Welcome to the all-new Vetlearn

  • Vetlearn is getting a new home. Starting this fall,
    Vetlearn becomes part of the NAVC VetFolio family.

    You'll have access to the entire Compendium and
    Veterinary Technician archives and get to explore
    even more ways to learn and earn CE by becoming
    a VetFolio subscriber. Subscriber benefits:
  • Over 500 hours of interactive CE Videos
  • An engaging new Community for tough cases
    and networking
  • Three years of NAVC Conference Proceedings
  • All-new articles (CE and other topics) for the entire
    healthcare team

To access Vetlearn, you must first sign in or register.

registernow

  • Registration for new subscribers will open in September 2014!
  • Watch for additional exciting news coming soon!
Become a Member

Veterinarian Technician July 2012 (Vol 33, No 7)

Canine Elbow Dysplasia

by Heidi Reuss-Lamky, LVT, VTS (Anesthesia)

    CETEST This course is approved for 1.0 CE credits

    Start Test

    Canine elbow dysplasia (CED) is a general term for several developmental abnormalities that involve the canine elbow (cubital) joint.1,2 The term elbow dysplasia was implemented by the International Elbow Working Group to describe all conditions resulting in elbow joint arthrosis, regardless of the underlying etiology.1 Dogs diagnosed with elbow dysplasia have pain and lameness due to one or more of the following conditions: ununited anconeal process (UAP) or fragmented medial coronoid process (FCP) of the ulna, osteochondrosis (OC) of the medial humeral condyle, or elbow incongruity1,3 (FIGURE 1) . These conditions primarily affect fast-growing, large- and giant-breed dogs younger than 1 year, although small, medium-sized, and chondrodystrophic canine breeds may also develop CED.2,3 CED frequently involves both elbow joints,1–4 and OC and FCP can occur together in the same joint.2,3 There is no sex predilection in dogs with OC, but FCP and UAP have been observed more frequently in males than in females.2–4

    Young, large- and giant-breed dogs with forelimb lameness should be evaluated for CED. Early diagnosis and treatment are recommended to improve comfort and function as well as decrease the progression of osteoarthritis (OA). All dogs with FCP, osteochondritis dissecans (OCD), and UAP should be eliminated from breeding.2,4

    Anatomy and Pathogenesis

    The elbow joint comprises the humeral, radial, and ulnar bones and their supporting ligaments. The elbow joint has three separate articulations: the humeroradial, humeroulnar, and proximal radioulnar joints,1,2 all of which are contained within a common joint capsule1 (FIGURE 2A; FIGURE 2B; FIGURE 2C) .

    The major pathogenetic mechanisms of CED are OC (e.g., OCD), trochlear notch dysplasia (e.g., FCP, UAP, OCD), and asynchronous growth of the radius and ulna (e.g., FCP, UAP, elbow incongruity).1 Numerous factors have been implicated in the pathogenesis of CED, including genetics, nutritional imbalances (excesses or deficiencies), growth disturbances, hormonal influences, and trauma.1,2,5

    Diagnosis

    Clinical signs of CED are usually first noted at 4 to 7 months of age, although they may not appear until the dog is older and develops signs of OA.2 An orthopedic examination may reveal elbow joint swelling, crepitus, and pain during elbow flexion or extension; reduced range of motion; and muscle atrophy.2–4 The degree of lameness may vary and is frequently most pronounced after exercise or rising.2,4 Dogs normally bear 60% of their body weight on the forelimbs, but painful dogs with CED may place only 40% to 50% of their weight on the forelimbs.3 Affected dogs may ambulate in short strides and often sit or stand with the affected elbow close to their bodies (adduction) while rotating the affected foot outward (abduction).3,4

    Diagnosis is confirmed by radiography or computed tomography (CT). Radiography can be used to diagnose UAP, most OCD lesions, and, often, elbow incongruity, but it is less effective for diagnosing FCP.2 Radiography is also useful for detecting advanced stages of OA secondary to CED and for ruling out other conditions, such as fractures or dislocations. However, CT is one of the best modalities for visualizing FCP lesions.2,4 CT allows three-dimensional visual reconstruction of the joint for thorough evaluation of specific regions of the elbow. Therefore, CT is more sensitive for diagnosing CED, providing fewer false-negative results than traditional radiography6  (FIGURE 3) . Additionally, dogs with forelimb pain or lameness but apparently “normal” elbow radiographs have been diagnosed with CED using CT, thereby leading to earlier intervention and improved prognosis in these patients.4,6

    Other diagnostic imaging options include positive-contrast arthrography (for OC), magnetic resonance imaging, nuclear scintigraphy, and arthroscopy.

