Thoracic+limb+lameness+Part+2+OL+2023.pptx

Thoracic Limb Lameness Part Two Learning Objectives • List differentials for lameness localizing to the carpus, elbow and shoulder regions of the forelimbs • Describe the etiopathology, diagnosis, treatment and outcome of carpal hyperextension injury, elbow dysplasia, incomplete ossification of th...

Thoracic Limb Lameness Part Two Learning Objectives • List differentials for lameness localizing to the carpus, elbow and shoulder regions of the forelimbs • Describe the etiopathology, diagnosis, treatment and outcome of carpal hyperextension injury, elbow dysplasia, incomplete ossification of the humeral condyle, elbow luxation, shoulder luxation/instability, and biceps/supraspinatus tendinopathy • Define the components of elbow dysplasia Incomplete Ossification of the Humeral Condyle • Ossification starts at 2 weeks • Two centers of ossification • Should be complete by 8-12 weeks • Predilection for Spaniel breeds • Predisposes to condyle fracture • It is generally at this point it is picked up clinically Incomplete Ossification of the Humeral Condyle • Clinical signs • Commonly present middle age • Lameness vs fracture • Retrospectively may have had a lameness prior to a fracture • Incidental • Diagnosis • Radiographs • Radiograph both sides regardless of bilateral lameness • CT scan • Arthroscopy Incomplete Ossification of the Humeral Condyle • Treatment • Conservative management • Only applicable if not already fractured • High fracture rate • Stabilize fracture (if present) • Screw + anti-rotational pin • Screw + plate • Prophylactic stabilization • Large screw • +/- vascular channels • +/- graft Incomplete Ossification of the Humeral Condyle • Complications • • • • Implant failure Infection Seroma Non-healing • Prognosis • Fair to good • High complication rate • Fracture • Decreased range of motion (ROM) • Will develop osteoarthritis Medial Lateral Traumatic Elbow Luxation • Most Often • Blunt trauma • Lateral > medial • 90% lateral direction • Relatively smaller lateral half of the condyle Traumatic Elbow Luxation • Diagnosis • Physical Exam • • • • Non weight bearing Abnormal limb carriage Swollen, painful Limited range of motion • Radiographs • Orthogonal views • Look for fractures • Look for concurrent injury • Neurologic • Other body systems Traumatic Elbow Luxation Treatment Traumatic elbow injury Acute luxation No or mild degenerative joint disease No fractures Moderate-severe degenerative joint disease Fracture present Failed closed reduction Closed reduction + splint Open reduction with ligament reconstruction (+/- fracture stabilization) Chronic luxation Open reduction and ligament reconstruction Total elbow replacement, arthrodesis, or amputation (salvage procedures) Traumatic Elbow Luxation • Closed reduction • Under general anesthesia • Reduced and ROM for 10 mins • Campbells test (dog) • Elbow and carpus at 90 degrees • Lateral collateral: normal 45o of medial rotation, > 70-140o is torn • Medial collateral: normal 30o of lateral rotation, > 60-100o is torn • Spica splint Traumatic Elbow Luxation • Aftercare • Spica splint • 2-3 weeks • Controlled activity and rehabilitation for another 4-6 weeks • No running, jumping playing • Slowly increases leash walks • Passive range of motion exercises • Bandage care • Change every 1-2 weeks • Monitoring at home Traumatic Elbow Luxation • Prognosis • Good for small dog, acute injury, and stable elbows following closed reduction • Fair after open reduction with minimal cartilage damage • Poor if chronic or severe cartilage damage • Will form osteoarthritis Conditions of the Shoulder Juvenile Adult • Osteochondritis Dissecans • Congenital Luxation/Glenoid dysplasia • Trauma • Biceps tendinopathy/rupture • Supraspinatus tendinopathy • Shoulder instability • Traumatic luxation • Infraspinatus/supraspinatus contracture • Incomplete ossification of the caudal glenoid Surgical Anatomy Acromio n Supraglenoid Tubercle Greater Tubercle Biceps Tendon Glenoid Cavity Lateral Glenohumeral Ligament Humeral Medial Glenohumeral Head Ligament Lateral Lesser Tubercle Intertubercul ar Groove Medi al Biceps and Supraspinatus Tenosynovitis • Trauma or overuse injuries • Biceps tendon • Origin: Supraglenoid tubercle • Intertubercular groove • Insertion: ulna tuberosity and radial tuberosity • Tendon sheath • Supraspinatus • Supraspinatus fossa • Greater tubercle Millers Anatomy Biceps and Supraspinatus Tenosynovitis • Presentation • • • • Active dog, working dogs Intermittent or progressive, chronic Variable degree of weight bearing Pain on palpation • Biceps groove • Insertion of the biceps • Flexion of the