Lameness in Companion Animals PDF

LAMENESS IN C O M PA N I O N A N I M A L S CHIARA BECHIS CERT AVP (GSAS), PG C (FVP) MRCVS LEARNING OBJECTIVES Understand how a variety of presentations of lameness in companion animals relate to different injuries Construct a differential diagnosis list...

LAMENESS IN C O M PA N I O N A N I M A L S CHIARA BECHIS CERT AVP (GSAS), PG C (FVP) MRCVS LEARNING OBJECTIVES Understand how a variety of presentations of lameness in companion animals relate to different injuries Construct a differential diagnosis list based on clinical presentations associated with common causes of lameness in companion animals and choose appropriate diagnostics Determine appropriate medical and surgical interventions in the management and treatment of common causes of lameness in companion animal Determine appropriate prognosis for common causes of lameness in companion animals LAMENESS: DISRUPTION OF NORMAL LOCOMOTION Orthopaedic Oncological Neurological  CLINICAL APPROACH History and signalment Is it a systemic issue or not? Distant observation Which limb/limbs List of Gait observation are affected differential diagnosis General physical Which structure/ examination structures are affected Orthopaedic/ neurological assessment  HISTORY WHAT IS THE OWNER'S COMPLAINT? Which limb(s) does the owner feel is affected? How severe is the lameness? When did it first develop? Acute or insidious onset? Was a traumatic episode associated? Is the lameness intermittent or continuous? In the lameness improving, worsening or remaining static? Does the lameness alter during the day, after rest or exercise? Does the severity of the lameness alter with the ground surface? Is the animal able to lie, sit and stand comfortably? How much exercise is the patient currently receiving? Is the animal well otherwise? Any travelling history? Was the animal imported from abroad? D I S TA N T O B S E RVAT I O N Off loading of affected limb during standing Weakness Plantigrade stance Difficulty in rising of sitting Does the animal sit “square”?  G A I T A N A LY S I S Now observe the animal's gait, at both walk and trot. Bilateral lameness may be difficult to observe! Signs of fore limb lameness: The head nods downward as the SOUND limb is placed The head nods upward when the LAME limb is placed Signs of hind limb lameness: Dorsal displacement of the pelvis Shortened stride LAMENESS GRADING Many lameness scoring systems but none of them have been validated BE CONSISTENT O R T H O PA E D I C E X A M I N AT I O N Should be completely methodically. It is best to examine the lame limb last as this is the point at which you may elicit pain. Large and giant breed dogs are most easily examined on the floor. Small breed dogs and cats should be examined on the clinical examination table. Might require assistance The purpose of the orthopaedic examination is to identify: Anatomical deformity or displacement Pain / crepitus The range of movement of each joint The integrity of supporting structures of each joint  LIST OF DIFFERENTIAL DIAGNOSIS DOGS < 1 year DOGS > 1 year Disorder of growth (panosteitis, hypertrophic Cranial cruciate disease CCLD osteodystrophy) Patella luxation Degenerative joint disease DJD Hip dysplasia Neoplasia Elbow dysplasia Neurological diseases Malalignment following growth plate trauma SMALL BREEDS and CATS LARGE BREEDS CONDRODYSTROPHIC BREEDS Patella luxation Panosteitis Spinal disorders Avascular necrosis of femoral Elbow dysplasia Disorder of growth in the head and neck forelimbs Cranial cruciate disease Hip dysplasia CCLD Cranial cruciate disease CCLD C R A N I A L C R U C I AT E D I S E A S E ( C C L D ) Signalment Small and large breeds Young and old Male and female Cats can be affected (usually traumatic) History Acute CCLD: sudden onset of non-weight bearing or partial weight bearing lameness Partial tear: mild weight bearing lameness associated with exercise, improves with rest. With time OA worsens, and lameness does not respond to rest Chronic: weight bearing lameness associated with OA P H Y S I C A L E X A M I N AT I O N Postural and gait changes Lameness and offloading of affected limb during stance Positive “sit-test” Palpation Stifle joint effusion Pain on hyperextension of the stifle joint Pain on flexion and loss of range of motion (ROM) Muscle atrophy Medial buttress Positive cranial drawer/tibial compression test Meniscal click CRANIAL DRAWER TEST With the patient in lateral recumbency, stand behind the limb and hold the patella and caudal aspect of the lateral femoral condyle with the first finger and thumb of one hand and the tibial tuberosity and fibular head with the first finger and thumb of your other hand. If the cranial cruciate ligament (CCL) is ruptured, you should be able to move the tibia forward relative to the femur. This can be difficult to elicit in the conscious animal as it is painful. The stifle should be tested in extension and partial flexion, as “draw” movement may be present in flexion only if the craniomedial part of the CCL is ruptured CRANIAL TIBIAL THRUST Hold the stifle in near full extension. Allow the forefinger of one hand to run down the straight patella ligament to the tibial tuberosity whilst holding the caudal aspect of the lateral femoral condyle with the thumb of one hand. Gradually flex the hock with your other hand. Loss of integrity of the cranial cruciate ligament will be identified as the tibial crest moves forward relative to the femur (which is appreciated with the first finger). Make sure the angle of stifle extension does not change as this will falsely lead to the perception of cranial tibial thrust I N V E S T I G AT I O N S RADIOLOGY Osteophytes around the distal patella, the supratrochlear region, the tibial and femoral margins and the fabellae Fat pad sign: the area cranial to the femur becomes whiter