Ortho ALD and Forelimb Flashcards
What are indications for BURP?
- treat cartilage malacia or limited fissures along radial incisure of MCP
- juvenile with clinical signs of bilateral elbow disease BUT minimal changes on arthroscopy
- adjuvant treatment to fragment excision in dogs with no radioulnar incongruity & mild cartilage disease
What is the disadvantage of static ulnar osteotomy/ostectomy?
more involved measurements, doesn’t change with growth of the limb
Where is the location to perform bi-oblique dynamic PUO?
junction of proximal and middle 1/3 of radius with angle 55 degrees caudal to cranial and 48 degrees lateral to medial
What has been found for PAUL biomechanically?
it does unload medial joint, but doesn’t transfer load to lateral compartment
What is the prognosis for dynamic osteotomies?
good - some have slower progression of OA, less pain & improved force plate analysis
Treatment for T/Y fracture of scapula?
fix articular surface 1st with saw cranial to caudal, then the rest can be fixed with any wire vs. plate
Treatment for medial/lateral labrum fracture glenoid?
larger dogs - 1or 2 lateral to medial lag screws
Outcome for scapular articular fracture repair?
most have residual lameness
Salvage for scapular articular fracture?
glenoid excision - good results
Treatment for scapular luxation?
Prognosis?
20/22g wire around 5th, 6th, 7th rib & holes drilled ream caudodorsal border of scapula
Treatment for scapular luxation?
Prognosis?
20/22g wire around 5th, 6th, 7th rib & holes drilled ream caudodorsal border of scapula
Px: excellent (if isolated injury)
Is ununited accessory ossification center of caudal glenoid usually bilateral or unilateral?
treatment?
bilateral
scope removal/debridement – resolves lameness
Medial and lateral humeral condyle appear when?
Fuse when?
Fuse to metaphysis when?
- medial: 14-22d
- lateral: 21-43d
- fuse to each other at 3mo
- fuse to metaphysis around 5.5-6mo
What % of humeral condylar fractures are lateral vs. medial vs. T-Y?
- lateral: 34-67% of HC fractures
- medial: 37% of all humeral fractures
- T-Y: 26-35% of HC fractures
What breeds are predisposed to humeral condylar fractures?
French Bulldogs - greatest
Yorkies
Cocker Spaniels (springer?)
What % of humeral condylar fractures are lateral vs. medial vs. T-Y?
- lateral: 34-67% of HC fractures
- medial: 37% of all humeral fractures
- T-Y: 26-35% of HC fractures
What breeds are predisposed to humeral condylar fractures?
French Bulldogs - greatest
Yorkies
Cocker Spaniels (springer?)
What % of all non-traumatic lameness to elbow in dogs is congenital luxation?
15-20%
What % of humeral condylar fractures are lateral vs. medial vs. T-Y?
- lateral: 34-67% of HC fractures
- medial: 37% of all humeral fractures
- T-Y: 26-35% of HC fractures
What breeds are predisposed to humeral condylar fractures?
French Bulldogs - greatest
Yorkies
Cocker Spaniels (springer?)
What are the 3 types of congenital elbow luxation?
- I: humeroradial (radius head –> lateral)
- II: humeroulnar (lateral rotation/subluxation or luxation of ulna)
- III: humeroulnar and humeroradial (often associated with generalized joint laxity)
What type of congenital elbow luxation most common?
II
Greater tubercle formed at ___ months
epiphysis fuses with metaphysis at ___ months (dogs vs cats)
- 4 months
- 7.5-12 months DOG
- 19-26 months CAT
What is the humeral head - greater trochanter fusion angle?
102 degrees
What are the most common Salter Harris fractures in the proximal humerus?
I / II
Generally for humeral fractures…what is the prognosis for T-Y fractures?
- 41% excellent
- 52% good
- 10% fair
- but Tobias says guarded
- depends on severity of complications
List different treatment options for OCD of humeral condyle?
- remove flap, abrasion arthroplasty = worse outcome than FCP
OATS
- allografts (cadavers)
- autogenous (femoral trochlea)
- synthetic osteochondral transplant (thermoplastic polycarbonate urethane plug with titanium base – good to excellent Px)
Describe the Modified Outerbridge scores for MCP
MOS1 = chondromalacia (soft, swollen, lucent, dull)
MOS2 = fibrillation (partial thickness defects)
MOS3 = deep fibrillation to subchondral bone (still has poor flocculent cartilage)
MOS4 = full thickness erosion
MOS5 = eburnation (burnished appearance)
What are 3 configurations for repairing acromion fracture?
- two wires (D–>V) with figure of 8 tension band
- inter fragmentary wire only (2)
- single inter fragmentary wire cross proximal then tie
What are the standard approaches to scapular neck fractures?
lateral or craniolateral with osteotomy of acromion process or tenotomy of acromial head of deltoideus
(+/- osteotomy of greater tubercle or tenotomy of infraspinatus or teres minor)
What is the alternative approach described for scapular neck fractures?
muscle separation between supra/infraspinatus & deltoideus
For Type I congenital elbow luxation
- breeds / age?
