Investigation & management of the juvenile lame animal Flashcards
(73 cards)
1
Q
Signalment
A
- generally less than 1y/o
- breed predispositions: e.g. Rottie & coronoid dz, Border collie & shoulder OCD
- cat rarely suffers from specific juvenile dz
2
Q
History
A
- chronic: greater than 2w duration
- shifting lameness e.g. panosteitis
- waxes & wanes?
- worse on rising or after exercise?
- associated with signs of systemic illness e.g. metaphyseal osteopathy
3
Q
Important points of the CE
A
- forelimb or hindlimb?
– occasionally can be hard to determine and the client is often confused - is the condition confined to a single limb?
- are there any joint swellings?
- is there pain or heat in a joint or bone?
- is there pain when palpating pads or twisting nails?
4
Q
Perthe’s disease - what is it?
A
- avascular necrosis of the femoral head
5
Q
Perthe’s disease - signalment & clinical hx
A
- the toy and small dog <6m/o
- inherited in the Manchester terrier
- a similar condition reported in the cat
- lameness with associated muscle atrophy
- reluctant to jump or go up and down stairs
- bilateral in 12-16% of cases
6
Q
Perthe’s disease - clinical signs
A
- often marked muscle atrophy (particularly the gluteal muscles)
– hip condition = gluteals
– stifle condition, particularly cruciate dz = quadriceps - considerable pain on extension of the hips
- crepitus on manipulation of hips
7
Q
Perthe’s disease - radiographic findings
A
- mottled appearance to femoral neck and head due to areas of lucency
- a misshapen and often triangular shape to femoral head
- secondary osteoarthritic changes
- loss of muscle mass
8
Q
Perthe’s disease - conservative management
A
- NSAIDs, nutraceuticals, etc
- physiotherapy
- rarely successful as these dogs walk well on 3 limbs and therefore avoid using the painful leg
9
Q
Perthe’s disease - surgical management
A
- femoral head and neck excision
- total hip replacement (micro and nano systems: Biomedrix)
10
Q
Femoral head and neck ostectomy - surgical technique
A
- craniolateral approach is made to the hip with a tenotomy of deep gluteal and partial cut to vastus lateralis improve visualisation of the femoral neck
- it is essential that the cut removes all the femoral neck
- the dog has a degree of anteversion to the head and neck therefore the cut needs to take more of the casual region of the neck than the cranial
- it is also important to leave the lesser trochanter intact (insertion of iliopsoas, a hip flexor)
11
Q
Femoral head and neck ostectomy - post-op radiograph
A
- post op radiographs should always be taken
- if not enough of the femoral neck has been resected further bone should be excised
12
Q
Perthe’s disease - prognosis post FHNE
A
- small dogs can manage well on 3 legs therefore rehab with analgesia, physio and hydrotherapy are essential to encourage early use of the limb
- it’s important to appreciate that the limb is always shorter and the hip has reduced extension
- the loss of limb length is compensated for by tilting of the pelvis
- overall the prognosis for these dogs is good and in the well managed case the O may be unable to recall which limb has undergone surgery
13
Q
Metaphyseal osteopathy - clinical hx and signs
A
- seen only in dogs
- metaphyseal osteopathy in the cat doesn’t seem to be the same condition
- unknown aetiology although there’s a suggestion that this may be an immune mediated condition
- less than 6m/o
- severe and excruciating painful swelling to the metaphyseal region of all limbs
- pyrexic and systemically unwell
14
Q
Metaphyseal osteopathy - clinical signs
A
- often unable to walk
- pyrexic and inappetence
- painful swellings to the distal limbs particularly the radius, ulna and tibia
- associated pitting oedema over the metaphyseal regions
15
Q
Metaphyseal osteopathy - radiographic signs
A
- soft tissue swelling
- ill define lucency parallel to the physics sometimes described as an extra growth plate
- periosteal lifting with mineralisation
- the bridging of the physis by the inflammatory change can result in angular limb deformities
16
Q
Metaphyseal osteopathy - tx
A
- hospitalisation
- multi-modal analgesia including opiates and CRIs
- corticosteroids can be helpful in pts that fail to respond to symptomatic tx
- IV fluids
- tube feeding if inappetent for longer than 3d
17
Q
