Elbow Conditions PDF

ELBOW CONDITIONS SUN YOUNG KIM PURDUE UNIVERSITY [email protected] OUTLINE  Anatomy review  Elbow luxation  Congenital  Traumatic  Elbow dysplasia  Ununited anconeal process (UAP)  Osteochondrosis Dissecans (OCD)  Coronoid disease  Joint in-congruity  Incomplete ossification of humeral...

ELBOW CONDITIONS SUN YOUNG KIM PURDUE UNIVERSITY [email protected] OUTLINE  Anatomy review  Elbow luxation  Congenital  Traumatic  Elbow dysplasia  Ununited anconeal process (UAP)  Osteochondrosis Dissecans (OCD)  Coronoid disease  Joint in-congruity  Incomplete ossification of humeral condyle (IOHC) LEARNING OBJECTIVES  List indications of closed or open reduction of a luxated elbow  Describe a technique of closed reduction and aftercare  List components of elbow dysplasia  Interpret radiographs and CT scan of elbow dysplasia  Prognosticate elbow dysplasia  Identify IOHC ANATOMY OF ELBOW  Congruity between 3 bones Image: Veterinary Surgery ANATOMY OF ELBOW  Stabilizers of elbow  Anconeal process, Medial epicondyle, collateral ligaments, joint capsule → Limit supination → Limit pronation Image: Veterinary Surgery Elbow luxation < Congenital Type I Type II Radius Ulna > Traumatic Type III Radius + Ulna > Elbow luxation Congenital Traumatic • Uncommon • More common than congenital luxation • Occur mostly in toy breed dogs +/- Fracture +/- Collateral ligament damage • Abnormal anatomy Tx: 1. 2. 3. 4. Conservative Reduction + corrective osteotomy Reduction + temporary fixation Salvage procedure Tx: 1. Closed reduction 2. Open reduction TRAUMATIC ELBOW LUXATION  Always rule out other trauma  Orthopedic examination  Posture  Gait  Non-weight bearing lameness  Palpation  Swollen elbow  Pain on manipulation of elbow  Limited range of motion  Abnormal anatomical landmarks (humeral epicondyles) TRAUMATIC ELBOW LUXATION  Diagnosis  Radiographs (Imaging)  Confirm Elbow luxation  Rule out other conditions contraindicating closed reduction  Fracture, Arthritis, etc. TRAUMATIC ELBOW LUXATION – DECISION MAKING Severe DJD? No Yes • Avulsion fracture of humerus ? • Articular fracture ? • Chronic luxation ? Salvage Yes No Closed reduction Stable? No Open reduction / repair ± Lig. reconstruction Yes External coaptation in extension CLOSED REDUCTION OF ELBOW 1. 2. 3. 4. 5. 6. 7. General anesthesia Reduce the anconeal process  Flex and abduction of the elbow Reduction of radial head  Pressure over radial head and medial epicondyle  Internal rotation of the antebrachium while extending the elbow Passive range of motion Campbell test (pronation/supination) Radiographs External coaptation for 10 – 14 days  Spica splint or Modified Robert-Jones CLOSED REDUCTION OF ELBOW ELBOW DYSPLASIA ELBOW DYSPLASIA  Definition  A syndrome that includes several developmental conditions that result in incongruence of the joint and subsequent degenerative joint disease  Ununited anconeal process (UAP)  Fragmented coronoid process (FCP)  Osteochondrosis (OC[D])  Joint incongruity (JI) Medial compartment Disease ELBOW DYSPLASIA  Breed predisposition  Large, giant & chondrodystrophic breeds  Rottweiler, Labrador retriever, BMD, SMD, Golden Retriever, GSD, Bassett hound  Possible to have multiple conditions  UAP ± OCD ± FCP ± JI  Clinical sign  Develops lameness as early as 5 – 6 months old age  Usually bilateral condition ELBOW DYSPLASIA  Orthopedic examination  Posture  External rotation of foot - not specific  Gait  Lameness (head bob)  Palpation  joint effusion/Thickening ± muscle atrophy  Pain on hyperextension of the joint  +/- reduced range of motion ELBOW DYSPLASIA – DIAGNOSTICS (IMAGING)  Radiographs – 3 Views CrCd MedLat  CT Scan (Cross sectional Image) Flexed MedLat  → Show coronoid process  Arthroscopy ELBOW DYSPLASIA - UAP  Ossification center of anconeal process (German Shepherd) 10 weeks 12 weeks AP mineralizes 12 weeks 16 weeks 24 weeks AP fuses at 16 to 24 weeks Small breeds do not have separate center of ossification ELBOW DYSPLASIA - UAP Normal  Clinical Signs  Pain and lameness at 5 to 12 months.  