- treatment options?
- prognosis?
- 2-5months of age
- Large breeds (Afghan, Golden Retriever, Bull Mastiff, Boxer, Collie)
- Smaller breeds (Pekignese, Doxie, Shih Tzu)
For Type I congenital elbow luxation
- treatment options?
For Type I congenital elbow luxation
- breeds / age?
- 2-5months of age
- Large breeds (Afghan, Golden Retriever, Bull Mastiff, Boxer, Collie)
- Smaller breeds (Pekignese, Doxie, Shih Tzu)
For Type I congenital elbow luxation
- treatment options?
- Medical management: rest, PT, controlled exercise, joint supplements
Surgery
1. Open reduction (recon LCL + joint capsule) +/- surgical synostosis (temporary transarticular pin or interosseous screw)
2. Radial head ostectomy
3. Arthrodesis
4. Amputation
For Type I congenital elbow luxation
- prognosis?
combination of shorter radius & temporary transarticular pin = functional improvement
What are the differences in angling IM pins for humeral fractures in dogs vs. cats?
- Dog: toward/inserted into trochlea (medial) of humeral condyle
- Cat: into central area of distal part of diaphysis just proximal to olecranon fossa
What % of the humerus should the IM be?
36-45% width and 80% of humeral length
How do you position blade for subtotal coronoidectomy?
What is the advantage of this procedure?
- start caudal to MCL & aim slightly caudal to most caudal extend of coronoid fragment/fissure
- direct distocaudally to limit proximal-distal length
- can do parallel directions to remove in “slices”
- advantage: improve joint incongruence if positive radioulnar incongruence localized to apex
Is scintigraphy sensitive or specific for diagnosis of IOHC?
Not specific - can see bilateral increased uptake in young dogs
What is the average fracture rate of conservatively managed cases of IOHC?
~30-45%
one study if partial radiolucent line was 43% and complete 8%
Which direction of drilling a transcondylar lag screw had a higher rate of penetrating the joint?
medial to lateral
When can you actually diagnose UAP on rads?
not until 20 weeks of age
What is the prognosis for anconeal process removal?
> 90% of owners satisfied
good to excellent (1994)
What situation may be amenable to anconeal process reattachment?
- ulnar osteotomy (UO) alone: success if <7mo & attached AP/non-displaced = good
- AP reattach + UO – fusion rate 93% (good to excellent)
- problem is you have to catch it early
What is sensitivity/specificity for detecting MCP disease with nociceptive blockade?
sensitivity = 87%
specificity = 87%
With MCP, where do you commonly see osteophytes on rads?
- proximal anconeal process
- cranial radial head
- cranial edge MCP
- caudal lateral supracondylar crest
- medial contour humeral trochlea
- medial contour MCP
What % of MCP disease show trochlear notch sclerosis?
40-86.7%
What other rad sign is suggestive of MCP disease?
blunting/blurring of cranial edge MCP
sens = 80%
spec = 100%
What breed has highest predisposition to OC/OCD & MCP?
Labs, Rotties, GSD, BMD, Golden Retriever
For medial compartment disease, what & is bilateral?
25-80%
What % of Bernese Mountain Dogs with MCP disease have radioulnar incongruence?
60%
For the external rotational humeral osteotomy (ERHO), how much do you rotate?
How much pressure is decreased in medial compartment?
- rotate by 15 degrees
- 50% reduced pressure
What are the components made of with the CUE procedure?
- polyethylene plug – MCP
- cobalt chromium prosthesis – humerus “figure eight”
- ulnar – porous titanium socket & polyethylene bearing surface
What are prognosis of traumatic elbow luxation with closed or open reduction?
- closed = early studies ~89% success (good to excellent) but reported as low as 47%
- open = good, provided not too much OA long term
- Sajilk JSAP 2016 - 20/37 needed open approach
What is the major complication of closed elbow reduction?
re-luxation
What breeds are predisposed / overrepresented to get medial humeral condylar fracture?
chondrodystrophic
List 3 approaches to T-Y fracture of humeral condyle
- osteotomy of olecranon tuberosity
- tenotomy of triceps brachii (avoid in immature patients)
- combo medial and lateral approaches
For bilateral approach to T-Y humeral condylar fractures, where is the plate placed?
medial plate - caudal or caudomedially
lateral - caudal
Is contrast arthography more or less sensitive than US to diagnose biceps brachii tendinopathy?
MORE!
List medial vs. surgical treatment options for biceps tendinopathy
Medical
- triamcinolone/HA injection
- NSAID + rest
- ESWT (shockwave)
- PRP
- stem cells
- transcutaneous electrical nerve stimulation
- therapeutic US
- PT
Surgical
- tenodesis
- tenotomy
What breeds reported for medial displacement of tendon of origin of biceps brachii?
Tx & Px?