Metaphyseal osteopathy - prognosis
A
- good to fair
- these dogs are prone to further attacks and other autoimmune dz in later life
– IMHA has been seen more commonly in animals that have had this earlier on in life
18
Q
Miscellaneous causes of lameness to consider in the juvenile
A
Early cruciate dz in larger breeds e.g. Mastiffs & Rotties
Patella subluxations in large and small breed dogs
Septic arthritis
- in the adult dog this is generally present in a single joint but can be multiple in the young animal
- the elbow is the commonest joint for sepsis
Polyarthritis
- multiple sterile arthropathy
- consider post vaccination in the dog and cat and in the cat can occur with calicivirus infections
Humeral intracondylar fissure in spaniels
Sesamoid dz
- pin point pain over the flexor sesamoids
19
Q
Craniomandibular osteopathy - signalment and CS
A
- small terriers particularly the WHWT and Cairn
- has been reported in larger dogs including the Dobermann
- less than 6m/o
- a very painful condition of the mandible, skull and occasionally long bones
- also known as Lion Jaw
- soft tissue swelling and oedema to jaw and long bones
- systemically unwell and pyrexic
- with chronicity becomes progressively difficult to open mouth as can develop so much periosteal new bone growth
20
Q
Craniomandibular osteopathy - radiographic features
A
- characteristic palisading (battlement-like) new bone to the mandible, occipital crest and tympanic bullae
- the TMJ may be involvement
- similar changes seen in the long bones
- associated soft tissue swelling
21
Q
Craniomandibular osteopathy - tx
A
- analgesia
- corticosteroids are often required to manage this condition
- fluids and enteral support
22
Q
Craniomandibular osteopathy - prognosis
A
- can be guarded as cases are difficult to manage and distressing for dog & O
- long term sequelae are not uncommon including reduced opening of mouth making eating and subsequent endotracheal intubation difficult
23
Q
Panosteitis - signalment and clinical history
A
- common but overlooked condition
- seen in the young dog less than 1y/o
- GSD and males are over represented
- has a characteristic waxing and waning signs
- often presents with a shifting lameness i.e a lameness that spreads from 1 limb to another
24
Q
Panosteitis - clinical signs
A
- often the dog is depressed and can be pyrexic
- lameness can be severe and the dog may not weight bear
- pain on palpation of the diaphysis
- may have had a previous episode lasting about a week in another limb (a shifting lameness)
25
Panosteitis - radiographic signs
- loss of normal trabecular pattern particularly around the nutrient foramen
- endosteal and periosteal new bone
- important to appreciate that radiographic and CS may not occur and sometimes its better to radiograph 2w after the signs have been seen
- the humerus is a common site to see radiographic changes
26
Panosteitis - tx
- rest and analgesia (NSAIDs)
- advise the O that this is an episodic condition usually lasting a week and is self limiting
27
Panosteitis - prognosis
- excellent
- episodes of acute lameness will become less severe and less frequent
- most cases have resolved by the time the dog is 1y/o
- occasional reports of the condition occurring in the 5y/o but this is very rare
- reassure the O
28
Rickets - signalment & cause
- a rare cause of lameness in the young growing animal
- it is associated with an absolute lack of vitamin D often compounded by reduced exposure to sunlight or a calcium/phosphorus imbalance
29
Rickets - CS & radiographic features
- pain and swelling around the physeal regions of the long bones and a reluctance to move
- the growth plates are widened due to poor or delayed mineralisation of the cartilage
30
Rickets - tx
- provision of a balanced diet containing adequate amounts of vitamin D and exposure to sunlight
31
Rickets - differential
A differential for this condition is nutritional secondary hyperparathyroidism
- poor skeletal mineralisation is due to a low calcium/high phosphorus, usually meat, diet
- in this the bones have thin poorly mineralised cortices and are prone to pathological folding fractures and vertebral body collapse
- dietary correction, analgesia and restriction of exercise is all that is required to treat this condition
32
Pituitary dwarfism - prevalence & what is it?