Normal stifle  T R E AT M E N T O P T I O N S Conservative treatment = 6-8 weeks of strict rest More effective in small dogs ( < 15kg) Surgical treatment Medium/large size dogs (>15kg) If ineffective consider meniscal damage Arthrotomy/arthroscopy Tibial plateau levelling osteotomy (TPLO), tibial wedge osteotomy (TWO),tibial tuberosity advancement (TTA) Instability will result into degenerative changes (DJD) Injury of the contralateral cruciate ligament occurs in 40% of patients  PAT E L L A L U X AT I O N Signalment Young dogs Small breed >>> large breed MPL >>> LPL LPL more common in large breed Cats can be affected. Less common than dogs. Can be traumatic or developmental. History Intermittent weight bearing lameness Severity of lameness is related to grade of luxation The patient holds the leg in a flexed position for few steps Skipping Lameness- 25% have concurrent CCLD C L I N I C A L E X A M I N AT I O N Identify patella Move the stifle through the range of motion Luxation is associated with a popping sensation If not luxating spontaneously try to luxate it manually For MPL extend the stifle and rotate the distal limb internally while pushing the patella medially For LPL partially flex the stifle, externally rotate the distal limb while pushing the patella laterally I N V E S T I G AT I O N S : R A D I O G R A P H Y Standard orthogonal radiographs of the stifle should be obtained. The craniocaudal views are used to evaluate the position of the patella. A lateral, flexed radiograph is used to assess for evidence of joint effusion and degenerative changes. With patella luxation they are generally mild; substantial changes indicate CCLD Radiographs cannot be used to rule out patella luxation Grade 1 the patella is located within the trochlear groove Grade 2 and 3 luxation the patella may temporarily be located within the trochlear groove. T R E AT M E N T P L A N Conservative treatment: Surgical treatment: Grade 1 and 2 Grade 3 and 4 Grade 2 that are lame or painful Physiotherapy Grade 4 cases are challenging and carry Hydrotherapy a less favourable prognosis BONE TUMOURS IN DOGS Signalment Middle age/old patients. Age > 7 year Large breeds History Severe lameness Poor response to analgesia Bony swelling Pathological fracture Most common bone npl: osteosarcoma Other differential diagnosis: chondrosarcoma, hemangiosarcoma, fibrosarcoma, secondary metastasis from carcinomas of the urinary tract and mammary tissue Common sites 75% appendicular skeleton Fore limbs> hind limbs  I N V E S T I G AT I O N S : Cortical bone thinning, bone lysis coupled with bone proliferation, elevation of periosteum, mottled appearance TISSUE BIOPSY J A M S H I D I B O N E B I O P S Y N E E D L E T O R E A C H D E F I N I T I V E D I A G N O S I S BONE NEOPLASIA IN DOG: T R E AT M E N T AND PROGNOSIS Fossum, T. W. (2018). Small animal surgery e-book : B O N E T U M O U R S I N C AT S Rare in comparison to dogs Osteosarcoma most common npl Signalment: mature cats Presentation: lameness, limb deformities, pathological fractures Diagnostic work-up: local radiographs and thoracic radiographs Treatment options: amputation Prognosis: reasonable with amputation. 10% risk of metastasis  PA N O S T E I T I S Signalment Young dogs < 2-year-old Male > female Large breeds History Shifting lameness Pain on deep bone palpation Chronic and intermittent lameness Investigation Radiography: patchy areas of increased opacity within medullary canal “thumb print” sign  T R E AT M E N T A N D P R O G N O S I S Conservative Pain relief Exercise restriction when animal is lame SELF LIMITING Might recur but usually resolves by the time the dog is 2- year-old  D E G E N E R AT I V E J O I N T D I S E A S E Signalment Middle age, old patients Small and large breeds Cats are affected as well! History Lameness/ stiffness Rarely primary Usually secondary i.e. dysplasia, Chronic presentation, insidious onset angular limb deformities, CCLD etc Worse in the morning and after rest that has followed a period of exercise Improves as the dog/cat warms up Difficulty in raising, jumping, climbing stairs Altered behaviour (aggression, lethargy). More time spent sleeping and less interaction with the owner (cats) Urination and defecation outside the litter tray (cats) C L IN IC A L EXA M IN AT IO N Stiffness, lameness Muscular atrophy Reduce range of motion Crepitus Altered gait (reduce stride length, altered swing phase) Unkept appearance (cat) due to lack of grooming Pain during examination Swollen joints I N V E S T I G AT I O N S Radiography Signs are nonspecific Osteophytes Enthesophytes Intra articular mineralisation Subchondral sclerosis Soft tissue enlargement Synovial fluid analysis Arthroscopy Conservative Surgical in end stage cases Client education- crucial to have owner engaged with Arthrodesis the process and manage expectations. Total hip/elbow replacement DJD can only be managed NOT cured Weight control. Ideal body condition score Exercise control. Regular controlled exercise on the lead. For cats establish environmental changes: facilitate access to feeding bowl, favourite sleeping spots and litter box. The response to specific medical Physiotherapy/ hydrotherapy. treatments varies from patient to patient Medical management: NSAIDs, paracetamol (not in cats!!!), gabapentin, amantadine, monoclonal antibody therapy (Solensia, Librela) Consider concurrent comorbidities. Nutritional supplementation AVA S C U L A R N E C R O S I S O F F E M O R A L HEAD(LEGG PERTHES DISEASE) Signalment Small breed dogs (miniature poodles, WHWT) Young 4-11 months of age Cats are affected by similar issue (young castrated male) History Variable lameness can be non weight bearing Clinical findings Pain Crepitus on hip examination Investigation radiology Treatment Femoral head and neck ostectomy, total hip arthroplasty ANY QUESTIONS?