Investigation and management of the juvenile lame animal

• What is the general signalment for juvenile lameness?

  Generally less than one year old.

  Breed dispositions - e.g. Rottweiler and medial coronoid disease, Border collie and shoulder Osteo-Chondrosis.

  The cat rarely suffers from specific juvenile disease.
• What is the general history of juvenile lameness?


  Chronic - greater than two weeks duration.

  Shifting lameness e.g. panosteitis.

  Can wax and wane.

  Can be worse on rising or after exercise.

  Associated with signs of systemic illness e.g. metaphyseal osteopathy.
• The clinical exam of the juvenile patient

  Forelimb or hindlimb? Can be hard to determine.

  Is the condition confined to a single limb.

  Are there any joint swellings. Pain or heat in a joint or bone.
• Perthe’s disease - signalment and clinical history

  The toy and small dog <6 months old. WHW terriers, chihuahua, jack russel terriers. Inherited in the Manchester terrier. A similar condition is reported in cats.

  Lameness with associated muscle atrophy.

  Reluctant to jump or go up and down stairs, primarily because its a bilateral condition (12-16% of cases), can be difficult to determine as they are not lame, but uncomfortable.
• Perthe’s disease - clinical signs

  Often marked muscle atrophy (particularly the gluteal muscles).

  Considerable pain on extension of the hips.

  Crepitus on manipulation of the hips.
• Perthe’s disease - radiographic findings

  Mottled appearance to femoral neck and head due to areas of lucency.

  A misshapen and often triangular shape to the femoral head.

  Secondary to oesteoarthritic changes.

  Loss of muscle mass.
• Perthe’s disease - conservative management

  NSAID (meloxicam), nutraceutricals etc

  Physiotherapy

  Rarely successful as these dogs walk well on three limbs and therefore avoid using the painful leg.
• Perthe’s disease - surgical management

  Femoral head and neck excision - problems associated with this procedure.

  Total hip replacement (micro and nano systems - Biomedrix) - ideal solution.
• Femoral head and neck ostectomy - surgical technique

  Craniolateral approach is made to the hip with a tenotomy of deep gluteal and partial cut to vastus lateralis improve visualisation of the femoral neck (essential that the cut removes all of the femoral neck). Leave the lesser trochanter intact (insertion of iliopsoas, a hip flexor).
• Femoral head and neck ostectomy-post-op radiograph

  Post-op radiographs should always be taken.

  If not enough of the femoral neck has been resected then further bone should be excised.

  
• Metaphyseal osteopathy - clinical history and signs

  Seen only in dogs (metaphyseal osteopathy in the cat does not seem to be in the same condition).

  Unknown aetiology although there is a suggestion that this may be an immune mediated condition.

  Less than 6 months old.

  Severe and excruciating painful swelling to metaphyseal region of all limbs, find it very difficult to move.

  Pyrexic and systemically unwell.
• Metaphyseal osteopathy - clinical signs

  Often unable to walk, as all limbs can be affected.

  Pyrexic and inappetent.

  Painful swellings to the distal limbs particularly the radius, ulna and tibia.

  Associated pitting oedema over the metaphyseal regions, due to the inflammatory conditions that are occurring within the metaphysical regions.
• Metaphyseal osteopathy - radiographic signs

  Soft tissue swelling.

  Ill defined lucency parallel to the physis (growth plate) sometimes described as an extra growth plate.

  Periosteal lifting with mineralisation - sometimes will fix the growth plate, stops it from growing.

  • The bridging of the physis by the inflammatory change can result in angular limb deformities.
• Metaphyseal osteopathy - Treatment

  Hospitalisation - so painful that you can not send the animal home.

  Multi-modal analgesia including opiates and constant rate infusions.

  Corticosteroids can be helpful in patients that fail to respond to symptomatic treatment, not only as anti-inflammatories but also to dampen down any further immune response.

  IV fluids

  Tube feeding if inappetent for longer than 3 days.
• Metaphyseal osteopathy - Prognosis

  Good to fair (erring on the fair rather than good)

  These dogs are prone to further attacks and other autoimmune disease in later life, like IMHA.
• What are the miscellaneus causes if lameness to consider in the juvenile?

  Early cruciate disease in larger breeds - e.g. Mastiffs + Rottweilers.

  Patella subluxations in the large and small breed dogs.

  Septic arthritis - can be multiple joints in the juvenile.

  Polyarthritis

  Humeral intracondylar fissure in spaniels.

