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Joint Diseases of the Forelimb > Elbow Joint – Developmental Elbow Disease > Flashcards

Elbow Joint – Developmental Elbow Disease Flashcards

1
Q

Pathologies of the medial coronoid process, osteochondritis of the medial aspect of the humeral condyle and elbow joint incongruity often occur simultaneously, all affect which compartment of the elbow?

A

Medial

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2
Q

What term currently used to summarise pathologies of the medial coronoid process?

A

Medial coronoid process disease (MCPD)

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3
Q

What are the 4 pathologies of the medial coronoid process?

A

Fissuring or fragmentation of the medial coronoid process;

Cartilage damage to the medial coronoid process;

Coronoid microfracture;

Medial coronoid process sclerosis.

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4
Q

What are proposed causes of the aetiology of medial compartment disease? (6)

A

Genetics
Nutritional excess
Nutritional deficiency
Growth disturbance
Osteochondrosis
Trauma

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5
Q

What is different about the ossification centre of the medial coronoid process? How does it ossify?

A

There is no ossification centre
Ossification via appositional ossification

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6
Q

The presence of what in the trabecular bone of affected coronoid processes have been suggested as evidence that fatigue microdamage of the underlying subchondral bone due to excessive loading plays an important role in the pathogenesis of medial coronoid process disease?

A

Micro cracks

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7
Q

During the medial approach to the elbow, what will need to be ligated?

A

The intermuscular branch of the recurrent ulnar artery and vein

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8
Q

Signalment for medial compartment disease:
A) Sex?
B) Age?
C) Breed size?

A

A) Male (2:1)
B) Young
C) Large - giant

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9
Q

Which breeds are predisposed to medial compartment disease? (4)

A
  • Labrador
  • Rottweiler
  • GSD
  • Bernese Mountain dog
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10
Q

Joint incongruity occurs in ? of elbows with medial coronoid process disease.

A

60%

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11
Q

What is the age of presentation for medial compartment dx?

A

6-18 mo

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12
Q

What is the incidence of bilateral medial coronoid process dx?

A

25-80%

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13
Q

Traditionally, three types of elbow joint incongruity were described. Can you guess them?

A

Radioulnar incongruity (e.g. short ulna or short radius).

Humeroulnar incongruity (e.g. abnormal shape of the ulnar notch).

Humeroradial incongruity.

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14
Q

How does the lameness present with MCD?
age? worse?

A

Forelimb lameness is usually present for several months beginning at 4 to 12 months of age, however, younger dogs and dogs as old as eight

The lameness is gradual and progressive and usually worse after exercise. Other signs of MCD include short striding and difficulty in rising or lying down.

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15
Q

Most dogs with MCD sit or stand with the elbow A) and the carpus B)

A

A) Abducted
B) Adducted

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16
Q

What is found on palpation of the elbow with MCD? (4)

A
  • ST swelling
  • Muscle atrophy
  • Pain
  • Crepitus
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17
Q

What specific aspects of lameness exam should be performed for MCD? (3)

A

Walk
Trot
Circling in a figure of 8

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18
Q

What is the normal weight distribution to the FLs?

A

60%

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19
Q

What weight distribution is seen in dog with MCD on the FLs?

A

40-50%

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20
Q

What radiographic views are needed to evaluate of MCD?

A

Craniocaudal;

Mediolateral;

Flexed mediolateral;

Craniocaudal medial-to-lateral oblique with the elbow maximally extended and supinated;

Medio-distal to latero-proximal oblique view is also helpful in some cases

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21
Q

What is IEWG?

A

International Elbow Working Group (IEWG) Grading system for Developmental Elbow Disease.

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22
Q

IWEG score - 0:
A) What degree of dx is this?
B) Radiographic findings?

A

A) Normal
B) Normal

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23
Q

IWEG score - 1:
A) What degree of dx is this?
B) Osteophyte Radiographic findings?
C) Sclerosis?

A

A) Mild
B) Osteophytes < 2 mm
C) Subtrochlear sclerosis with trabecular pattern

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24
Q

IWEG score - 2:
A) What degree of dx is this?
B) Osteophyte Radiographic findings?
C) Sclerosis?
D) Radioulnar step?

A

A) Moderate
B) Osteophytes 2-5 mm
C) Subtrochlear sclerosis without trabecular pattern
D) Radioulnar step 3-5 mm

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25
Q

IWEG score - 3:
A) What degree of dx is this?
B) Osteophyte Radiographic findings?
C) Sclerosis?
D) Radioulnar step?

A

A) Severe
B) Osteophytes >5 mm
C) Subtrochlear sclerosis
D) Radioulnar step >5 mm

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26
Q

What are the conservative management options for MCD? (5)

A

might include weight control, exercise management, multimodal analgesia, physio/hydrotherapy and nutraceuticals

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27
Q

In MCD cases where conservative treatment fails, what should be considered?

