Exam 3: Lecture 15: Surgery of the Elbow I Flashcards
(142 cards)
1
Q
Define arthrosis
A
denotes a joint but has also been defined as degenerative disease of a joint
2
Q
Define Polyarthritis
A
inflammation affecting several joints
3
Q
Define Osteoarthritis or osteoarthrosis
A
non-inflammatory degenerative joint disease (DJD) characterized by articular cartilage degeneration, marginal bone hypertrophy (osteophytosis) and synovial membrane changes
4
Q
Define Ankylosis
A
Results of DJD or inflammatory disease
- joint is fused after new bone is produced
5
Q
Define Synovial joints
A
Joints lined with synovial membrane
- allow relatively free movement
6
Q
Define Fibrous joints
A
- skull and tooth sockets
- connected with fibrous tissue allowing for little to no movement
7
Q
Define Cartilaginous joint
A
- Mandibular symphysis and growth plates
- Connected with cartilage allowing for little to no movement
8
Q
Define Arthroscopy
A
use of endoscope to examine/treat joints
9
Q
Define Arthrotomy
A
surgical exposure of a joint
10
Q
Define Arthroplasty
A
revision of a joint structure
11
Q
Define Arthrodesis
A
surgical treatment for joint fusion
12
Q
Define Dysplasia
A
abnormal development of tissues, organs, or cells
- frequently diagnosed in dogs as hip or elbow dysplasia
13
Q
What is the leading cause of forelimb lameness in dogs?
A
canine elbow dysplasia
14
Q
Is there a breed disposition for canine elbow dysplasia
A
- indicates genetic influence
- polygenic trait with both hereditary + Enviornmental influence (like hip dysplasia)
15
Q
canine elbow dysplasia is hereditary, so what recommendation would you give on breeding dogs with this condition
A
should be strongly discouraged
16
Q
Elbow dysplasia includes OCD, fragmented coronoid process, medial compartment disease and ?
A
ununited anconeal process
17
Q
Another development disease of canine elbow which may cause similar clinical signs or lead to fracture of humeral condyle is?
A
incomplete ossification of humeral condyle
18
Q
Strong evidence of _______ component in etiology of elbow dysplasia
A
hereditary
19
Q
Loss of elbow ROM (evidence of DJD) in immature large dogs may indicate presence of which disease
A
Elbow dysplasia
20
Q
Radiographic positioning is essential for doagnosis of ________ lesions and Ddx in animals with canine elbow dysplasia
A
subtle
21
Q
In animals with canine elbow dysplasia should you radiograph both elbows to ensure disease presentation and conformation?
A
YES! highly recommended
22
Q
Does surgical removal of bone and cartilage pieces usually improve or limit limb function in animals with canine elbow dysplasia
A
usually improve limb function
23
Q
Which disease is seperation of small portion of medial coronoid process of ulna
- results in lameness and DJD
A
FCP (Fragmented coronoid process)
24
Q
Fragmented coronoid process may occur as osteonecrosis of coronoid or fissures within medial coronoid. Can it be a complete or incomplete fracture
A
Yes! It may not be a complete fragmentation
25
Synonyms for Fragmented coronoid process include?
- ununited coronoid process
- fractured coronoid process
- Elbow dysplasia
- Jump-down syndrome
26
Etiology for Fragmented coronoid process?
unknown
27
Fragmented coronoid process may be characterized by?
- complete fragmentation and seperation
- partial fissuring of coronoid
- osteonecrosis
28
Large dogs are commonly affected by Fragmented coronoid process, those including
- labrador retriever
- rottweiler
- bernese mountain dog
- newfoundlands
- golden retrievers
- german shepherd
- chows
29
When does the disease process for Fragmented coronoid process start
when the animal is immature
30
When are clinical signs of Fragmented coronoid process apparent ?
5-7 months of age
- dogs may present at any age for OA secondary to FCP
31
General history for animals with Fragmented coronoid process include?
Forelimb lamness
- worsens after exercise
- acute or chronic
- owners complain dog is stiff in morning or after rest
- may be coinidental history of trauma
32
PE findings in animals with Fragmented coronoid process include?
