Exam 3: Lecture 16: Surgery of the Elbow II Flashcards
(127 cards)
1
Q
Elbow replacement surgery was most abdoned due to high complication rates such as?
A
- joint subluxation
- fracture
- loosening
- infection
2
Q
Total elbow joint replacement (TER) is a high advanced procedure and perfromed by?
A
expierenced surgeons trains in the technique
3
Q
Which diease in large growing dogs does the anconeal process not form the bony union with the proximal ulnar metaphysis
A
Ununited anconeal process (UAP)
4
Q
Which process arises as secondary center of ossification in elbow at 11 to 12 weeks old?
A
Anconeal process
5
Q
Why can you not diagnose an animal with UAP until after 4-5 months of age
A
because the anconeal process does not fuse to the ulna until 4-5 months of age
6
Q
Ununited anconeal process (UAP) may be free within the joint or in most cases it is attached to the?
A
ulna with fibrous tissue
7
Q
Ununited or fractured anconeal process are unstable and results in?
A
secondary DJD
8
Q
Pathologic changes for Ununited anconeal process (UAP) include?
A
- joint effusion
- chrondromalacia
- Periarticular fibrosis
- osteophyte formation
9
Q
Large to giant breed male dogs are most common in Ununited anconeal process (UAP), but which breed is overrepresented?
- around 6 to 12 months old at presentation
- older animals present for lameness caused by secondary OA
A
german shepherd dogs
10
Q
What history can be noted in animals with Ununited anconeal process (UAP)
A
- intermittent lameness of one of both forelimbs (worsen after exercise)
- owners complain dog is stiff in morning or after rest
11
Q
With Ununited anconeal process (UAP) lameness of one forelimb is usually evident, gait may be stiff or stilted (because elbow ROM is decreased), dog may sit and stand with paw externally rotated, may be crepitation during elbow flexion/extenions (if OA present) and what is the last PE finding?
A
decrease ROM causes elbow to circumduct laterally during swing phase of gait
12
Q
In animals with Ununited anconeal process (UAP) joint effusion + periarticular soft tissue swelling may be present, pain during joint manipulation (particulary during palpation over anconeal process) and what is the final PE finding?
A
Shoulder not flexed + extended during elbow manipulation
- avoids mistaking shoulder pain for elbow pain
13
Q
How can we diagnose animals with Ununited anconeal process (UAP)
A
basis of radiographic signs of DJD
14
Q
Why do we want a flexed lateral DI for animals with Ununited anconeal process (UAP)
A
- joint at 45 degress flexion and slightly rotated medial
- brings anconeal process into view
15
Q
Which DI view is the elbow flexed 30 degress and slightly rotated medially 15 degrees
- good for animals with Ununited anconeal process (UAP)
A
Oblique craniocaudal view
16
Q
With Ununited anconeal process (UAP) we should radiograph both elbow. Bilateral disease is present in ________% of cases
A
20-35%
17
Q
UAP visible as what type of line which seperates the anconeal process from the ulna
A
Lucent indistinct line
18
Q
Ununited anconeal process (UAP) is best visualized on which view
A
flexed lateral view
19
Q
Can concurrent FCP occur with UAP?
A
yes
20
Q
What is important to ensure before diagnosing animals with UAP
A
Be sure the animal is old enough for physeal closure
21
Q
What does this image show?
A
Ununited anconeal process (UAP)
22
Q
What view is this radiograph taken in?
A
Flexed lateral radiograph of elbow with Ununited anconeal process (UAP)
23
Q
What is the arrow pointing to?
