SA Forelimb Flashcards
What are some potential problems you can get with the shoulder joint?
- soft tissue injuries –> instability
- biceps tendon injury
- osteochondrosis / OCD
- infraspinatous contracture
- fracture of scapula or proximal humerus
- osteoarthritis
What are some shoulder soft tissues that can be damaged to cause shoulder instability?
- Medial glenohumeral ligament
- Lateral glenohumeral ligament
- Subscapularis tenson
What is the treatment for the shoulder instability with soft tissue injuries?
Conservative: motnhs
Surgical imbrication (capsulorrhaphy) or reinforcement (some debate as to the usefulness of these techniques)
How can you diagnose a biceps tendon injury in the shoulder?
Can be difficult to diagnose
Biceps test - pain on shoulder flexion with elbow extension
Usually partially torn at insertion on supraglenoid tubercle of scapula
What is the treatment for a biceps tendon injury of the shoulder?
- Conservative –prolonged rest (months) + NSAID’s
- Intra-articular corticosteroid injection
- Surgical release of biceps tendon at insertion +/-re-attachment to proximal humerus with screw and spiked washer (tenodesis)
- One treatment is to cut the tendon if slightly torn –reduces the pain, the lameness may come from discomfort from the tearing of the fibres,so can relieve this by getting rid of the tearing but actually cutting it
What is the signalement for osteochondrosis of the shoulder?
Young, medium to large breed dogs particularly border collies
What is the diagnosis for osteochondrosis of the shoulder?
- Radiography –subchondral bone lucency
- Arthrogram –highlights flap
- Arthroscopy –direct visualisation of the flap. – can see the flap without the cause for any radiographic technique. Also allows you to remove the flap. Some don’t want flap removing, they just exercise the dog a lot so the flap comes off
What is wrong with this arthrogram radiograph?
Shoulder: osteochondrosis
What are the treatment options for osteochondrosis of the shoulder?
What is the prognosis?
Treatment:
- Conservative if not very lame
- Surgery to remove flap (arthrotomy or arthroscopy)
- Prognosis: good to excellent (esp. if < 12-months-old)
What can cause mineralisation of soft tissues in the shoulder?
- May be incidental finding
- May be associated with forelimb lameness and pain on firm palpation of region
- Mineralisation of various tendons can occur –can seeonthebicipital groove.Sometimesofno significancebutoccasionally can occurontendon ofinsertion and can be indicative of some pathology in these tendons, some can remove these and it improves lameness but this is questionable
- Supraspinatous muscles
- Bicipital groove
What is wrong here with this radiograph?
Mineralisation of soft tissues
Supraspinatous muscle
Bicipital groove
What is the treatment for mineralisation of soft tissues?
Sometimes of no significance and is an incidental finding - sometimes no treatment required
Conservative
Surgical excision
What is infraspinatous contracture?
Occurs in working dogs mostly
Repetitive trauma is a possible association
Contracture - a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints
What is the classical posture for infraspinatous contracture?
Flexed elbow with external rotation of the limb - elbow flexed and hold leg abducted out to the side
What is the treatment for infraspinatous contrature?
Isolate and identify this tendon and cut it –> instant improvement, good long-term prognosis
What is this posture a sign of?
Flexed elbow with external rotation of the limb - elbow flexed and hold leg abducted out to the side
Classical posture of infraspinatous contracture
What things can go wrong most commonly with the elbow joint?
Elbow dysplasia
Osteoarthritis
Elbow fractures
What is elbow dysplasia and what causes it?
- Dysplasia = abnormal elbow development
- group of developmental problems
- insufficient evidence for single underlying mechanism
- can be bilateral or unilateral
- can be > 1 condition in same elbow
- ‘ medial compartment disease ’
- Not clear there is a single underlying mechanism that causes it, there is an element of genetics and developmental abnormalities
- Can be bi or unilateral
- Gives rise to more than one particular condition within the elbow
What is the general underlying cause of elbow dysplasia?
Incongruence - alteration in the smooth transition of the articular surfaces
What can incongruence result from?