- Greyhounds, Afghan, GSD, Border Collie
- primary reconstruction of THR - or augment with screws & PDS or staples & polypropylene mesh
- excellent prognosis
What breeds predisposed to supraspinatus tendinopathy?
success of treatment?
- Rottweilers, Labradors
- variable, surgery vs. medial management debated
Describe classifications of scapular fractures
I. body + spine
II. neck
III. glenoid (including SGT)
What has been recommended for plate application on scapular body with regards to proximal and distal spine?
plate caudal to spine on proximal 1/2
plate cranial to spine on distal 1/2
What is prognosis for partial scapulectomy?
removal of 60% – excellent recovery
For treatment of humeral condylar fractures, what are 2 approaches for lag screw?
- normograde with fracture reduced
- retrograde (glide hold) – you can see lateral exit clearly, but medial could be severely affected
For lateral humeral condylar fracture repair, screw should be parallel to ____?
Outcomes?
parallel to lateral part of humeral condyle to decrease shear force
good outcomes
List treatment options for proximal humerus fracture with humeral head and greater tubercle together
- young dogs: 2 pins GT into humeral neck
- mature dogs: 2 K-wires and tension band or lag screws
List treatment options for proximal humerus fracture when humeral head and greater tubercle separate
- repair both with pins or K wires
- HH: wire cranial to caudal with pins inserted distal to GT directed proximally/caudally
- GT: wire and tension band
List treatment options for proximal humerus fracture with fracture of lesser tubercle
2 K wires or small screw in lag fashion
For IM pin placement in humerus, which insertion technique is NOT often recommended? Why?
Distal retrograde –> damage to periarticular ST & articular cartilage, & ulnar nerve entrapment
What are disadvantages of humerus for ILN?
- tapering bone
- often only 1 space available distally
- thickness of cortex proximally doesn’t enhance screw holding power
With intact ligaments, you can rotate the paw ___ degrees in supination and ____ degrees pronation?
- supination = 17-50 degrees
- pronation = 31-70 degrees
Peak contact pressure shifts to MCP apex in (pronation/supination?) and away in (pronation/supination?)
- increased with PRONATION
- decreases with SUPINATION
What anatomic structures do you look out for when approaching the elbow via olecranon osteotomy?
- ulnar nerve
- collateral ulnar artery
The distal growth plate of humerus contributes to what & length?
20%
What age does the distal humerus GP close?
5-8 months
What are treatment options for bi-apical antebrachial ALD?
- plates (following a type of osteotomy)
- Hinged ESF
- *remember, ulnar osteotomized at each CORA
Prognosis for ALD of antebrachii?
depends on the study…
- studies on ESF show severity of OA & other functional impairments as prognostic indicators
- worse with bi-apical
For the CUR, what is the reported outcome?
- full function = 48%
- acceptable = 44%
- unacceptable = 9%
What is overall prognosis for surgery to treat end-stage MCP disease?
- favorable regardless of technique
- up to 90% good to excellent
Which procedures for elbow dysplasia have least complications?
DPUO «< PAUL < CUE < SHO
List 6 treatment options for treatment of medial shoulder instability
- transposition of origin of biceps or tendon of supraspinatus
- augmentation of exciting MCL – synthetic suture, screws/washer, bone tunnels, or suture anchors
- imbrication of tendon of subscapularis
- radio frequency induced thermal modification
- excisional arthroplasty
- arthrodesis
List treatment options for supracondylar fracture
- Pin/cross
- unilateral plating
- bilateral plating
- screw and anti-rotation wire
- transcondylar pin + anti-rotation pin
- transcondylar screw + anti-rotation screw or pin
For the humerus, which side (proximal vs. distal) of the bone has tension?
- proximal = craniolateral
- distal = caudomedial
For distal supracondylar fracture, what is the benefit of placing plate on caudomedial aspect? Caudal aspect?
- Caudomedial = helps angle screws in cranial direction avoiding olecranon fossa & max screw length/purchase
- Caudal = can place additional place craniomedial for fracture of small distal fragment
What % of developmental elbow disease is FCP? OC? Incongruity?
- FCP = >96%
- OC = 2.7-25.4%
- RUI = 6-50.3%
What breed is prone to radioulnar incongruity? What % get it with development elbow disease?
Bernese Mountain Dog
50%
What breed commonly gets OC?
Golden Retriever
seen in 25.4% of GR with development elbow disease
What % of dogs have bilateral elbow disease?
35%
usually giant breeds
What are 3 tests to perform for biceps tendinopathy?
- Biceps tendon test - flex shoulder, press on inter tubercular groove
- Drawer test - flex shoulder, grasp humerus, stabilize scapula, push cranial with humerus
- Biceps retraction test - grasp tendon insertion near cranial elbow and pull caudal while standing
What are treatment options described for IOHC?
Prognosis?
Complication rate?
- transcondylar cortical screw
- transcondylar lag screw (shaft screw)
- transcondylar cancellous screw
- transcondylar cannulated screw
- transcondylar fenestrated tubular screw