- Lameness of one forelimb typical
- stiff gate or stilted if bilateral lameness present
(becaise animal may walk with shortened steps)
- palpation of dog standing
(may have symmetrical or asymmetrical muscles atrophy) = from chronic pain + decreases muscle tone
- Joint effusion + periarticular soft tissue swelling
(most easily felt while dog standing)
33
Which disease does the following define?
- +/- decreased ROM
- pain on hyperextension of elbow
(may be the earliest signs of FCP)
- decreased ability to flex elbow
(indicates more severe OA)
- crepitation during elbow flexion + extenion
(if advanced OA present)
Fragmented coronoid process
34
Which disease does the following define:
- Manipulation of joint often painful
- shoulder not flexed + extended during elbow manipulation
(prevents mistaking shoulder pain for elbow pain)
Fragmented coronoid process
35
How can we diagnose Fragmented coronoid process
often on basis of radiographic signs of DJD
36
Radiographic views for Fragmented coronoid process include?
- standard craniocaudal view
- standard lateral view
- flexed lateral (joint 45 degress flexion to exposure anconeal process)
- oblique craniocaudal view (elbow flexed 30 degrees + rotated medially 15 degrees) = elevates lateral profile of medial coronoid process
37
What type of Disease does this positioning for DI account for?
Fragmented coronoid process
38
For Fragmented coronoid process you shold radiograph both elbows. When does earliest radiographic signs present?
Sclerosis of distal aspect of trochlear notch
- visible as loss of fine trabecular pattern + increased opacity
39
Early radiographic findings of Fragmented coronoid process is?
blunting of medial coronoid process (MCP)
**important thing you are looking for**
40
When taking DI images for Fragmented coronoid process are fragments rarley seen?
Yes! visible fragments rarley seen!
41
_______ with coronoid and anconeal processes in animals with Fragmented coronoid process
- visible later in process
Osteophytes
42
How can you diagnose Fragmented coronoid process off DI
made by presence of Osteoarthritis
43
Joint incongruence should be evaluated on radiographs. But, High rate of false + and - for incongruence ________ mm in animals with Fragmented coronoid process
less than 3 mm
44
Fragmented coronoid process radiographs may have very subtle changes such as
- occult elbow dysplasia
- Even in presence of ______
Consult with radiologist or orthopedic surgeon
Arthrosis
45
Which technique can evaluate articular surfaces for defects + incongruity
- **more accurate for identifying FCP than radiographs**
- cant dx fissuing + microcracks of coronoid (only made histologically)
- Aids in evaluating elbow joint for incongruence
CT - Computed Tomography
46
What are the advantages of CT (computed Tomography) over arthroscopy?
diagnosis incomplete fragmentation of medial coronoid
- that does not reach cartilage surface
47
What does this image show?
Fragmented coronoid process - DI
A. Preop radiographs with FCP and DJD
- subchondral bone sclerosis caudal + distal to trochlear notch of ulna (arrowheads)
B. Same dog 8 years after surgical removal of FCP
- Note progression of degenerative chnages (arrowheads)
48
What does this image show?
CT scan showing osteomalacia of medial coronoid process (arrows)
49
What is the most valuable tool for diagnosing FCP
Arthroscopy
50
What are the benefits of Arthroscopy for Fragmented coronoid process
- direct visualization + assessment of cartilage surface
- fragmentation clearly visible
(except with incomplete fragments + do not reach cartilage surface)
51
What does this image show?
Arthroscopic view of elbow showing osteochondral fragment of MCP
52
Is there a strong or weak evidence for hereditary componet of FCP and OCD
strong evidence
53
_______ radiograph both elbows
- high frequency of bilateral disease
Always
54
Unless animal shows clinical signs with elbow dysplasia should we do surgery on the opposite limb?
Surgery of opposite limb not performed
55
Surgical removal of bone and cartilage pieces may improve function of limb. This is beneficial is treated before _________ changes occurs in joint
degenerative
56
dog with elbow dysplasia should be confined with limited exercise (short walks on leash) for how long?
