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Applied Clinical Veterinary Nursing > Ortho - Hips, elbows and cruciates > Flashcards

Ortho - Hips, elbows and cruciates Flashcards

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1
Q

what is hip dysplasia?

A

a common inherited developmental disease characterised by laxity of the hip joint

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2
Q

are hips lax from birth?

A

no, puppies are born normal - laxity apparent from 4-5 months

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3
Q

which animals are commonly affected by hip dysplasia?

A

most commonly large and giant breed dogs
also affects small breeds and cats

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4
Q

when are the earliest signs of hip laxity usually seen?

A

4-5 months

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5
Q

what is the usual signalment for hip dysplasia?

A

4-12 months at first presentation

second phase affects adults - present with arthritis secondary to hip dysplasia - no laxity

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6
Q

what is the usual history associated with hip dysplasia?

A

hindlimb stiffness and difficulty mobilising, affecting both legs, bunny hopping, adducted hindlimbs

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7
Q

what can we see on gait analysis which is characteristic of hip dysplasia?

A

short stride on hindlimbs

lateral sway to avoid full stride - uses back

bunny hopping

adducted hindlimbs

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8
Q

what might we see upon orthopaedic examination of a patient with hip dysplasia?

A

muscle atrophy (quadriceps)
pain on hip extension
crepitus
clunking

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9
Q

what radiographic views are useful in diagnosing hip dysplasia?

A

v/d extended
frog leg
lateral pelvis

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10
Q

which manipulation tests can be used to test for hip dysplasia?

A

ortolani test

Bardens hip lift test

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11
Q

in which cases is the ortolani test not useful?

A

older dogs with arthritis

negative in cases of dislocation - will be unable to relocate joint

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12
Q

how is the Bardens hip lift test performed?

A

patient in lateral

hip is levered out of acetabulum to see how much ‘bounce’ is achieved

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13
Q

can the Bardens hip lift test be done on a conscious patient?

A

no - patient must be heavily sedated/under GA - painful test

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14
Q

what is classed as an abnormal Bardens hip lift result?

A

> 0.5cm

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15
Q

what are the available treatment options for hip dysplasia?

A

conservative managament

myotomies

growth plate fusion

osteotomies

THR

FHNE

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16
Q

what type of growth plate fusion is carried out on patients with hip dysplasia?

A

juvenile pubic symphysiodesis

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17
Q

which patients are suitable for growth plate fusion/osteotomy?

A

young patients with early diagnosis

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18
Q

what is involved in conservative management of hip dysplasia?

A

restricting exercise to lead-only - short regular walks, no off-lead

hydrotherapy

controlling food intake to restrict weight and slow down growth

judicious use of NSAIDs and other medication

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19
Q

can conservative management improve degree of subluxation?

A

not shown to improve - remains same or worse

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20
Q

what is juvenile pubic symphysiodesis?

A

iatrogenic closure of the pubic symphysis

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21
Q

how is juvenile pubic symphysiodesis achieved?

A

electrocautery to create thermal necrosis

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22
Q

what does juvenile pubic symphysiodesis result in?

A

growth of acetabulum which increases dorsal cover of the femoral head

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23
Q

why is juvenile pubic symphysiodesis rarely done?

A

must be done when patient is very young, during early growth phase - rarely identified this early

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24
Q

why is it important to neuter dogs who have had juvenile pubic symphysiodesis?

A

to ensure they are not bred from to avoid passing the condition on

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25
Q

when should a triple/double pelvic osteotomy be performed?

A

by 6-7 months, no DJD present

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26
Q

why is a triple/double pelvic osteotomy not commonly performed?

A

most cases are identified too late for this approach

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27
Q

how do we identify patients who are suitable for a triple/double pelvic osteotomy?

A

good clunk on ortolani test

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28
Q

what is the aim of a triple/double pelvic osteotomy?

A

increase dorsal cover of the femoral head

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29
Q

how is a triple/double pelvic osteotomy performed?

A

cutting into bone of ilium, pubis and ischium and rotating bone round to improve dorsal cover of the femoral head

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30
Q

what are the possible complications of a triple/double pelvic osteotomy?

A

screw pullout
screw breakage

  • do not usually require correction
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31
Q

what is the success rate of triple/double pelvic osteotomy?

A

90% success

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32
Q

does a triple/double pelvic osteotomy prevent arthritis?

A

no - may still require salvage surgery later on

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33
Q

what type of procedure is a FHNE?

