An alternative technique, which provides acute radial elongation while preserving load sharing, is the completion of a sagittal sliding (or “stairstep”) osteotomy. Note the exuberant callus that has formed along the cranial and caudal aspects of the ulna. Fibers of this joint capsule are confluent with the distal extremity of the interosseous membrane and form a stout attachment between the distal ulna and radius referred to as the. Using the values of joint orientation angles as measured from the contralateral normal side, the radial anatomic axes are determined. Sagittal sliding osteotomy can be performed with or without the application of a neutralization plate or external coaptation (Figure 55-6). Proximally, the radius articulates with the ulna along its caudal border, which rests within a corresponding concavity in the ulna called the radial notch. Utilizing a cadaver model, Mason et al.34 determined the sensitivity and specificity of lateral radiographic projections to be 78% and 86%, respectively. Figure 55-12 Illustrations depicting localization of the center of rotation of angulation (CORA) of an antebrachium with a uniapical angular limb deformity in the frontal plane. This larger gap will help prevent the ulna from completing osseous union before cessation of radial growth. Figure 55-8 Illustration depicting the completion of a dynamic oblique ulnar osteotomy for the purpose of elongating a shortened ulna. C, Radial anatomic axis (red) determined from the mid-diaphyseal points measured at the proximal and distal diaphyseal-metaphyseal junctions (gray lines). Similar to radial lengthening, surgical options include both acute and gradual techniques. As with all fractures, fractures of the radius and ulna can also be classified as “simple” if each bone breaks into two pieces or “comminuted” if there are multiple pieces. Radius This is a radiograph of a forelimb. Over a period of 14 days, the radial head was able to slide proximally, eventually matching the coronoid process and reestablishing contact with the humeral capitulum. Derek B. Most imaging modalities focus on examining the radioulnar relationship at the level of the elbow joint to document the presence and severity of radial shortening. Figure 55-8 Illustration depicting the completion of a dynamic oblique ulnar osteotomy for the purpose of elongating a shortened ulna. The limb was eventually reoperated, an autogenous cancellous bone graft was placed, and the ulna was stabilized with a bone plate. The primary goal of this technique is to determine the apex of the deformity or deformities (also referred to as CORAs) using the radial anatomic or mechanical axis in conjunction with the joint orientation angles as determined by orthogonal radiographs in a step-by-step process. Diagnosing and quantifying the condition can be challenging if the degree of shortening is very slight. The most common tumor of the ulna is an osteosarcoma, although any primary or metastatic bone tumor can involve the ulna. Both the radius and the ulna possess physes proximally and distally that contribute to growth of each bone. Radial shortening can range from being extremely pronounced to very subtle. In this case, the patient presented with a sequestrum, osteolysis with marked endosteal and periosteal reaction centred at the nutrient foramen of the proximal right radius. A pressure sore formed in the soft tissues along the caudal aspect of the ulna overlying the callus. Following ostectomy, the proximal ulna can be guided in a semi-controlled or controlled fashion. 3. The biceps brachii and brachialis muscles each have tendons of insertion that bifurcate and insert on the medial surface of the radius and the ulna. The antebrachium comprises two bones, the radius and ulna, which cross one another in the frontal plane as they extend from the elbow joint proximally to the carpus distally (Figure 55-1). Placement of Hohmann retractors around the ulna will isolate the ulna and protect the radius while the ostectomy is completed. Note: Recall that normal procurvatum should exist, so in this case, the pathologic procurvatum should be corrected back only to whatever normal value was measured from the other side.< div class='tao-gold-member'> This process can also be completed in the sagittal plane, where the joint orientation lines are generated from the most proximal aspects of the radial head, both cranially and caudally, for the elbow joint, and upon the most cranial and caudal distal aspects of the radius for the radiocarpal joint (Figure 55-4, A, B). Step 1: If the dog has a normal contralateral antebrachium, the joint orientation lines, anatomic axis, and intersecting joint orientation angles are measured as outlined in the first section of this chapter (Figure 55-12, A) for the frontal plane. Many traumatic events are true accidents and thus unavoidable. Related terms: antibrachial fracture, fracture non-union, fracture malunion, fracture delayed union.Outline: Pomeranians, like dogs of other miniature and toy breeds, have a high prevalence of fractures of the distal radius and ulna, that is, of the lower part of the forearm. Pain medication. What remains unknown is how large of a defect can be treated successfully this way. Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window)Click to share on Google+ (Opens in new window) Other older techniques to deal with a prematurely closed distal ulnar physis in the skeletally immature dog include distal radial physeal stapling48 and ulnar styloid transposition with aggressive distal ulnar ostectomy.13 Right image, articulated, caudal aspect. Treatment for shock involves intravenous fluid administration to maintain blood pressure and adequate oxygen delivery to the body. Figure 55-6 Sagittal sliding osteotomy of the radius for elongation with subsequent fixation via transversely positioned bone screws placed in lag fashion. A thorough physical examination is very important to make sure your pet is not showing signs of hypovolemic shock secondary to the trauma or blood loss. Radius and ulna, frontal plane: Joint orientation lines, radial anatomic axis, and joint orientation angles. Based on the location and severity of the fracture, a more informed discussion with the owner can occur regarding potential treatments, prognosis and costs. Although conflicting sentiment is seen in the literature regarding the use of radiography, with some reports suggesting high sensitivity and specificity,3 the consensus resulting from most research is that more sensitive diagnostics are required to adequately assess radioulnar congruity. A haematog- Developmental antebrachial angulation can arise from (1) asymmetric premature closure of the physis of the proximal or distal radius or both, (2) premature closure of the distal ulnar physis with continued radial development, or (3) a combination of the two. If a lame dog is presented it is advisable to radiograph ... proximal radius and ulna, is the treatment of choice. Damage to this growth plate limits growth of the ulna. Sagittal sliding osteotomy can be performed with or without the application of a neutralization plate or external coaptation (Figure 55-6).55 Irrespective of the technique used to perform an acute correction, confirmation that the final position of the radial head is appropriate requires radiography or, optimally, arthroscopy, following distraction. The ulna shaft tapers distally, lying oblique to the radius, i.e. Another method used to avoid instability and recurvatum of the ostectomized ulna is completion of an ostectomy of the distal ulnar diaphysis or removal of the physis itself. Both elbows are radiographed. Semi-controlled, gradual elongation of a shortened radius (due to symmetric closure of the distal radial physis) in young dogs was reported by Mason and Baker.35 This report described a transverse osteotomy of the proximal radius and the placement of separate pins in the radial metaphysis and across the humeral condyle. In general, gradual, dynamic elongation following the principles of distraction osteogenesis (discussed in greater detail in Chapter 41) has advantages in the young animal, as these techniques allow some adjustability to adapt to the dog’s continued growth. arrows). the elbow, radius/ulna and the carpus only. Several muscles share their origination between radius and ulna at the level of the mid-diaphysis and include the pronator quadratus, deep digital flexor, and abductor pollicis longus muscles. In the interim between treating the emergency patient and surgical repair of the radius and ulna fracture, all of the orthopedic injuries that have been found should be addressed with splints and/or pain medications to keep the animal comfortable until the fracture can be properly addressed. The time of appearance of ossification center y for dogs between 25 to 35kg was reported to be variable for anconeal process, prenatal for proximal epiphysis and distal epiphysis of the radius, 3-4 months for proximal and distal epiphysis of the ulna … Chapter 55 Growth and Development ulna were ‘‘cystlike’’ in appearance, with reduced radiographic opacity in the center of the ‘‘cyst.’’ The irregular changes seen in the metaphysis at 6 months were in regression in both radius and ulna at 12 months. This causes forward bowing of the forearm with lateral (outward) deviation of the carpus. Some radius and ulna fractures require anesthesia and surgical stabilization of the bone fragments for the best results. When an antebrachial angular limb deformity is first detected, the surgeon is faced with a number of decisions regarding timing and the type of correction to be completed. The radius revolves around the ulna. C, Radial anatomic axis (red) determined from the mid-diaphyseal points measured at the proximal and distal diaphyseal-metaphyseal junctions (gray lines). The radius “pushes” the humerus in a proximal direction, against the anconeal process.6 In young Basset Hounds up Table • 55-1 Instability may result in the