Elbow x-rays: FMCP?

Re: Elbow x-rays: FMCP?

Malcolm Ness — Thu, 15 May 2014 22:03:11 GMT

[quote user="John Flynn"]On the xrays: would I be overinterpreting (I suspect I am, but if I'm afraid to ask I won't learn!) to call that subtrochlear sclerosis of the ulna, particularly on the right?[/quote]

I think you are right about the so-called sub-trochlear sclerosis. I don't find that to be a useful diagnostic feature - it is easy to find it on some apparently normal elbows and similarly difficult to find it on some grossly abnormal elbows.

John makes a good point about the clinical examination - the amount of clinical direction that can be got from the taking of history, the laying on of hands and the application of common sense almost always exceeds that yielded by "tests"

Re: Elbow x-rays: FMCP?

Matt Hilary — Wed, 14 May 2014 16:30:45 GMT

Many thanks for all the input, much appreciated.

No L flexed available. Apologies for poor quality image.

Re: Elbow x-rays: FMCP?

Virginia Campbell — Tue, 13 May 2014 23:17:10 GMT

[quote user="John Flynn"]subtrochlear sclerosis of the ulna, particularly on the right?[/quote]

I thought that too.

Re: Elbow x-rays: FMCP?

John Flynn — Tue, 13 May 2014 19:45:56 GMT

That's amazing advice once again from Malcolm!

[quote user="Matt Hilary"]Quite uncomfortable at limits extension on exam though is quite nervous.[/quote]

Re localising the source of pain for the lameness: I find that as well as full elbow extension, that elbow flexion with both pronation and supination (i.e. flex elbow and carpus in sitting dog then rotate carpus fully one direction then the other) can sometimes help.

On the xrays: would I be overinterpreting (I suspect I am, but if I'm afraid to ask I won't learn!) to call that subtrochlear sclerosis of the ulna, particularly on the right?

Re: Elbow x-rays: FMCP?

Neil Wheadon — Tue, 13 May 2014 19:36:25 GMT

Hi Malcolm Why full activity? Not doubting in any way, just would like to know the logic? Maintaining athletic muscular support to the elbow? Neil

Re: Elbow x-rays: FMCP?

Malcolm Ness — Tue, 13 May 2014 17:44:06 GMT

The age and breed are good reasons to suspect coronoid process disease in this case though by 10 mtgs old, most coronoid dogs would be showing more obvious signs of secondary elbow OA. I can see no significant evidence of coronoid process disease or secondary OA on these rads. However, a lateral 90 degree radiograph is not the best way to go looking for evidence of this disease. The flexed lateral is better - the first sign of elbow OA secondary to coronoid disease is usually osteophyte formation on the caudal anconeus. Orthoganal views are essential. Even the best radiographic studies will fail to demonstrate a proportion of coronoid cases. CT scan is considered the most sensitive imaging modality, arthroscopy is useful (but invasive) though nothing is perfect - all are prone to false negatives and the clinical significance of a coronoid abnormality is not well understood.

Bear in mind that even if you confirm your diagnosis, there is little if anything that can be done surgically that has been shown to improve the prognosis. There are many, very many reported techniques that have been used but not one has been properly evaluated AND shown convincingly to help the dog. It is massively popular to attack these cases with an arthroscope and while it is great fun and immensely satisfying (as well as comfortably profitable) to be able to identify and remove a fragmented coronoid, there is next to nothing other than surgeon anecdote to support the practice. Similarly, there are many osteotomy procedures that wave in and out of fashion but these, too, are more predictably effective at draining insurance pots than they are at improving the prognosis.

That said, if this does turn out to be coronoid process disease, the outlook is quite good. Most affected dogs will enjoy a normal and almost normally active life with only episodic management with NSAIDs. I advise full activity, weight control and lengthy NSAID courses during adolescence (3mths or more of continuous NSAID that can usually be withdrawn as the dog matures). Occasionally, we encounter a dog that responds poorly to appropriate meds and for those, salvage surgery (elbow replacement) offers the best/least bad option.

WRT this particular case, I would review the provisional diagnosis and consider other candidate diagnoses. If nothing shows itself then I would send the dog away on 5 weeks NSAIDs and FULL ACTIVITY with a view to repeating the clinical and radiographic exam (elbows, shoulders and hips as a minimum) after six weeks.