A
Lucent irregular line between anconeal process and olecranon
- subchondral bone sclerosis of olecranon
24
Q
What type of medical management is used to treat older dogs with eastablished OA from UAP
A
medical therapy
25
Does surgical removal or anconeal process after extensive OA stop progression of OA
NO, it does not stop
26
For conservative treatment in animals with UAP what principles do we follow for medical management of OA
five principles
27
What are the five principles of medical management of OA
1. weight management
2. nutritional supplementation
3. exercise moderation
4. physcial therapy
5. anti-inflammatory
28
What surgicat treatment is the standard treatment if UAP diagnosed before onset of extensive OA
surgical removal of anconeal process
29
Which surgery technique was reported sporadically since 1980s and outcome not uniformly successful (implant failure can occur)
Surgical reduction + lag screw fixation
30
Which surgical technique relieves pressure on anconeal process allowing spontaneous healing of fragment to ulna in **immature dogs**
Ulnar osteotomy
31
Which surgical technique is a combined technique with higher rate of radiographic union than ulnar osteotomy alone
Ulnar osteotomy may be used concurrently with lag screw fixation of anconeal process
32
Surgery for UAP is recommended in dogs under what age with minimal DJD in joint and at site of nonunion
under 1 year of age with minimal DJD
33
Counsel owners about probability of _________ even after surgery in animals with UAP
progressive OA
34
What does this image show?
Postoperative radiograph of lag screw fixation of UAP
35
In animals with UAP Prognosis is _______ for normal limb function
- secondary OA
gaurded
36
In animals with UAP prognosis is _______ for limb function is most dogs
- if younger than 1 year old when treated surgically
good
37
Despite treatment of UAP what are the outcomes?
- loss of ROM
- Crepitation
- Progressive OA
38
This type of condition is not usually included in category of elbow dysplasia, but developmental disease that may cause similar clinical signs
incomplete ossification of the humeral condyle
39
What condition is defined as the failure on bony union between medial and lateral portions of humeral condyle
incomplete ossification of the humeral condyle
40
What is the underlying condition of incomplete ossification of the humeral condyle
unknown
41
Normal ossification of the humeral condyle starts around ______ weeks of age + complete between 8 and 12 weeks
2 weeks
42
Which condition causes an increase humeroulnar joint space?
- a factor based on indentification of radioulnar incongruence in CT examination of fogs with incomplete ossification of the humeral condyle
Elbow incongruence
43
Which dog breed has overrepresentation of incomplete ossification of the humeral condyle
- suggest genetic cause
spaniel breeds
44
In one study, incidence of Bilateral disease was ____% based on CT evaluations
90%
45
What does the image show?
incomplete ossification of the humeral condyle
- radiographic of IOHC
- **Note fissue line**
46
Signalment of incomplete ossification of the humeral condyle includes?
Any breed
- spaniel breeds overrepresented
Age of presentation varies from youg to middle-aged dogs
- an increased incidence in middle-aged male dogs
47
Animals that present with incomplete ossification of the humeral condyle may have a history of?
- Weight bearing lameness worse after exercise
- IOHC may lead to **lateral humeral condylar fracture**
(patient will present with NWB lameness)
- Dogs with humeral condylar fractures
(possibly results of IOHC (spaniel breeds))
(radiograph contralateral limb to evaluate IOHC)
48
PE on dogs with IOHC usually shows?
- lameness of one forelimb usually evident
- gait may be stiff of stilted
- pain elicted during elbow joint manipulaition
49
Which DI view can we detect IOHC of elbow joint?
- radiographic beam must be lined up with sagittal plane of lesion or lesion may be missed
cranioaudal view
50
In animals with IOHC the ulna is superimposed over the lesion, which cause it to be?
more difficult to see
51
Which condition of the lateral epicondylar crest may be seen in animals with incomplete ossification of the humeral condyle
Sclerosis
52
Which DI technique is more sensitive than radiography in detection of IOHC
CT
53
Where may new bone formation be seen with IOHC
lateral humeral eipcondyle
54
Can increased humeroulnar joint space be seen on CT with IOHC
yes!
55
What does this image show?
