Andrew Craig Elbow dysplasia - Vetcpd · erythrophagia may be present) or inflam-matory conditions...
2
Page 44 - VETcpd - Vol 2 - Issue 2 VET cpd - Orthopaedics Peer Reviewed Andrew Craig BVSc PGCertSAS MRCVS Andrew graduated from the University of Liverpool in 2009. Following several years in mixed and small animal practice he completed a small animal internship at Southern Counties Veterinary Specialists where he has now taken a position as ECVS Resident in Small Animal Surgery. He completed the BSAVA Certificate in Small Animal Surgery (PGCertSAS) in 2014 and plans to sit the ECVS Diploma in Small Animal Surgery in 2018. Philip Witte BVSc BSc CertAVP MRCVS Philip graduated from the University of Bristol in 2005. Following two years’ work in mixed practice he completed a surgical internship and an orthopaedic residency at Southern Counties Veterinary Specialists where he has been working as an orthopaedic clinician since 2013. He completed the RCVS Certificate in Advanced Veterinary Practice (CertAVP) in September 2013 and the RCVS Synoptic CertAVP Examination in General Small Animal Surgery in 2015. Philip plans to sit the RCVS Diploma in Small Animal Surgery (Orthopaedics) in 2016. Elbow dysplasia part 2 – investigation Elbow dysplasia is a common cause of forelimb lameness in dogs. This article is the second of a three part series on elbow dysplasia. It discusses an approach to the diagnosis of elbow dysplasia including the information pertinent to making appropriate treatment decisions. Treatment will be discussed in the third article. Key words: canine, orthopaedics, elbow, forelimb lameness, elbow dysplasia, diagnosis Introduction In a previous article the authors discussed the aetiology of developmental conditions of the elbow covered by the blanket term ‘elbow dysplasia’. These conditions include medial coronoid disease, ununited anconeal process, osteochondrosis and joint incongruity. It was explained that radioulnar incongruity, either transient or permanent, may be implicated in the aetiology of these conditions. Whilst ununited anconeal process and osteochondrosis are relatively uncommon, medial coronoid disease is a very common condition and should be high on the differential diagnosis list for dogs with forelimb lameness. History Forelimb lameness in a dog of appropriate signalment (i.e. young medium to large breed, especially Labrador Retrievers), should place elbow dysplasia (ED) high on the differential diagnosis list. ED is commonly bilateral, resulting in bilateral forelimb lameness such that asymmetry in the gait may not be present. Sometimes the history will include “shifting” forelimb lameness i.e. a lameness affecting either forelimb at different times. Additionally, owners frequently confuse left and right forelimb lameness, so a gait examination should always be the first step. An assessment of posture may also be useful. Dogs with medial coronoid disease are often reported to stand with pronation and elbow abduction, and may raise the affected paw when sitting. Physical examination The physical examination should comprise the following features: Palpation of muscle mass Asymmetry in forelimb muscle mass may indicate unilateral muscle atrophy (or bilateral muscle atrophy, more severe on one side). Muscle atrophy indicates disuse Southern Counties Veterinary Specialists Forest Corner Farm, Hangersley Ringwood, Hampshire BH24 3JW E: [email protected] Tel: (01425) 485615 www.scvetspecialists.co.uk For Orthopaedic Referrals in your area visit: vetindex.co.uk/ortho For Orthopaedic Equipment: vetindex.co.uk/orthoequip For Xray equipment: vetindex.co.uk/xray ® 16th Edition 15 THE A-ZDIRECTORYOF VETERINARYPRODUCTS, SUPPLIES ANDSERVICES THE A-Z DIRECTORY OF VETERINARY PRODUCTS, SUPPLIES AND SERVICES 2015 www.vetindex.co.uk 21st Edition Vet CPD Journal: Includes 5 hours of FREE CPD! See inside for further details!!! Vet CPD VETcpd Vet CPD VETcpd Vet CPD VETcpd Vet CPD VETcpd 5 hours FREE CPD!! and is suggestive of a