- rare condition
- congenital hereditary abnormality causing pituitary panhypopituitarism seen primarily in the GSD but occasionally seen in the spitz and Manchester terrier
- the pars distalis is affected and results in somatotropic, adrenotropic and thyroid stimulating hormone deficiencies
- proportionate dwarfism and alopecia with hyperpigmentation reported
- physis remain open but never grow
- no guard cells in the coat and small testes or absent oestrus cycles
33
Pituitary dwarfism - tx & prognosis
- cortisol, thyroxine and progestogens
- side effects of the meds are common and include pyometra, insulin resistance and mammary hyperplasia
- life expectancy is reduced but these dogs can make good pets
34
Angular limb deformities - signalment & cause
- occur in the young growing animal when 1 of 2 or part of a growth plate closes prematurely
- this arises from either trauma or bridging with periosteal bone (e.g. metaphyseal osteopathy)
35
Angular limb deformities - clinical signs
- there are many types of these deformities, those in the ante brachium are the most common
- lameness arises from joint pain due to abnormal stresses and associated subluxations
36
Angular limb deformities - treatment
- depends on whether there is any growth left in the affected limb
37
Angular limb deformities - valgus vs varus
- valgus is a lateral deviation of the distal limb
- varus is a medial deviation of the distal limb
38
Angular limb deformities - CORA
= centre of rotation of angulation
- this is an important concept when correcting limb deformities
- it determines the place where any definitive correction should be performed
- correcting the angular deformity away from this centre results in an S shaped bone and poorer function
39
Angular limb deformities of the antebrachium
Short ulna
- this is the most common abnormality
- due to the conical shape of the distal ulna growth plate this is more prone to trauma and premature closure
- it results in a valgus deformity, cranial bowing of the radius and external rotation of the paw
Short radius
- premature closure of the distal radius
- results in subluxation of the radiohumeral joint
40
Short ulna syndrome - tx
In some cases in which there is no valgus deformity only elbow incongruity the short ulna can be managed by an osteotomy which releases its bow string effect
- this technique is prone to long healing times and occasionally non unions
Immature dogs
- staple the medial radial growth plate to correct the disparate growth rates
- timing of this is difficult and this correction is rarely performed
Mature dogs
- easier to perform any correction at this time (they have stopped growing, therefore you know you are dealing with the maximum deviation)
- calculate the CORA
- osteotomy of the ulna to release the bowstring
- opening wedge osteotomy of the radius fixed with ESF or Ilizarov circular fixator which facilitates limb lengthening
- or a closing wedge osteotomy of the radius fixed with custom bone plate and applied with the use of a jig (3D printing v useful for these abnormalities)
41
Short radius syndrome - tx
Proximal radial osteotomy with Ilizarov fixator and motors to lengthen the radius (A motor is a means of changing the position of the rings relative to the frame and may only be a screw mechanism)
Alternatively a low tech alternative is to perform a proximal radial osteotomy, place external fixator pins in the proximal radius and the distal humerus. Connect these pins with strong elastic bands to slowly pull the radial head into its correct position against the capitulum of the humerus (lateral condyle).
Shorten the ulna and apply a plate
Short radius' rarely produces an ALD. The major problem associated with this condition is the lack of articulation of the radial head with the humerus. Often with ALD it is the associated joint incongruence that give rise to the lameness
42
Angular limb deformities - hindlimb
- much less common
- same principles apply
Pes varus seen in the dachshund and in this case treated with distal osteotomy and opening wedge stabilised with ESF
Tarsal valgus treated with closing wedge ostectomy and plate fixation. A wedge of bone is resected. The deficit is closed and plate applied. This can be aided by the use of 3D models with printing methods using the CT images
43
Angular limb deformities - 3D printing and the use of a jig
- CT is used to produce models of the limb and a jig
- the jig allows accurate cutting of the bone to correct the angulation and to guide placement of the screws in a custom plate
- this has made the correction of such abnormalities both more accurate and easier for the surgeon
44
Osteochondrosis - signalment, aetiology
- very common developmental condition of the articular cartilage
- it is seen in the juvenile animal (usually 5-7m/o) but its consequences extend into adult life
- the underlying pathology is a failure of ossification of the articular cartilage
- this might arise from abnormal stresses on the cartilage brought about by joint incongruity
- it results in a thickened cartilage which fragments and allows contact of the synovial fluid with the subchondral bone and resulting inflammation. this is seen as sclerosis on radiographs
- the cartilage can form a flap -> osteochondrosis dissecans
- the subchondral bone can fracture -> fragmented coronoid process or there may be a failure of a physis to close -> ununited anconeal process
45
Osteochondrosis - sites
Elbow
- very common and carries a guarded prognosis
Shoulder
- rare and prognosis is good
- border collie common, also bull mastiffs
Stifle
- rare but carries a poor prognosis
- occasionally seen in the cat
Hock
- uncommon and carries a poor prognosis
Other sites
- occasionally seen in the lumbosacral joint
46
Elbow dysplasia - what is it?