A

salvage procedure - pseudoarthrosis

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34
Q

what is a pseudoarthrosis?

A

fills in with bone and fibrous tissue

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35
Q

how can we improve outcome after a FHNE?

A

encourage exercise after surgery - outcome improved by good post-op rehabilitation programme

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36
Q

what is denervation?

A

removal of the nerves on the dorsal acetabulum - not commonly done

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37
Q

when might denervation be carried out?

A

with cost constraints - cheaper and provides pain relief

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38
Q

what are the aims of a THR?

A

pain relief

return of high level function

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39
Q

what are the indications for THR?

A

end-stage hip arthritis

hip dysplasia (younger dogs)

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40
Q

what are the 2 main types of prosthesis in THR?

A

acetabular prosthesis

femoral prosthesis

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41
Q

what are the overall steps of the surgical procedure for a THR?

A

femoral head excision

ream acetabulum and femur

cement acetabulum and femur

place “femoral head”

reduce hip

take bacterial swab

suture joint capsule, routine closure

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42
Q

which approach is used during a THR?

A

craniolateral approach

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43
Q

what does it mean to ‘ream’?

A

remove cartilage

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44
Q

why should the joint capsule be sutured as part of a THR?

A

helps reduce the chance of dislocation following surgery

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45
Q

why should we take a bacterial swab during a THR?

A

to ensure no contamination of the site during surgery

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46
Q

what are we assessing on the immediate post-op radiographs after a THR?

A

positioning of femoral stem and acetabulum

cement fill - no fissures, leakage

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47
Q

what are we assessing on long-term radiographs after a THR?

A

position of femoral stem and acetabulum

periosteal reaction

cement/bone interface

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48
Q

when should post-op radiographs be taken for a THR?

A

immediately post-op and 6 weeks post-op

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49
Q

what are the possible complications after a THR?

A

fracture

loosening

dislocation

infection

subsidence

cement granuloma

neurological issue

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50
Q

what are the 2 main type of hip implant available?

A

cemented vs uncemented

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51
Q

which factors influence the type of THR performed?

A

surgeon preference, shape of femur/acetamulum, equipment available in practice

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52
Q

what is involved in post-op care after a THR?

A

cage

lead walks only

ehmer sling

hobbles

avoid slippery surfaces, avoid jumping

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53
Q

what occurs at the end of the post-op period?

A

re-examination and further radiographs taken - ensure no complications have occurred

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54
Q

how can loosening of the THR implant be seen on radiographs?

A

increased lucency between the bone and cement

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55
Q

how can infection of the THR implant be seen on radiograph?

A

periosteal reaction

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56
Q

what should occur is progress is satisfactory at the 6 week check?

A

gradual return to normal exercise over the next few months

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57
Q

what is the most common cause of forelimb lameness in dogs?

A

developmental elbow disease (DED)

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58
Q

what type of abnormalities can be involved in developmental elbow disease?

A

fragmented medial coronoid process of the ulna

osteochondritis dissecans

joint incongruity

ununited anconeal process of ulna

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59
Q

why does joint incongruity occur in the elbow?

A

asynchronous growth of radius and ulna

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60
Q

what does developmental elbow disease result in?

A

varying amounts of elbow osteoarthritis

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61
Q

can different abnormalities of developmental elbow disease occur at the same time?

A

yes

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62
Q

what is the common signalment for elbow dysplasia?

A

large breeds e.g. labradors, rottweilers, retrievers, BMDs

6 months and older (at presentation)

males over-represented - females also affected

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63
Q

when might a dog present older with developmental elbow disease?

A

if have arthritis secondary to elbow disease

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64
Q

what are the signs of elbow dysplasia?

A

lameness

elbow effusion if severe

decreased ROM

pain on extremes of flexion and extension

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65
Q

what is the common history for a dog with elbow dysplasia?

A

low grade mild lameness, bilateral

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66
Q

which radiography views are helpful in the diagnosis of DED?

A

cranio-caudal, medio-lateral and flexed lateral views of the elbow

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67
Q

which radiographic features are indicative of DJD in elbow dysplasia?

A

sclerosis of the ulnar notch

flattened or blurred coronoid process

increased humeroradial joint space

68
Q

what is the neutral lateral view of the elbow useful for?

A

looking for incongruity

69
Q

what is the fully flexed mediolateral view of the elbow useful for?

A

looking at dorsal osteophytes on the anconeus

70
Q

what is the cranio-caudal view of the elbow useful for?