  Sesamoid disease. Pin point pain over the flexor sesamoids.
• Craniomandibular osteopathy - signalment and clinical signs

  Commonly affects skull and mandible, affects small terriers particularly in the WHW terrier and Cairn.

  Has been reported in larger dogs including the Dobermann.

  Less than 6 months, very painful condition, dog is usually very head shy. Also known as lion jaw.

  Soft tissue swelling and oedema to jaw and long bones (rarely affected). Systemically unwell and pyrexic
• Craniomandibular osteopathy - radiographic findings

  Characteristic palisading (battlement-like) new bone to the mandible, occipital crest and tympanic bullae.

  The temporomandibular joint may be involved, can extend the joint.

  Similar changes seen in the long bones.

  Associated soft tissue swelling.

  
• Craniomandibular osteopathy - treatment

  Analgesia

  Corticosteroids are often required to manage this condition.

  Fluid and enteral support.
• Craniomandibular osteopathy - prognosis

  This can be guarded as cases are difficult to manage and distressing for dog and owner.

  Long term sequelae are not uncommon including reduced opening of the mouth making eating and subsequent endotracheal intubation difficult.
• Panosteitis - signalment and clinical history

  A common but often overlooked condition.

  Seen in the young dog less than one year of age.

  GSD and males are over represented.

  Has a characteristic waxing and waning signs.

  Often presents with a shifting lameness i.e. a lameness that spreads from one limb to another.

  Can be a bit unwell as well, Pyrexic.
• Panosteitis - clinical signs

  Often the dog is depressed and can be Pyrexic.

  Lameness can be severe and the dog may not weight bear.

  Pain on palpation of the diaphysis.

  May have had a previous episode lasting about a week in another limb (a shifting lameness).
• Panosteitis - radiographic signs

  Loss of normal trabecular pattern particularly around the nutrient foramen.

  Endosteal and periosteal new bone.

  Important to appreciate that radiographic and clinical signs may not occur and sometimes its better to radiograph two weeks after the signs have been seen.

  
• Panosteitis - treatment

  Rest and analgesia (NSAID)

  Advise the owner that this is an episodic condition Uusually lasting a week and is self limiting, the episodes will become less severe and less frequent as the animal gets older.
• Panosteitis - prognosis

  Excellent

  The episodes of acute lameness will become less severe and less frequent.

  Most cases have resolved by the time the dog is 1 year old.

  Occasional reports of the condition occurring in the 5 year old but this is very rare.

  Reassure the owner.
• Angular limb deformities CORA

  Centre of rotation of angulation (CORA)

  • This is an important concept when correcting limb deformities.
  • It determines the place where any definitive correction should be performed.
  • Correcting the angular deform in its away from this centre results in an S shaped bone and poorer function.
• Antebrachium - short ulna overview


  This is the most common abnormality.

  Due to the conical shape of the distal ulna growth plate this is more prone to trauma and premature closure.

  It results in a valgus deformity, cranial bowing of the radius and external rotation of the paw.
• Antebrachium - short radius overview

  Premature closure of the distal radius.

  Results in subluxation of the radiohumeral joint.
• Treatment for the short ulna syndrome

  Immature dog

  • Staple the medial radial growth plate to correct the disparate growth rates. Timing of this is difficult and this correction is rarely performed.

  Mature dog:

  • Easier to perform any correction at this time, generally wait for the dogs to become fully grown.
• What are the surgical options for short ulna syndrome?

  Calculate the CORA.

  Osteotomy of the ulna to release the bow string.

  Opening wedge osteotomy of the radius fixed with ESF or llizarov circular fixator which facilitates limb lengthening.

  Or a closing wedge osteotomy of the radius fixed with custom bone plate and applied with the use of a jig (3D printing particularly useful for these abnormalities).
• Short radius syndrome

  Proximal radial osteotomy with llizarov fixator and motors to lengthen the radius (a motor is a means of changing the position of the rings relative to the frame and may only be a screw mechanism).

  Alternatively a low tech alternative is to perform a proximal radial osteotomy, place external fixator pins in the proximal radius and the distal humerus. Connect these pins with strong elastic bands to slowly pull the radial head into its correct position against the capitalism of the humerus (which is the lateral condyle).

  Shorten the ulna and apply the plate.
• Angular limb deformities - hind-limb


  These abnormalities are much less common.

  Same principles apply, opening widge osteotomy.

  Pes varus seen in the dachshund and in this case treated with distal osteotomy and opening wedge established with ESF.