Investigation and management of the mature lame animal

• What is the most common neoplasia of the bones?

  Osteosarcomas account for 80% of bone tumours.
• What are the clinical signs of neoplasia in the bones?

  Insiduous and poorly responsive to analgesia.

  Moderate to marked pain on palpation of the tumour site.

  May be accompanied by marked muscle atrophy.

  Moderate to marked soft tissue swelling.

  There may be an acute deterioration when the weakened bone fractures. This is termed a pathological fracture.

  The pathological fracture often occurs with minimal trauma.

  Always consider this when an older dog has fractured a limb with no or little history of trauma.
• How to diagnose neoplasia in the bones?

  Clinical signs and history are highly suggestive.

  Radiography - this may show both a Proliferative and destructive pattern.

  The joint is usually spared with an osteosarcoma cf. arthritis or a synovial cell tumour or the histiocytic sarcoma which is centred on the joint.

  Always radiograph the chest to look for metastases.
• Bone neoplasia - histological diagnosis

  Often the diagnosis can be made on clinical and radiographical signs alone.

  If diagnosis unclear or need to determine whether the lesion is a primary or secondary neoplasm, then it is important to know the precise nature of the tumour.

  Radiography confirms correct placement of the needle.

  Biopsies should be taken from the centre of the lesion (the periphery may contain reactive bone only).
• What is the treatment for bone neoplasia?

  It is unlikely in the case of bone tumours for the treatment to be curative.

  Limb amputation offers immediate pain relief. It is better tolerated in the hind limb and smaller dogs.

  Limb sparing procedures are available with the use of an auto or allograft having excised the tumour.

  All surgical treatments can be followed with chemotherapy.
• What is the prognosis for bone tumours?

  The prognosis for appendicular osteosarcoma in the dig is generally poor with lung metastasis being the usual outcome and cause of death.

  Average survival times without treatment would be less than one month, with limb amputation alone the median survival time is 4-5 months.
• Nerve route tumours - overview

  Nerve root tumours arise from the connective tissue around the nerve, a neurofibroma or sarcoma or the schwann cells, or Schwannoma. They can occur in the brachial and lumbosacral plexuses.

  They are rare tumours of the older dog c.8 years old. Rarer in the cat.

  Chronic and insidious in their nature, painful.

  Marked muscle atrophy usually in one limb as there is neurogenic as well as disuse atrophy.
• What is the treatment for nerve root neoplasia?

  Surgical resection but this can be difficult and limb amputation is often to remove the tumour.

  Significant neurological deficits can result from the surgery if the limb is spared.

  The tumour may extend into the spinal canal making full excision, even with a laminectomy, difficult.

  Recurrence is common following incomplete surgical excision. Adjuvant chemotherapy can be employed or radiotherapy.
• Cruciate rupture in the cat

  Usually obese

  Minimal trauma

  Mineralisation of Intra-articulation findings may be insignificant.

  Extra articular stabilisation but generally improve with rest only.
• Patella fracture and dental anomaly syndrome (PADS) - feline


  Associated with retained deciduous teeth and a variety of other typical fractures.

  Familial tendency occurring in young cats often with littler or no history of trauma.

  Various attempts to get the patella to heal have been shown to fail.

  Soft tissue suturing will often be enough to produce a functional repair.
• Capital physis separation in the cat

  Fracture/separation of femoral head physis

  • Usually animals are 6-7 months old.
  • Epiphysis remains in the acetabulum attached by the teres ligament.
  • Often minimally displaced - always to a frog-leg view.

  
• Joint disease in the dog and cat - clinical signs

  Walking stiffly

  Lamness in one or several either as a result of effusion or periarticular fibrosis.

  Pain on manipulation, reduced range of movement.

  Muscle atrophy
• Joint disease in the cat and dog - diagnosis

  Clinical examination

  Manipulation under general anesthesia.

  Radiography CT

  Joint taps

  Arthroscopy/arthrotomy

  Ultrasound of periarticualr structures.

  Whichever modality is employed always compare with the other limb.
• Joint disease in the cat and dog - imaging

  Radiography

  CT

  MRI

  Ultrasound
• Joint disease in the cat and dog - arthroscopy


  Morbidity low

  Magnification allows for the identification of subtle pathologies.

  Allows therapeutic intervention as well as diagnostic.

  Steep learning curve.

  Increased expense for the owner but in many joint disease it can be considered to the be the gold standard e.g. elbow dysplasia.
• Joint disease in the cat and dog - arthrotomy

  More invasive and hence increased morbidity but allows direct visualisation.

  Readily available and with limited approaches.

  Some procedures are difficult to do arthroscopically e.g. meniscus removal.

  Can obtain a synovial biopsy.
• Osteoarthritis - treatment and management

  Analgesia

  • NSAIDs - meloxicam, Carprofen
  • Prednisolone and cinchophen (no longer licensed in the UK)
  • Opiates can be used for severe acute flare ups of the arthritis. Tramadol, Buprenorphine, Paracetemol.
  • Monoclonal antibodies - librela
• Osteoarthrits - DMOAD + corticosteroids

  Corticosteroids:

  • Prednisolone, triamcinolone, dexamethasone.
  • Can be given systematically, Intra-articularmy and extra-durally.

