Focus on Canine Sports Medicine Carpal and Tarsal Injuries By Gayle H. Jaeger, DVM, MSpVM, DACVS and Sherman O. Canapp Jr., DVM, MS, DACVS
Injuries to the carpal and tarsal joints are Cause of Injury (sudden) or chronic (slowly progressive) common in performance dogs. These Carpal and tarsal injuries can result from lameness of varying degrees depending joints act as shock absorbers during weight either acute traumatic events or activities on the severity of the injury as shown in bearing and are prone to injury due to their that cause sudden repetitive sprains to Figure 3. Palpation of the affected joint anatomic complexity and lack of muscular the joints’ supportive structures. Possible may reveal soft tissue swelling, discomfort, support. It is this complexity that creates a modes of injury include hyperextension crepitus (crunching on manipulation), diagnostic problem for many veterinarians, (the most common type seen in agility decreased range of motion, or instability and many carpal and tarsal injuries, dogs), hyperflexion with rotation, varus when stressed (either in extension, flexion, particularly those that go undiagnosed or (inside of the limb) or valgus (outside of the varus or valgus, internal or external untreated, can result in an increased risk limb) injuries, degeneration of ligaments rotation). Palpation of the nonaffected of osteoarthritis and potential long-term in some breeds (Collies and Shelties), and joint on the opposite limb can be helpful lameness. certain immune-mediated diseases such as in determining normal from abnormal rheumatoid arthritis. motion. Anatomy X-rays can be taken to evaluate the type Figure 1 illustrates the anatomy of the Diagnosis and severity of injury as seen in Figure 4. carpus and Figure 2 the tarsus: these are Diagnosing mild carpal and tarsal injuries Although you cannot see ligamentous multilevel joints with several supportive can be difficult, but is possible using a structures on x-rays, you can see bone ligaments and a joint capsule. The carpus combination of physical examination and fractures, luxations (dislocations or is composed of three articulations: the imaging techniques. Dogs with carpal or misalignments), and abnormal opening antebrachiocarpal joint, the middle carpal tarsal injuries can present with either acute of a joint when stressed (extension, flexion, joint, and the carpometacarpal joint. The majority of carpal range of motion (70%) is at the antebrachiocarpal joint, while the middle carpal and carpometacarpal joints have minimal range of motion. A thick fibrocartilage pad on the underside of the joint attaches to the individual carpal and metacarpal bones. The main supportive ligaments of the carpus include the medial (radial) and lateral (ulnar) collateral ligaments, which support each side of the Radial Collateral Ligament Antebrachiocarpal Joint Antebrachiocarpal Joint joint, and numerous dorsal (upperside) and Middle Carpal Ulnar Collateral Middle Carpal Joint palmar (underside) ligaments. Joint Ligament Carpometacarpal Joint Dorsal Carpometacarpal Similarly, the tarsal joint is complex Ligament Joint and composed of four articulations: the tibiotarsal joint, proximal (top) intertarsal Ulnar joint, distal (bottom) intertarsal joint, Collateral and tarsometatarsal joint. The majority Ligament of tarsal range of motion (80%) occurs at the tibiotarsal joint. The tarsal joint is supported by numerous ligaments, including the medial and lateral collateral ligaments, dorsal (upperside) and plantar (underside) ligaments.
Figure 1. Canine Carpus (front foot)
74 Clean Run | May 08 the ligament, resulting in joint instability. Since ligaments have a poor blood supply and require the formation and organization of collagen (scar tissue) for their repair, ligament healing times can be quite lengthy. Ligaments only regain about 60% of their courtesy of Dr. Don Hulse courtesy of Dr. Don Hulse original strength after one year. If a gap forms or is present at the junction of the ligament ends during healing, permanent ligament elongation and subsequent instability may result, even if an intact Figure 3. Dog that has sustained a left forelimb Figure 4. X-ray of a dog with a carpal ligament reforms. carpal hyperextension injury. hyperextension injury. Luxation, or dislocation, involves the disruption of multiple ligaments and varus or valgus), which can help determine Types of Injuries the joint capsule. In the carpus, the ligament integrity. Chronic or repetitive Carpal and tarsal injuries can be classified antebrachiocarpal joint is the most common injuries may have bone spurs where into sprains, luxations, fractures, or a site of luxation due to its increased range ligaments attach, and those will also show combination of the three. Sprains are the of motion and its conformation. In the up in an x-ray. most common injuries in performance tarsus, however, the intertarsal joints are Fluoroscopy, which is performed in “real dogs, and sprains to the carpal and tarsal commonly affected due to the relative time,” takes an x-ray movie while you put joints are the most likely to go undiagnosed. lack of bone interdigitation of these joints the joint through its range of motion. It A sprain is an injury to a ligament that can compared to the tibiotarsal joint, which can show excessive openings of the joint occur in the midportion of the ligament serves as an inherent joint stabilizer. spaces or abnormal gliding (subluxation) or at its attachment to bone. Sprains are Common fractures associated with carpal in carpal and tarsal injuries. When available, graded by severity. Grade 1 sprains are and tarsal injuries in performance dogs fluoroscopy is preferred over “stress” x-rays mild and described as an overstretching include the attachment sites for the to evaluate carpal or tarsal joint motion of the ligament, without a tear or loss of collateral ligaments (avulsion fractures) or during manipulation. If there is carpal or function. Grade 2 sprains are moderate in bone fractures due to compression or shear tarsal pain without x-ray abnormalities, severity and are described as a partial tear. forces. Fractures at these sites result in joint an MRI (magnetic resonance imaging) or The general continuity of the ligament is instability when stressed on palpation or arthroscopy can be useful in diagnosing intact though its strength is significantly during weight bearing. Another fracture minor ligament sprains. reduced. Grade 3 sprains are severe and site is the accessory carpal bone in the involve complete disruption or tearing of front limb, where the flexor carpi ulnaris tendon attaches. A hyperextension injury © Gayle H. Jaeger can result in fracture of the accessory carpal bone where the tendon attaches, as well as damage to the palmar (underside) ligaments. Similarly, in the hind limb, fractures of the calcaneus (heel bone) can occur.
