BVSc other forelimb conditions lecture 2022 - Tagged.pdf

The Shoulder Andrew Tomlinson BVSc Cert(AVP)GSAS DipECVS FHEA MRCVS Senior Lecturer in Small Animal Surgery DISEASES OF THE SHOULDER Congenital luxation and dysplasia Osteochondritis dissecans (OCD) Muscle, tendon and ligament problems • Biceps brachii avulsion, rupture and displacement • Bicipit...

The Shoulder Andrew Tomlinson BVSc Cert(AVP)GSAS DipECVS FHEA MRCVS Senior Lecturer in Small Animal Surgery DISEASES OF THE SHOULDER Congenital luxation and dysplasia Osteochondritis dissecans (OCD) Muscle, tendon and ligament problems • Biceps brachii avulsion, rupture and displacement • Bicipital tenosynovitis • Glenohumeral ligament tears • Subscapularis tears • Supraspinatus mineralisation • Infraspinatus bursa mineralisation Trauma • Luxation and fractures Neoplasia MAJOR DIFFERENTIAL FOR SHOULDER LAMENESS • Caudal cervical lesion (e.g. disc) with nerve root compression • Brachial plexus tumour or neuritis • Occult thoracic limb disease • e.g. Medial coronoid disease DIAGNOSTIC APPROACH Clinical examination • Dynamic assessment • Posture • Palpation • Manipulation Diagnostic imaging • Radiography/CT • Arthrography • Arthroscopy • Ultrasonography (biceps tendon) • (MRI) Synovial fluid analysis SHOULDER INSTABILITY Assessment of medial collateral integrity Measurement of angles of abduction for diagnosis of shoulder instability in dogs using goniometry and digital image analysis. Vet Surg. 2005 Sep-Oct;34(5):463-8 • Requires sedation/GA • Variation between breeds and individuals • Interpretation should be made with a degree of caution 70 70 60 60 Angle 50 50 40 40 30 30 20 20 Affected Affected Gon Gon Affected Affected Image Image Unaffected Unaffected Gon Gon Unaffected UnaffectedImage Image RADIOGRA PHY Projections: • Mediolateral • Elevate head and neck • Pull limb cranially • Tracheal position – ET tube • Craniocaudal • Cranioproximal-craniodistal • Bicipital groove RADIOGRA PHY Mediolateral view • Humeral head shape • Glenoid shape and integrity • Non-specific changes • osteophytosis RADIOGRA PHY Craniocaudal view ARTHROCENT ESIS Preparation: • Aseptic preparation • 1-2” 21 – 23g hypodermic needle • 5ml syringe Landmarks: • Enter joint between acromion and greater tubercle • Orientate needle in craniolateral to caudomedial direction Analysis: • Make smear • EDTA tube • Blood culture medium ULTRASONOGRAPH Y • Minimally invasive • Good to visualize the infra- and supraspinatus tendons, teres minor and caudal aspect of humeral head • Biceps tendon • Core lesions • Fibre pattern • Shape • Mobility COMPUTED TOMOGRAPHY Can be used to detect: • OCD • Tendon calcification • Interpret with caution • Up to 40% of dogs with periarticular soft calcification were not lame • OA CT-Arthrography • Highlight intraarticular soft tissue structures ARTHROSCOPY Shoulder OCD Caudal humeral head Glenohumeral ligaments Bicipital tendon OCD OF THE SHOULDER Signalment: • Usually affects young large and giant breed dogs • Typically between 4 – 8 months of age Clinical signs: • Thoracic limb lameness • Not usually painful on palpation • Pain of extremes of extension and flexion Diagnosis: • • • • Plain radiography Contrast radiography Computed tomography Arthroscopy TREATMENT OF SHOULDER OCD • Conservative • Generally inferior to surgical management • Exercise until flap detaches • Surgical: • Flap removal • Arthrotomy or arthroscopically • Stimulate fibrocartilage formation - Shaver - Curette - Forage (microfracture) • OATS Good prognosis for minimal OA progression and normal or near