  Disease modifying osteoarthritic drugs (DMOAD)

  • Cartophen, is a potent anti-inflammatory but not an analgesic.
  • Improves blood flow to affected joints, and the quantity and quality of affected joints.
• Osteoarthritis - physiotherapy

  Hydro and physiotherapy—

  • Cats are not food candidates for this treatment.
  • The use of non-weight bearing therapies such as swimming and particularly the use of a water treadmill can be very helpful. Improves muscle mass and the weight bearing can be titrated by the depth of the water in the treadmill.
• What are common ligament injuries

  Plantar and palmar to hock and carpus respectively

  Collateral:

  • Shoulder particularly medial glenohumeral
  • Stifle - associated with luxation
  • Elbow - associated with luxation.

  Cruciates:

  • Cranial and very occasionally caudal.
• What is a first degree ligament injury?

  Few collagen fibres broken.

  Swelling.

  Treatment is to rest, administer NSAIDs and cold compress.
• What is a second degree ligament injury?

  Marked damage to the collagen fibres.

  Haematome

  Loss of some funciton.

  Treat with support dressings, NSAIDs, cold compress in the acute phase. Rest for 3-6 months.

  Slow to heal.
• What is a third degree ligament injury?

  Complete rupture or avulsion from insertion/origin.

  Primary repair if possible

  Support repair - prosthesis or transarticular fixator.

  Arthrodesos for carpal and tarsal hyperextension and resulting in subluxation.
• What is an incongruent joint luxation?

  Joint surfaces are abnormal in shape and do not articulate perfectly.
• What is a dysplasia joint luxation?

  Abnormal joint development.
• What is a subluxation of the joint?

  Joint surfaces are displaced but maintain some contact.
• What is a joint luxation?

  No contact maintained between joint surfaces. Luxation is described by the position of the distal articular joint surface.
• What are the aetiologies of joint luxations?

  Traumatic - common

  Congential - rare

  Acquired/ developmental - frequent e.g. hip dysplasia.
• What is the signalment for congenital joint luxations?

  Rare

  Toy breeds - shoulder

  Staffordshire bull terrier - elbow.

  The constituent bones and articular surfaces are abnormal in shape.

  This results in abnormal tensions on the joint and articulation.
• Congenital elbow luxation - overview.

  Two types reported.

  Many of these animals show surprisingly little lameness which may be more mechanical than originating from pain.

  Prognosis is fair.

  Treatment can be conservative or surgical.
• Management of congenital luxations?

  Conservative:

  • Analgesia. weight restrictions, physiotherapist.

  Surgical management:

  • Difficult due to the abnormally shaped articualr surfaces.
  • Success improved by early intervention.
  • Salvage procedures such as arthrodesis, arthroplasty and amputation may be required.
• What are the developmental subluxations/incongruencies?

  Elbow dysplasia

  Hip dysplasia

  Often bilateral

  Develop secondary arthritis.
• Traumatic luxations - aetiology

  Considerable force required e.g. RTA or being hung from a fence.

  Associated with 3rd degree sprains i.e. complete rupture of the restraining ligaments.

  A traumatic arthritis is an almost inevitable consequence of this injury.
• What are the types of acquired traumatic luxations?

  Hip - most common, commonest in the craniodorsal direction.

  Talocrural - associated with malleolar fractures or collateral ligament rupture. Common in RTA shear injuries.

  Elbow - rare, associated with major trauma.

  Carpus - subluxation following a fall.
• How do you diagnose acquired traumatic luxations?

  Palpation often requiring anaesthesia.

  Radiography:

  • Orthogonal views essential.
  • Can miss luxations of a single view is taken, particularly of the elbow.
  • Stressed views may be required to determine site and severity of subluxation.
  • Examine for any articular bone fragments which make reduction impossible or unstable.

  
• What structures are responsible for stabilisng the hip?

  Teres ligament

  Joint capsule

  Dorsal acetabular rim.

  Surface tension of the joint fluid.
• What are the surgical options for acquired traumatic luxation of the hip?

  Closed reductions

  Open reductions

  Transarticular pins.

  Toggle pin
• What is the presentation of acquired traumatic luxation of the elbow?

  Often occurs after suspension from a fence.

  Characteristic posture:

  • Elbow outwardly rotated and abducted.
  • A medial luxation.
• How to reduced an acquired traumatic luxation of the elbow?

  General anaesthesia

  Flex elbow and inwardly rotate to engage anconeus in the olecranon fossa/supratrochlear foramen.

  Extend elbow.

  Check collaterals after reduction.

  Often damaged, reduction may not be complete.

  External support for one week.
• What is the presentation of a Stifle luxation/ dislocation/ derangement in the cat?

  Devastating injury associated with RTA and falls from height and attempting to free the limb when trapped.

  Multiple ligament injuries including collaterals and cruciate.

  Associated damage to the menisci and joint capsule.