A

looking for osteochondritis dissecans

71
Q
A
72
Q

what is the craniolateral-caudomedial oblique view of the elbow useful for?

A

looking for fragmentation of the coronoid process (FCP)

73
Q

what is the distomedial-proximolateral oblique view of the elbow useful for?

A

viewing the coronoid process (looking for FCP)

74
Q

what is the gold standard method for diagnosis of fragmentation of the coronoid process in the elbow?

A

CT scan

75
Q

what is the signalment for ununited anconeal process?

A

large breed dogs, esp. german shepherds

76
Q

at what age should the anconeal process fuse to the proximal ulna?

A

4-5 months

77
Q

what happens if the anconeal process doesn’t fuse to the proximal ulna?

A

elbow stability is compromised and osteoarthritis ensues

78
Q

how does ununited anconeal process occur?

A

short ulna compared to radius - growth proceeds and creates a shear separating the anconeal process from the ulna

79
Q

how is ununited anconeal process diagnosed?

A

fully flexed mediolateral radiographs or CT scan

80
Q

what are the treatment options for ununited anconeal process?

A

conservative treatment

removal of anconeal process (older dogs)

proximal dynamic ulna osteotomy

lag screw fixation (reattachment)

81
Q

what determines treatment options for ununited anconeal process?

A

age and displacement of the anconeus

82
Q

what happens during a proximal dynamic ulnar osteotomy?

A

cutting of the ulna - allows lengthening of the ulna as the radius grows and removes the shear stress of the anconeal process, allow it to reunite with the ulnar metaphysis

83
Q

when might fragment removal for ununited anconeal process be performed?

A

not usually recommended unless the fragment is very displaced or abnormal

usually done in older dogs with OA

84
Q

what is an ulnar ostectomy?

A

removal of small part of the ulna

85
Q

how can short radius syndrome be improved?

A

dynamic partial ulnar ostectomy - allows improved humeroradial contact

86
Q

what is the signalment for osteochondrosis dissecans?

A

medium-sized and larger breeds

presentation around 6 months, sometimes younger

87
Q

which part of the elbow is usually affected be osteochondritis dissecans?

A

medial humeral condyle

88
Q

what is the common history for a osteochondritis dissecans case?

A

forelimb lameness since 5-6 months age

can have some improvement on NSAIDs

89
Q

what is osteochondritis dissecans?

A

cartilage flap on the medial condyle of the elbow

90
Q

what is the presenting sign of osteochondritis dissecans?

A

forelimb lameness and effusion

91
Q

how can osteochondritis dissecans be seen on radiographs?

A

craniocaudal and flexed mediolateral views

92
Q

how is osteochondritis dissecans usually seen on radiographs?

A

flattening of medial humeral condyle on CC view - subchondral bone defect

93
Q

what are the treatment options for osteochondritis dissecans?

A

conservative treatment - restricted exercise, NSAIDs

surgery - arthrotomy/arthroscopy and debridement for flap removal

abrasion arthroplasty or microfracture of the subchondral bone (stimulating bone to heal)

94
Q

what is treatment of osteochondritis dissecans dependent on?

A

severity of lameness and size of lesion

95
Q

what is the most common elbow pathology diagnosed in dogs with elbow dysplasia?

A

fragmented medial coronoid process

96
Q

where is fragmentation most commonly seen with fragmented medial coronoid process?

A

craniolateral aspect of the medial coronoid process of the ulna, adjacent to the radial head

97
Q

how do bone fragments look under arthroscopy in fragmented medial coronoid process?

A

bone fragments often dead and yellow in appearance compared to well-vascularised red-coloured live bone

98
Q

what are the possible causes of fragmented medial coronoid process?

A

shallow ulnar notch

short ulna during growth

99
Q

what is the signalment for fragmented medial coronoid process?

A

6-10 months old

medium-large breed dogs (some small)

often bilateral

100
Q

how is fragmented medial coronoid process diangosed?

A

x-ray/CT

101
Q

how is fragmented medial coronoid process treated?

A

arthroscopic debridement

medical management of arthritis well established already

102
Q

what do dogs with elbow dysplasia go on to develop?

A

osteoarthritis

103
Q

what is involved in medical management of OA?

A

NSAIDs, weight loss, hydrotherapy, physiotherapy

104
Q

how can severity of OA be evaluated?

A

arthroscopy

105
Q

what is the goal of surgical OA treatment (arthroscopically)?