    Treatment

    Medical and surgical options are available for treating CED. Conservative therapy of CED is analogous to treating OA and may consist of rest, weight control, judicious exercise, and administration of analgesic medications (including NSAIDs).2–4 Young dogs diagnosed before the onset of degenerative joint disease may have a better prognosis after surgery.4

    Arthroscopy is considered the gold standard for treating CED because it can also be used for diagnosis (FIGURE 4) . Compared with open arthrotomy, minimally invasive arthroscopy has many advantages, including smaller incisions requiring little postoperative wound care, the ability to perform copious flushing, superior joint surface visualization due to magnification and illumination, a decreased risk of infection, a low rate of complications, a rapid recovery, and earlier return to function, resulting in decreased patient morbidity and the ability to treat multiple joints during the same procedure.7 Additionally, arthroscopy facilitates removal of abnormal tissue and allows evaluation of elbow incongruity.

    Introduced in 2004, the TATE Elbow System (BioMedtrix, Boonton, NJ;  FIGURE 5 ) has had a success rate of ~80% in select cases but is considered unproven by many.8

    Osteochondritis Dissecans

    OC has been implicated in the development of OCD.4 OC is a disturbance of cartilage and bone formation during growth that leads to the thickening of the joint cartilage, which often progresses to separation of the cartilage (fissuring) and formation of a flap.1,9 OC has been associated with the shoulder, stifle, and tarsus but affects the medial humeral condyle most frequently.2,4 OC that results in cartilage fissuring and a subsequent flap is known as OCD (FIGURE 6) . OCD results in pain, swelling, inflammation, and, eventually, OA. A loose cartilage flap that becomes completely detached may be referred to as a joint mouse.4

    Most affected dogs belong to rapid-growing, large or giant breeds such as the Newfoundland, Labrador retriever, and golden retriever. Other affected breeds include the Bernese mountain dog, chow chow, German shepherd, mastiff, Old English sheepdog, rottweiler, and standard poodle.2

    Surgical treatment involves removal of the cartilage flap and abrasion arthroplasty (curettage of subchondral bone until bleeding is observed) or forage (drilling small holes into the bone) of the defect bed to promote healing of the defect with fibrocartilage.2,3 The prognosis after medical or surgical treatment of OCD is good but is limited by the progression of secondary joint disease.3

    Fragmented Medial Coronoid Process

    FCP is the most frequently encountered manifestation of elbow dysplasia.9 The coronoid process of the ulna forms the distal extent of the trochlear notch, where most of the humeroulnar joint surface comes into contact with the humerus and ulna. An FCP lesion develops when fragmentation or fissuring of the craniolateral aspect of the medial portion of the coronoid process leads to separation from the proximal ulnar bone (FIGURE 7) . Delayed ossification of the coronoid process may also be a contributing factor to developing FCP.2,4

    FCP is also prevalent in dogs with ulnae that are proportionately longer than their radii (i.e., asynchronous growth of the radius and ulna). This abnormality results in overloading and failure of the medial coronoid process. Most asynchronous growth of the radius and ulna occurs before 6 months of age and may be most notable in achondroplastic dwarfs (i.e., dogs with chondrodysplasia), chondrodystrophic breeds, large-breed dogs with a retained ulnar cartilaginous core, and normal dogs with physeal trauma.1,3,5

    Elbow incongruity due to trochlear notch dysplasia was proposed by Wind et al during a study involving Bernese mountain dogs.1 The trochlear notch of the ulna articulates with the trochlea of the humerus. Slight misshaping in the curvature of the trochlear notch puts excessive pressure on the coronoid and anconeal processes of the ulna and the medial humeral condyle. Trochlear notch dysplasia in the Bernese mountain dogs was determined to result in failure of the coronoid process due to overload, fatigue, and fracture.1

    FCP commonly affects large- and giant-breed dogs such as Labrador retrievers, rottweilers, Bernese mountain dogs, Newfoundlands, golden retrievers, and chow chows. Clinical signs, including pain, lameness, swelling, and OA, become apparent at 5 to 7 months of age.4

    Surgical treatment consists of correcting articular incongruity and removing loose or free-floating cartilage or bone fragments via arthroscopy or arthrotomy.3,4 Diagnosis and treatment before the development of severe clinical signs have been associated with better prognoses. However, dogs with evidence of severe OA may not respond as well and may require long-term, conservative treatment.3

    Ununited Anconeal Process

    UAP is a failure of the anconeal process to fuse to the ulna by 5 months of age and can often be diagnosed using a lateral radiograph of a fully flexed elbow  (FIGURE 8) . UAP is common in many large- and giant-breed male dogs (i.e., German shepherds, Irish wolfhounds, Newfoundlands, Labrador and golden retrievers, Great Danes, Great Pyrenees, Weimaraners, rottweilers, Saint Bernards, mastiffs, bloodhounds, and Gordon setters2), spaniel breeds, French bulldogs, and some chondrodystrophic breeds (e.g., basset hounds2).2,4,7 Asynchronous growth of the radius and ulna may play a role in the development of most UAP lesions because many large-breed dogs have secondary centers of ossification located in the anconeal process, while small-breed dogs do not.1 There may be a genetic predisposition to UAP in some German shepherd lines, given the incidence of 18% in this breed.1–3,5,7

