Tarsal Joint 2 Flashcards
What injuries can all lead to tarsocrural instability, subluxation or luxation? (3)
Malleolar #
Collateral ligament rupture
Shearing injury
Tarsocrural subluxation:
What is present on CE? (3)
Severe lameness
Periarticular bruising
Swelling
How can you Differentiate between fractures of the malleolus and collateral ligament ruptures?
Xrays
How are malleolar # diagnosed?
xrays (orthogonal views)
How are avulsion # of the malleolar treated?
Internal stabilisation: Pins and tension band wire
Internal stabilisation of malleolar avulsion #:
A) Size k wire?
B) Orthopedic wire?
A) Small diameter
B) Large
With internal fixation of avulsion # - what extra care is needed when placing pins?
Care must be taken to angle the pins so that that they do not enter the joint.
Malleolar #:
Early mobility is beneficial - why? (3)
minimise joint fibrosis
loss of function
maintain cartilage health.
Malleolar #:
Temporary augmentation of the repair with what (2) is often required as the repair can be tenuous.
transarticular external skeletal fixator or external coaptation
Immobilisation alone does not heal # of malleoli alone - what is often needed?
of pin/tension band wire
Does collateral ligament rupture or # of malleolar have better prognosis?
of malleolar
Collateral ligament rupture can occur as an avulsion from the bone, where? (3)
At the tibia
Fibula
Mid substance tear
An avulsedcollateral ligament may be able to be re-attached with a ? but this can be challenging in smaller patients.
small pin or screw
How to repair a mid-substance tear?
Not possible normally
How can a prosthetic ligament be created?
bone anchors or screws placed at the attachment points of the ligament
Wire or nylon is then placed between these anchor points to augment or replace the ligament
What can be used instead of prosthetic ligaments?
Transosseous tunnel
Collateral ligament rupture:
Failure to augment or replace the ?parts significantly reduces the immediate stability of the joint function of collateral ligaments
short
Primary repair or augmentation of the ligaments - what is the complication rate?
- How well does lameness recover?
- High
- Persistent lameness expected
When is a temporary transarticular external skeletal fixator removed when used as sole treatment for collateral ligament rupture?
4-6 weeks
What remains when a temporary transarticular external skeletal fixator removed when used as sole treatment for collateral ligament rupture is used?
Residual instability
Collateral ligament ruptures can be challenging to treat and treatment is not always successful. Some patients need to undergo what surgery?
Pantarsal arthrodesis
Shear injury of the tarsus is a common injury in dogs and cats. What is the frequent cause of Shearing injury?
It is usually the result of a road traffic accident where the limb has been caught under a tyre and the abrasive road surface causes loss of tissue.
Tarsal shear injury, what must be addressed/ (4)
*Contamination and possible infection (open contaminated wound and joint and bone exposed).
*Loss of vital structures.
*Instability of the tarsal joints.
- Is there sufficient remaining tissue to achieve an acceptable function?
Open or closed wound management for tarsal shear injury?
Open
Open wound management should be continued until healthy granulation tissue is present and reconstructive surgery can be considered.
It is advised to treat tarsal shear injuries with?
temporary transarticular external skeletal fixator
Using a temporary transarticular external skeletal fixator for shear injuries - what is the benefit of this? (3)
Stabilise joint
Minimise ongoing damage
Access for wound management
In the majority of cases, tarsal stability is adequate after removal of the external skeletal fixator- why is this?
Due to scar tissue formation so that no further surgery is required.
For those shearing tarsus cases where residual instability following ESF what might be required?
Pantarsal arthrodesis
What does Plantar tarsal luxation or subluxation result from?
Rupture of plantar ligaments
Plantar tarsal luxation or subluxation:
Breed?
Overweight middle-aged Shetland Sheepdogs but other Collie
Due to the strong breed predisposition, what has been hypothesised?
intrinsic weakening of the plantar ligament
Progressive Plantar Intertarsal ligament degeneration often means the onset is?
Insidious
Progressive Plantar Intertarsal ligament degeneration:
- How is the proximal intertarsal joint affected?
Hyperextension
Progressive Plantar Intertarsal ligament degeneration often develop what stance?
Plantigrade
Progressive Plantar Intertarsal ligament degeneration:
How is the calcaneus rotate and why?
Proximally by the common calcanean tendon
Plantar Intertarsal Luxation:
What instability is there on manipulation?
Proximal intertarsal
Plantar Intertarsal Luxation:
Pain levels?
Minimal
What can indicate an impending degenerative problem with the Plantar intertarsal lig?
Plantar thickening is normally palpable before any instability
Which projections should be used to confirm diagnosis of plantar intertarsal ligament?
