X-rays - Just another cruciate?

Re: X-rays - Just another cruciate?

james herriot lied — Mon, 05 Mar 2012 20:53:45 GMT

Sorry - obviously some issues with formatting: the right hand side of both pics has been trimmed off.

Re: X-rays - Just another cruciate?

james herriot lied — Mon, 05 Mar 2012 20:49:35 GMT

On, the other hand, this one presented today. I'm pretty sure it's not a bi-partite sesamoid.......

Dog presented looking like a classic cruciate (right aetiology, right dog, right toe-tip gait), but with no pain on attempt to cranial drawer, on lateral or medial extension or caudal palpation; slightly thickened over patella, some effusion and only mild-mod pain on palpation of the kneecap, in flexion or extension (extremely stoic rural collie).

For once, exposure better than appears here - not great digital camera work - although the knees are a bit rotated. And the other kneecap was completely normal.

Thoughts?

Re: X-rays - Just another cruciate?

Malcolm Ness — Sat, 25 Feb 2012 09:03:37 GMT

The couple that I have looked at PM have had the appearance of two patellas within the same tendon with a bit of reaction, possibly an enthesophyte at the margin. There wasn't any obvious abnormal, reactive or metaplastic tissue between the to bits of bone. Patella is not true bone only insofar as it lacks a periosteum. The pathologists might know more about this condition than me but there is likely to be a dearth of good information as it is uncommon and usually clinically insignificant and therefore little pressure to study.

Re: X-rays - Just another cruciate?

Martin Atkinson — Fri, 24 Feb 2012 19:26:00 GMT

Interesting indeed Malcolm. Given that my understanding is that the patella is not a true bone and is an osiffied tendon is it not surprising that we don't see more variations on this theme. Out of interest - would the bipartite patella be joined by tendonous or cartilaginous material?

Re: X-rays - Just another cruciate?

Julian Earl — Fri, 24 Feb 2012 17:48:31 GMT

Yes, that's a bit harsh. Murray's the best hope we've had of a losing finalist at Wimbledon for years.

Re: X-rays - Just another cruciate?

Kate Richardson — Fri, 24 Feb 2012 17:18:53 GMT

[quote user="Gerry Henry"]

Is Andy Murray?

[/quote]

LOL!!!!!

Re: X-rays - Just another cruciate?

Mark Hedberg — Fri, 24 Feb 2012 14:29:04 GMT

[quote user="Gerry Henry"]

Is Andy Murray?

[/quote]

Owch :)

Re: X-rays - Just another cruciate?

Gerry Henry — Fri, 24 Feb 2012 14:20:54 GMT

Is Andy Murray?

Re: X-rays - Just another cruciate?

Malcolm Ness — Fri, 24 Feb 2012 11:46:01 GMT

I forgot to say, Andy Murray has a bipartite patella. Is this dog any good at tennis?

Re: X-rays - Just another cruciate?

Hannah Wynne Richards — Fri, 24 Feb 2012 11:31:32 GMT

Thanks Malcolm I'm impressed

Wynne

Re: X-rays - Just another cruciate?

Malcolm Ness — Fri, 24 Feb 2012 08:44:31 GMT

Interesting case. The patella is abnormal and so is the stifle joint. I suspect that there are two unrelated abnormalities.

Patella fractures are uncommon and almost always the consequence of substantial direct trauma (the last one I saw clipped a wall with its stifle while jumping it (or failing to jump it) at some speed). The rads in this post are not typical of a traumatic injury being rather smooth and somewhat irregular. There is no evidence of soft tissue swelling or bony reaction adjacent to this patellar lesion. This is most likely a bi-partite patella - an unusual congenital/developmental anomaly and usually of no clinical significance.

The stifle is arthritic with typical new bone formation evident in all the usual places as well as synovitis leading to "loss" of patellar fat pad. The primary cause of this stifle OA is most likely a failed CCL. The chronicity of the OA contrasts with the apparently recent lameness so the reason for presentation is probably an acute flare of the chronic OA which can be expected to settle with NSAIDs and time.

