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Joint Diseases of the Forelimb > Shoulder Joint Part 3 > Flashcards

Shoulder Joint Part 3 Flashcards

1
Q

Order these shoulder subluxations in terms of the most common:
Cranial
Caudal
Medial
Lateral

A

Medial
Lateral
Cranial/Caudal (rare)

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2
Q

What is the signalment for shoulder instability/subluxation? (age, sex, breed)

A

Middle aged
Male
Large breeds

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3
Q

What is the proposed aetiology of medial shoulder instability in small dogs?

A

Congenital soft tissue laxity

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4
Q

What is the proposed aetiology of medial shoulder instability in large dogs?

A

Chronic repetitive trauma

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5
Q

What are the anatomical possible causes of shoulder instability? (2)

A
  • Loss of concavity compression
  • Disruption of the glenohumeral balance
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6
Q

What is the anatomy of the humeral head and glenoid cavity in shoulder instability?

A

Normal

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7
Q

What are the anatomical changes due to chronic repetitive wear which can lead to loss of concavity compression? (3)

A
  • Anormal development of glenoid
  • Ruptured glenohumeral ligaments
  • Decreased depth of glenoid cavity (due to wear)
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8
Q

What can the glenohumeral balance be disrupted by? (3)

A
  • Dynamic muscle imbalance
  • Abnormal angulation of glenoid
  • Disruption of capsuloligamentous restraints
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9
Q

Congenital shoulder luxation is most commonly diagnosed in small and medium breed dogs at what age?

A

3-10mo

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10
Q

Is congenital shoulder luxation bilateral or unilateral?

A

Most commonly unilateral (with no hx of trauma)

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11
Q

Prediposed breeds of shoulder luxation? (6)

A
  • Toy poodle
  • Chihuahuas
  • Pomeranians
  • Collies
  • Shetland sheepdog
  • CKCS
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12
Q

What is the degree of lameness with shoulder instability?

A

Subtle - intermediate - severe
VARIES

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13
Q

What can be identified on CE with shoulder instability? (2)

A

Mild muscle atrophy
Varying pain

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14
Q

What +ve tests can indicate shoulder instability? (2)

A
  • Biceps tendon
  • Shoulder drawer
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15
Q

What are the normal shoulder abduction angles?

A

30 degrees

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16
Q

What shoulder abduction angles are associated with medial shoulder instability?

A

50 degrees

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17
Q

What is the specificity of shoulder abduction angles?

A

Low

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18
Q

What is the benefit of xrays in shoulder instabiity?

A
  • info on OA presence
  • Rule out trauma/neoplasia
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19
Q

What radiographic changes of the shoulder joint are highly suggestive of shoulder instability? (1) Include other views.. (2)

A

Degenerative changes in the absence of OCD

However, radiographs can also be normal in patients with shoulder instability. Varus and valgus stressed radiographs can show excessive joint capsule and glenohumeral ligament laxity

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20
Q

What does MRI underdiagnose with shoulder instability?

A

Severity of damage

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21
Q

What are the most common arthroscopy findings with shoulder instability? (3)

A

Superficial erosion of the cartilage of the caudal humeral head,
Erosion of the medial ridge of the glenoid
Thickening or tearing of the medial glenohumeral ligament

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22
Q

What is the treatment of choice for medial and subluxations in multiple directions?

A

Surgical stabilization

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23
Q

What are possible surgical approaches of shoulder instability? (5)

A
  • Prosthetic reinforcement
  • Replacement of collateral ligaments
  • Reposition tendon of origin of biceps brachii
  • Reposition tendon of the supraspinatus muscle
  • Radiofrequency induced thermal modification
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24
Q

Is the following sentence true or false?

Placement of synthetic suture on the medial aspect of the scapular neck and humeral head is a more biomechanically sound approach to stabilization of the medial shoulder joint.

A

It is true. This technique generally provides the most stable repair compared to other techniques.

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25
Q

What is the most stable repair method to stabilse medical shoulder joint?

A

Placement of synthetic suture on the medial aspect of the scapular neck and humeral head

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26
Q

Imbrication of the tendon of the subscapularis muscle:
A) What suturing? method and material
B) When is this most suitable?

A

A) 2-5 horizontal mattress sutures using PDS)
B) mild degrees of shoulder joint instability with the tendon being intact and the medial joint capsule being only mildly distended.

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27
Q

How does Thermal capsulorrhaphy work? (2)

A

proposed to tighten a stretched shoulder joint capsule. Application of thermal energy to the joint capsule can cause shrinking of the collagen fibres

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28
Q

Thermal capsulorrhaphy - when does it give best results? (3)

A
  • normal biceps tendon
  • No cartilage defects
  • Normal lateral compartments
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29
Q

When should Thermal capsulorrhaphy NOT be used? (3)

A

Complete rupture of the medial glenohumeral ligament,
Bilateral disease
Severe degenerative changes.