shoulder, extension of the elbow Biceps and Supraspinatus Tenosynovitis • Diagnosis • Physical examination • Radiographs • Lateral, cranio-caudal, skyline • Calcification • Ultrasound • Loss of architecture • Calcification, fluid accumulation • MRI • Arthroscopy • Intraarticular portions Abnormal Biceps Tendon Normal Biceps Tendon Biceps Tenosynovitis • Conservative treatment • Biceps tenosynovitis • Intraarticular/intra sheath injections • Methylpredisone or triamcinolone • Rest for 6 weeks • Around 50% respond to one, another 50% to two. Remaining need surgery • Body weight management Biceps Tenosynovitis • Surgical Therapy: Biceps Tenosynovitis • • • • Tenotomy vs Tenodesis Open approach Arthroscopically Post-operative instability? Supraspinatus Tenosynovitis • Supraspinatus • Conservative • • • • • Rehabilitation NSAIDs Exercise restriction Shock wave therapy Stem cell therapy? • Surgery • Excision of calcified material Biceps and Supraspinatus Tenosynovitis • Prognosis • Biceps • Good to poor for medical management • Good to excellent with surgery • Physical therapy! • Optimum recovery is slow (~9 month) • Supraspinatus • Variable success rate of both conservative and surgical management Shoulder Instability and Luxation • Stabilizers of the shoulder • Passive support • Joint capsule + fluid • Glenohumeral ligaments (medial and lateral) • Labrum • Active support • Surrounding muscles and tendons (biceps, supraspinatus, infraspinatus, teres minor and subscapularis Shoulder Instability • Stretching of the supporting joint structures • Presentation • Older, active dogs • Moderate weight bearing, chronic lameness • Pain on shoulder manipulation https://www.dogsinmotion.com.au/ Shoulder Instability Diagnosis • Sedated Examination • Shoulder abduction • Spine of the scapula + humerus • < 30 is normal • > 50 is considered abnormal* Tobias Small Animal Surgery *Cook, vetsurg, 2005 Shoulder Instability • Diagnosis • Radiographs • OA if chronic • Arthroscopy • Tearing of the medial or lateral glenohumeral ligaments or subscapularis tendon • MRI • Possible to assess extraarticular structures Shoulder Instability • Conservative management • • • • Rest and rehabilitation Manage body weight External support Often poorly responsive • Increased OA • Chronic lameness https://www.dogleggs.com/ Shoulder Instability • Arthroscopic techniques • Radiofrequency shrinkage • “tightens” joint capsule and ligaments • Open Techniques • Ligament/tendon imbrication • Ligament augmentation • Arthrex Tightrope Shoulder Instability • Post operative care • Open approach: velpeau sling for 2 weeks • Tightrope: hobbles for 6-12 weeks • All procedures need exercise restriction for 1216 weeks • Rehabilitation • Prognosis • Variable • Degree of instability and OA Shoulder Luxation • Types of luxation • Traumatic • Any direction, result of tearing of the ligaments or joint capsule • Normal development of the glenoid cavity • Named for the direction of luxation • Medial and lateral are common • Cranial and caudal are rare • Congenital • Result of a hypoplastic/deformed glenoid and/or insufficient development of the ligaments and joint capsule • Usually medial Shoulder Luxation Presentation Traumatic • Traumatic • Acute, non weight bearing, any age • Elbow in flexion • Externally rotated foot = medial • Internally rotated foot = lateral • Painful • Other trauma • Congenital • Young dogs • Chronic lameness +/- progressive • Weight bearing, variable degree of lameness and pain Congenital Shoulder Luxation • Diagnosis • Orthopedic exam • Radiographs • Assess for other trauma Shoulder Luxation Treatment • Conservative • Traumatic • Reduction under GA • Splica splint for lateral and velpeau sling for medial luxations • 2 weeks in support • 2-4 weeks rehabilitation • Congenital • Mild to moderate pain free lameness • Exercise modification • NSAID for flair ups Shoulder Luxation Surgery • Traumatic • Suture Augmentation • Repair of existing ligaments • Prosthetic ligaments • Biceps transposition • Move medial for medial luxation and lateral for lateral luxation • Supraspinatus transposition Shoulder Luxation Surgery • Congenital • Indicated for persistent painful lameness • Excisional arthroplasty • Excise the glenoid +/- part of the humeral head • Forms a pseudoarthrosis • Encourage early limb use • Arthrodesis • Fusion of the joint at 105 degrees • Spica splint following for 10-12 weeks • Salvage procedure, greatly alters gait Shoulder luxation • Prognosis • Traumatic • Good with prompt treatment • Will likely develop osteoarthritis • Gait alteration if glenoid excision or arthrodesis • Congenital • Guarded for normal function Questions?