Incongruence can result from either a short radius or ulna
What can abnormal stresses placed on the articular surfaces cause?
Fragmented medial cornoid, osteochondrosis dessicans and ununited anconeal process and possible a fragmented medial epicondyle and tendon enthesiopathy
- all of these give rise to OA/DJD
What is a tendon enthesiopathy?
an enthesopathy refers to a disorder involving the attachment of a tendon or ligament to a bone. This site of attachment is known as the enthesis
What is the characteristic stance of a dog with elbow dysplasia?
Hold the affected leg slightly abducted, wont take full pressure on it and slightly externally rotated
What is the most important factor that gives rise to elbow dysplasia?
It is a multifactoral disease, but most important factor is genetic make up of the dog: polygenic + high heritability
High degree of heritability
What are some things that can influence the severity of elbow dysplasia?
- Growth rate
- Diet
- Exercise
They cannot prevent the disease or reduce the potential of the dog to pass it on to its offspring
How are we attempting to reduce the prevalence of elbow dysplasia?
What is the problem with this?
Use of various genetic or screen tests - radiography
Problem is that its not always successful at finding it - but arthroscopy suggests that radiographs poorly predict pathology within the joint
What can be seen on the following radiographs?
- Extreme example of elbow incongruity
- Ulnar is short
- Look at anconaeus (beak of bone on more proximal aspect) can appreciate its coming up against caudal aspect of humeral condyles
- Look at supratrochlear notch, can appreciate radial head appears to be adjacent
- Ulnar isn’t in line with articular surface
- Joint incongruity –abnormal pressures in the joint
- Can cut the ulnar (leftpic) which allows it to move proximally, so have more congruent joint surfaces
What is fragmentation of the medial aspect of the cornoid process?
the big condition of the elbow –major consequence of incongruence.
Comes under abnormal stress, pressure from humerus, and it fragments and breaks.
Articular cartilage is damaged –get loose piece of bone in the joint process
What is the presentation with a fragmentation of the medial aspect of the coronoid process?
- Large breeds -Rottweiler, Bernese mountain dog, Newfoundland, Staffordshire bull terriers and retrievers (occasionally small breed of dogs)
- More males affected than females (2-3:1)
- Commonly bilateral disease in 50-90% cases
- If you have a case and have early arthritic change, always essential to radiograph the other limb as there are likely changes in the other one also
Are males and females more affects with a fragmentation of the medial aspect of the coronoid process?
Males more affected
Is fragmentation of the medial aspect of the coronoid process unilateral or bilateral?
Commonly bilateral disease in 50-90% of cases
What are the clinical signs of a fragmented cornoid process?
Clinical signs usually by 4-7 months:
- variable forelimb lameness, pain on elbow manipulation
- Tends to be worse when they have been resting and then they get up
- elbow flexion and rotation of antebrachium
- If rotate radius and ulnar, animal will often pull back. Always compare one with the other
- may have elbow joint effusion –if severely affected. Just caudal to the trochlear ridge, just behind humerus –can sometimes see it, but can feel it
- Arthritis becomes then apparent at a later stage. They start off lame in early life, maybe get better and then arthritis kicks in
- Watch them as they get up and come into consult room
- When they stand–slight outward rotation, limb slightly abducted, taking weight off affected limb
What is the pathology of a fragmented medial cornoid process?
- fissure / fragmentation of the craniolateral part of the MCP
- usually a single fragment of the bone when the fissure becomes complete, with attachments to the annular ligament
- ±thickened cartilage
- ±gross ‘ step ’ between cranial border of articular surface of ulna and radius
- ±eburnation resulting in a ‘ kissing lesion ’ on opposing humeral articular surface
- Some of the osteochondrosis and cartilage defects–a consequence of damage to coronoid process
What do you notice about these pictures?
Fragmented Medial Coronoid Process
Can see step between radial head and ulnar on right pic after it has fragmented off
How can you diagnose fragmented medial coronoid process?