- IOHC
Arthroscopic image of imcomplete ossification of humeral condyle
56
Medical management is ineffective for IOHC, because?
lesion can lead to complete fracture of humeral condyle
57
Surgical treatment of IOHC is aimed at?
stabilizing medial and lateral humeral condyles
58
Which treatment for IOHC is most described, but screw failure due to cycling loading may occur months to years post-op
Lag screw fixation
59
Does the largest or smallest diameter screw minimize screw failure in animals treated using lag screw fixation for IOHC
Largest
60
Which surgical technique is described to create a biological bone bridge between medial and lateral condyles
Autogenous cancellous autograft core
61
Which surgical treatment of IOHC is a highly advanced procedure and needs to be performed by expierenced surgeons trained in this technique
Autogenous bone core grafting
62
What does this image show?
post-op radiograph after lag screw fixation of IOHC
63
What surgical technique is shown in the image?
lag screw fixation of IOHC
- using partially threaded cancellous bone screw
64
Placement of lag screws generally results in resoultion of lameness after surgery, but what type of clinical signs may occur months to years post-op
breakage of lag screws and recurrence
65
What are the 3 types of Elbow luxation
1. traumatic
2. luxation/subluxation caused by premature closure of the distal ulnar or radial physes
3. congenital
66
Traumatic elbow lunation aka dislocated elbow is usually associated with blunt trauma or elbow joint. This causes _____ displacement of radius and ulna with respect to humerus
lateral
67
is Traumatic elbow lunation common or rare in cats
rare
68
Which age of animals usually have physeal fractures
young animals
69
Elbow trauma
- results in rupture or avulsion of one or both collateral ligaments
- allows luxation of which two bones
radius and ulna
70
In animals with Traumatic elbow lunation the radius and ulna usually luxation in which direction
laterally
71
What may or may not happen to the collateral ligements in animals with Traumatic elbow lunation
- may be avulsed
- may rupture
72
What type of injuries can cause origins of extenor or flexor muscles to rupture or become avulsed from humeral condyle
severe injuries of elbow lunation
73
What type of damage may occur at the time of Traumatic elbow lunation
cartilage damage
74
Chronic luxation from Traumatic elbow lunation results in?
- chondromalacia
- articular cartilage destruction
- secondary DJD
75
Traumatic elbow lunation PE findings might show?
- unable to bear weight on affected limb
- elbow is carried in flexed position
- forelimb is abducted + externally rotated
76
Palpation of elbow after Traumatic elbow lunation revels?
- prominent radial head
- indistinct lateral humeral condyle
- lateral displacement of lecranon
77
Most animals are painful and resist elbow _____ due to Traumatic elbow lunation
extension
78
How are Most luxated elbows reduced if treated within first few days after injury
reduced by closed manipulation
79
What type of fractures are Candidates for open reduction and stabilization of fractured bones and provide greater immediate stability
Avulsion fractures
80
What type of reduction is described by these techniques
- suspend limb from IV pole for 5 to 10 minutes + using dogs body weight to distract joint + encourage muscle relaxation
- dog then placed in lateral recumbency with affected limb up
- Objective during manual reduction
(Hook anconeal process between condyles)
Closed reduction
81
What is the objective during manual reduction in animals with Traumatic elbow lunation
Hook anconeal process between condyles
82
What does the image show?
indirect reduction using the animals own weight in Tibial/radial fractures
- suspend fractured limb from ceiling to aid in fracture distraction
- technique to facilitate closed reduction of elbow luxation
83
In the image does this technique faciliate open or closed reduction of elbow luxation
closed
84
When should you attempt a closed reduction of the elbow after Traumatic elbow luxation
ASAP
85
______ of elbow carefully evaluated after reduction.
- response to trauma is DJD and dimished ROM
Stability
86
What is the prognosis of Traumatic elbow luxation if the elbow is quickly reduced and stabilized
good
87
What does A show?
Craniocadual view
- radius and ulna luxated laterally
88
What does B show?
