Orthopedic and Neurologic Examination Physiotherapy Tibia Tuberosity Advancement Oncosurgery Case Discussion
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University Zurich Small Animal Surgery Clinic Orthopedic and neurologic examination Physiotherapy Tibia tuberosity advancement Oncosurgery Case discussion 5th Continuing Education Course for Japan Small Animal Surgeons at the Small Animal Surgery Clinic, Vetsuisse Faculty, University Zurich, University August 23 – 27, 2004 page 2 Contents Contents 2 Program 3 Examination of the orthopedic patient 4 Examples, x-rays 9 Physical therapy 12 Cases and revisions 13 Introduction to neurophysiology 30 Localisation of neurologic disorders 32 Prevention and revision of perioperative and postoperative complications with Zurich cementless canine hip prosthesis 35 Cranial cruciate ligament rupture: pathogenesis, diagnosis, overview methods 38 Tibial tuberosity advancement (TTA) for the treatment of cranial cruciate disease in dogs: evidences, technique and initial clinical results. 40 Oncosurgery 42 Biopsy 42 Tumor staging 47 Surgical oncology 51 Chemotherapy 57 Canine mast cell tumor 63 Tumors of the skeletal system 67 Reconstructive surgery 90 Mammary gland tumors 92 Perianal tumors 98 Cancer of the oral cavity 101 Paraneoplastic Syndromes 126 page 3 Program Orthopedic examination, physical therapy, cases Monday, Aug 0800 Gait analysis Venzin 23rd 2004 0900 Examples Venzin 1000 x-rays Koch 1200 Lunch 1300 Physical therapy Koch, Mouwen 1500 - Cases and revisions from Japan Voss, Keller 1700 veterinarians and Zurich faculty including biomechanics, failures, problems 1700 Champagne party Neurologic examination, cases, THP complications Tuesday, 0800 Introduction to neurophysiology Riediger Aug 24th 0900 Exam of the normal and pathological Steffen 2004 neuropatient 1100 Electrodiagnosis Steffen 1200 Lunch 1300 THR cup and stem loosening: Tepic, Montavon introduction and discussion, morphometry hip joint 1500- Cases and revisions /ctd) Voss, Keller 1700 Tibia tuberosity advancement (TTA) Wednesday, 0800 ACL rupture: introduction, Koch Aug 25th pathogenesis, diagnosis, overview 2004 methods 0900 TTA: principles, technique Montavon 1000 TTA: video, comments Guerrero 1045 TTA: Wet lab Montavon, Faculty 1200 Lunch 1300 Excursion De Robillard Oncosurgery Thursday, 0800 Introduction to oncosurgery Rod Straw Aug 26th 1000 Organ specific lectures Rod Straw 2004 1200 Lunch 1300 Cases Rod Straw 1400 Wet lab Rod Straw, faculty 1700 End of wetlab Oncosurgery Friday, Aug 0800 Organ specific lectures Rod Straw 27th 2004 0900 Wet lab Rod Straw, faculty 1200 Lunch 1300 Paraneoplastics Rod Straw 1400 Wet lab Rod Straw, faculty page 4 Examination of the orthopedic patient Claudio Venzin, Dr. med. vet. A full orthopedic examination should only be performed once a thorough history (Signalement: breed, age, size, history: how long is the problem, progressive.) and physical examination has been completet. Manipulation of the affected limb should be left until the end of the examination in order to avoid sensitizing the animal. Cats are more difficult to examine than dogs, as they do not stand still and are less tolerant of manipulation and restraint. Gait standing: Certain visual will help you determine the site of involvement. The body weight often shifted towards the normal limb. The normal limb may appear to be help closer to the midline or under the body, while the affected limb is held out to the side or away from the body. (Toes of the unaffected leg may appear to sread further apart due increased weight bearing). The back may arch dorsally as weight is shifted to the front or rear limbs. Hip joint dysplasia or CrCL rupture both side then the weight will be forward, causing the elbows to appear abducted, the head and neck to carried low, back to arch dorsally. Nails will get longer in limbs not bearing full weight. Gait: Gait should be observed at walk and trot. The head and neck move upward as the affected forlimb touchess the floor, and downward when the normal forelimb touches the floor. (say „yes“ to the normal foreleg). The stride is shortened on the affected side and the animal spends less time on the affected limb. Audible clicks may somtimes be heared in young dogs with hip subluxation and in dogs with medial meniscal tears secondary to cranial cruciate ligament ruptures. Palpation A complete knowledge of structure and funktion helps you decide how to perform specific tests and how to interpret the results. Comparing one side with the other may help you detect specific abnormalities. Palpation standing: Important to exclude neurologic problems ( proprioceptive positioning, head turning, sinal cord pain ) Palpation to detect swelling, pain, muscle atrophy, bone deformities and effusion or subtile differences in periarticular soft tissue. Palpation lateral