- Hard to see radiographically
- Often wont see it
- Sometimes people will do lazy cranio caudal view –let elbow adduct slightly but often you will mainly see secondary changes within the joint –have to extrapolate form this thatitslikelyto dog has a FMCP
- CT is best to see – it is whiter than you would expect
Should you treat a fragmented medial cornoid process conservatively or surgically?
- Studies report variable results: some indicate better (short-medium term) outcomes following surgical removal of fragments, others show no benefit compared to conservative management.
- DJD progresses with both
- Longterm, dogs don’t do well if they have FMCP –short term may be beneficially to remove it, but if you expose subchondral bone, may cause large inflammatory response –so most try to manage these cases conservatively and ONLY REMOVE if you are NOT getting anywhere with conservative management –e.g. rest, NSAIDs and seeing back at regular intervals and keep case under constant review
Treatment:
Conservative management Surgical options:
- arthrotomy or arthroscopy to remove fragment
- proximal ulnar osteotomy –morbidity
- sliding humeral osteotomy –moving humerus a little, trying to reduce amount of pressure applied to fragmented coronoid and allowing it to heal
Which breeds have a predispostion to osteochondritis dissecans?
Males or females more common?
Predisposition in retrievers and Newfoundland
Greater incidence in males
Is osteochondritis dissecans unilateral or bilateral?
Bilateral in 50-90% cases
When do you see clinical signs with osteochondritis dissecans?
Onset of clinical signs 4-7 months
What is the cause of osteochondritis dissecans?
Increased incidence with increased energy intake (+/- increased Ca/P), growth rate and birthweight (being heavier than other dogs)
What is the treatment for osteochondritis dissecans?
- Conservative : exercise restriction, analgesia, nutraceuticals, balanced diet
- Surgical : remove flap and debride subchondral bone -blood and mesenchymal stem cell precursors –> encourage healing by fibrocartilage
What are the breed predispositions for an ununited anconeal process?
Males or females?
Breed disposition: GSD and bassett hounds
Frequency is males twice as much as females
What are the clinical signs of an ununited anconeal process?
- Onset of clinical signs 4-12 months –a little bit later than others
- Lameness, pain on elbow manipulation (+ crepitus) • joint effusion(s )
- Bilateral lameness in 11-47% cases –not as bilateral as other forms of elbow dysplasia
What is the pathology of an ununited anconeal process?
Genuine disturbance of minor physis:
- anconeal process develops as secondary centre of ossification and is usually fused by 16-20 weeks
- failure to fuse (presence of a lucent line) after 20 weeks regarded as abnormal and then it breaks
- Form of OCD? -failure to fuse results in AP remaining detached within joint
What is the conservative treatment for an ununited anconeal process?
Conservative
- Very poor prognosis with conservative management
- Occasionally see these when they are much older, fat elbow and very poor range of movement.
What are some surgical treatment options for the treatment of an ununited anconeal process?
- (a) Removal -variable results: short-term clinical improvement, long term instability and progression of DJD. Use to try and remove it but it a major part of stabilisation of the joint –get much greater progression of OA
- (b) re-attachment
- 4.0 cancellous screw (lag) and K-wire –trying to screw fragment back into place
- poor reduction –> incongruity still there –> implant failure
- (c) ulnar osteotomy
- Good/excellent function in majority of cases
- (d) ulnar osteotomy and re-attachment
- ‘excellent’ outcome at 18 months with only mild increases in DJD
What are some breed predispositions for the incomplete ossification of the humeral condyle (now called humeral intercondylar fissure)?
Mainly spaniels particularly english springer, cocker and cavalier King Charles
Also labradors
What are the clinical signs of a humeral intercondylar fissure (incomplete ossification of the humeral condyle)?
Clinical signs:
- chronic, low-grade, intermittent lameness –this is general presentation, or
- acute, severe lameness if condyle fractures
- pain on elbow manipulation and pressure applied across condyle
- If you squeeze condyle, they will object as you close the fissure between the 2 condyles
What is the diagnosis of a humeral intercondylar fissure (incomplete ossification of the humeral condyle)?
