Vetgirl Forelimb Lameness Webinar 12-2015
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12/11/15! Deciphering the Head Bob! Forelimb Lameness in Dogs ! Michelle Trappler, VMD, DACVS! December 16, 2015! Introduction! Garret Pachtinger, VMD, DACVECC! COO, VETgirl! Introduction! Justine A. Lee, DVM,! DACVECC, DABT! CEO, VETgirl! 1! 12/11/15! Conflict of Interest Disclosure! VETgirl…On-The-Run! The tech-savvy way to get online veterinary CE!! A subscription-based podcast and webinar service offering veterinary RACE-approved CE! VETgirl ELITE! 50-60 podcasts/year plus 24+ hours of webinars!! $199/year! 30+ hours of RACE-CE! 2! 12/11/15! TEAM Memberships!! Recorded, Archived, Available!! Easier playback, less buffering – better!! Download our iTunes podcasts free!! 3! 12/11/15! Social media and our blog!! Logistics: CE Certificates! ! No need to raise your hand! ! Type in ques3ons ! Emailed to you 48 hours aer the webinar ! Ac3ve par3cipaon = no quiz ! Watching video later, must complete quiz ! ELITE members only ! Email / contact with ANY ques3ons ! [email protected] ! [email protected] Call in from Smart Phone!! 4! 12/11/15! Introduction! Michelle Trappler, VMD, DACVS! Surgeon at Hospital Veterinario San Francisco de Asis! Forelimb Lameness ! History and Presentation! Gait Observation! Orthopedic and Neurologic Exam! Specific Conditions! History and Presentation! Acute vs. Chronic?! Progressive- improving vs. worsening?! Exacerbated by activity?! Changes with medications?! Why presenting now?! 5! 12/11/15! Gait Observation! Watch from afar! Check posture! Look for asymmetry and muscle atrophy! Gait Observation! Look at relationship of carpus and elbow! Gait Observation! Straight line walk and trot! Circles to both sides! Video Credit: Dr. Sherman Canapp, VOSM! 6! 12/11/15! Gait Observation! Abduction/ Adduction! Stride length! Orthopedic/Neurologic Exam ! • Start at the toes and work your way up! • Palpate each bone for pain, fractures! • Metaphyseal vs Diaphyseal ! • Check joints for increased/decreased/painful/abnormal ROM! • Localize any swelling! • Joint effusion vs soft tissue swelling! • Check tendons and ligaments as you go! • Save injured limb for last! ROM Normals! 7! 12/11/15! Orthopedic/Neurologic Exam! • Paw pads! • Nail bed! • Interdigital areas! • Toe ROM! • Nails! • Flex and extend toes! Orthopedic/Neurologic Exam! • Metacarpals! • Carpal ROM! • Carpal joint effusion! • Med/Lat Stability! Orthopedic/Neurologic Exam! • Radius/Ulnar palpation! • Look for angular limb deformities! 8! 12/11/15! Orthopedic/Neurologic Exam! • Flexion/Extension of elbow! • Isolate medial compartment ! • Hyperextension! • Medial/Lateral instability ! • ROM, Effusion! • Crepitus! Orthopedic/Neurologic Exam! • Humerus palpation! Orthopedic/Neurologic Exam! • Flexion/Extension of shoulder! • Abduction/Adduction! • Biceps stretch! • Supraspinatus stretch! • Palpate biceps tendon! • Palpate supraspinatus tendon! 9! 12/11/15! Orthopedic/Neurologic Exam! • Palpate scapula for fx, pain! • Note scapular spine! • Note any supra/infra atrophy! • Check relationship to thoracic wall! Orthopedic/Neurologic Exam! Check ROM of neck! Check CPs! Check withdrawl, biceps, triceps reflexes! Check toes for scuffing! Palpate axillary area! Specific Conditions! Carpal Hyperextension! Elbow Dysplasia Complex! Shoulder OCD! Biceps tendonopathy ! Supraspinatus Tendonopathy! Medial Shoulder Syndrome/Instability! Cervical IVDD! Brachial plexus! 10! 12/11/15! Carpal Hyperextension! Can be seen in puppies due to excessive ligament laxity, as a result of trauma, or due to degeneration! Carpal Hyperextension! Stressed radiographs- very important!! Elbow Dysplasia Complex! Radio-ulnar incongruity (RUI)! Ununited Anconeal Process (UAP) (2)! Fragmented Medial Coronoid Process (FMCP) (3)! Humeral OC/OCD (4)! 11! 12/11/15! Elbow Dysplasia Complex! Leading cause of forelimb lameness in dogs! Large to giant breed, juvenilles! Genetic basis, *Heritable*! Elbow Dysplasia Complex! Unilateral or bilateral forelimb lameness! Lameness exacerbated by activity! Abduction of limb on gait analysis! Elbow Dysplasia Complex! Decreased ROM (normal flexion 70-75o)! Pain on hyperflexion, hyperextension! Pain on isolation of medial compartment! Thickening of elbow, effusion! Crepitus with ROM! 12! 