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
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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?
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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
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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
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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
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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
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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
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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)
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
Questions?
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