VSR 511 Class 12,13 and 14

ELBOW DYSPLASIA

• Elbow arthrosis is caused by Fracture of Coronoid Process, Ununited Anconeus Process, Osteo Chondrosis Desicans of medial epicondyle of humerus, articular cartilage anomaly, and/or joint incongruity (incompatability) , and is the manifestation of inherited elbow dysplasia,
  The purpose of International Elbow Working Group (IEWG)  is to coordinate efforts to lower the incidence and prevalence of elbow dysplasia by
  • coordinating worldwide research,
  • dissemination of information,
  • guidelines for national registries,
  • education about elbow arthrosis
• Etiology
  • Incongruity due to asymmetrical growth of the radius and the ulna, resulting in an intra-articular “step” between radius and ulna

• Ulna relatively short leads to
• Ununited Anconeus Process
• Cartilage erosions
• Degenerative Joint Disease
• Ulna relatively long leads to
• Osteo Chondrosis Desicans of medial epicondyle of humerus
• Fracture of Coronoid Process  
• Cartilage erosions
• Degenerative Joint Disease  
• Risk factors
• Genetics
• Incongruity
• OFA (Orthopedic Foundation for Animals) and GDC (Institute for Genetic Disease Control in Animals; screening for elbow dysplasia
• Nutrition
• Calcium
• Energy
• Trauma
• Rapid growth
• Presentation
• Young dogs
• Strong breed predisposition
• More in males than in  females
• 4 - 8 months of age
• Often bilateral
• Older dogs
• usually presented because of secondary DJD
• Diagnosis
• Orthopedic examination
• Pain on hyperextension/hyperflexion
• Joint swelling
• Crepitus
• Radiographic examination
• Diagnostic problem
• Orthopaedic exam points towards elbow problem
• Exploratory (arthrotomy or arthroscopy) to make final diagnosis

Treatment

• Conservative treatment
• Rest
• NSAIDs
• Nutrition
• Surgical treatment
• Arthrotomy
• Arthroscopy
• Dynamic ulnar ostectomy
• Prognosis
• Progressive DJD
• Often intermittent and sometimes permanent lameness

HIP DYSPLASIA

Hip dysplasia is of four types

      a)Coxa Magna: Head and neck of the femur is broad.

b)Coxa Plana: Flatened articular surfaces in longitudinal plane, osteochondrosis of                     

  epiphysis of head (Legg-Perthes Disease)

c)Coxa Valga: Neck is almost in straight line along shaft, more angle between neck and shaft.

d)Coxa Vara: The angle between neck and shaft is decreased, opposite of coxa valga.

  

• Abnormal development hip joint(s) ,leading to unequal wear and tear
• Developmental Orthopaedic Disease  by heredity.
•  
• History
• Lameness
• Exercise intolerance
• Arthritis history
• Clinical diagnosis
• Pain on extension
• Pain on abduction or circumduction  
• Crepitus
• Radiographic diagnosis
• Wear of  dorsal acetabular  rim
• Degenerative Joint Disease
• Traditionally extended VD  

Treatment

Canine Hip Dysplasia	Without DJD	With DJD
Conservative management	Goal is to increase muscle mass Exercise Weight control Medical management NSAIDs Poly Sulfated Glucosamino Glycan	Goal is pain control Exercise Weight control Medical management NSAIDs   PSGAG (chondro protective)
Surgical management	Triple pelvic osteotomy (TPO) Intertrochanteric osteotomy (ITO) Pectineal myectomy	Femoral head and neck ostectomy (FHO) Total hip replacement (THR)

Femoral head and Neck Ostectomy (FH(N)O)

• Chronic lameness, not responding to conservative management
• Patients < 25 kg
• Pain medication
• Physical therapy
• Rest  
• Good prognosis

Total Hip replacement (THR)

• Chronic lameness, not responding to conservative management
• Patient > 25 kg
• Working dog

RUPTURE OF CRUCIATE LIGAMENT

Cruciate ligaments are strong bands in inter condyloid fossa of femur. Anterior cruciate starts from central fossa on tibial spine and ends on lateral wall on intercondyloid fossa.

Posterior cruciate is medial to anterior cruciate, starting from poplitial  notch of tibia and joining on anterior part of inter condyloid fossa of femur.

Etiology

• Cranial or Anterior Cruciate rupture in over 95% of affected patients, than  posterior cruciate ligament rupture.
• May occur in cats
• Violent internal rotation
• Hyperextension
• Hypothyroidism

Mostly in

• Younger dogs: 0.5 – 4 years; Larger breeds
• Older dogs: 5 – 8 years; Smaller breeds

Diagnosis

• Lameness
• Joint swelling
• Pain on hyperextension/flexion
• Crepitus
• “Click”
• Joint instability (positive drawer or tibial compression test)
• Different angulations
• Mild drawer in young dogs
• Partial or complete rupture
• Radiography

Cranial cruciate rupture

• Complete rupture
• Acute lameness
• Peri-articular (soft) swelling
• Pain on hyperextension
• Severe drawer sign
• + “Click”
• Incomplete rupture
• Chronic lameness
• Peri-articular (firm) swelling
• Pain on hyperextension
• Mild drawer sign
• + “Click”