- a broad term that encompasses all manifestation of osteochondrosis seen in the elbow
- it is very common and has several manifestations but all involve the medial aspect of the joint, hence it is also called Medial Compartment Disease
- it is a polygenic inherited dz which may result in joint incongruity but also is affected by growth rate, diet and exercise regimes
47
Elbow dysplasia - signalment & CS
- seen in many breeds but particularly labs, rotties, GSD, Basset hound
- has not been reported in the cat
- increased incidence in the male
- 50-90% of these cases are bilateral
- insidious onset at 5-7m
- initially worse on rising
- moderately responsive to NSAIDs
48
Elbow dysplasia - manifestations
There are several manifestations in the dog
Fragmented medial coronoid is seen in many breeds but particularly the lab, Rottie and Bernese mountain
Osteochondritis dissecans a lesion of the medial humeral condyle seen in the lab in particular and may occur concurrently with FCP
Ununited anconeal process is seen in the GSD and Basset hound
Incomplete ossification of the medial humeral epicondyle (rare and unclear how this sits into the elbow dysplasia picture
49
Elbow osteochondrosis - CS
- hx of chronic lameness worse on rising
- tends to hold the limb abducted and externally rotated
- pain on manipulation particularly internal rotation that loads the medial compartment of the joint
- pain on flexion with an ununited anconeal process
- joint effusion
- in chronic cases muscle atrophy
- always check the contralateral limb
50
Elbow dysplasia - radiography
- deep sedation or GA is required
- 2 orthogonal views of the elbow are generally sufficient to demonstrate the abnormality
-- flexed mediolateral and craniocaudal view
- an extended mediolateral and 'lazy' craniocaudal view might also be helpful
- the primary lesion may not be identified in the case of those animals with fragmented medial coronoids
- in these animals secondary changes such as sclerosis of the trochlea notch of the ulna and new bone highlighted on the anconeal process in the flexed mediolateral view may be the only indicators of elbow dysplasia
- early cases may show minimal or no radiographic signs
- craniocaudal view allows visualisation of the medial coronoid process
51
Elbow dysplasia - radiographic features
Fragmented medial coronoid (FCP)
- early degenerative changes to the joint but rarely is the primary lesion seen
Osteochondrosis of the medial humeral condyle
- small deficit seen on the medial condyle
- the mineralised cartilage flap can occasionally be seen and there are associated degenerative changes to the joint (osteochondritis dissecans)
Ununited anconeal process
- fully flexed mediolateral view
- this condition is a failure of ossification of the growth plate (cf FCP)
- the physis should close at 120d
Ununited medial epicondyle
- a rare manifestation of ED
52
Elbow dysplasia - advanced imaging
For examination of bone CT is generally considered to be superior to MRI
It is excellent for all types of ED particularly FCP.
53
Elbow dysplasia - arthroscopy
- involves placement of cameras and instruments into the joint while it is inflated by a saline solution
- occasionally it allows detection of lesions not seen with CT
- magnified image can be very helpful
- it facilitates tx at the same time as diagnosis
54
Elbow dysplasia - FCP tx
Many tx options available suggesting none are superior
Conservative management:
- weight control, NSAIDs, platelet rich plasma, stem cell therapy, nutraceuticals, cartrophen?
Removal of the fragment ± ulna osteotomy to correct joint incongruence
- may improve the short term outlook for the pt but long term doesn't reduce the pathology and is performed less often
50% improve with surgical management, 45% unchanged and 5% deteriorate possibly due to exposure of subchondral bone
55
Elbow dysplasia - FCP surgical options
Off loading the medial compartment of the joint to reduce the weight bearing on this aspect of the joint which is the site of pathology
- PAUL technique (proximal abducting ulna osteotomy)
- sliding medial humeral osteotomy
Partial elbow replacement/joint resurfacing (Arthrex CUE (canine unicompartmental elbow system))
Elbow arthrodesis (surgical fusion)
- difficult to obtain the correct limb length to allow good function
Elbow replacements
- 2 types available Sirius and TATE
- still in their infancy and do not (as yet) result in the consistent outcomes seen in total hip replacement
56
Elbow dysplasia - FCP prognosis
- guarded
- irrespective of the technique employed the development of degenerative joint dz is inevitable
- long term medical management of the joint changes set in train by the original lesion can be anticipated (i.e. OA)
- warn the O from the outset
57
Elbow dysplasia - ununited anconeal process surgical management
- remove the fragment -> this results in joint incongruity and OA
- reattachment of the fragment with screw
- reattach fragment and ulna osteotomy to lengthen the ulna (it has been postulated that a short ulna, as part of the joint incongruity results in pressure applied to the anconeus and its failure to fuse)
-- better outcomes