more chronic lame- ness in comparison with the ‘snap-shot’ appreciation of limb function afforded by a gait examination. Subtle muscle atrophy is most easily identified by palpation of a prominent scapular spine and acromion process. Note that palpation of atrophy of the shoulder muscles does not necessarily indicate a shoulder problem. Severe muscle atrophy may be suggestive of denervation. Palpation of the elbows An effusion is a fluid distension of the joint and indicates inflammation. Effu- sion may be palpable on the caudo-lateral aspect of the joint (Figure 1). The presence of an effusion is a very useful indicator of elbow disease. To gain an understanding of the difference between normal and abnormal landmarks, frequent palpation of elbows in all dogs is recommended. In more advanced cases of ED peri-articular fibrosis may obscure any effusion present. The finding of thickened joints with poorly defined anatomy suggests a degree of secondary osteoarthritis. Manipulation of the elbows Full extension and flexion may be resented. Pressure can be applied through the medial compartment by supinating the carpus with the elbow fixed at 90° flexion. Lack of resentment to manipula- tion may be observed in stoic dogs so an absence of resentment to manipulation does not exclude the elbow as a cause of lameness. Advancing peri-articular new bone formation may result in a reduced range of motion. The canine elbow should extend almost to 180°, while full flexion should displace a thumb placed in the crux of the canine elbow. Synoviocentesis Synovial fluid aspiration may be useful to definitively confirm the presence of a mononuclear arthropathy suggestive of elbow dysplasia/osteoarthritis, and
Transcript of Andrew Craig Elbow dysplasia - Vetcpd · erythrophagia may be present) or inflam-matory conditions...
-
Page 44 - VETcpd - Vol 2 - Issue 2
VETcpd - Orthopaedics Peer Reviewed
Andrew Craig BVSc PGCertSAS MRCVS
Andrew graduated from the University of Liverpool in 2009. Following several years in mixed and small animal practice he completed a small animal internship at
Southern Counties Veterinary Specialists where he has now taken a position as ECVS Resident in Small Animal Surgery.
He completed the BSAVA Certificate in Small Animal Surgery (PGCertSAS) in 2014 and plans to sit the ECVS Diploma in Small Animal Surgery in 2018.
Philip Witte BVSc BSc CertAVP MRCVS
Philip graduated from the University of Bristol in 2005. Following two years’ work in mixed practice he completed a surgical internship and an orthopaedic
residency at Southern Counties Veterinary Specialists where he has been working as an orthopaedic clinician since 2013.
He completed the RCVS Certificate in Advanced Veterinary Practice (CertAVP) in September 2013 and the RCVS Synoptic CertAVP Examination in General Small Animal Surgery in 2015. Philip plans to sit the RCVS Diploma in Small Animal Surgery (Orthopaedics) in 2016.
Elbow dysplasia part 2 – investigationElbow dysplasia is a common cause of forelimb lameness in dogs. This article is the second of a three part series on elbow dysplasia. It discusses an approach to the diagnosis of elbow dysplasia including the information pertinent to making appropriate treatment decisions. Treatment will be discussed in the third article.
Key words: canine, orthopaedics, elbow, forelimb lameness, elbow dysplasia, diagnosis
IntroductionIn a previous article the authors discussed the aetiology of developmental conditions of the elbow covered by the blanket term ‘elbow dysplasia’. These conditions include medial coronoid disease, ununited anconeal process, osteochondrosis and joint incongruity. It was explained that radioulnar incongruity, either transient or permanent, may be implicated in the aetiology of these conditions. Whilst ununited anconeal process and osteochondrosis are relatively uncommon, medial coronoid disease is a very common condition and should be high on the differential diagnosis list for dogs with forelimb lameness.
