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Small animal surgery I > Shoulder disease > Flashcards

Shoulder disease Flashcards

1
Q

What is the signalment for OCD of the shoulder in the dog?

A
  • Developmental orthopedic disease
    • Biphasic age distribution
    • 4-8mo (cartilage injury)
    • Middle aged to older (secondary DJD)
  • May have bilateral disease
  • Young, male, large do giant breed dogs
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2
Q

What are the PE/orthopedic exam findings on a dog with OCD of the shoulder?

A
  • Forelimb lameness
    • Head bob–“down on sound”
    • Muscle atrophy
  • Pain on hyperextension of the shoulder joint
  • Pain on flexion of the shoulder joint
  • May have unilateral lameness despite bilateral disease (one side can be worse)
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3
Q

What 3 characteristics are required in order for a patient with OCD to qualify for conservative therapy only?

A
  • Small defect
  • Minimal to no lameness
  • Very young dog (< 6mo)

ALL must be true

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4
Q

Which treatment is typically recommended for OCD of the shoulder (general)?

A

Surgical

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5
Q

What is involved in conservative treatment of OCD of the shoulder?

A

Rest

Diet: controlled energy, vitamin D, Ca

NSAIDs

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6
Q

Describe in general terms what is involved in the surgical treatment of OCD of the shoulder

A
  • Surgical treatment is the standard of care
  • Flap removal and joint lavage
  • Debridement of bone with curette or shaver
  • Defect heals with fibrocartilage
  • Arthroscopy preferable to arthrotomy
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7
Q

What is the prognosis for OCD of the shoulder?

A
  • Much better with sx than w/o
  • Near-normal to normal function w/ sx
    • Pet dog–good to excellent
    • Working dog–fair to good
    • (Assuming sx is done prior to onset of DJD)
  • DJD expected w/o surgery
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8
Q

What is the typical pathogenesis of biceps brachii tendinopathy in dogs?

A
  • Repetitive strain microtrauma
  • Injury w/ tendon fiber disruption
  • Acute to chronic inflammation of tendon and associated synovial tissues
  • Both acute and chronic inflammation present histopathologically
  • If etiology is repetitive trauma or overuse –> probably seen unilaterally in adult dogs
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9
Q

What is the signalment of biceps brachii tendinopathy in dogs?

A
  • Mature adult dogs
  • Medium and large breeds
  • Wt.-bearing lameness
    • Chronic, intermittent
    • Progressive
    • Lameness worsens w/ exercise
    • Unilateral
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10
Q

What are the PE/orthopedic findings associated with biceps brachii tendinopathy?

A

Muscle atrophy

Pain

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11
Q

What manipulations are used during the orthopedic exam to evaluate the biceps tendon when biceps brachii tendinopathy is suspected?

A
  • Maximally flex shoulder and extend elbow
    • Deep palpation over intertubercular groove
    • Apply tension to biceps insertion
  • Standing exam, under load: tension to biceps
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12
Q

What is the relationship between the anatomy of the tendon and the ortho exam manipulations?

A
  • Palpate insertion of biceps tendon
  • Pressure there applies tension to biceps
  • Stretch in biceps tendon elicits pain
  • May also be done in lateral recumbency
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13
Q

Why are radiographs taken when diagnosing biceps brachii tendinopathy? Which views are used?

A
  • “Standard” craniocaudal and lateral views taken to rule out other diagnoses
  • “Skyline” view and arthrograms exist, but are not commonly used–overlap with other conditions
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14
Q

What are the pros and cons of using ultrasound for biceps brachii tendinopathy?

A

Pro: non-invasive

Con: requires experience

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15
Q

What are the pros and cons of using MRI for biceps brachii tendinosis?

A
  • Pros
    • Cross-sectional anatomy of all soft tissues
    • Identify concurrent problems
  • Con: over/underinterpretation possible
  • Not generally used in clinics
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16
Q

Is arthroscopy helpful for the diagnosis of biceps brachii tendinopathy?

A
  • Diagnostic and therapeutic
  • Practical considerations
    • If PE suggestive, often used in lieu of other imaging
    • Lateral/craniocaudal rads + arthroscopy
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17
Q

What is the treatment for acute presentation of biceps brachii tendinopathy?

A
  • Confinement for 4-6wks
  • NSAIDs
  • +/- PT
  • EBM lacking
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18
Q

What is the treatment for recurrent/persistent lameness presentation of biceps brachii tendinopathy?

A
  • Moderate, acute signs
  • Intraarticular corticosteroid injection
    • Methylprednisolone acetate (Depo-medrol)
    • Sample for joint fluid analysis/culture
  • Strict confinement, 4-6wks
  • PT
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19
Q

What are the indications for surgical treatment of biceps brachii tendinopathy?