A

arthroscopic fragment retrieval and/or subtotal coronoidectomy (SCO)

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28
Q

When might biceps ulnar release be considered in MCD cases?

A

BURP might be considered in cases with suspected radio-ulnar conflict. It is currently unclear whether this group of dogs could profit from more invasive surgery, as described under MCD, aiming to change the weight bearing axis.

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29
Q

Advantages of arthroscopy (4) over surgery?

A

Minimally invasive
Reduced morbidity (low infection rate)
Treatment of multiple joints in a single session
Improved visualisation of intra-articular structures

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30
Q

Disadvantages of arthroscopy (5) over surgery?

A

Fluid extravasation
Iatrogenic cartilage damage
Median/ulnar nerve damage
Cost of equipment
Learning curve

31
Q

Arthroscopy using medial portals
The egress portal is established by inserting a what? several millimetres to the most proximal aspect of the olecranon process in an oblique proximodistal angle directed slightly mediolaterally.

A

1 inch, 18 or 20 Gauge needle

32
Q

How much fluid is injected into the joint to distend for arthroscopy of the elbow via medial ports?

A

10-20ml irrigation fluid

33
Q

The arthroscope portal is established by inserting a needle 1 to 1.5 cm where ?angled perpendicular to the table top.

A

distal and caudal to the medial epicondyle,

34
Q

The joint is inspected in a systematic way starting centrally by inspecting the A) and the B), then moving caudally to inspect the C), and finally moving cranially to inspect the D) of the elbow joint including medial coronoid process, medial humeral condyle, E) and radial head.

A

A) Ulnar notch
B) Lateral coronoid process
C) Anconeal process
D) Medial compartment
E) Intracondylar area

35
Q

What can arthroscopy via medial portals be used for? (3)

A

fragment removal,
abrasion arthroplasty
subtotal coronoidectomy

36
Q

A recent study comparing long-term outcome of lameness in normal dogs following arthroscopy versus arthrotomy found which to be superior?

A

Arthroscopy

37
Q

Define Subtotal coronoidectomy

A

removal of at least 4 mm of the medial portion of the coronoid process)

38
Q

When is a subtotal coronoidectomy advised? (4)

A

Large fragments were present involving most of the medial portion of the coronoid process.

Focal lesions of the medial portion of the coronoid process surrounded by severe cartilage disease.

Severe cartilage disease of the humeral trochlea.

Radioulnar incongruity.

39
Q

What is the aim of treatment for elbow joint incongruity?

A

re-establish congruency to reduce loading of the medial compartment.

40
Q

When is a dynamic proximal ulna osteotomy indicated?

A

treat a too short ulna

41
Q

When is a dynamic proximal ulna ostectomy indicated?

A

too short radius thereby reducing the load placed on the medial portion of the coronoid process.

42
Q

Where is The bi-oblique dynamic proximal ulnar osteotomy is carried out?

A

at the junction of the proximal and middle one-third of the radius.

43
Q

Surgical steps for bi oblique dynamic proximal ulnar osteotomy?
- Positioning
- Ulnar approach
- Muscles incised and elevated
- Osteotomy
- Instruments and use
- Closure

A

The patient is placed in lateral recumbency with the affected leg uppermost.

The ulna is approached through a skin incision just lateral to the caudal edge of the ulna.

On the caudal aspect of the ulna the extensor and flexor carpi ulnaris muscles are incised and elevated.

The ulna osteotomy is performed 3-6 cm below the radial head joint surface, starting from proximal, lateral and caudal directed towards a point distal, medial and cranial. This should result in a long and shallow osteotomy (mean angle of 55º caudal to cranial and 48º lateral to medial).

A periosteal elevator should be used to elevate the interosseous membrane and the most proximal portion of the interosseous ligament.

Deep and superficial fascia, and skin are closed in separate layers.

44
Q

What is the rationale for the proximal abducting ulna osteotomy (PAUL) ?
What movement/degrees is used?

A

to unload the medial compartment and thereby alleviating lameness, stiffness and joint pain by introducing a light abduction of the proximal ulna of 4-6 degrees.

45
Q

What has recently been proposed for the treatment of rotational incongruity of the elbow joint. This procedure may also be considered as an adjunct to fragment excision in dogs with no apparent radio-ulnar incongruence and mild cartilage disease.

A

A bicipital ulnar release procedure (BURP)

46
Q

Treatment options for elbow joints with advanced degenerative changes ? (6)

A

medical treatment
canine unicompartmental elbow (CUE),
sliding humeral osteotomy combined with arthroscopic treatment of medial coronoid lesions,
arthrodesis and
total elbow replacement.