2-4 weeks
57
Does surgical treatment alter the progression of DJD (OA)
Heck no!!
58
In the elbow is incongruent changes may be moderate or severe and may require _______ after surgery
medical therapy
59
Dogs with OA of the elbow usually function well as pets but not as?
may not be working or competitive sporting dogs any more
60
Canidates for FCP surgery are?
young animals
- intermittent or chronic lameness
61
Animals with advanced OA may have medial compartment disease (MCD)
- Persistent lameness not amenable to medical therapy
- How may these animals benefit from surgery
- May benefit from joint exploration and removal of loose fragments
62
What is the basis of treatment for FCP
fragment removal by arthroscopy or open arthrotomy
63
Arthroscopic treatment of FCP has numerous advatages over open surgery. What are the 4 advantages
- superior visualization + magnification of joint
- less invasive
- lower postoperative morbidity
- provides greater oppertunity for topical treatment of OA lesions
64
If arthroscopy or arthrotomy fails to demonstrate fragment in FCP what procedure is performed?
- based on suspicion of fissuring + incomplete fragmentation of coronoid
Subtotal coronoidectomy
65
Which procedure is also performed in addition to fragment removal if there is a concern for fissuring or future fragmentation
Subtotal Coronoidectomy
66
Release of ulnar inertion of which muscle may decrease transarticular forces between distal medial humeral condyle + medual coronoid process
Biceps brachii muscle
67
Bicipital ulnar release may aid in healing of microcracks in coronoid and decrease risk of ______
MCD
68
What is number 1
Osteotomy line
69
What is number 2
Fracture of coronoid process
70
What does this image show?
Subtotal Coronoidectomy
71
What is the benefit and drawback of the following open surgery for FCP
- tenotomy of pronator teres m. + incising medial ligament
- offers good exposure
- but at expense of supporting structures
72
What is the benefit and drawback of the following open surgery for FCP
- Muscle splitting technique
- prevents supporting tendons + ligaments
- But limits exposure
73
What is the benefit and drawback of the following open surgery for FCP
- Osteotomy of medial epicondyle
- Best exposure
- but requires implantation of lag screw or wire
- secures epicondyle (more postop complications than other procedures)
74
What does this image show?
Transcetion of pronator teres muscle
75
What does this image show?
Using muscle splitting approach
76
Where would you evaluate radial-ulnar incongruence (RUI)
elevation of coronoid above level of radial head
77
Which issue is the suggested cause of gragmentation of MCP + medial compartment disease
Radial ulnar incongruence
78
Asynchronous growth between the radius and ulsa causes an increased force across which compartment?
- leads to bone fragmentation + cartilage damage
medial compartment
79
What breed / species is affected by Radial Ulnar Incongruence
large dogs
labs
rottweilers
bernese mountain dogs
newfoundland
goldens
german shepherds
chows
80
Disease process of Radial Ulnar Incongruence starts when the animal is immature. Clinical signs start at what age
- dogs may present at any age for OA for elbow dysplasia
5 to 7 months of age
81
The history of animals with Radial Ulnar Incongruence include?
Forelimb lameness
- worsens after exercise
- acute or chronic
- owners complain dog is stiff in morning or after rest
- may be coincidental history of trauma
82
Radial Ulnar Incongruence during PE presents as?
- Lameness of one forelimb typical
- stiff gait or stilted if bilateral lameness present (because animal may walk with shortened steps)
- palpation of dogs standing (may have symmetrical or asymmetrical muscle atrophy) from chronic pain and decrease muscle use
- joint effusion + periarticular soft tissue swelling (most easily felt while dog was standing)
83
Which disease is described as:
- +/- dereased ROM
- pain on hyperextension of elbow (may be the earliest signs of FCP)
- decreased ability to flex elbow (indicates more severe OA)
- crepitation during elbow flexion + extension (if advanced OA present)
- manipulation of joint often painful
- Shoulder not flexed + extended during elbow manipulation (prevents mistaking shoulder pain for elbow pain)
Radial Ulnar Incongruence
84
What can you do during a PE to prevent mistaking shoulder pain for elbow pain
shoulder not flexed + extended during elbow manipulation
85
Radial Ulnar Incongruence can be investigated with?