12/11/15! Elbow Dysplasia Complex! Look for radiographs signs that point to elbow:! Osteophytes along anconeus! Sclerosis of ulnar notch! Osteophytosis, Osteoarthritis! Elbow Dysplasia Complex- RUI! Radio-Ulnar Incongruity (RUI)! Asynchronous growth between radius and ulna! Step defect in joint! May put excess pressure on medial coronoid process! Elbow Dysplasia Complex- RUI! Diagnosis! Radiographs! CT! Arthroscopy! MRI! 13! 12/11/15! Elbow Dysplasia Complex- RUI! Radius too short? ! Osteotomy of proximal radius! Ulna too short?! Ulnar lengthening! Elbow Dysplasia Complex- UAP! Ununited Anconeal Process (UAP)! Large to giant breeds, Males! German Shepherds overrepresented! Clinical signs at 6-12 months! Elbow Dysplasia Complex- UAP! History of intermittent lameness, worse after exercise! Circumduction of forelimb during swing phase! Effusion in caudal compartment ! Crepitus! Pain on hyperextension! 14! 12/11/15! Elbow Dysplasia Complex- UAP! Diagnostics! X-rays! Arthroscopy*! CT! MRI! Elbow Dysplasia Complex- FMCP! Fragmented Medial Coronoid Process (FMCP)! Large breeds overrepresented ! Clinical signs at 5-7 months ! Can see older dogs with secondary OA! Elbow Dysplasia Complex- FMCP! Acute or chronic lameness! Worsens after exercise, heavy activity! Abduct forelimb on gait analysis! Decreased ROM of elbow ! Crepitus, Effusion! Pain on hyperextension, hyperflexion! 15! 12/11/15! Elbow Dysplasia Complex- FMCP! Diagnostics! X-rays! Arthroscopy*! CT! MRI! Treatment! Fragment removal! Elbow Dysplasia Complex- OCD! CS at 5-10 months! Large breeds, Males > Females! Exacerbated by exercise! Pain on elbow hyperextension or flexion! Often bilateral! Elbow Dysplasia Complex- OCD! Diagnosis! Radiographs! CT! Arthroscopy*! MRI! 16! 12/11/15! Shoulder OC/OCD! Large, giant breed, Males > Females! 27-68% have bilateral lesions, unilateral lameness*! Clinical signs at 4-8 months! Caudal humeral head most often affected! Shoulder OC/OCD! May be painful in extreme extension! May see shoulder muscle atrophy, OA if chronic! Rads- subchondral bone defect, sclerosis +/- mineralized flap in caudal pouch! Shoulder OC/OCD! Conservative tx: Exercise dog until flap falls off! Surgical tx: Arthroscopy recommended, Arthrotomy! Good long-term prognosis with prompt treatment! 17! 12/11/15! Biceps Tendonopathy! Can be primary or secondary! Middle-age to older, medium- to large breed dogs ! No breed or sex predilections! Chronic or progressive lameness, worse with exercise! Non-responsive to NSAIDs! Biceps Tendonopathy! PE findings! Biceps “stretch” test! Shoulder drawer test! Biceps reaction test! Biceps Tendonopathy! Diagnosis! Radiographs! Ultrasound ! Arthroscopy! MRI! 18! 12/11/15! Supraspinatus Tendon! Middle-age to older, medium- to large breed dogs ! Rotties and Labs predisposed, No sex predilections! Chronic or progressive lameness, worse with exercise! Non-responsive to NSAIDs ! Supraspinatus Tendon! PE: Supraspinatus stretch! Video Credit: Dr. Sherman Canapp, VOSM! Supraspinatus Tendon! Diagnosis:! Radiographs! Ultrasound! Arthroscopy! MRI! 19! 12/11/15! Medial Shoulder Syndrome/Instability! MSS/MSI! Congenital: CS at 3-10 months. Toy breeds.! Luxation usually medial.! Acquired: CS with injury/overuse. Large breeds.! Subluxation: Middle-aged, Male, Large Breed dogs! Medial Shoulder Syndrome/Instability! Chronic, intermittent or continual lameness! Can be intermittently severe! Minimal to no response to NSAIDs! Worse with excercise! May have agility history, history of getting leg caught! Medial Shoulder Syndrome/Instability! Physical Exam! Shoulder muscle atrophy! Increased abduction of shoulder! Normal abduction approx. 30o! Compare to contralateral limb!! May only show under sedation! 20! 12/11/15! Medial Shoulder Syndrome/Instability! Diagnosis! Radiographs! MRI! Arthroscopy*! Shoulder/Elbow Pathology! Can be a combination of multiple shoulder pathologies! Can also be “shelbow”! Cervical IVDD! 60% cervical IVDD dogs had no neuro deficits, only pain! Root signature in 22-50% of dogs with cervical IVDD ! 55% of dogs have chronic onset! 21! 12/11/15! Brachial Plexus Tumors! Unilateral paresis/ lameness! Significant muscle atrophy! Pain in axillary area! +/- reduced CPs, withdraw! +/- ipsilateral Horner’s/miosis! Brachial Plexus ! Palpate axillary region to feel for any masses ! MRI - diagnostic modality of choice! Tx - Amputation +/- chemo vs RT! 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