recumbency: Examination is started at the level of the digitis and proceeds proximally. Response to palpation, manipulation and range of motion is assessed at this time. forelimb: digitis: page 5 - nail beds (inflamation, infection, neoplasia) - phalanges, phalangeal joints (swelling,pain,bony bnormalities) - footpads (laceration, infection, pododermatitis, neoplasia, sesamoid fractures or rheumatoid arthritis metacarpals: - soft tissue swelling, crepitus from fracture or subluxation carpus: - performed in slight flexion, allowing for palpation of the radiocarpal joint and intercarpal joints - flexion and extension in addition to stressing the joints medially and laterally to evaluate the collateral ligaments stability. antebrachium: - examination for any evidence of growth disparity between the radius and ulna. - pain (panostitis, fracture,hyperthrophic osteodystrophy, premature growth plate closure, osteomyelitis, neoplasia elbow joint: - Direct pressure applied over the medial coronoid process of the ulna is a useful method of eliciting a painful response in dogs having fragmented coronoid process. Other common causes for ellbow pain are OCD, DJD, articular fracture, luxations, ellbow incongruity and ununited anconeal process. humerus: - some of humeral bone pain include panosteitis, osteomyelitis, fracture and neoplasia. shoulder: - extension of the shoulder puts pressure onto the cranial lip of the glenoid cavity and tension on the triceps muscle. Flexion puts pressure on the caudal surface of the humeral head (OCD). Abduction exacerbates pain due to joint capsule lesion. Extrinsic causes of shoulder pain can include brachial plexus tumors, infraspinatus contracture, tricepstendon avulsion, medial displacement biceps brachii tendon and cervical disc disease. - Biceps stretch test: The shoulder is slowly flexed to maximum flexion with the dog’s elbow held 90° to the humerus. hindlimb: digitis: - same as for forelimb examination tarsus: page 6 - The tarsus should be palpated in extension and flexion for any medial or lateral instability. tibia/fibula: - Bone pain can include; panostiteis, osteomyelitis, fracture and neoplasia stifle: - The joint should be taken through a full range of motion repeatedly to assess for any crepitus or patellar luxation. Collateral instability is examined with the joint in extension and flexion. The drawer sign is used to test for stability of the cruciate ligament. The tibial compression test can also be used to test for cruciate ligament instability in dogs that resent stifle palpation (Fig. 2). Since in some patients there may be only partial tear of the cranial cruciate ligament, the drawer test should be performed with the stifle in both extension and flexion (Fig.3). With partial tears of the craniomedial band of the cranial cruciate ligament, there will be drawer in flexion and no drawer in extension. The patella should be examined for any evidence of medial or lateral luxation in extension and flexion. femur: - Bone pain can include; panostiteis, osteomyelitis, fracture and neoplasia hip joint: - The hip is evaluated by putting the joint through a full range of motion including flexion, extension, adduction, abduction internal and external rotation. Marked subluxation is occasionally associated with an audible clicking sound as the dog walks, caused by the femoral head snapping in and out of the acetabulum. This can be felt by placing your hand over the greater trochanter as the animal walks. Hip luxation can also be checked with the Barden or Ortolani sign (Fig.1). The hip should also be evaluated for luxation, by checking the alignment of the ilial wing, greater trochanter and ischium. pelvis: - palpation is difficult due to the gluteal musculature. The wing of the ileum and ischium are easy palpable. Evaluation of symmetry of the greater trochanter ileum and ischeum may indicate the presence of acetabular, ilial wing or ischial fractures and hip luxation (Fig4). Additional diagnostic tools: Neurologic examination X-Ray Ultrasound CT MRI Arthroscopy Biopsy page 7 Fig. 1 page 8 Fig. 3 Fig. 2 page 9 Examples, x-rays Daniel Koch, Dr. med. vet. ECVS Case Additional information from Additional information from Differential diagnosis and remarks diagnostic imaging orthopedic examination page 10 page 11 page 12 Physical therapy Marco Mouwen Daniel Koch, Dr. med, vet. ECVS page 13 Cases and revisions Katja Voss, Dr. med. vet. ECVS Marcel Keller, Dr. med. vet. Accepted for publication in V.C.O.T. Internal splinting of dorsal intertarsal and tarsometatarsal instabilities in dogs and cats with the ComPact UniLock 2.0/2.4TM System a K. Voss, M. Keller, P.M. Montavon Summary tarsometatarsal instabilities (3, 14, 18). Because the short dorsal ligaments are not under tensile stress Dorsal intertarsal and tarsometatarsal instabilities are during weight bearing, fibrous