A

debridement of necrotic cartilage
removal of sclerotic bone
neovascularisation
recruitment of pluripotential mesenchymal cells

106
Q

how can OA be surgically treated?

A

removal of loose cartilage and subchondral bone via abrasion arthroplasty

stimulation of healing bone using microfracture - induced stem cell healing of hyaline cartilage

107
Q

why is long bone osteotomy for DED often performed on the medial side?

A

dogs with DED often have more problems on the medial aspect of the the joint than the lateral (medial compartment disease)

108
Q

what is the aim of a long bone osteotomy?

A

decrease medial compartment load

109
Q

what is the aim of a sliding humeral osteotomy?

A

transfer weightbearing from the medial aspect of the joint to the lateral aspect

110
Q

what is the purpose of a proximal abducting ulna osteotomy?

A

transfer weightbearing from the medial aspect of the joint to the lateral aspect

111
Q

what are the surgical options for long bone osteotomy?

A

sliding humeral osteotomy

proximal abducting ulnar osteotomy

proximal dynamic ulnar osteotomy

112
Q

what is proximal dynamic ulna osteotomy performed for?

A

medial compartment disease

radioulnar icongruence

ununited anconeal process

113
Q

why is elbow replacement not commonly performed in dogs?

A

complications are common, often require additional surgery and ultimately may lead to arthrodesis or amputation

114
Q

when might an elbow arthrodesis be performed?

A

final salvage procedure for end-stage painful joint

115
Q

what are the indications for arthroscopy?

A

exploration of joint for diagnosis

removal of loose bodies

topical treatment for OA - microfracture and abrasion arthroplasty

debridement and lavage

assisted joint stabilisation or fracture repair

116
Q

what are the advantages of arthroscopy compared to arthrotomy?

A

decreased morbidity

more rapid recovery

decreased complications and improved outcomes

decreased surgery/GA/hospitalisation times

117
Q

what are the disadvantages of arthroscopy?

A

high skill level required, long learning curve

expensive equipment

increased cost to client

118
Q

which diameter arthroscope is used for elbows?

A

1.9, 2.4 or 2.7mm

119
Q

what is the lens angle for an elbow arthroscope?

A

30 degrees - allows for wider view

120
Q

what is the normal working length for an elbow arthroscope?

A

short 8.5cm or long 13cm

121
Q

what does the cranial cruciate ligament do?

A

resists stifle extension

resists internal rotation

prevents tibia moving cranially

122
Q

which animals are affected by cranial cruciate ligament rupture?

A

dogs, rarely cats

overweight females, neutered, middle aged

123
Q

via what 3 ways can cruciate ligament rupture occur?

A

traumatic

degenerative

inflammation

124
Q

how does traumatic cranial cruciate rupture occur?

A

can be seen after heavy fall, catching foot at awkward angle, RTA

125
Q

how does degenerative cranial cruciate rupture occur?

A

rupture occurs secondary to minimal trauma through ligaments that how evidence of degeneration and ageing

126
Q

how does inflammatory cranial cruciate rupture occur?

A

occurs in joints with evidence of inflammation e.g. rheumatoid arthritis

127
Q

how can we diagnose cranial cruciate ligament rupture?

A

cranial draw test

tibial compression test

radiographs - mediolateral and cr/cd views

128
Q

what can be seen on radiographs where cranial cruciate rupture has occurred?

A

joint effusion - seen as compression of the parapatellar fat pad

chronic - evidence of OA/DJD seen as osteophyte formation on various parts of stifle

129
Q

how can we surgically treat cranial cruciate ligament rupture?

A

intra-articular replacement of ligament

extra-articular replicate function of ligament

combination of above

alteration of joint angles

130
Q

what is involved in conservative management of cranial cruciate ligament disease?

A

strict rest for 6-8 weeks

131
Q

which animals are more suited to conservative management for cranial cruciate ligament disease?

A

dogs and cats <15kg

132
Q

which type of stifle lesion does not do well with conservative management?

A

those with meniscal tears

133
Q

what happens if there is not improvement from conservative management for cranial cruciate ligament disease?

A

surgery is indicated if no improvement after 6-8 weeks of rest

134
Q

what are the principles of surgical therapy for cranial cruciate ligament disease?