formation of an exuberant callus, which has the potential to form a bridging synostosis with the radius and to be a source of irritation because of the sparse soft tissue coverage overlying the caudal aspect of the ulna (Figure 55-9). This author has also utilized a sagittal sliding osteotomy with subsequent placement of transverse cortical screws in lag fashion (Figure 55-11). Great differences exist, however, with respect to relative contributions to total longitudinal growth from the physes of each bone. These changes occur as the radius continues to grow “around” the distal ulna, which is located caudolateral to the distal radius. Mediolateral radiograph of the antebrachium of a dog that underwent a dynamic ulnar osteotomy with intramedullary pin placement 6 weeks previously that presented with worsening lameness of the operated limb. Minimally displaced fractures that involve the middle or distal end of the bones might fit into this category. Preoperative distal radial valgus greater than 25 degrees was detected in most cases unsuccessfully treated with distal ulnar ostectomy alone in this study and necessitated additional surgery, whereas those treated successfully possessed distal radial valgus less than 25 degrees.21 Thus, whereas ulnar ostectomy is a relatively less invasive procedure than osteotomies/ostectomies of the radius and ulna, its utility as the sole corrective procedure appears to be limited to those cases where radial valgus, procurvatum, and torsion are attributable to premature closure of the distal ulnar physis, and the radial angulation is not severe. Symmetric premature closure of the distal radial physis has been created in juvenile dogs experimentally through irradiation, thus serving as a model for the clinical scenario.40 Through this study, it was determined that when the distal radial physis is symmetrically insulted, the proximal physis assumes the majority of longitudinal growth in the radius, as the amount of elongation of the distal radius slows dramatically. Recommendations of one small retrospective study suggest that despite diagnosing and treating affected animals at a young age (5 months), the technique was still frequently unsuccessful. Ulnar shortening is predominantly recommended for skeletally mature animals. Each arises from its respective epicondyle of the humerus and bifurcates into two crura: a cranial division, which attaches to the proximal radius, and a caudal crus, which attaches to the ulna. The IHC Group. However, the distal ulnar physis is conical in shape and thus is unable to shear, regardless of whether the offending force is axial or lateral in nature. The ligament proper terminates distally about midshaft of the antebrachium, where the two bones diverge medially and laterally as they cross one another. Radius and ulna fractures may be surgically repaired in many different ways based upon the specific fracture type, location, and age of the animal. It is important to recognize that the pulling force of the triceps brachii muscle is not perfectly axial, but rather the triceps brachii muscle pulls on the olecranon at an angle, thereby exerting a bending moment at the level of the ostectomy. For example, if a young patient is presented with premature closure of the distal ulnar physis with subsequent radial angulation, an ulnar osteotomy can be attempted to try to improve elbow joint incongruity and to release the bowstring effect of the affected ulna on radial development. The following radiographs are the mediolateral and craniocaudal views of the left radius and ulna of a seven-month-old mixed breed. It is important to recognize that the pulling force of the triceps brachii muscle is not perfectly axial, but rather the triceps brachii muscle pulls on the olecranon at an angle, thereby exerting a bending moment at the level of the ostectomy. Dog positioned for dorsopalmar collimated image of carpus (A) and corresponding radiographic image However, acute one-stage radial elongations are an option in the adult dog, particularly in those with less severe radial shortening, because there is no risk that the animal will outgrow the correction. Another method used to avoid instability and recurvatum of the ostectomized ulna is completion of an ostectomy of the distal ulnar diaphysis or removal of the physis itself. Elbow joint congruence can be reestablished by lengthening the radius or shortening the ulna. The second angle measured was taken from the lateral radiograph of the carpus. All four regions are present in pediatric patients while only the metaphysi… Treatment options for radial shortening vary, depending on the severity of the condition and the age of the patient. Updated Website - Mobile Friendly - 11/19/2019 Browsers: For best results, please use the most recent version of browsers when viewing the site. A, Medial aspect. 