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30
Q

What salvage procedures should be used for the management of severe or chronic shoulder joint instabilities? (2)

A

shoulder joint arthrodesis or excision arthroplasty

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31
Q

X for four to six weeks in combination with physiotherapy forms an important part of both, conservative treatment and the rehabilitation after reconstructive surgery?

A

Shoulder hobbles

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32
Q

Other than shoulder hobbles, what else has been proposed?

A

The use of a Velpeau sling for six weeks followed by a gradual return to normal activity over 6-12 weeks

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33
Q

Shoulder instability complication rate with surgery?

A

10-15%

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34
Q

What form of reconstruction has a better outcome?

A

glenohumeral ligament reconstructions

35
Q

How do you classify Scapulohumeral luxations?

A

according to the direction in which the humeral head has moved

36
Q

Most common shoulder luxation?

A

Medial

37
Q

What is the anatomy with a Traumatic lateral humeral luxation? (2)

A

lateral glenohumeral ligament and infraspinatus tendon rupture

38
Q

What is the anatomy with a Traumatic medial humeral luxation? (2)

A

traumatic medial humeral luxations are associated with tearing of the medial gleno-humeral ligament and subscapularis tendon

39
Q

What other trauma is common alongside a traumatic shoulder luxation?

A

Concurrent thoracic trauma is common (i.e., pneumothorax, haemothorax, pulmonary contusions, or fractured ribs).

40
Q

What position does the patient present with a lateral shoulder luxation?

A

limb often is carried in a flexed position with the distal part being adducted

41
Q

What position does the patient present with a medial shoulder luxation?

A

limb often is carried in a flexed position with the distal part being abducted

42
Q

Lateral luxation:
A) Foot is rotated?
B) Greater tubercle is palpable…. to normal position?

A

A) Internally
B) Lateral

43
Q

Medial luxation:
A) Foot is rotated?
B) Greater tubercle is palpable…. to normal position?

A

A) Externally
B) Medial

44
Q

How is the direction of luxation confirmed?

A

Medio-lateral and CrCd radiogrpahs

45
Q

What treatment can be attempted for a traumatic shoulder luxation - but MUST be under GA?

A

Closed reduction

46
Q

How to reduce a lateral luxation?

A

A lateral luxation is reduced with the affected leg held in extension.
Medial pressure is applied to the humeral head, and lateral pressure is applied to the medial surface of the scapula. The humeral head should remain in place when it is gently moved through a normal range of motion.

47
Q

If a lateral luxation is recued, what should be applied for 10-14 days?

A

Lateral spica splint

48
Q

What should not be applied to a reduced lateral shoulder luxation, as it will force the shoulder joint into adduction predisposing it to reluxate?

A

Velpeau sling

49
Q

How should a reduced medial luxation be immobilised?

A

Velpeau sling for at least 2 weeks followed by another 2 - 4 weeks of lead walks only.

50
Q

What splint can be used for a cranial and caudal reduced immobilisation?

A

Spica splint

51
Q

If closed reduction is not successful or reluxation occurs.. what is the next step?

A

Open reduction and reconstruction or augmentation of the glenohumeral ligaments and joint capsule is indicated.

52
Q

What can be performed in recurrent cases of lxation?

A

transposition of the origin of the biceps tendon can be performed

53
Q

How long should a splint be used after reduction?

A

10-14 days

54
Q

How long should activity be limited following the removal of a split?

A

6-12 wks

55
Q

How can a transarticular plate be used for subluxations?

A

Temporary stabilisation, from scapula to proximal 1/3 of humerus.

56
Q

When is arthrodesis used following shoulder luxation? (3)

A

Animals with chronic intractable luxation,
Concurrent # of humeral head/glenoid
severe DJD precludes 1ry fixation
SALVAGE - kast resot

57
Q

Because scapular mobility compensates for loss of motion in the ? joint, most animals have good limb function after shoulder arthrodesis.

A

scapulohumeral

58
Q

How long should a spica splint be used following arthrodesis?

A

signs of bone union are seen, usually 6 to 12 weeks after the operation. Once bone union is evident, the splint can be removed and the animal gradually returned to normal activity.

59
Q

Describe excision arthroplasty

A

a salvage procedure that causes a pseudoarthrosis to form between the scapula and the humerus, allowing limited scapulohumeral joint motion. This procedure does not require implantation of orthopaedic hardware (plates, screws), and most dogs are pain free and bear weight on the limb at a walk or run.

60
Q

What -ves are noted after an excision arthroplasty surgery? (2)

A

Gait abnormalities
Mild/moderate atrophy of shoulder muscles

61
Q

After excision arthroplasty, when should activity be encouraged? Why?

