ORTHO THINGS THAT MAKE NOISE
I was on the floor recently and got up. Settle down in the Peanut Gallery!
Yes, I managed to get up at my age… Anyway, my point is that my joints
made lots of noise in the process of rising, and insto-presto, I had a
theme for “November from DVS”. Gotta have a theme to focus the mind a bit with all of this gorgeous weather calling to me. (And I had a present I wanted to send to y’all, and it is ortho- related, so had to talk a bit about that!)
Let’s start with broken bones. If I had a 10-spot for all of the times I have almost lost a veterinary professional to the afore mentioned floor when a broken pet leg goes “crunch, crackle, flop”, I’d be in the Seychelles right now (instead of in the Great White North staring down the nose of Old Man Winter approaching.) Bones, especially broken ones, can make some nice sound effects. Now, I don’t recommend using one’s sense of hearing to diagnose fractures, but don’t ignore those sounds either. Flat bones in the head, shoulder and pelvic girdle, and ribs can make subtle noises as you probe and explore the swellings and lamenesses that are not a slam-dunk diagnosis.
With regard to the long bones, I strongly recommend avoiding inducing noises with these types of fractures. It is counter-intuitive for most, but traction (pulling very firmly on the limb) is the best stabilizer against the “crunch, crackle, flop” scenario. “Gently” supporting, and whatnot, does not prevent those sharp major fragments from slicing 1cm swipes (or more!) through the surrounding soft tissues. Pain, muscle injury, pain, vascular laceration, pain, further fragmentation, pain are all sequelae to bone fragments performing a drum solo. With emphasis and gratitude, please traction broken legs when moving for radiographs, restraining for splinting, and clipping for surgery. Bones should be seen not heard. (Ok, that was a motto during small farm training regarding vegetable harvest/cleaning, but you get my point.)
On to a more common abnormality that owners hear and report, Patella Luxation. Take home message right from the get-go…. If it is older than 2yrs, think ACL until proven otherwise (even if you palpate a movable patella). If it is under 2yrs, go ahead and bank on the patella being a source for the clinical signs (and noise.) Young dogs (<2yrs) likely benefit from patella stablization if it moves around enough to spontaneously pop in/out, if they are a bully/chondrodystrophoid breed, or if they exibit lameness (not just a skip step). That statement must not be taken to mean that a dog that is 2yrs and 3mo old does not need the patella stabilized, it just means we need to apply our PE skills and problem solving brains a little closer to these patients.
For the skeletally immature patella cases (<9mo), patella management is not black and white. Generally speaking, if the grade is getting higher as the months progress, pursue surgical advice early. Operating a grade IV is a bit of an irritation! The preference with immature patients is to try to encourage quadriceps alignment with (simple) soft tissue imbrication/release until skeletally mature. Thereafter, a tibial tubersity transposition (more involved) can be used to finalize proper aligment and stabilization. Not all pups need both, but many do.
“Funny hips” are another common noise report from owners of young dogs. The clunking of hip subluxation (due to the laxity known as Hip Dysplasia) is a combination of feeling, hearing and seeing in my experience. Prophylactic hip treatment remains elusive in these kids simply because of logistics. A minor procedure, Juvenile Pubic Symphysiodesis (JPS), must be performed prior to 5mo of age; knowing about hip laxity (Congenital Hip Dysplasia) prior to 5mo of age is rare without a proactive protocol for screening. And screening timing is complicated by the timing of other puppy needs (i.e. visits) such as vaccines and spay/neuter. Definitive JPS planning ideally uses the additional PennHip Study—yet another experience, sedation, cost most owners are not inclined to pursue. The Triple Pelvic Osteotomy is another prophylactic procedure that can rescue lax hips, if done young enough and before too many secondary changes have developed in the hips. Less than a year of age is a rough target, with <10mo probably being most ideal. It is a big procedure, especially having to do it bilaterally, but can preserve good hip function throughout a lifetime and into geriatric years.
A favorite orthopedic procedure in the “unique” category is the Superficial Digital Flexor tendon luxation. SDF lux is an MPL in the heel. What!? Yep, the tendon normally rides over the caudal aspect of the calcaneus in a bursa. Where it contacts the calcaneus is pretty much a joint-like groove with the tendon bound in place by retinaculum medially and laterally. In certain breeds (shelties, springers), this is not a surprise and bilateral is a risk, but it can happen to any. Usually brought on by vigorous play/exercise, probably juking when they should have been jiving, they pull up with a “YIPE!” and carry the leg. The heel swells with fluid, edema, cellulitis, making for a soft bulbous appearance. Within that bulbous heal, you can hear and feel the tendon pop in and out of the groove. The tarsal joints are just fine. It is just this one tendon that needs stabilization by imbrication…and then splinting of course (what a pain!) The sooner the better with this one, avoiding wear and tear and granulation/fibrosis that develops from the tendon flipping in and out.
And finally, not to be out done, cat legs can make noise too. Another unique orthopedic injury is the fibular fracture with resultant tarsal sub-lux/luxation. The distal fibula is the attachment point of the lateral collateral ligament of the tibiotarsal joint. When it fractures (commonly from a leg-hanging trauma), the joint luxates. Kitty-level clunking is appreciated as you rotate the tibiotarsal region allowing the tarsus to reduce and luxate while the fibular fragments snap/crackle/pop. On radiographs it looks like an uninterpretable mess unless you carefully reduce and then take proper AP and lateral films with external props and support to maintain reduction during radiographs. Repair targets the distal fibular fragment, tension banding it back to the distal tibia and re-establishing tibiotarsal integrity. Fairly straight forward until you get to the part about splinting. Cats and splints for 6-8wks is THE challenge. See my other writings about bandaging but suffice to say here that bulk is not anyone’s friend. Careful application of appropriately narrow materials and strong but minimal splinting materials is the key.
Since I brought up “proper radiographs”, and as a token of my appreciation, I’ll leave you with the enclosed R/L marker and size reference (coming by post). As digital radiographs have taken over, we are all too often left wondering whether we are looking at a Chihuahua or a Dane. Use of this card, with its built-in reference, will help shrink or grow the radiographs to appropriate size for interpretation and measurements.
Y’all have a wonderful Fall Season. Drop me a line if you have one of these noisy conditions, and I’ll see you when the snow is falling! 😊
Lara Marie Rasmussen, DVM, MS
Diplomate, American College of Veterinary Surgeons Direct Veterinary Surgery, LLC www.directvetsurg.com
directvetsurg@gmail.com