Bilateral in 20 ~ 35%  +/- FCP (13 %)  Can be incidental finding in adult dogs  Radiographs (Flexed view) UAP  Radiolucent line at the anconeal process  Older than 22 – 24 W (5-6 months)  Rule out other conditions  FCP, Panosteitis Incongruity ELBOW DYSPLASIA – UAP: TREATMENT  Conservative  Dogs with no ~ mild lameness  Surgical  Excision of the process  Only 50 % of dogs were lameness free  90% of owners were satisfied  Screw fixation ± Proximal ulnar ostectomy (PUO)  Limited information after fixation  union in 2 – 6 m opstOp / good outcome ELBOW DYSPLASIA - OCD  Bone defect on the medial humeral condyle  Can occur with FCP  Diagnostics  Radiographs (craniocaudal, Mediolateral views)  CT scan  Arthroscopy ELBOW DYSPLASIA - OCD  Treatment  Reparative procedure  Long term Prognosis  Guarded to Poor  Removal of flap  DJD (OA) progress regardless Tx  Subchondral bone bleeding  The early intervention, the better  Strict activity restriction for 2 M results  Re - surface procedures?  Osteochondral graft  Synthetic graft ELBOW DYSPLASIA – CORONOID DISEASE  Coronoid disease (Fragmented Coronoid Process: FCP)  The most common type of elbow dysplasia  Etiology (Hypothesis)  Polygenic mode of inheritance  Asynchronous growth of the radius → Overloading on the process due to joint incongruity  Form of OCD?  Environmental factors (nutrition, activity)? ELBOW DYSPLASIA – CORONOID DISEASE (FCP)  Diagnosis  Orthopedic Exam  Weight bearing lameness  Joint swelling  Pain on hyperextension of the elbow  Pain on pressure over coronoid process  Radiographs (3 views)  Hard to visualize  DJD + ruling out OCD and UAP in young dogs  CT scan  Over 85% accuracy  Arthroscopy ELBOW DYSPLASIA – FCP: TREATMENT  Conservative  Surgical management Dynamic Proximal ulnar osteotomy Subtotal coronoidectomy ELBOW DYSPLASIA – FCP: TREATMENT  Conservative  Surgical management Small Mild damage Radiographs CT Arthroscopy Fragment size? Cartilage damage? Fragment excision Resurfacing Incongruity between radius and ulna Dynamic Proximal ulnar osteotomy Large, progressed damage of medial compartment Subtotal coronoidectomy ELBOW DYSPLASIA – FCP: PROGNOSIS  Guarded prognosis • Progression of DJD no matter what Tx is done • Better prognosis with early surgical intervention before progression of DJD • Most animals are functional pets  Early detection, Early surgical treatment may slow down progression of OA ELBOW OSTEOARTHRITIS  Definition  A syndrome that affects synovial joint causing pain and dysfunction in association with degeneration of articular cartilage and changes in periarticular tissues  Treatment  Conservative  Surgery – Salvage procedures  Sliding humeral osteotomy  Joint replacement  Joint resurfacing HUMERAL INTERCONDYLAR FISSURE (HIF) HUMERAL CONDYLE OSSIFICATION CENTER Fusion of ossification center by 3-month old age 2 months old 5 months old HIF  Signalment  Older than 3-4 months old  Spaniels, French bulldogs and any breed  Unknown etiology  Failure of fusion of humeral ossification center (IOHC)  Chronic stress from shear force → Fissure  Often Bilateral  Consequence  Fracture of humeral condyle without major trauma HIF - DIAGNOSIS  Humeral condylar fracture without trauma  Check the contralateral side  Bilateral orthogonal radiographs of humerus  CT scan After 1 yr HIF - DIAGNOSIS After 1 yr Contralateral Fx  Fracture repair  Slow or no fracture healing in Condyle → Strong repair (screws and a bone plate) especially in mature dogs  Prophylactic fixation of contra-lateral Vs. side???  No Standard way  No strong clinical evidence Fx without HIF Fx with HIF or IOHC SUMMARY Miniature ~ Small Breeds Immature Common Elbow conditions Mature • Congenital elbow luxation • Condylar fracture (IOHC) • Condylar fracture (w/wo IOHC) • Elbow luxation (trauma) Medium ~ Large ~ Giant Breeds Immature • Elbow dysplasia • UAP • OCD • FCP • Jt. Incongruity • Condylar fracture (w/wo HIF) Anatomical landmarks, Joint swelling, Range of motion Hyperextension !!! Check Contralateral side (Radiographs, CT) Mature • Elbow OA secondary to elbow dysplasia • Elbow luxation (trauma) • Condylar fracture (HIF)