Differential diagnosis

• Young dog
• Patella luxation
• Caudal cruciate rupture
• Meniscal trauma
• Arthropathy

Meniscal injuries

• Concomitant medial meniscal injuries common
• Partial or total meniscectomy

Treatment

• Conservative treatment
• If body weight is less than 10-15 kg.
• Rest, Robert Jones bandage
• Surgical treatment
• If body weight is more than 10-15 kg
• Intra-articular techniques – reconstruction cranial cruciate ligament
• Often in combination with extra-articular and augmentation techniques
• Extra-articular techniques
• Soft tissue imbrication
• Lateral collateral ligament (fibular head transposition)
• Tibial plateau leveling osteotomy (TPLO)
• Long term stability provided by peri-articular fibrosis.

Prognosis

• Limb function dependent on the weight of the patient and the presence of meniscal injuries
• Always progressive DJD, usually no lameness
• 50% of the patients with a cranial cruciate rupture will get a cruciate rupture on the contra lateral side.

CLASSIFICATION AND GENERAL PRINCIPLES OF FRACTURE REPAIR

FRACTURE

Fracture: A fracture is the break in the continuity of hard tissues like bone or cartilage.

Etiology:

Indirect (Predisposing) causes	Direct (Exciting) causes
1.Superficial position , shape of bone	External violence(Kicks, blows)
2.Smooth slippery roads	Internal violence(Excessive muscular movements like jumping in horses, Struggle while casting)
3.Bone diseases like osteomalacia, caries	-------
4. Old age	-------

 

 

Classification

I. Depending on type of fractures

1. Simple (Closed)fracture	No wound on the skin
2. Compound (Open)fracture	Wound on the skin
3. Complicated fracture	Injury to blood vessels,nerves,joint or visceral cavity, and opening outside.

II. Fracture can also be

1. Incomplete fracture	Does not extend complete thickness of bone Eg:1.Green stick fracture       2.Splints       3.Fissured fracture       4.Intra periosteal fracture       5.Deferred fracture like broken back in horses
2. Complete fracture	Extends all through the thickness of bone Eg: 1.Single fracture        2.Double fracture        3.Multiple (Comminuted) fracture
3. Avulsion fracture	The tearing of bony prominences or tuberosities  by forcible pull of tendons or muscles

 III. Based on the portion of the bone involved

1. Diaphysary fracture	Fracture along diaphysis or shaft of bone
2. Epiphysary fracture	Fracture along epiphysis and  shaft of bone (Salter fracture)
3.Supra codyloid	Above the condyle
4.Condyloid	Condyle separated from bone
5.Transcondylar	Fracture at the level of condyles
6.Intercondylar	Between the condyles
7.Petrochanteric	Fracture of femur through greater trochanter
8.Transcervical	Through neck of the femur
9.Periarticular	Fracture around the joint
10.Articular	Fracture through joint structure
11.Extracapsular	Fracture outside joint capsule
12.Intercapsular	Fracture within joint capsule

 IV. Depending on the direction of fracture

1.Transverse Fracture	Fracture at the right angles to the axis of bone
2.Longitudinal	In a longitudinal direction
3.Oblique	Oblique direction break
4.Spiral	Spiral direction break

 

 

V. Depending on the relationship between the fragments in the fracture

1.Torsion Fracture	Fracture in which one of the fragments are twisted and separated
2.Impacted fracture	One bone is driven into the fracture site of another
3.Dentate fracture	Ends of the fragments are toothed and interlocked
4.Riding(over riding) fracture	Fragments override causing shortening of the limb
5.Distracted fracture	Fragments separated by muscular pull

VI. Fracture could also be

1.Compression fracture	Fracture by compression like cancellous bone reduction fracture
2.Depression fracture	Fracture of skull
3.Colles fracture	Fracture of distal end of radius
4.Pathological fracture	By weakening of bone by some disease(spontaneous fracture)
5.Congenital fracture	Fracture of bone of foetus (intrauterine fracture)

Unger et al. (1990) developed a computer filing system for the classification of fractured long bones that included definition of terms and a method of classification based on fracture criteria seen on radiographs.

Clinical signs

• Sudden onset of Pain
• Swelling
• Deformity of structure
• Loss of function or weight bearing ability
• Crepitus or grating sounds of rubbing of bone ends

Pain:

After fracture for 10-20 minutes there will be no pain as muscles relax, at fracture site numbness is observed, so reduction is easy in that window period, after that by strong muscular contractions there will be intense pain, and no pain is seen after 24 hrs of reduction and immobilisation.

Deformity:

By displacement of fracture fragments, deviation from normal posture/position.Eg: Shortening, angulation, rotation, abduction, adduction and local swelling.