A

confirm diagnosis via exploratory arthrotomy

debridement of ruptured ligament

check and remove torn pieces of menisci

stabilisation of the stifle joint

135
Q

give a brief overview of the lateral (DeAngelis) suture technique for cranial cruciate ligament disease

A

suture is placed medial to the lateral femorofabella ligament, under the patellar ligament and through a small tunnel in the tibial tuberosity

progressively increase tension and check for cranial drawer

136
Q

which suture material should be chosen for lateral suture technique?

A

non-absorbable, monofilament, very strong

large gauge nylon in smaller patients (ethilon/prolene)

fishing leader line (monofilament nylon) in larger patients

137
Q

how is the suture secured in the lateral suture technique?

A

metal tube and crimp fastener

138
Q

how is the fascia lata repaired during lateral suture?

A

modified mayo mattress suture

139
Q

what are the possible complications of lateral suture?

A

suture failure - breakage, stretching, pull through crimp

instability

infection

meniscal tear

anchor pull-out

140
Q

what is the advantage of a lateral suture technique?

A

common complications are rarely severe

141
Q

how does the femur move in relation to the tibia when the cranial cruciate ligament is ruptured?

A

femur slides caudally down the slope of the tibial plateau - tibial thrust is cranial

142
Q

what is the average angle of the tibial plateau?

A

24 degrees

143
Q

what are the general concepts involved in TPLO surgery?

A

medial arthrotomy to inspect cruciate and menisci

medial approach to proximal tibia - circular saw used to cut proximal tibia

cut part of tibia rotated a predetermined number of degrees to increase tibia plateau to 5-7 degrees

bone stabilised in new position with TPLO plate

144
Q

why does the tibia move when the cranial cruciate ligament ruptures?

A

it is the only passive restraint to ‘slippage’ against weight and muscular propulsive forces

145
Q

what type of technique is a TPLO?

A

joint mechanic altering technique

146
Q

why are locking plates preferred over traditional plates for TPLO?

A

increased stability and better limb alignment

147
Q

where is the TPLO plate positioned?

A

medial surface of the tibia

148
Q

which type of saw is used for a TPLO?

A

oscillating

149
Q

what are possible complications of TPLO?

A

fibula fracture

peroneal nerve damage

popliteal artery trauma

tibial tuberosity avulsion fracture

patella ligament desmitis

pivot shift

osteomyelitis

seroma formation

150
Q

what is the prognosis with TPLO?

A

80% of patients return to soundness

151
Q

what are some of the alternative techniques to TPLO?

A

cranial closing wedge/tibial wedge ostectomy

tibial tuberosity advancement

modified maquet technique

triple tibial osteotomy

152
Q

what do all the surgical procedures for cranial cruciate rupture have in common?

A

work on a similar principle of trying to eliminate the tibial thrust that occurs after CCL rupture

153
Q

what is involved in post-op care after cruciate surgery?

A

confinement and minimal exercise for 4-6 weeks

carefully controlled and gradual increase in exercise for the following 6-10 weeks

physiotherapy and hydrotherapy

154
Q

what are menisci?

A

‘C’ shaped pads of fibrocartilage in the stifle joint

155
Q

what is the function of menisci in the stifle joint?

A

shock absorption and aid in fluid shift and nutrition in the joint

156
Q

which meniscus is more commonly damaged?

A

medial meniscus

157
Q

why might the medial meniscus be more commonly damaged?

A

possible due to its attachment to the medial collateral ligament - means it is less mobile and more prone to crushing and grinding

158
Q

what usually goes alongside meniscal injuries?

A

usually seen subsequent to cranial cruciate disease - rarely in isolation

159
Q

how might we detect meniscal injury?

A

may have a palpable or audible click on stifle manipulation (not reliable)

stifle is painful

160
Q

how can meniscal injury be confirmed?

A

careful inspection during stifle arthrotomy/arthroscopy using a stifle/Senn retractor or Hohmann retractor and good light

161
Q

what types of meniscal injuries are possible?

A

bucket handle tears

detachment of the caudal horn

fibrillation

162
Q

what is involved in treatment for meniscal injuries?

A

probe with meniscal probe

torn portion removed using meniscal forceps and sharp narrow scalpel blade

163
Q

why should owners be advised to carefully observe their animal after cruciate surgery?

A

meniscal tears can occur late after cruciate surgery (months/years)

164
Q

why do dogs with meniscal tears have a poorer prognosis than those without?

A

they are more prone to developing DJD and post-cruciate stiffness/lameness long-term

165
Q
A

Applied Clinical Veterinary Nursing (31 decks)

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