HistoryForelimb lameness in a dog of appropriate signalment (i.e. young medium to large breed, especially Labrador Retrievers), should place elbow dysplasia (ED) high on the differential diagnosis list. ED is commonly bilateral, resulting in bilateral forelimb lameness such that asymmetry in the gait may not be present. Sometimes the history will include “shifting” forelimb lameness i.e. a lameness affecting either forelimb at different times. Additionally, owners frequently confuse left and right forelimb lameness, so a gait examination should always be the first step. An assessment of posture may also be useful. Dogs with medial coronoid disease are often reported to stand with pronation and elbow abduction, and may raise the affected paw when sitting.
Physical examinationThe physical examination should comprise the following features:
Palpation of muscle massAsymmetry in forelimb muscle mass may indicate unilateral muscle atrophy (or bilateral muscle atrophy, more severe on one side). Muscle atrophy indicates disuse
Southern Counties Veterinary SpecialistsForest Corner Farm, Hangersley Ringwood, Hampshire BH24 3JW
Tel: (01425) 485615
www.scvetspecialists.co.uk
For Orthopaedic Referrals in your area visit: vetindex.co.uk/orthoFor Orthopaedic Equipment:vetindex.co.uk/orthoequipFor Xray equipment: vetindex.co.uk/xray
®
16th Edition
VetIndex 2015 the a-z d
irec
tory o
f veter
ina
ry pro
du
cts, su
pplies an
d serv
ices
the a-z directory of veterin
ary
products, supplies and serv
ices
2015
www.vetindex.co.uk
21st Edition
Vet CPD Journal:
Includes 5 hours
of FREE CPD!
See inside for
further details!!!
Vet CPD Vol 1 - Issue 4
Peer ReviewedVETcpd
VETcpd - Vol 1 - Issue 3
The peer reviewed clinical journal with
online exams to turn your educational
reading into documented CPD
Vet CPDJournal
Vol 1 - Issue 3
Peer ReviewedVETcpd
VETcpd - Vol 1 - Issue 3
The peer reviewed c
linical journal with
online exams to turn
your educational
reading into docume
nted CPD
Cover_2014.indd 1
07/09/2014 18:05
Vet CPDJournal
Vol 1 - July 2014Peer ReviewedVETcpd
The peer reviewed clinical journal with
online exams to turn your educational
reading into 5 hours of certified CPD
VETcpd - Vol 1 - April 2014
Cover_2014.indd 1
11/06/2014 15:16
VetIndex 2015 - Web
site Design | Vet CPD
Journal
Vet CPDJournal
VETcpd Reprints fro
m Vol 1 - Issues 1 - 4, 2
014Peer Review
ed
The peer reviewed clin
ical journal with
online exams to turn yo
ur educational
reading into documente
d CPD
5 hours
FREE
CPD!!5 hours
FREE
CPD!!
Cover 2015_mod_futura.in
dd 1
27/02/2015 10:00
and is suggestive of a more chronic lame-ness in comparison with the ‘snap-shot’ appreciation of limb function afforded by a gait examination. Subtle muscle atrophy is most easily identified by palpation of a prominent scapular spine and acromion process. Note that palpation of atrophy of the shoulder muscles does not necessarily indicate a shoulder problem. Severe muscle atrophy may be suggestive of denervation.
Palpation of the elbowsAn effusion is a fluid distension of the joint and indicates inflammation. Effu-sion may be palpable on the caudo-lateral aspect of the joint (Figure 1). The presence of an effusion is a very useful indicator of elbow disease. To gain an understanding of the difference between normal and abnormal landmarks, frequent palpation of elbows in all dogs is recommended. In more advanced cases of ED peri-articular fibrosis may obscure any effusion present. The finding of thickened joints with poorly defined anatomy suggests a degree of secondary osteoarthritis.