 

Diagnosis

• Physical examination
• Radiography

Treatment

1. Reduction of fracture
2. Retention and immobilization of fracture
    

1. Reduction: The fragments are aligned in normal alignment, for overriding fractures extension and counter extension procedure is followed under general anaesthesia and a muscle relaxant.
2. Retention and immobilization:
   Coaptation splints or casts for immobilization of fracture part by materials like cloth bandages, POP, wooden pieces, metal strips, metal sheets etc.
   a)Gum bandage-Guaze with gum for Birds and small animals.
   b)Starch bandage-Guaze with starch
   c)Splints and bandages-Splints of light metal/wooden sticks. Good padding with cotton involving two joints on either side of the fracture.
   d)POP(Plaster of Paris)-Guaze with POP (Gypsona POP bandages). Bandage after bubbling stops to apply plaster cast. Tinc benzoin/Colloidon over skin before POP.
   e)POP Splints and Gutters
   f)Poroplastic felt- Felt cloth(porous) with resin substance prevents retention of moisture and necrosis of skin.
   g)Thomas splint-Modified in small animals, Duraluminium rods of 1/4^th ,3/8^th inch 6-12 feet long.
   h)Mason metasplints: flat metal splints of aluminium for metacarpal, carpal and fetlock joints in small animals.
   i)Suturing bone fragments: Holes are drilled into bones and sutured.
   j)Applying bone plates-Vitellium bone plates and screws
   k)Bone pinning by 2 methods
    

External Pinning	Intramedullary Pinning
Eg:Rush pins Cross Pinning Wires(Circlage) Screws(Cortical/Cancellous) Transfixation Plate fixation(Dynamic compression plates)	Open method	Closed method
	Pin sharp at both ends, lands in epiphysis	1.Femur-Pin inserted from trochanteric fossa by feeling trochanter major along medial aspect.
		2.Humerus-1/4th inch below the ridge on lateral tuberosity
		3. Tibia-1/4th inch below medial meniscus between anterior and medial tuerosities.

STAGES OF FRACTURE HEALING

Stage 1: Haematoma formation with Inflammation

              In 24 hrs of fracture, blood vessels are injured and blood gets collected in bone and surrounding tissues to form haematoma which coagulates.

Stage 2: Soft callus (Temporary callus)

In 1-2 weeks, fibroblast and capillaries form into clot from periosteum, haversian system, endosteum and bone marrow. Macrophages removes RBC and debris. Clot is formed of granulation tissue with fibrin from fibroblasts and capillaries, in fibrous callus vascularity decreases.

Stage 3: Primary Bone callus formation

         In early stage of fracture, acidic clot is formed by cellular debris of damaged             tissues and haemorrhage.

Mobilization of calcium from blood and bone fragments as calcium phosphate.

Phosphotase enzyme from osteoclasts release calcium from plasma to create supersaturation of calcium.

With proper immobilization, alkaline state is developed , calcium gets deposited as primary bone callus. Osteoblasts from bone fragments invade callus and calcium gets deposited in intercellular spaces.

Osteoblasts are more in periosteum and endosteum and few in compact bone, so mineralization is at periphery and central zones causes temporary union and immobilizes the fragments until normal bone tissue is formed. Primary callus is irregular hard mass of cartilage bone.

Calcification takes place from 10^th day and by 3^rd week it is radiographically visible as firm, round mass around the seat of fracture.

Upto 4-8 weeks, primary callus is firm to make clinical union, but on x-ray complete union is not visible.

Stage 4: Mature bone formation/secondary bone callus formation

         From 4-8 weeks of age, consolidation and ossification of primary callus  takes place.

         Osteoblasts deposite new bone and osteoclasts remove excess connective tissue and debris, by which resorption of callus takes place by contraction of excess thickening.

         Bone completes radiographically by uniform calcification of callus and approaching density of mature bone but without haversion system.

 

Stage 5: Bone remodelling stage:

From 8 to 1 2 weeks after the injury, the fracture site remodels itself, by development of haversian system, correcting any deformities that may remain as a result of the injury. This final stage of fracture healing can last up to several years.

• The rate of healing and  remodelling  depends on  age,  health, the kind of fracture, and the bone involved.

Factors affecting fracture healing

• Energy transfer of the injury
• The tissue response
• Two bone ends in apposition or compressed
• Micro-movement or no movement
• Blood supply
• Type of bone
• No infection
• The patient
• The method of treatment

 

Dislocation or Luxation or Displacement:

Separation of articular surfaces of bones, In latin Locare=to place and Luare=to displace, leading to word Luxation.

Classification:

1.	Complete dislocation
2.	Partial dislocation
3.	Acute
4.	Chronic
5.	Recurrent
6.	Simple (Closed)
7.	Compound (Open)
8.	Complicated (Without Fracture)
9.	Fracture Dislocation
10.	Pathological dislocation(By paralysis/By Pathology of bone)

Incidence:

In Bovines-Femur/Patella, Hip, Shoulder

In Dogs-Hip/Shoulder/Elbow

Etiology:

1.	Congenital	By Birth
2.	Trauma	By Jumping/Slipping
3.	Pathological	By Bone, ligament problem or Muscle Paralysis

Symptoms:

1.Pain,

2.Swelling,

3.Restricted mobility,

4.Functional interference,

5.Deformity.

 

Treatment:

1. Reduction—By open /closed traction and counter traction.
2. Retention or Immobilization.