A
  • Refractory to medical therapy
  • Radiographic changes
  • Mechanical deficits
  • Moderate to severe lameness
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20
Q

What is included in surgical treatment of biceps brachii tendinopathy?

A
  • Arthroscopic evaluation of the joint
    • Ensures no other problems
  • Enotomy of biceps tendon
  • Tenodesis of bicipital tendon
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21
Q

What is the difference between tenotomy and tenodesis of the biceps tendon?

A
  • Tenotomy = cutting of tendon and setting free
  • Tenodesis = cutting of tendon and fixing in place
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22
Q

What is the prognosis for medical treatment of biceps brachii tendinopathy?

A
  • Good to poor
    • Lack of confinement
    • PT improves results (presumptively)
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23
Q

What is the prognosis for surgical treatment of biceps brachii tendinopathy?

A
  • Good to excellent
    • Tenotomy–excellent results reported
    • Tenodesis–“classic treatment”
      • Good results reported historically (esp. arthroscopically assisted)
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24
Q

What is the definition of shoulder instability?

A
  • Abnormally increased ROM
  • Laxity in support structures of the shoulder
    • Medial/lateral glenohumeral ligaments
    • Joint capsule
    • Subscapularis tendon (medial)
    • Teres minor, supra- and infraspinatus (lateral)
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25
Q

What is the etiopathogenesis of shoulder instability?

A
  • Repetitive microtrauma (“overuse” injury)
  • ~80% medial shoulder instability
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26
Q

What is the most common direction of shoulder instability?

A

Medial

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27
Q

What is the typical signalment of shoulder instability?

A

Medium/large breed

Adult

28
Q

What is the typical history of a dog with shoulder instability?

A
  • +/- active dog
  • Variable lameness
    • Usually subtle, intermittent
    • Occasionally severe
  • Poor response to rest and NSAIDs
29
Q

What are the typical PE findings on a dog with shoulder instability?

A
  • Muscle atrophy
  • Pain on manipulation of joint
  • Medial instability–hallmark of diagnosis
    • Inc. abduction angle
    • Exam requires sedation
    • Gross instability palpable
    • Normals not well-established
30
Q

Which tests may be used during an orthopedic exam to detect shoulder instability?

A
  • Radiographs
  • MRI
  • Arthroscopy
  • Angle tests
    • Compare with contralateral limb
31
Q

How do you interpret the sedated examination of the shoulder when evaluating for shoulder instability?

A
  • Normal ~30 degrees
  • Abnormal ~50 degrees
  • Variation between breeds/individuals
32
Q

What are the values of using standard radiographic views when evaluating for shoulder instability?

A
  • Rule out other conditions
  • Normal or non-specific degenerative changes
  • No special fancy views described
33
Q

Which modality is best for evaluating joints for shoulder instability?

A

Arthroscopy

Diagnostic and therapeutic if PE is supportive

34
Q

What are the treatment options for shoulder instability based on?

A

Degree of instability

35
Q

What is the treatment for mild shoulder instability?

A

Rest, PT, Hobbles

36
Q

What is the treatment for moderate shoulder instability?

A
  • Arthroscopic thermal “capsulorrhaphy”
    • Thermal insult induces repair
    • Weakens tissue before it strengthens
  • Rest, PT, Hobbles
    • Must restrict movement after cauterization therapy
37
Q

What is the treatment for severe shoulder instability?

A
  • Medial glenohumeral ligament reconstruction
  • Velpeau sling instead of Hobbles
    • Keeps limb against body–takes pressure off joint
38
Q

When is hobbles recommended for shoulder instability?

A
  • Postop rehab 3wks
  • Activity restriction 3-4mo
  • Retraining begins 4-6mo
39
Q

T/F: For the test of craniocaudal instability of the shoulder, it is possible to have a positive “biceps tendon” test and a positive “shoulder drawer” test

A

TRUE

40
Q

What is capsulorrhaphy?

A

The use of heat to shrink and tighten the shoulder capsule, which is the connective tissue around the shoulder joint that helps keep it stable

41
Q

What is medial glenohumeral ligament reconstruction (in basic terms)?

A
  • Procedure for installing a cannulated bone screw and ligament washer to retain ligament at a bone site
  • A first cannula is used in conjunction with selected obturators to engage and relocate the ligament
  • A drill is used to drill a bone hole
  • A second larger cannula with a driver to screw a bone screw into the bone hole retaining the relocated ligament at the anchoring site
42
Q

Understand when ligament reconstruction is indicated

A

Severe shoulder instability

43
Q

What is the definition of contracture?