    Other factors implicated in the development of UAP include hormonal influences, excessive weight, nutrition (e.g., excess calcium), and acute or chronic trauma.2,4,5 The loose bone fragment can result in pain, swelling, lameness, forelimb muscle atrophy, and OA in one or both elbows.2,4

    Spontaneous fusion of the anconeal fragment has rarely been reported, and conservative treatment alone is considered less successful than surgical treatment options and is likely to result in rapid development of severe OA. Early treatment is advised and can be favorable if surgical intervention takes place before severe degenerative changes occur. In cases in which the anconeal process is considered stable at the time of surgery or the dog is very young, the fragment has successfully fused after ulnar osteotomy or partial ostectomy to correct joint incongruity and remove pressure from the anconeus.3,7 Other reported surgical treatments for UAP include fragment removal or reattachment via lag-screw or screw-and-pin fixation, possibly combined with ulnar osteotomy or partial ostectomy to restore joint congruency.2,3,7

    Elbow Incongruity

    Elbow incongruity typically occurs in chondrodystrophic breeds with a genetic predisposition to premature closure of a growth plate, but it can occur either without apparent growth plate injury or secondary to trauma.4 Although elbow incongruity can be caused by premature partial or complete closure of the distal radial physis, trauma to the distal ulnar physis is the most common cause of growth deformities in immature, nonchondrodystrophic dogs. Due to the location and cone shape of the distal ulnar growth plate, this plate is most susceptible to injury and subsequent early closure, resulting in decreased growth of the ulna. Elbow incongruity may be evidenced by radial bowing and external rotation of the elbow or carpus joint in the affected limb as well as by partial elbow dislocation3,4 (FIGURE 9) . Elbow incongruity can result in lameness, swelling, pain, and OA.

    Premature closure of the distal ulnar or radial growth plates is not amenable to medical management; thus, early surgical intervention to restore congruity and alignment in the elbow joint is imperative to minimize the potential for the development of severe OA.3,4 Depending on the cause, treatment of elbow incongruity generally involves either ostectomy  (FIGURE 10A; FIGURE 10B)or corrective osteotomy (FIGURE 11) . Dogs diagnosed with elbow incongruity that have growth potential (i.e., radiographic evidence of open physes) may be treated with ostectomies and fat grafting, while corrective osteotomies are indicated in dogs with evidence of closed physes (i.e., in mature dogs).4

    Prognosis

    The prognosis for patients with CED depends on the severity of preexisting arthritic changes at the time of treatment. Many patients have clinical improvement despite residual OA and its progression, but all patients with CED demonstrate progression of OA and may display intermittent lameness or stiffness. These patients generally respond to administration of NSAIDs, chondroprotectants, or agents designed to slow cartilage degradation; weight management; judicious exercise; and diets containing a high concentration of omega-3 fatty acids, which can have antiinflammatory effects that ease the clinical signs of OA.

    Downloadable PDF

    1. Trostel CT. Canine elbow dysplasia: anatomy and pathogenesis. Compend Contin Educ Vet 2003;25(10):754-762.

    2. Slatter D. Textbook of Small Animal Surgery. 3rd ed. Philadelphia, PA: Saunders; 2003:1927-1952.

    3. Trostel CT. Canine elbow dysplasia: incidence, diagnosis, treatment, and prognosis. Compend Contin Educ Vet 2003;25(10):763-773.

    4. Fossum TW. Small Animal Surgery. St Louis, MO: Mosby; 1997:818-826, 918-928, 933-936.

    5. Von Pfeil D, Decamp C, Abood SK. The epiphyseal plate: nutritional and hormonal influences; hereditary and other disorders. Compend Contin Educ Vet 2009;31(8):E1-E14.

    6. Carpenter LG, Schwarz TP, Lowry JE, et al. Comparison of radiologic imaging techniques for diagnosis of fragmented medial coronoid process of the cubital joint in dogs. J Am Vet Med Assoc 1993;203:78-83.

    7. Kapatkin A, Capaldo F, Gilley R. An in-depth look: diagnostic and surgical applications of arthroscopy in dogs: general applications and forelimb joint diseases. Compend Contin Educ Vet 2005;27(8):580-594.

    8. Conzemius M, Aper R, Corti L. Short-term outcome after total elbow arthroplasty in dogs with severe, naturally occurring osteoarthritis. Vet Surg 2003;32:545-552.

    9. Beale BS. Elbow dysplasia: diagnostic tips and tricks for treatment. Proc North Am Vet Conf 2009.

    References »

    NEXT: Final View: Eels Can Have Back Problems, Too

    CETEST This course is approved for 1.0 CE credits

    Start Test

    didyouknow

    Did you know... In a prospective study of horses with naturally occurring suspensory desmitis, a combination of shock wave therapy and controlled exercised compared favorably with other treatments.Read More

    These Care Guides are written to help your clients understand common conditions. They are formatted to print and give to your clients for their information.

    Stay on top of all our latest content — sign up for the Vetlearn newsletters.
    • More
    Subscribe