Manipulation of the elbowsFull extension and flexion may be resented. Pressure can be applied through the medial compartment by supinating the carpus with the elbow fixed at 90° flexion. Lack of resentment to manipula-tion may be observed in stoic dogs so an absence of resentment to manipulation does not exclude the elbow as a cause of lameness. Advancing peri-articular new bone formation may result in a reduced range of motion. The canine elbow should extend almost to 180°, while full flexion should displace a thumb placed in the crux of the canine elbow.
SynoviocentesisSynovial fluid aspiration may be useful to definitively confirm the presence of a mononuclear arthropathy suggestive of elbow dysplasia/osteoarthritis, and
-
Full article available for purchase at www.vetcpd.co.uk/modules/ VETcpd - Vol 2 - Issue 2 - Page 45
VETcpd - Orthopaedics
prompting further investigation of the joint in question. However, it should be noted that there is significant overlap in the ranges of concentration of mononu-clear cells in joints with ED/osteoarthritis and in normal joints. Synovial fluid cytol-ogy may also be useful to exclude trauma (in which case macrophages demonstrating erythrophagia may be present) or inflam-matory conditions (immune-mediated or infectious conditions, where an elevated neutrophil concentration may be present).
Imaging Once the elbow has been identified as the cause of lameness, imaging is required to identify which, if any, of the conditions of ED are present. Imaging typically involves radiography and / or computed tomography (CT). Further investigation of the elbow joint may be afforded by arthroscopy which allows direct visualisation of the cartilage health.
RadiographyRadiographs of the elbow should include the following projections:• cranio-caudal (Figure 2)• flexed medio-lateral (Figure 3)• neutral medio-lateral (Figure 4)
Radiographs may be used to diagnose osteochondrosis (Guthrie 1989) and ununited anconeal process (UAP).
Osteochondrosis (OC) most commonly occurs on the medial aspect of the medial humeral condyle and is identified on the cranio-caudal projection of the elbow (Figure 2), although the lesion may be subtle and is sometimes difficult to confirm by radiography alone.
Ununited anconeal process (UAP) is often more easily confirmed and may be identi-fied on a flexed medio-lateral projection of the elbow, where a proximo-distal radiolu-cent line (often irregular) is present at the base of the anconeal process (Figure 3).
Medial coronoid disease is rarely con-firmed definitively by radiography alone, as the medial coronoid process is superim-posed upon the radial head and humeral condyle on a medio-lateral projection. Radiographic features suggestive of medial coronoid disease on the medio-lateral projection include: subchondral sclerosis in the ulna at the level of the coronoid process/trochlear notch, occurring in approximately 87% of cases (Fitzpatrick et al, 2009, Burton et al, 2007) and a poorly demarcated medial coronoid process where it is superimposed over the radial head (Figure 4B).
Figure 1: Drawing of the lateral view of the elbow, left is a normal joint and right illustrates a distended joint in a dog with elbow dysplasia. The caudo-lateral aspect is the only palpable area for joint effusion (red arrow), due to the presence of soft tissue coverage on other aspects of the joint
Figure 2: Cranio-caudal radiographic projection of a five month old Labrador retriever revealing a defect in the margin of the articular surface of the medial part of the humeral condyle, consistent with an osteochondrosis lesion (green arrow)
Figure 3: Flexed medio-lateral radiographic projec-tion of a dog with a wide irregular radiolucent line visible in the region of the base of the anconeal process (green arrow), consistent with ununited anconeal process (UAP)
Figure 4: Neutral medio-lateral radiographic projections: Left – normal elbow. Right – with medial coronoid disease; note the loss of definition of the medial coronoid process (green arrow) and subchondral sclerosis of the ulna at the level of the coronoid and trochlear notch (red arrow). Apparent narrowing of the medullary canal has been highlighted (blue arrow). This is often the easiest way to identify subchondral sclerosis of the ulna
loss of definition of the medial coronoid process
subchondral sclerosis of the ulna at the level of the coronoid and trochlear notch
Apparent narrowing of the medullary canal
4A: Normal elbow 4B: Medial coronoid disease