- results of all these techniques are variable
- in the mature animal treat this condition medically as likely to develop OA
- osteotomy allows the ulna to elongate and take pressure off the anconeal process so it can unite with the ulna
58
Elbow dysplasia - control
As tx outcomes have bee poor there has been increasing emphasis on prevention
- BVA Kennel Club Elbow Dysplasia Scheme introduced in 1998
- originally 3 views of each elbow required, now only 2 mediolateral views (flexed & neutral or moderately extended)
- each below has a max score of 3
- the score of any individual is that of the worse elbow
- breeding is discouraged from any animal with a score greater than 0
- scored by degree of degenerative changes seen in the joint
- the estimated breeding value looks at the breed overall as well as the ED score and advises a breeder whether its appropriate t breed from their dog (its an indication of the genetic value of the dog avoiding the influence of environmental factors such as exercise and diet)
59
Shoulder osteochondrosis - signalment
- lab
- border collie
- 6-8m/o
60
Shoulder osteochondrosis - history
- lame on rising
- worse after exercise
- pain on shoulder extension
- scapular muscle atrophy
- rarer than it used to be
61
Shoulder osteochondrosis - radiographic diagnosis
- radiographic positioning for the shoulder
- heavy sedation or GA required
- 2 views taken
-- mediolateral
-- caudocranial: the animal is placed in a trough with the body slightly rotated away from the x-ray plate
62
Shoulder osteochondrosis - diagnosis
Radiography
- easily seen on plain radiographs with flattened caudal 3rd of humeral glenoid
- joint mouse or mineralised cartilage flap (OCD) can be seen on occasions
- arthrogram can be useful but rarely performed now
CT
Arthroscopy
63
Shoulder osteochondrosis - treatment
Surgical management
- remove the fragment and deride the deficit edges and forage the bone bed to encourage healing with fibrocartilage
OR
- limited caudal arthrotomy with flexed shoulder and perform same procedure (modified Cheli approach)
Can give excellent results
Some advocate conservative management with vigorous exercise with analgesia to dislodge flap
Shoulder osteochondrosis has the best prognosis of all joints affected by this condition. Once the abnormal cartilages comes out the way, they do better immediately
64
Stifle osteochondrosis - signalment
- 6-12m
- lab
- staffie
- has been reported in the cat
65
Stifle osteochondrosis - CS
- chronic lameness esp on rising
- joint pain
- joint effusion
- differential would be early cruciate dz
66
Stifle osteochondrosis - radiographic diagnosis
- radiographic positioning for the stifle
- heavy sedation or GA required
- 2 views taken
-- the mediolateral in which a pad is placed under the hock to de-rotate the femur and superimpose the femoral condyles
-- either a caudocranial or craniocaudal
-- a pad should be placed under the stifle to prevent it slipping laterally when taking the caudocranial view
Potential findings:
- flattened condyle on mediolateral view
- deficit to either the medial or the lateral femoral condyle on the caudocranial view
- a joint mouse may be seen in the caudal joint pouch on the mediolateral view
- joint effusion (loss of subpatellar fatpad)
Joint mouse - cartilage flat that comes away and lies in the caudal joint compartment
67
Stifle osteochondrosis - diagnosis
- radiography
- ct
- arthroscopy
68
Stifle osteochondrosis - tx
- generally surgically managed
- arthroscopy/arthrotomy
- remove fragment and curette deficit
- can attempt replacement of the deficit with OAT (osteochondral autograft transfer) or SOR (synthetic osteochondral resurfacing)
- prognosis is fair to guarded
69
Hock osteochondrosis - signalment & CS
- labs
- rotties
- 6-12
- lameness particularly after exercise
- joint effusion to both medial and lateral aspects of talocrural joint
70
Hock osteochondrosis - diagnosis
- radiographs & CT
- arthroscopy
CT can be preferable to radiography esp if lesion is in the lateral talus and hence overlaid by the calcaneus. The lesion is more commonly on the medial condyle of the talus
71
Hock osteochondrosis - radiographic diagnosis
- heavy sedation or GA required
- several views may be helpful
- mediolateral
- caudocranial or craniocaudal
- on occasions when there's a lesion on the lateral trochlea of the talus a flexed view to displace the calcaneus from the image of the trochlea ridge may be helpful
Potential findings:
- widened joint space
- flattened aspect of the caudal trochlea
- sclerosis of the subchondral bone
- mineralised cartilaginous flat (OCD)
- secondary arthritic changes
72
Hock osteochondrosis - tx & prognosis
Surgical management
- removal of the osteochondral fragment either arthroscopically or with an open arthrotomy
- salvage procedure: pantarsal arthrodesis
Medical management
- weight control
- NSAIDs
Prognosis
- guarded to poor and often a salvage procedure such as a pantarsal arthrodesis is required to manage these cases
73
Lumbosacral osteochondrosis
- rare condition
- infrequently causes CS
- can result in instability and disc extrusion/protrusion and back pain
