip dysplasia.

66
Q

Primary repair of hip luxation

A

Open reduction, debridement (of ruptured round ligament and fibrin in the acetabulum) and repair of the joint capsule with non-absorbable or slowly absorbable suture material.

67
Q

Prosthetic (synthetic) capsule technique

A

after debridement of the acetabulum and reduction of the femoral head two screws & spiked washers (latter to prevent sutures slipping off) are placed in the acetabulum

Sutures are then placed through a hole drilled in the greater trochanter and looped around the screws.

This technique is useful for large and medium sized dogs.

68
Q

Transarticular pinning for hip luxation

A

a suitable size intramedullary pin or K wire is driven from the fovea capitis laterally through the neck to exit the lateral femoral cortex distal to the third trochanter.

Following hip reduction the pin is driven through the acetabular wall and 5-6mm into the pelvic canal.

The pin is then cut short but left long enough for ease of removal later.

Post operative exercise reduction (or an Ehmer sling should be applied) and the pin can be removed 2-3 weeks later.

This technique is no longer recommended due to pin breakage and migration.

69
Q

Iliofemoral suture for hip luxation

A

after hip reduction a hole is drilled through the pelvis just cranial to the hip at the origin of the rectus femoris muscle.

Another hole is drilled across the greater trochanter.

Suture material (50,80 or 100lb monofilament nylon leader line) is passed through the holes and tied or secured with crimps with the hip held in a internally rotated and slightly abducted position.

70
Q

Hip toggle for hip luxation

A

the hip is kept reduced with a toggle pin, placed through a hole in the acetabulum to the medial aspect of the acetabulum and secured with strands of suture fed through a hole in the femural head and neck .

After hip reduction the suture strands are tied around a button along the lateral femoral cortex.

The hip has, postoperatively, a full range of movement, however, as the suture is placed into a very hostile abrasive environment, it will fail eventually.

71
Q

Prognosisof hip luxation

A

with closed reduction the success rate is 17-75% (depending on whose paper you read! The success rate after surgery is also variable but around 85% successful.

If the luxation is chronic or recurrent and there is articular cartilage damage then arthritis may develop and a permanent lameness may result.

Salvage options such as FHNE or a THR may have to be considered.

72
Q

Stifle disruption

A

multiple ligamentous injury can be seen after severe trauma or catching the foot in a fence.

Most commonly both cruciates and one collateral ligament are ruptured.

Also called stifle derangement.

73
Q

Stifle luxation - history

A

non weight-bearing lameness after severe trauma (RTA) or catching a foot in a gate whilst jumping.

74
Q

Stifle luxation - physical examination

A

in acute stages the stifle joint will be swollen and painful.

A thorough examination should be carried out with the animal anaesthetised.

75
Q

Stifle luxation - investigations

A

examination for instability under anaesthesia – perform cranial draw, varus and valgus stress tests.

Take survey radiographs and stressed radiographs to demonstrate instability.

Comparison with the opposite stifle may be useful.

76
Q

Stifle luxation - treatment options

A

surgical repair is usually indicated.

Primary repair of ruptured ligaments is often not possible so a prosthetic replacement is required using polydioxanone (PDS™) or nylon anchored through bone tunnels or around screws and washers.

Wire can be used to splint the repair.

The suture material will likely fail eventually but peri-articular fibrosis will hopefully be sufficient by the time this occurs.

77
Q

Stifle luxation - post op care

A

With severe disruption then post-operative external coaptation should be provided with a cast, splint, or ESF for 4-6weeks.

78
Q

Stifle luxation - prognosis

A

Variable.

At best a reduction in ROM, and some stiffness will generally result at worst the animal will be permanently lame or non-weight bearing on the limb.

In working animals the prognosis is guarded for an adequate return to function.

79
Q

Luxation of the metacarpophalangeal joints or interphalangeal joints

A

Seen most commonly in greyhounds.

The collateral ligaments will be damaged and these need repair using locking loop or mattress sutures of non-absorbable suture material.

Small avulsion fractures can be repaired using a lag screw or wire mattress suture.

Post-operative support in the form of bandaging should be applied for 2-4 weeks post operatively.

SA Orthopaedic surgery (8 decks)

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