Laurie's Blogs.

Hi Laurie,

  I would love some guidance on a new patient, if you would be so kind.  Patton is a 3 yr old MN Golden mix, about 40 pounds, who was found in an abandoned home with a brachial plexus injury of unknown origin or duration on his left thoracic limb.  He was taken in by a local rescue group and recently adopted by a family.  While I feel pretty good about my plan for working with the injured limb, I'm also very concerned about his right thoracic limb.  When checking range of motion to the right carpus, I can get to 215 degrees of extension, so 35 degrees past 180.  In active weight bearing, watching his video in slow motion, I would guess that goes to almost 240-250 degrees when walking.  He has sensation to the lateral paw of the affected left thoracic limb, so I'm hopeful he will make improvements and ideally be able to do more than just the very brief toe touching he is currently doing on that limb.  My concern is the length of time it is going to take to get to a more functional left limb and the effect it will have on his right carpus.  Searching through Four Leg (which I love, thank you very much!), I read/saw that you like the TheraPaw CarpoFlex X brace.  Do you have a "cut off" point of severity of hyperextension that you will opt for a more rigid support, like a hinged OrthoPets orthosis?  Does that depend of whether he will potentially live in this for the rest of his life?  If the dog is essentially going to be a tripawd for the foreseeable future, is there any hope that the hyperextension will improve with a brace/orthosis or is the goal now just to protect it from breaking down further?  I'm feeling a bit lost as how to best protect his "good" limb.    Do you see any benefit to doing the TheraPaw custom carpal support vs the CarpoFlex X?  Thank you for your time and any advice you might have...

Best, 

LP

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Hi L,

Great question!  So just to touch on the brachial plexus injury first, sensation to that side of the paw would constitute innervation of the C8 nerve root.  The biggest unknown in a brachial plexus injury is whether or not there was a complete nerve lesion or an avulsion of the nerve roots from the spinal cord.  So keep checking the other side of the foot, and for function of the triceps which tends to have more innervation from the C7 nerve root.

But back on topic now - I would absolutely think about supporting that right carpus given the clinical picture you describe. So here's the thought process I would go through in order to decide what's best.

• Short term vs long term:  In all likelihood, this is a long-term project, and in which case, you need to think about 'acceptance' of the device (will the owners use it, will the dog tolerate it), and skin breakdown (in whichever / whatever device you choose).  The carpal wraps don't really let the area 'breath' - so long term use could result in some skin breakdown.  The rigid braces, would have more pinpoint areas of pressure that could cause skin breakdown.  Both would need to be monitored and managed.
• Price: The carpal wrap is going to be substantially less expensive than a rigid brace.  However, this fact alone should not be the driving force behind making the decision on which option to use.
• Your Involvement & Owner compliance:  These clients will need to know that they may need to check in with you on a semi-regular basis to assess how things are going.  Checking for skin breakdown, fit of the device, alterations needed for the device, compensation issues, a need for a different solution on down the road, etc.  As an example, you may want to add foam padding to a carpal wrap, and that foam will squish and break down over time, hence needing replacing.  Another example could be that with a rigid brace, the animal's leg may change in shape over time (increase in muscle mass or decrease), so you'll want to check on it periodically to ensure a continued good fit.

So, in your case specifically, I'd first try a wrap.  I'd get the Therapaw Carpo-Flex X, order padding (foam), and maybe a sheet of thermoplastics to have on hand (you may not need it now, but you'll have it for future if need be).  This model will firstly get you knowledgeable with the product (or first line of product) and will be a way of testing the dog's acceptance of an 'external contraption' on the leg.  It will be the most economical way of assessing the situation.  See how the dog does with it.  See how the owners do with it.  Maybe teach tricks to get the dog to accept it (i.e. rewarding the dog when the wrap gets put on).  Monitor the skin.  Monitor movement.  Monitor secondary compensations.  If more support is needed, try adding the thermoplastic part (check out the FourLeg video on that!), and if it seems to be working but needs just a little more support, then check out the custom carpal support by Therapaw.

Now, if you don't think the wrap provides enough support, or the dog is resistant to the wrap, then start looking into orthotic companies.  I've used goherogo.com and orthopets.com.  Ask them questions first, give them the information about the dog, and see what they recommend.  I'd be a bit concerned that if the dog is resistant to the wrap that he/she may not accept a brace either, but perhaps it might depend on the type of hinge that could be used.  As I said, ask them.  They want their product to be successful and to be the 'right' product for the case, and as such, I think you would get an objective opinion.  If you do go down the route of a more rigid brace, then watch the casting video on FourLeg, and be sure to have the dog come in for visits to work on 'using the limb' properly with the brace on.

And lastly, you need to educate the owners that this is a 'long-haul process', and that you are there for them throughout this dog's life as need be.  Let them know that what you are recommending now is 'step one' but that the recommendation could change on down the road depending on the factors discussed above. Reassure them that you have lots of ideas on how to help them now and in the future, and that you are willing and able to help them through this process.

I hope this helps, and thanks for asking!

Cheers!

Laurie