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Hi Laurie!

This feels very exciting emailing you for advice after reading so many emails of others and your amazing replies on fourleg.com. I have a new case this week that I really want to do the best for and thought you might be able to help?

He is a 5 year old German Shepherd Police dog who jumped 25 ft on a training session out an open window. He was suddenly left forelimb lame 10/10. He was taken to the vets, had x-rays and no fractures but increased space between carpal bones and diagnoses with carpal laxity/ligament damage. He was put in a cast for 6 weeks.

His owner said when he first came out the cast he looked ok for a few days but had developed blisters over his pads from the cast so lameness increased again. The owner thought it looked like it was a foot issue so got that x-rayed but nothing seen.

He initially went to another rehab centre who were concerned that he was so lame (8/10 then) and the carpus was hot so they sent him back to the vet suggesting more investigations were needed. They did give him a neoprene support for the carpus though. The vet wasn't best pleased with this and sent him our way (which was his original plan but that's another story).

When I assessed him he was 6/10 lame with marked hyper-extension of the carpus on weight-bearing. There was some reaction end range carpus flexion and full extension with some hyper-extension. There was definite laxity into valgus position - suggesting MCL issue? No heat detected or effusion. He does not like handling of the limb but did allow it and no obvious specific areas of tenderness. There was full ROM all other joints in the limb. After trying to find advice on fourleg I checked sesamoids but no pain. No flexor tendon issues from what I can tell.

So my treatment plan is:
1. Source a more supportive orthotic initially as I feel maybe going from full immobilisation to nothing was too dramatic and increased joint irritation (when he was seen by the other physio) which is now settling now he has some more support again - then gradually reduce support and gradually wean off?
2. Ultrasound to carpus area (medially) to aid ligament healing
3. Proprioception work - reasoning he may have lost a lot of awareness from being immobilised for so long and this may improve the hyper-extension/foot position
4. UWTM for strengthening to provide muscular support of the carpus and gait re-ed
5. I considered joint mobs/traction from what you have suggested elsewhere for neurological input - would you say this is ok?

Am I heading in the right direction? The owner obviously wants to get him back to work asap and wants time frames and answers if this is going to be realistic. I have said we should know in 6 weeks if the strengthened muscles etc will be able to cope with providing the stability lost. Do you think this is rehabable?! I'm just a bit scared after the other rehab placed were so concerned about him. He's such a valuable dog with a great career ahead of him I just want to make sure I am doing everything I can.

Thanks for your help in advance - if you get any time to reply as I know you are a busy bee!

A.

Hi A.!

Interesting case! And I’m glad you looked at sesamoids! I was going to mention that, and then I read further and there they were in your assessment as well! Nicely done!
The only other thing / place to look (in addition to a very real carpal issue) would be the neck and C7-T1 in particular. I am just now treating an Obedience & Field Trial Golden Retriever with a switching front leg lameness with pain specific to C6 - T1. So check for pain on palpation, pain with mobility testing, and pain with pressure on ribs 1.

Now… back to the carpus. I agree - foolish to go from full support to none!
Firstly, I would mobilize / assess the mobility of the carpal bones to glide cranially / dorsally. The mechanism of injury could subluxate them caudally / palmarly. (I always hate naming carpal bone glides, as it depends on a standing position or taking the view point of the carpus by itself… however I’ll assume you understand my meaning.) I wish that every vet knew how to glide carpal bones dorsally before applying a splint for a carpal hyperextension, as it would make a difference as to scar tissue helping to hold a bone in the correct position.

Next… brace & splint: I think he needs fuller support, which then gets reduced as he heals. I find that I can do this with a Therapaw carpoflex X. (Contact Nycky Edleston in the UK) I’d use extra straps (rigid), and thermoplastic to start. When he’s moving better with that, remove the thermoplastic but keep the rigid straps. When he looks good with that, reduce the rigid straps. And so on.
WHEN, the owner wants to start any kind of training, add a layer of support. (i.e. when tracking.) I’ve had canine-unit police officers / handlers say that the best way to exercise their dog during rehab is to lay a track in their back yard, or a field, etc. It depends on how trustworthy the dog is out with civilians as to whether a ‘walk’ is appropriate.

I agree with your plan - Ultrasound (or laser if you have it), dorsal carpal bone mobs (i.e. into flexion - as described above), Proprioceptive work (in a brace…), UWT would be fine… maybe in a brace as well, which means they should get 2 braces - because you won’t want the wet one going on again immediately afterwards.
Digging would be good. Swimming could be good. Perhaps even e-stim to the carpal flexors while weight shifting onto the leg (IF able).

Your time frame is also acceptable! There’s no way you can know more at this point, and you’ll need that 6 weeks to know how the joint will hold up.

I would also advise / ensure that he is properly medicated - pain management… not necessarily an anti-inflammatory, but perhaps acetaminophen or gabapentin. If the joint is still hot, then okay for an anti-inflammatory, but they can delay healing. I would also recommend a joint supplement with glucosamine and fatty acids - high doses of both!

Good luck… but you are totally on the right track!

Cheers,

Laurie

To me, this sounds like a probably surgical case. If it has been casted for 6 weeks and still has demonstrable hyperextension laxity (suggestive of an intercarpal ligament tear), then I would be prepping the owner for some degree of carpal arthrodesis (partial or full depending on the level of hyperextension). Fingers crossed for partial because then he can still return to work. Collateral ligaments heal well with supportive splints, but again, I would expect improved stability after 6 weeks of casting and no hyperextension if that is all there was.

If owner wishes to try the non-surgical plan you suggested, I would suggest an orthotic to eliminate the hyperextension, and let the manufacturer know that this case may progress to an arthrodesis, so make the orthotic that it has room for a dorsal plate down the road. That way, if the treatment fails and the dog does go to surgery, you have a much better external coaptation system than you would with a regular cast.

David Lane DVM
ACVSMR

That was my 'gut' feeling as well David. I guess from just reading I was hoping that the original vet made the right call about healing via immobilization in the first place. But one cannot always assume such things!

Thanks for your input!

Laurie

Stress radiographs are needed to determine which joints are involved. Injury to the caudal static stabilization of the inter (middle) carpal and/or carpal metacarpal can be managed with a partial carpal arthrodesis. This could still result in good radoiocarpal rom and hopeful return to athletic function. Since this patient has been injured for so long I would consider immediate surgery followed by rehab. On the other hand, if injury is determined to be in the radoiocarpal joint a pan carpal arthrodesis would be the surgical remedy and I have not had good success returning these to athletic performance. Perhaps if your patient is dual trained he may still have a career in detection.

So with the later I might continue with more conservative therapy in attempt to avoid pancarpal arthrodesis. Custom orthotic for support, regenerative medicine (ultrasound guided preferred) and extracorporeal shock wave.

Rick Wall