12 The distal ulna, radius, and tibia are most commonly affected. Figure 55-3 Radius and ulna, frontal plane: Joint orientation lines, radial anatomic axis, and joint orientation angles. Illustration depicting the completion of a dynamic oblique ulnar osteotomy for the purpose of elongating a shortened ulna. Thus it can be seen that in the sagittal plane, a wide range of procurvatum is present normally. In the absence of concurrent angulation, the goal of any surgical intervention is to reestablish radioulnar congruency at the level of the elbow joint while maintaining appropriate bone alignment. An alternative technique, which provides acute radial elongation while preserving load sharing, is the completion of a sagittal sliding (or “stairstep”) osteotomy. Open fractures have a greater chance of getting infected and may have more complications than closed fractures. Treatment of radial shortening in skeletally mature dogs can be accomplished with any of the more gradual dynamic lengthening procedures. radiograph. This technique allows the interosseous ligament to help stabilize the ulna from the bending force created by the triceps brachii muscle, while still allowing the ulna to slide proximally. An instructional video recorded for the San Juan College Veterinary Distance Learning Program VETT 215 Spring 2017 Veterinary Radiology III course. The basic principles employed with any of the dynamic ulnar ostectomy (semi-controlled and controlled) procedures can also be used for the skeletally mature animal diagnosed with humeroulnar incongruity due to a shortened ulna. No laboratory tests are required to make the diagnosis, but your veterinarian may recommend the following: Emergency care for concurrent problems caused by the trauma is the most important part of treatment. ), Both the radius and the ulna possess physes proximally and distally that contribute to growth of each bone. A "pathologic” fracture (a fracture that occurs because there is underlying pathology in the bone) in the radius and ulna of a seemingly normal dog that jumped out of a truck and yelped in pain. Preoperative distal radial valgus greater than 25 degrees was detected in most cases unsuccessfully treated with distal ulnar ostectomy alone in this study and necessitated additional surgery, whereas those treated successfully possessed distal radial valgus less than 25 degrees. Although most of the dogs in this study did not develop angulation secondary to the uniform insult to the distal radial physis, concomitant distal displacement of the ulnar styloid process resulted in a varus deformity with internal rotation of the carpus in 3 of 8 dogs.40 Despite the fact that the proximal radial physis contributes less to longitudinal radial growth than the distal physis does in normal dogs,8 premature closure of the proximal radial physis can result in overall radial shortening. If these dogs are allowed on the furniture, ramps or stairs may allow these dogs to get up and down without risk of injury. This is of importance when attempting to surgically move a portion of one bone separate from the other, as is often necessary to treat some pathologic conditions. Related terms: . Figure 55-11 Mediolateral radiograph following completion of a sagittal sliding osteotomy of the ulna to lengthen a shortened ulna. Radiographically, an irregular, translucent zone initially appears in the metaphysis and is separated from the growth plate by an excessively dense band of bone. It is a malignant cancer called osteosarcoma. These can indicate problems with the incision or infection. Proximally, the elbow joint capsule is singular and common to all three bones. Many different cancers can cause this. Radius and Ulna Acute elongation techniques involve an osteotomy of the radius, the use of bone spreaders for radial distraction, and subsequent stabilization with a bone plate or an external skeletal fixator. Open growth plates are visible at the proximal and distal radius and ulna. Potential problems can include migration (movement) or infection of the implant. These options can be used individually or in combinations to provide stability to the bone fragments while they heal. Minimal age for routine screening is 12 months Check specific breed-club requirements! Fibers of this joint capsule are confluent with the distal extremity of the interosseous membrane and form a stout attachment between the distal ulna and radius referred to as the radioulnar ligament. This is of importance when attempting to surgically move a portion of one bone separate from the other, as is often necessary to treat some pathologic conditions. A radial tuberosity provides a site of attachment for brachialis and biceps brachii mm. Other complications involving the intramedullary pin include pin migration, irritation of the tendon of insertion of the triceps brachii muscle, and pin failure (Figure 55-10). For the radiocarpal joint in the frontal plane, the orientation line can be drawn tangentially across the distal radial articular surface, while disregarding the radial styloid process (Figure 55-3, B).
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