Orthogonal projections of the tarsus should be obtained to confirm the diagnosis. Stressed projections to hyperextend the proximal intertarsal joint can facilitate this.
plantar intertarsal ligament dx, where are entheseophytes normally visible? (2)
Plantar aspect of calcaneous and 4th tarsal bone
Treatment for plantar intertarsal (sub)luxation is..?
calcaneoquartal arthrodesis.
What is used in calcaneoquartal arthrodesis.?
Pin and plantar wire loop, lag screw +/- plantar wire loop or a lateral plate.
External coaptation with plantar intertarsal luxation?
With plate can be avoided
plantar intertarsal luxation prognosis?
Good with arthrodesis
Complications following plantar intertarsal luxation arthrodesis
- failure to acheieve arthrodesis –> Implant failure and infect
Benefits of calcaneoquartal arthrodesis over pin/tension band wire for plantar intertarsal ligament? (2)
- lower complication rate
- more readily achieve arthrodesis
Dorsal intertarsal subluxation occurs A) and is usually the result of B)
A) sporadically
B) a fall
What does damage to the short dorsal intertarsal ligaments result in?
Instability
The instability of the dorsal intertarsal ligament can be difficult to appreciate as the A) aspect is the B) side of the joint and weight bearing holds it in C).
A) Dorsal
B) Compression
C) Reduction
What imaging diagnoses dorsal intertarsal luxation?
Stress xrays
How can isolated dorsal intertarsal luxation be treated?
Non surgical.
External coaptation for 4-6 weeks
How should severe dorsal intertarsal luxation be treated? (2)
Augmentation of the ligaments with screws and wires
A temporary transarticular external skeletal fixator can be attempted.
How common is arthrodesis following dorsal intertarsal luxation?
Very rare
Prognosis following dorsal intertarsal luxation?
Good
Tarsometatarsal luxation or subluxation is normally the result of?
severe trauma such as road traffic accident or a fall
Where is swollen with Tarsometatarsal Luxation or Subluxation?
Distal tarsus
How to diagnose Tarsometatarsal Luxation or Subluxation?
CE + radiograph
Which # are common with Tarsometatarsal Luxation or Subluxation? (3)
4th tarsal bone
metatarsal II
Metatarsal V
What instability is seen with Tarsometatarsal Luxation or Subluxation? (4)
- Plantar
- Medial
- Lateral
Dorsal may occur
What is the treatment for Tarsometatarsal Luxation or Subluxation?
Arthrodesis of the tarsometatarsal joint
How can arthrodesis of the tarsometarsal joint be achieved? (4)
*Intramedullary pin and tension band wire fixation
*Multiple pins inserted through the metatarsal bones to cross the tarsometatarsal joint
*External skeletal fixation
*Plate applied laterally (most reliable) or medially (less commonly performed).
Tarsometatarsal Luxation or Subluxation:
True or false
Casting is contraindicated.
False
Tarsometatarsal Luxation or Subluxation:
True or false
Prognosis in general is guarded.
False
What is required following arthrodesis with pins for Tarsometatarsal Luxation or Subluxation?
Cast for 6-8 weeks
What is required following plate fixation for Tarsometatarsal Luxation or Subluxation?
Soft padded bandage is all that is required for seven to ten days.
Prognosis following repair for Tarsometatarsal Luxation or Subluxation?
Good
What are the 3 parts of the common calcanean tendon?
- The paired tendons of the gastrocnemius muscle;
The combined tendon of the gracilis, semitendinosus and biceps femoris muscles;
The tendon of the superficial digital flexor muscle (SDFT).
How can Disruption of the common calcanean tendon be classified?
Type 1-3
What is type 1 dx of the common calcanean tendon?
Complete rupture
common calcanean tendon type 1:
A) What stance do they regularly have?
B) What does this often follow?
C) With the stifle held in extension, what can happen to the tarsus?
D) Palpating the tendon..
A) Plantigrade
B) Trauma
C) Hyperflex manually
D) May reveal palpable defect
common calcanean tendon
DEfine Type IIa
Musculotendinous rupture
common calcanean tendon
Define Type IIb
Common calcanean tendon rupture with in tact paratenon
common calcanean tendon
Define Type IIc
Avulsions of the tendon of insertion of gastrocnemius with intact SDFT
Type 2 lesions of common calcanean tendon:
A) What happens to common calcanean tendon mechanism?
B) What happens to the hock?
A) Lengthens
B) Drops
Type 2c lesions of common calcanean tendon:
A) Hock position?
B) Digit position?
C) What is the above caused by?