plain film radiography or CT
86
severe cases (greater than _______mm)
- Radial Ulnar Incongruence recognized on lateral or craniocaudal view
greater than 4 mm
87
Which disease / issue will appear proximal to radial head when looking at Radial Ulnar Incongruence
MCP
88
Are routine medial-lateral radiographs accurate or not for diagnosis of mild incongruity
inaccurate for diagnosis
89
Incongruence more accurately evaluated in which view
flexed lateral view
90
What is the most accurate diagnosis for radial-ulnar incongruence
Arthroscopy
91
The goal in Surgical treatment of RUI is?
restore normal congruence between proximal articular surface of radius and ulna
**shortening ulna or lengthening radius**
92
Surgical treatment for Radial Ulnar Incongruence includes
- proximal ulnar segmental osteotomy
- distal ulnar segmental osteotomy
For the distal ulnar segmental osteotomy what are the limitations
Interosseous ligament limitations
93
what type of osteotomy in Proximal Ulnar segmental osteotomy is described as in the proximal 1/3 of ulna
- removing approximately 1/2 cm of bone
Segmental Osteotomy
94
What are the two angles of osteotomy for Proximal Ulnar segmental osteotomy
- caudoproximal to craniodistal
- craniolateral to caudomedial
95
How would you reappose the periosteum for Proximal Ulnar segmental osteotomy
simple continuous pattern
96
How would you close deep fascia in Proximal Ulnar segmental osteotomy
simple continuous patterns
97
How long should you bandage Proximal Ulnar segmental osteotomy
3 to 5 days
98
During an distal Ulnar segmental osteotomy make a ______ incision over lateral distal 1/3 of ulna
- ending at distal ulnar physis
3 cm
99
For distal Ulnar segmental osteotomy dissect between tendon of lateral digital extensor muscle and tendon of ulnaris lateralis musle. The goal is to?
expose diaphysis of the ulna
100
for distal Ulnar segmental osteotomy Incise and elevate periosteum. What instrument do you use to isolate the ulna
Hohmann retractors
101
During distal Ulnar segmental osteotomy remove 5 mm length section of ulna. What tools can be used to do this?
- Osteotome
- rongeur
- bone saw
102
How would you reappose periosteum in distal Ulnar segmental osteotomy
simple continuous pattern
103
How would you close the deep fascia in distal Ulnar segmental osteotomy
simple continuous pattern
104
How long do you bandage the distal Ulnar segmental osteotomy
3 to 5 days
105
Elevation of interosseous ligament off ulna aids in distal migration of ulna. This may lead to significant ________
Hemorrhage
106
What does A show?
Mediolateral radiographs
- showing osteotomy lines for proximal ulnar osteotomy
107
What does B show?
Craniocaudal radiographs
- showing osteotomy lines for proximal ulnar osteotomy
108
Medial compartment disease (MCD) refers to?
- limited to medial aspect of canine elbow joint
moderate to severe cartilage erosion
109
Regions of Medial Compartment Disease (MCD) comonly affect?
- medial portion of coronoid process
- medial distal aspect of humeral condyle
- in some cases: medial portion of radial head
110
What is the etiology of Medial compartment disease
unknown
111
The most likely cause of Medial compartment disease is?
Mechanical overload or incongruity of elbow joint
112
Seversity of cartilage loss with Medial compartment disease is graded using which system?
modified outerbridge scale
113
The modified outerbridge scale for arthroscopic grading of osteoarthritis ranges from?