A

Muscle shortening not caused by active contraction

44
Q

What is the etiology/pathogenesis of muscle contracture?

A
  • Acute, traumatic disruption of muscle fibers
  • Fibrosis and contracture secondary to necrosis
  • Similar lesion in supraspinatus also documented
45
Q

Apply the described principles of contracture to similar lesions in the supraspinatus

A

Rupture of muscle belly–>scar tissue

46
Q

What is the typical signalment of a dog with infraspinatus contracture?

A
  • Active
  • Adult
  • Medium to large breeds
  • Hunting breeds overrepresented
47
Q

What is the typical history of a dog with infraspinatus contracture?

A
  • Acute lameness, subsides in 10-14days
  • Chronic, static lameness 2-4wks later
  • Non-painful, non-weightbearing lameness
  • Elbow adducted, antebrachium abducted
48
Q

What is the pathognomonic stance/physical appearance of a dog with infraspinatus contracture?

A
  • Scapulohumeral joint cannot be internally rotated–scapula elevates when shoulder is rotated
  • Limited ROM
  • Usually no pain on manipulation of joint
49
Q

What is the value of conservative treatment for infraspinatus contracture?

A

None–it’s useless

50
Q

What are the goals of surgical treatment and aftercare of infraspinatus contracture?

A
  • Tenectomy of infraspinatus tendon
  • Release other capsular adhesions
  • PT ideal
51
Q

What is the prognosis following surgical treatment of infraspinatus contracture?

A

Excellent

52
Q

What are the palpation findings and limb positioning of a dog with traumatic shoulder luxation?

A
  • Non-wt. bearing lameness
  • Pain on palpation of shoulder
  • Malpositioning of greater tubercle
  • Medial luxation: distal limb abducted
  • Lateral luxation: distal limb adducted
53
Q

What is the nomenclature rule for traumatic shoulder luxation?

A

Named for the position of the humeral head relative to the glenoid

54
Q

What is the most common direction of traumatic shoulder luxation?

A

Medial

55
Q

What are the indications for a closed reduction following traumatic shoulder luxation?

A
  • Recent injury
  • No fractures
56
Q

Which form of coaptation should be applied for each direction of luxation?

A
  • Medial luxation = Velpeau sling
  • Lateral, cranial, caudal luxation = Spica
57
Q

What are the indications for surgical reduction of traumatic shoulder luxation?

A
  • Chronic/recurrent/unstable luxation
  • Accompanying fractures
58
Q

What is involved in surgical reduction of traumatic shoulder luxation?

A
  • Open reduction + ligament repair
    • Simple arthrotomy to evaluate/reduce joint
    • Imbrication/repair of capsule during closure
    • Glenohumeral ligament reconstruction
59
Q

Which glenohumeral ligament of the shoulder should be reconstructed for medial luxation? Lateral?

A

Medial repair for medial luxation

Lateral repair for lateral luxation

60
Q

What is the expected functional outcome following traumatic shoulder luxation?

A
  • Prognosis: good to excellent
    • Closed reduction generally successful
      • Restores normal joint function
    • Open reduction
      • Capsulorrhaphy and MGHL reconstruction
      • Goal is to maintain normal joint motion
      • Function typically good long-term
  • Mild DJD over time may follow trauma
61
Q

What is the origin of congenital luxation?

A

Congenital laxity of capsule and ligaments

62
Q

What is the most common direction of congenital luxation?

A

Usually medial

Usually unilateral

+/- glenoid dysplasia

63
Q

What are the PE findings in congenital luxation of the shoulder?

A
  • Greater tubercle relative to the acromion (as for traumatic luxation)
  • Joint easily reduced and re-luxated
  • Glenoid dysplasia–reduction not possible
  • Pain on manipulation may be minimal
64
Q

What does the term glenoid dysplasia indicate?

A

Salvage procedure

65
Q

What is the value of conservative and surgical treatments for glenoid dysplasia?

A

BOTH WILL FAIL

66
Q

What are the procedures for congenital luxation vs. traumatic luxation?

A
  • Medical management: nope
  • Normal glenoid
    • Open reduction/capsulorrhaphy only
    • Glenohumeral ligament construction
  • Salvage procedures
    • Arthrodesis
    • Glenoid excision
    • Amputation
67
Q

Compare the 3 salvage procedures for glenoid dysplasia

A
  • Arthrodesis
    • Invasive, inexpensive
    • Moderate mechanical lameness (“peg leg”)
    • Use w/ caution for bilateral disease
  • Glenoid excision
    • Outcome similar to arthrodesis
    • Less technically challenging
  • Amputation

Small animal surgery I (25 decks)

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