47
Q

What does The canine unicompartmental elbow arthroplasty involve?
- prosthesis type
- Where

A

figure of 8 shaped cobalt chrome prosthesis into the humeral condyle and porous titanium socket covered by polyethylene bearing surface into the ulna.

48
Q

The mid to long-term prognosis for patients with medial coronoid process disease and/or OCD with medial compartment disease..?

A

remains poorly defined.

49
Q

Clinical signs (such as lameness) generally improve in 50-100% of cases despite…?

A

radiological progression of degenerative joint disease.

50
Q

Which patients do you think have the best prognosis with MCD?

A

Patients with traumatic fracture of the medial coronoid process appear to have the best prognosis. Patients with combined presence of fragmented medial coronoid process and osteochondritis dissecans have a guarded to poor prognosis.

51
Q

The usual age of presentation for Ununited Anconeal Process (UAP) is..?

A

6-12mo

52
Q

UAP:
a) Male vs female?
B) Size?
C) Breed?

A

A) Male
B) Large - giant
C) GSD

53
Q

The diagnosis of UAP cannot be made before what age?

A

20 weeks

54
Q

Aetiology of UAP?

A

unclear. Possible causes include trauma, nutrition, genetics and metabolic abnormalities.

55
Q

What are significant factors in the development of UAP? (2)

A

Malformation of the humeral trochlea and radio-ulnar incongruence

56
Q

UAP diagnosis?

A

UAP can be identified on standard and flexed lateral and craniocaudal radiographs as a radiolucent line between the anconeal process and the remaining ulna.

57
Q

When are dogs stiff with UAP?

A

the morning or after rest.

58
Q

UAP clinical exam findings? (5)

A

Orthopaedic examination often reveals lameness and a stiff gait.

Manipulation of the affected elbow joint can reveal pain, joint effusion and reduced range of motion.

59
Q

WITH UAP, when can Conservative treatment (weight management, nutritional supplementation, exercise moderation, physical rehabilitation, and anti-inflammatory medication) can be considered?

A

Older dogs with established OA

60
Q

What surgery has been recommended as an alternative treatment in dogs younger than 24 weeks of age with UAP?

A

Surgical reattachment of the anconeal process

61
Q

What is the traditional surgical approach for UAP?

A

Surgical removal of the anconeal process

62
Q

Another strategy for UAP addresses elbow joint incongruity as the underlying cause of UAP - What 2 methods could this involve?

A
  • Ulnar osteotomy
    +/- reattachment of the anconeal process
63
Q

What age should an ulnar osteotomy with reattachment of the anconeal process be performed on? and what pathological changes?

A

Under 1 year of age with minimal degenerative changes in the joint and at the site of non-union.

64
Q

Lag screw fixation of UAP in dogs; Combination with elbow arthroscopy is recommended in order to assess..? (3)

A

Stability of the anconeal process,
To inspect the joint for signs of concomitant coronoid disease
To observe reduction during screw fixation

65
Q

What is a Lag screw fixation of UAP in dogs combined with surgically? (2)

A

Ulna osteotomy/ulna osectomy

66
Q

What movement of the elbow is necessary to explore the anconeal process?

A

Full flexion

67
Q

Approach to the elbow: The anconeus is held with pointed reduction forceps and its attachments are released with (2)

A

Osteome
Periosteal elevator

68
Q

What would be considered the optimum treatment for ununited anconeal process in 7 month old German Shepherd dog before the onset of significant degenerative changes?

A

Osteotomy of the proximal ulna combined with lag screw fixation of the ununited anconeal process

69
Q

Lag screw fixation of UAP in dogs:
- Positioning
- Skin incision
- Fascia and muscle incision?

A

The animal is placed in lateral recumbency with the affected leg uppermost.

The skin is incised in a curve between the lateral humeral condyle and the olecranon from a level of the distal fourth of the humerus to a level of the proximal fourth of the ulna.

Incision of the fascia parallel to the lateral head of the triceps tendon is followed by incision of the anconeal muscle on its insertion on the tubercle of the olecranon.

70
Q

Lag fixation of UAP in dogs:

The A) is reduced and a bone tunnel is drilled from the B) towards the anconeal process. Alternatively, a hole can be created from the C) of the anconeus to the caudal ulna cortex. A cannulated drill bit or C guide can be useful.

A

A) Anconeal process
B) Caudal surface
C) Articular surface

71
Q

What screws can be used for lag fixation of UAP? (2)

A

Cortical screw
Threaded cancellous

72
Q

What can additionally be placed to support rotational stability following lag fixation of UAP in dogs?

A

placement of a small Kirschner wire

73
Q

What is the prognosis of dogs with UAP?

A

Guarded - 2ry OA likely to develop
If dogs are treated surgically before they turn one year of age, a good prognosis for limb function can be expected.

Joint Diseases of the Forelimb (10 decks)

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