Diagnosis:
- difficult to see on plain radiographs, obvious on CT.
- Fissure likes between 2 parts of condyle and unless you get radiograph parallel to this fissure,you will not see it.
- Also get extra bit of bone as when the dog walks, the condyle parts spring apart –which is why new bone forms Incomplete ossification of the humeral condyle (now called humeral intercondylar fissure)
What is the treatment of a humeral intercondylar fissure (incomplete ossification of the humeral condyle)?
- Conservative: risk of fracture
- Surgical: prophylactic transcondylar lag screw although may be associated with morbidity
- Run the risk of them getting a condylar fracture if they jump about a lot! Incomplete ossification of the humeral condyle (humeral intercondylar fissure)
What is the end result of aforementioned conditions of the elbow?
End result is DJD/OA
What is the conservative management for DJD/OA of the elbow?
Conservative management
- weight control essential Salvage procedures if can’t control pain e.g. joint replacement (dogs), arthrodesis (guarded prognosis), amputation (?)
What are some types of elbow fracture?
Supracondylar:
- fracture through the supratrochlear foramen
- epicondyles symmetrical, but gross instability in supracondylar area
Unicondylar
- intra-articular
- usually lateral condyle
What is the prognosis for elbow fractures?
Prognosis generally favourable for single condylar and supracondylar fractures: 64-70% regain ‘reasonable’ function
How can you fix supracondylar/unicondylar fractures of the elbow?
Young animal –screw
Old animal–place lag screw and also a plate on the supratrochlear ridge as pin wont be strong enough and the screw will be what the animal walks on, the intercondylar fissure will never heal –requires support, which is why a plate and a screw is appropriate
How can you fix bicondylar fractures like the one shown in the image?
- very challenging -refer ! Require 2 plates and a large screw across the condyles –so if you get one, immediately refer to orthopaedic surgeon
- marked swelling and instability –> collapse
- intracondylararticular fracture, with supracondylar transverse ( ‘ T ’ ) or oblique ( ‘ Y ’ ) fracture lines • guarded prognosis
- Exercise must be restricted post-operatively, but must maintain joint ROM with passive physio and swimming
What are some treatment options for METACARPAL fractures?
Treatment options include:
Conservative:
- bandage or cast -must extend beyond toes to minimise weight-bearing
Surgical:
- ESF
- small plates and screws
- (intramedullary pins and wires)
- If one or two metacarpal bones intact, acceptable to place a cast or bandage but if more fractured –may need to do something in the way of repair. 3 rd and 4 th most important metacarpals.
What are some primary and secondary neoplasia of the limbs?
Primary:
- Osteosarcoma - predilection sites : proximal humerus, distal radius
- fibrosarcoma, haemangiosarcoma, chondrosarcoma
- synovial cell sarcoma
Secondary (metastatic) -less common
What are some clinical signs and diagnoses of appendicular neoplasia?
- increasingly severe lameness despite analgesia
- increasingly severe muscle atrophy
- characteristic radiographic changes –> biopsy
What are some treatment options for appendicular neoplasia?
- amputation / limb-sparing + chemo
- radiation
- palliation (short-term): analgesia
What should you always advise the client on with appendicular neoplasia?
What do you advise client?
Some want a Noel Fitzpatrick, but usually followed up with chemo – but it is important to appreciate that the dog will succumb as a result of this particular condition.
Amputation?
Otherwise, just go for palliation and PTS when time is right
What are some clinical signs for a nerve root tumour?
- Often:
- chronic lameness
- very severe lameness
- marked muscle atrophy
- older animals
- +/-palpable axillary mass
- Neurological deficits
- Poor response to analgesia
Cats:
- How common are shoulder problems in cats?
- What are some common problems of the elbow?
- Elbow dysplasia?
- Shoulder problems are rare in cats
- Elbow –osteoarthritis and synovial cysts of the cat is not uncommon
- (Cats don’t seem to develop elbow ‘dysplasia’) –not something they suffer from