A) Slight drop
B) Flex
C) ncreased tension in the SDFT that the partially collapsed tarsus
What is a type 3 lesion of the calcanean tendon?
Tendinopathy
Type 3 lesion of the calcanean tendon:
A) Where is the swelling?
B) Effect of length on common calcanean mechanism?
A) Distal part of the gastrocnemius tendon just proximal to the calcaneus
B) No functional lengthening
Which x ray view gives most information about the common calcanean tendon?
Mediolateral
Common calcanean tendon disease:
A) General xray findings?
B) What is found on type 2c and 3?
A) Soft tissue swelling in the area of disruption
B) Periosteal new bone formation
Common calcanean tendon disease:
True or false:
Ultrasonography can be useful in type 1, 2a, 2b and 3 lesions to identify the site and nature of the injury.
True
Type 3 Common calcanean tendon disease:
A) Tarsal position?
B) Digit position?
C) Lameness?
A) Normal
B) Normal
C) Mild
How is Type3 Common calcanean tendon disease managed?
non-surgically.
This consists of short lead exercise for six to eight weeks and NSAIDs. If the lameness does not resolve or there are progressive postural changes, surgery is indicated.
Type 1, 2a, 2b Common calcanean tendon disease managed?
Are managed by primary repair of the tendon. Specialised suture patterns are used such as the locking loop or three-loop pulley.
Which suture patten for surgical repair of the Common calcanean tendon? Why?
The three-loop pulley has been shown to resist gap formation to a greater extent than other suture patterns so is recommended for use in in common calcanean tendon repairs.
Suture material for surgical repair of Common calcanean tendon?
Non-absorbable (e.g. Monofilament polypropylene) or long lasting absorbable suture (e.g. PDS) material should be used. Monofilament polypropylene and PDS are ideal due to its good gliding properties, longevity and strength. The tendon junction should then be sutured with horizontal mattress sutures of polydioxanone.
Care should be taken to avoid further damage to the tendon ends with common calcanean tendon, how is this achieved?
This can be achieved by placing a needle or K-wire through the tendon at 90° a short distance from the end. This can help in manipulating the tendon.
The primary repair must be protected during the early phase of healing.
With the calcanean tendon.
How?
This can be achieved by a cast or splint, a calcaneotibial screw (protected with a cast or splint) or a transarticular external skeletal fixator.
How successful is healing after calcanean tendon immobilization?
Successful
Complications following calcanean tendon repair? (5)
cast sores/rubs
calcaneotibial screw breakage
external skeletal fixator pin loosening
pin tract infection
pin breakage.
How to manage acute type 2c calcanean tendon rupture?
Type 2c lesions are more challenging to treat. Acute lesions can be managed with primary repair using a modified three-loop pulley suture to re-attach the tendon to the calcaneus by the use of a bone tunnel in the calcaneus.
What is the problem of trying to manage chronic type 2c calcanean tendon rupture?
extensive scar tissue and it is usually impossible to identify the individual tendons
How to approach the surgical repair of chronic type 2c calcanean tendon rupture?
A section of abnormal tissue needs to be resected to restore the functional length of the tendon. After resection, a three-loop pulley suture or the modified version used to re-attach the tendon to the calcaneus.
What is the new surgical repair of chronic type 2c calcanean tendon rupture?
However needs long term evaluation?
Augmentation of the resected degenerated gastrocnemius tendon with a synthetic polyethylene terephthalate prosthesis, which bridges the gap in the tendon and allows tissue ingrowth,
True or false
Calcanean tendon:
These repairs need protection during the early healing process as with acute repairs.
True
True or false
Calcanean tendon:
A calcaneotibial screw can be used to immobilise the tarsus in flexion to allow healing of the tendon without disruptive tensile forces.
True
If primary repair of the calcanean tendon cannot be achieved - what approach can be taken?
A calcaneotibial screw can be used to immobilise the tarsus in extension to allow healing of the tendon without disruptive tensile forces.
When would A calcaneotibial screw not be appropriate with calcanean tendon repair? What is the sx option?
Significant lengthening of the common calcanean mechanism. If this is the case pantarsal arthrodesis
The prognosis after successful surgical management of common calcanean tendon disease is
Good
What do failures of the surgical management of common calcanean tendon disease relate to? (2)
not addressing the functional lengthening
immobilisation failures/complication
What is the significance of the knuckled digits with achilles tendon?
This suggests that the CCT injury is partial, the superficial digital flexor tendon remains intact contracting the digits, with the tendon of the gastrocnemius having separated from the calcaneus leading to the plantigrade stance.
What are the 3 tendon suture patterns?
Krackow
Bunnell
Interlocking loop