Given the uncertainties around this case, I would suggest 4-6 weeks of NSAIDs and normal activity with a view to frequent clinical review and repeat rads in six weeks. I suspect that things will settle down to their pre flare-up "normality". If not, the repeat rads should confirm that nothing has changed in the patella confirming it to be clinically insignificant and attention can be focussed on the presumed CCL failure. I would take pictures of the other stifle next time and I wouldn't be too surprised if that patella looks the same.

Re: X-rays - Just another cruciate?

james herriot lied — Thu, 23 Feb 2012 15:00:15 GMT

And is it just me, or does the possible patellar fracture line look more convincing in the AP view, with marked reduction of opacity of distal fragment?

Re: X-rays - Just another cruciate?

james herriot lied — Thu, 23 Feb 2012 14:58:24 GMT

[quote user="Chris Barker"]

[/quote]

Would have to take your word for it - currently viewing on a somewhat limited screen (not all progress is progressive). But the distal patella is certainly a bit mottled, which would suggest some degeneration that could be secondary to trauma, or else to a non-traumatic pathology. Seen a good few non-displaced sesamoid fractures etc over the years.

I guess the real question is, what would one do about it. If funds allow, this would be an excellent candidate for arthroscopy, with concurrent visualisation / biopsy of the distal patella. If not, the knee seems stable and rest/painkillers would be 'almost' as good as a shot of depomed into the joint.

As somebody who's perennially guilty of trying to keep costs down by omitting the 'other' view on x-ray, I have to say that stifles are the one place where I hold fast and x-ray both knees for comparison. It's amazing what oddities are re-produced on the other knee - which either means they're nothing, or else double trouble......

Re: X-rays - Just another cruciate?

Chris Barker — Thu, 23 Feb 2012 14:15:56 GMT

Nice x-rays Lovely detail And therefore odd that no-one has pointed out the second pathology in the joint On the lateral view there is another bony fragment overlying the distal edge of the most proximal fabella, visible in the D-Pl overlying the medial fabella Together with a defect in the medial epicondyle which I presume is from where this bone fragment has been avulsed So given the odd nature of the patella fracture/fragment perhaps all of this is post-trauma

Chris B

Re: X-rays - Just another cruciate?

Anonymous — Thu, 23 Feb 2012 13:45:39 GMT

38kg entire male 5y6m Boxer.

No radiographs of contralateral stifle.

Stifle felt reasonably stable under sedation, without a convincing cranial drawer sign, but I was somewhat hesitant to manipulate it too firmly becasue of appearance of patella and I didn't really know the history at that stage (I've not personally spoken to the owners, so still don't really know the Hx, but get a feeling probably acute lameness on this occaison and was some mention of possibly running into wall? I'd have to phone them for more accurate details).

Had wondered about patella fracture (that was why posted radiographs), but looks like a complete fracture of patella on cd-cr view and was surprised that one could get a non-displaced complete patella fracture without patella alta (contrast position of patella in patellar tendon laceration case in separate dog from few months previous - radiograph below).

Stifle effusion and some DJD i thought were probably consistent with cruciate disease (if fresh patella fracture, then I might expect stifle effusion, but not DJD?), but patella was bit of mystery to me - could this be incidental/artifactual or old injury?? If fresh injury, then I'm surprised why not displaced given pulling force of quadriceps on proximal 'fragment' - presumably if this was a recent patella fracture then I should at the very least place the stifle in extension in some form of external coaptation to prevent displacement?

Thanks for the thoughts - any more welcome.

[x-ray from case few months ago of patella tendon laceration showing patella alta to contrast to normally positioned patella in this case]

Re: X-rays - Just another cruciate?

Busybee — Wed, 22 Feb 2012 23:20:24 GMT

I agree, the patella doesn't look happy. What age and breed is the dog? How did the stifle feel under sedation? Any cranial drawer? There appears to me to be evidence of DJD within the joint. Was the lameness acute this time around or persisting from previous?

Re: X-rays - Just another cruciate?

Lindsay Sissons — Wed, 22 Feb 2012 21:53:13 GMT

?Patella fracture

Re: X-rays - Just another cruciate?

Rob Loxley — Wed, 22 Feb 2012 19:24:04 GMT

And what does the other one look like?

Re: X-rays - Just another cruciate?

Evelyn Barbour-Hill — Wed, 22 Feb 2012 18:01:59 GMT

What's with the patella?