Lateral view
- loss of humeroradial joint space
89
What does A and B show?
closed reduction
- flex elbow and inwardly rotate antebrachium to hook anconeal process into olecranon fossa
90
what does C show?
extending the elbow slowly
- abduct + outwardly roate antebrachium while placing pressure on the radial head
91
Excessive instability of joint indicates the need for what type of stabilization of joint tissue
open stabilization
92
If the joint is stable despite collateral ligament damage from Traumatic elbow luxation immobilization allows perarticular fibrosis and some degree of stability, execpt for which dogs?
large active dogs (may not be provided the stability)
93
What does A and B show?
open reduction using blunt curved instrument as lever
94
What does C and D show?
Perform olecranon osteotomy to eliminate pull of triceps muscle during reduction
95
How would you stabilize the elbow in A and B?
replace collateral ligaments using 2 screws + figure 8 wire
96
How would you stabilize C and D
secure an avulsed fragment
- use lag screw with spiked washer
97
What does A show?
make 2 osteotomies + remove portion of proximal ulna
98
What does B show?
Contour plate to caudal surface of humerus and caudal surface of ulna
99
What are the two ways you would perform an arthrodesis of the elbow?
- make 2 osteotomies and remove portion of proximal ulan
- Contour plate to caudal surface of humerus and caudal surface of ulna
100
What are the two syndromes grouped under elbow subluxation or incongruity
1. One: Part of pathophysiology of premature closure of distal ulnar or radial physes after trauma in immature dogs
2. Other: Primarily in chondrodystrophic breeds
- caused by asynchronous growth of radius and ulan with no overt injury to growth plate
101
What does the image show?
radiograph of elbow incongruence due to radial shortening
102
Elbow incongruity is can cause elbow pain and lameness in dogs with ________ radial and ulnar growth
asynchronous
103
elbow incongruity contributes to FCP and ?
UAP
104
Elbow incongruity leads to secondary ______
DJD
105
Surgical treatment in elbow incongruity is directed at restoring elbow congruity. We perform corrective osteotomy on which two bones
Radius and Ulna
106
Lengthening osteotomy indicated when cause of elbow incongruity in ______ us too short
Ulna
107
Shortening ostectomy or radial lengthening osteotomy is performed when _____ shortening has caused subluxation (widening) of humeroradial joint
radial
108
What does this image show?
The Ulna is too short
- Ulnar lengthening osteotomy
109
What does this image show?
Radius too short
- Ulnar shortening ostectomy
110
What does this image show?
Radius too short
111
What technique is shown to correct the issue when the radius is too short
Corrected with Ulna-shortening Ostectomy
112
Which surgical treatment in elbow incongruity is also performed by distraction osteogenesis using circular external fixator + motors
Radial lengthening
113
Which surgical treatment in elbow incongruity is highly advanced procedure performed only by an expierenced surgeon trained in this technique
Distraction osteogenesis
114
Congenital elbow luxation results in _____ rotation of proximal ulna subluxation or luxation of humeroulnar joint
lateral
115
Synonyms for congenital elbow luxations include?
- congenital elbow luxation
- congenital elbow malformation
116
Etiology of congenital elbow luxation is _______
unknown
117
In congenital elbow luxation, when does bone malposition occur?
at a young age
118
Because bones do not articluate normally with congenital elbow luxation, what is the effect on congruent joint surfaces?
they do not form
119
Around _______ of age secondary remodeling occurs and degenerative changes develop in animals with congenital elbow luxation
around 3 months of age
120
What breed(s) of dogs are affected by congenital elbow luxation?
Small dogs are affected by- pugs, yourksire terriers, boston trriers, minature poodles, etc.
121
Can congenital elbow luxation be unilateral or bilateral
yes, it can be both
122
Usually when is congenital elbow luxation recognized?
when puppies begin to walk
- around 3 to 6 weeks of age
123
What does this image show?
Preoperative craniocadual radiograph of forelimb of dog with congenital elbow luxation
124
What does this image show?
Transarticular pin to hold ulna in position after manual reduction of congenitally luxated elbow
125
When does surgical tx provide the best outcome
Immediate
126
When you reposition the Ulna = improved limb function
- Because the oull of which muscle is redirected
triceps muscle
127
Does limited ROM and DJD still occur even when surgery is performed on animals with congenital elbow luxation
true