Tibiotarsal Medial Collateral Joint Lateral Dr. Jaeger is a Diplomate of the American College of Ligament Tibiotarsal Joint Collateral Veterinary Surgeons. She received her DVM degree from Ligament North Carolina State University, after which she completed Proximal Intertarsal Lateral Collateral Proximal Intertarsal Joint Joint Ligament an academic internship at Oklahoma State University and Distal Intertarsal Joint Distal Intertarsal Joint a specialized surgical internship in Orlando, Florida. She Tarsometatarsal Tarsometatarsal Joint then completed a three-year residency at North Carolina Dorsal Ligaments Joint State University, while earning a Masters degree in Specialized Veterinary Medicine. She has also been trained in rehabilitation through the Univeristy of Tennessee. Dr. Jaeger’s interests include fracture and ligament repair and joint replacement. She is currently practicing orthopedic surgery at the Veterinary Orthopedic and Sports Medicine Group with Dr. Canapp. Dr. Canapp, a Diplomate of the American College of Veterinary Surgeons, completed a combined D.V.M./M.S. at Kansas State University, an internship in small animal medicine and surgery at the University of Missouri, a three- year residency in small animal surgery at the University of Florida, and training in canine rehabilitation by the Canine Rehabilitation Institute. He currently practices orthopedic surgery and sports medicine at the Veterinary Orthopedic & Sports Medicine Group (VOSM) in Ellicott City, Maryland, and is a consultant to local zoos, police K-9 units, agility, flyball, and disc competition dogs. See additional information about Figure 2. Canine Tarsus (rear foot) Dr. Canapp at www.vetsportsmedicine.com.
May 08 | Clean Run 75 Treatment instability of the antebrachiocarpal or tibio- tarsal joints, complete arthrodesis is usually Treatment is based on the location and necessary. Arthrodesis can be performed severity of the injury. Mild to moderate by long-term stabilization with an external ligament sprains (Grades 1 and 2) are skeletal fixator, plate and screws, or internal amenable to external support, using pins and wire. Surgical reconstruction or specialized wraps, orthotics, a splint, or a internal arthrodesis requires additional cast for six to eight weeks, in addition to support from an external bandage for at rehabilitation therapy. Supportive bandages least six weeks. Fractures warrant open sur- allow for joint immobilization, preventing gical reduction and internal fixation (plate further injury to the affected ligament and screws or pins and screws). Internal and providing stability so the ligament fixation of fractures of the small bones of can heal. Specialized support wraps and the carpi and tarsi can be difficult due to the orthotics like those shown in Figure 5 can small and irregular size of their bones. be custom designed and manufactured Figure 5. Carpo-flex support wrap for a carpal injury for each individual dog. For more severe cases, an external fixator with a hinge can Severe sprains or luxations causing insta- Prevention be placed above and below the injured bility (Grade 3) usually require surgery. Although carpal and tarsal injuries may joint. This allows the joint to heal, while Surgical options include primary repair occur due to repetitive activity and at the same allowing controlled range of of the torn ligament, the placement of a recurrent sprains, a majority of these motion to strengthen the resulting repair. prosthetic ligament (suture) when primary injuries occur out of the ring. Jumping Unsupported or premature weight bearing repair cannot be performed, or a partial or down from high levels is one of the most during healing can result in an elongated complete arthrodesis (joint fusion). common causes of severe injury. Therefore, ligament, negating the return of ligament Luxations of the middle carpal, metacar- this activity should be avoided whenever strength and resulting in persistent palphalengeal joint, intertarsal or tarso- possible. Agility dogs with chronic carpal instability. Nonsteroidal anti-inflammatory metatarsal joints, or disruption of the pal- and tarsal injuries may benefit from a medications and cryotherapy (ice wraps) mar or plantar ligaments can be stabilized custom support wrap during practice and can be administered in the initial stages with partial arthrodesis. This allows for competition. Unfortunately, however, few of the injury to improve comfort, reduce stabilization of the joint while maintaining agility organizations allow dogs to compete swelling, and facilitate overall limb use. the majority of joint motion. When there is with support wraps. D
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