normal function BICEPS TENDINOPATHY Clinical signs: • Usually middle aged medium to large breed dogs • Progressive thoracic limb lameness • Becomes worse with exercise Diagnosis: • Pain on shoulder flexion with concurrent extension of the elbow • Careful that not elbow pain! • Contrast arthrography • Ultrasonography • Arthroscopy BICEPS TENDINOPATHY Treatment: • Conservative: • Usually refractive to standard nonsteroidal • Intraarticular methylprednisolone • 10 – 40mg/shoulder • Strict rest for 4 – 6 weeks • ?Extracorporeal shockwave therapy • ?PRP • Surgery: • Tenotomy • Arthroscopic or via arthrotomy • +/- tenodesis to proximal humerus Good long-term outcome can be expected following surgery RUPTURE OF BICEPS BRACHII Look for hyperextension of elbow with shoulder in full flexion Normal Ruptured biceps brachii The Carpus Andrew Tomlinson BVSc Cert(AVP)GSAS DipECVS FHEA MRCVS Senior Lecturer in Small Animal Surgery SPECIFIC CONDITIONS OF THE CARPUS • Luxations/subluxations • • • • • Antebrachiocarpal joint Luxations of radial carpal bone Middle carpal luxation/subluxation Carpometacarpal luxation/subluxation Collateral instability • Fractures • • • • Fracture of radial carpal bone Fracture of accessory carpal bone Fracture of ulnar carpal bone Fracture of individual carpal bones • Hyperextension of the carpus • Shearing injuries ANATOMY • 3 level joint • 7 carpal bones • Support by: ligaments palmar fibrocartilage ANATOMY ANATOMY CLINICAL SIGNS • • • • • • • Thoracic limb lameness Abnormal stance Soft tissue swelling Joint effusion Pain/discomfort on manipulation Crepitus on ROM Instability: • Mediolateral or craniocaudal CARPAL HYPEREXTENSION INJURY Damage to the flexor retinaculum and palmar fibrocartilage: • Traumatic • Degenerative • Palmigrade stance • Affected joint: • 31% = antebraciocarpal • 22% = middle carpal • 47% = carpometacarpal CARPAL HYPEREXTENSION INJURY –DIAGNOSTIC IMAGING Stressed Mediolateral radiographic projections Compare with contralateral limb Allows identification of level of injury • May influence treatment options CARPAL HYPEREXTENSION INJURY - TREATMENT Pancarpal arthrodesis: • Dorsal plate most common application • Hybrid plate common to allow smaller screws to be used in MC III • Plates should extend 50% of the length of MC III • Palmar plate: • Biomechanically best location Technically challenging • External fixator – rarely used Partial Carpal arthrodesis: • Not really indicated for hyperextension injury? 40% OF HDCP CASES WERE CONSIDERED HEALED AT A MEAN OF 209 DAYS Post-operative 11-months PO 12-months PO – implant removed PANCARPAL ARTHRODESIS - COMPLICATIONS COMPLICATIONS REPORTED IN ~35% OF PCA CASES WITH HYBRID DYNAMIC COMPRESSION PLATE… • SSI – 18% • Implant loosening/breakage – 11% • Wound complications – 7% • Fracture 3% • Failure of arthrodesis – 2% Implant removed in 18% of cases PANCARPAL ARTHRODESIS – POSTOPERATIVE CARE ANALGESIA • Non-steroidal anti-inflammatory medication • Paracetamol/codeine EXERCISE RESTRICTION • Strict rest for two weeks • Gradual reintroduction of lead-restricted work EXTERNAL COAPTATION • Modified RJB for 5 – 10 days • No splint required • No casting RADIOCARPAL BONE FRACTURES Signalment: • Males more common than female • Boxers, Springer Spaniels and Pointers predisposed Configuration: • Dorsal slab, midbody sagittal or comminuted most common Surgery: • Lag screw + immobilization • Carpal arthrodesis ACCESSORY CARPAL BONE FRACTURES Injury of racing greyhounds: • 80% right carpus • 5 configurations • Lag screw • Removal of small fragment Questions??