Scale: 1-5
114
What is the modified outerbridge scale for arthroscopic grading of osteoarthritis number 1
chondromalacia
115
What is the modified outerbridge scale for arthroscopic grading of osteoarthritis number 2
partial thickness fibrillation and fissuring
116
What is the modified outerbridge scale for arthroscopic grading of osteoarthritis number 3
full thickness fissuring
117
What is the modified outerbridge scale for arthroscopic grading of osteoarthritis number 4
full thickness cartilage loss
118
What is the modified outerbridge scale for arthroscopic grading of osteoarthritis number 5
eburnated cartilage
119
What is the signalment for Medial compartment disease
- Large breed dogs usually affected (MCD diagnosed in any size dog)
- Age of onset of disease process unknown
120
Medial compartment disease diagnosed in dogs as young as _______ months old
- frequently not diagnosed until several years of age
6 months
121
History in animals that present with Medial compartment disease may include?
- forelimb lameness - worsens after exercise
- may be acute or chronic
- owners report dog is stiff in morning and after rest
122
In animals with Medial compartment disease _____ lameness of forelimbs are typical
- stiff gaist or stilted if bilateral lameness present (because animal may walk with shortened step)
- palpation of dog standing
(may have symmetrical or asymmetrical muscle strophy - from chronic pain and decreased muscle use)
- Joint effusion + periarticular soft tissue swelling
- Most easily felt when the dog is _______
Bilateral lameness
Most easily felt while dog is standing
123
PE finding in animals with Medial compartment disease include?
- +/- decreased ROM
- decreased ability to flex the elbow indicative or more severe OA
- manipulation of joint is often painful
124
What cen be seen on DI in animals with Medial compartment disease
- Suspected on basis of radiographic signs of DJD
- radiographic signs are variable
- severe cartilage damage may be present with minimal radiographic changes
125
_______ associated with coronoid process + tip of anconeus may be visible using DI for Medial compartment disease
- severe diffuse osteophytosis may be observed
- severity of radiographic changes not correlate with severity of cartilage damage
Osteophytes
126
What is the most definitive tool for diagnosing Medial compartment disease
Arthroscopy
127
What is the benefit of Arthroscopy
enables direct visualization and assessment of cartilage surface
128
Which technique is superior to open surgery
- allows less invasive exam of greater portion of joint
- severity and extent of cartilage damage more easily seen
Arthroscopy
129
What does this image show?
Arthroscopic view of elbow with Medial compartment disease with full thickness (grade IV) cartilage damage (full thickness cartilage loss)
130
Many pts with Medial compartment disease also have which disease?
FCP
131
Why is the benefit of gragment removal alone questionable?
Pain associated with cartilage damage remains
132
Arthroscopic techniques for treatment of arthritic lesions is microfracture and abrasion arthroplasty. This is where you create channels for revascularization of arthritic lesions from bone marrow. How can this help in healing?
May aid in more recruiting stems cells
133
What are the two arthroscopic techniques used for treatment of arthritic lesions
- create channels for revascularization of arthritic lesions from bone marrow
Microfracture + Abrasion arthroplasty
134
Why are the techniques Microfracture and abrasion arthroplasty likely limited benefit?
beause mechanical forces that led to cartilage erosion also prevent healing of cartilage lesions
135
What are 4 other surgical treatments for Medial compartment disease
- decrease pain + joint inflammation
- removal of coronoid (subtotoa; coronoidectomy)
- decreasing transarticular loads
- replacing bearing surface (total elbow replacement)
136
For Medial compartment disease treatment how can you decrease pain and joint inflammation?
by decreasing stimulation of nerve endings in subchondral bone
137
For Medial compartment disease treatment how can you decrease transarticular loads
- sliding humeral osteotomy?
- radial osteotomy
- **segmental ulnar osteotomy**
138
What does the image show?
Postoperative radiograph of sliding humeral osteotomy
139
Have most of the Medial compartment disease surgries been evaluated for efficacy?
no
140
Release of biceps insertion on ulna. This muscle exerts what type of force on the radius and ulna
signifiant proximal force
141
When we release ulnar insertion, we decrease which force between distal medial humeral condyle and medial coronoid process?
decrease transarticular force
142
Which technique for Medial compartment disease may aid in healing of microcracks in coronoid and decrease risk of Medial compartment disease
Release of biceps insertion on ulna