A

Once the sutures have been removed (10 to 14 days after surgery), activity should be encouraged to promote rapid formation of a pseudoarthrosis.

62
Q

How often is lameness evident for following excision arthroplasty?

A

4-8 weeks

63
Q

What is the major complication associated with surgical repair with reduction of scapulohumeral joint luxations?

A

Reluxation of the humeral head

64
Q

Prognosis for shoulder lucation:
A) After closed reduction, if the shoulder joint is stable during forelimb manipulation?
B) conservative management of shoulder joint luxation if the instability persists

A

A) Good
B) Guarded - In these cases, early joint stabilisation should be considered.

65
Q

When do you think excision arthroplasty will be indicated?

A

Indications for excision arthroplasty include the management of severe or chronic shoulder joint instabilities, but also comminuted articular fractures, malunions and non-unions, pain associated with osteoarthritis, glenoid dysplasia and osteochondromatosis.

66
Q

How to position a patient for excision arthroplasty?

A

Lateral recumbency with the affected leg uppermost

67
Q

How to approach the shoulder for excision arthoplaty - skin, fascia, muscle.

A

Make a curved incision from the distal third of the scapula spine to the craniolateral aspect of the midshaft humerus.

Incise the deep fascia at the cranial aspect of the acromial part of the deltoid muscle.

Retract the belly of the acromial part of the deltoid muscle with a retractor and identify the infraspinatus tendon.

68
Q

Where is the infraspinatous tenotomy performed?

A

5mm from insertion on humeral bone and incise joint capsule

69
Q

Which nerve should be identified and protected during excision arthroplasty? Have a think before revealing the answer.

A

The suprascapular nerve should be identified and protected while carrying out the ostectomy of the scapular neck in a distolateral-to-proximomedial direction.

70
Q

What can be performed during excision arthroplasty, to provide a more rapid proliferation of fibroplasia and a better pseudarthrosis. However, some others do find this step not required of even counterproductive to optimise function of the pseudarthrosis.

A

An ostectomy of the humeral head, parallel to the first ostectomy, starting just caudal to the greater tubercle

71
Q

What is the functional outcome of excision arthroplasties performed in small breed dogs?

A

Excision arthroplasties performed in small breed dogs usually show good to excellent function, pain free range of motion and no significant degrees of muscle wastage.

72
Q

Why is shoulder joint arthrodesis is a demanding surgery? (3)

A

Scapula offers limited bone stock for good screw purchase;

Plates require significant bending;

Challenges positioning the osteotomies.

73
Q

What approach is used to perform shoulder arthrodesis?

A

Cranio-lateral

74
Q

Shoulder arthrodesis:
- perform and ostetomy of (2)

A

acromion process and greater tubercle or tenotomy of the supraspinatus and deltoid muscle.

75
Q

What is transected in shoulder arthrodesis? Which order (2)

A

Transect the origin of the biceps tendon from the supraglenoid tubercle.

Transect the tendon of insertion of the infraspinatus muscle.

76
Q

Shoulder arthrodesis:
Remove the cartilage from the A) and the glenoid fossa using a B) or perform an ostectomy of the glenoid process and the humeral head in cases of severe glenoid dysplasia and malunions.

A

A) humeral head
B) motorised burr

77
Q

Shoulder arthrodesis - Be aware to ostectomize the humeral head and glenoid to achieve maximum contact at a shoulder joint angle of?

A

105-110

78
Q

Following the removal of the cartilage of humeral head, what are the next steps?
- stabilisation
- contour
- identify
- Harvest
- place

A
  • Glenoid and humerus temp stabilised with k wire, to keep joint in position while bone plate and screws are applied
  • Contour a plate of sufficient
  • Identify and preserve suprascapular n
  • Harvest cancellous bone graft and place around joint space
  • Place screws along cranial aspect of humerus and craniolateral aspect of scapula
79
Q

It is beneficial to place one of the screws as a ?screw across the osteotomy.

A

Lag

80
Q

What placement can reduce implant failure and delayed unions durin arthrodesis?

A

Placement of a 2nd plate caudal to the 1st plate can reduce the risk of implant failure and delayed unions

81
Q

What attachments are placed to end arthrodesis?

A

The biceps tendon is reattached (e.g. bone screw) and greater tubercle and acromion are reattached (e.g. tension band or bone screw in lag fashion).

82
Q

What is recommended if a single plate is applied during arthrodesis?

A

A spica splin

83
Q

Is the following sentence true or false?

Dogs are expected to regain a near normal gait six months after the arthrodesis?

A

False. within 3 mo

84
Q

Most common complications after arthrodesis? (3)

A
  • Implant fail
  • Infect
  • Delayed union

Joint Diseases of the Forelimb (10 decks)

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