Delayed Pelvic Limb Use
Posted: Thu Jun 25, 2020 12:02 am
Aloha!
Looking for guidance concerning delayed use of a right hindlimb following post-op repair of a femoral fracture…
The dog in question is a 13-month old, male neutered Australian Shepherd who suffered a femoral fracture after falling out the back of a truck at the end of January. No neuro deficits noted. Nothing special noted in the surgery report, except that an arthrotomy in the stifle was done (not sure why).
Owner noted that “recovery” was uneventful and that they did their best in keeping him exercise restricted. Xrays were done at the 8-week mark (see attached) and surgeon said it was okay to return to normal activity (running on property, hard play with other dogs in households).
Looking at the 8-week rads, I assumed that callous formation was due to the dog’s age, as well as the potential for a third separate bony fragment to have been replaced, but not secured. Additionally, there appears a bit of radiolucent lines in the bone indicating the need for more healing. Other variables are the abnormal position of the patella (but the views looked a bit rotated) and the length of the plate.
I began seeing him about 15- weeks post-op for delayed continued delayed use of the limb. On initial exam, he was 2/5 lame at walk with weight-bearing lameness at stand. He was the definition of maldaptive pain and even light palpation elicited attempts to bite. We re-started on pharmaceuticals (Carprofen, Amantadine) which facilitated better handling and more ability to perform manual therapy, acupuncture, and photobiomodulation.
After working on all the regions with compensatory strain (hips, SIJ, lumbar), Karl’s the degree of Karl’s weight-bearing improved, as did functionality (much better ease with stairs, ability to jump, etc). However, at a stand, Karl always off-loaded weight from the surgical limb.
Recently, we tried to wean analgesics and Karl developed a worsening in gait (with more pain at the level of the stifle). Serial exam features have demonstrated reduced stifle flexion by about 15 degrees, moderately thickened/proliferative stifle, as well as crepitus-like sensation on the localized to the lateral aspect of the affected stifle. Not painful during passive ROM of the stifle and no instability appreciated. Some mild patella tendon thickening, with no pain on palpation.
Based on regression, I had the owners get repeat xrays to look at healing and while the implants do not demonstrate movement/changes, I am still concerned about the length of the plate and the position of the patella.
My concern is that we could do all the strengthening and postural re-training in the world, but if there is pain at the level of the implant that requires constant analgesia, that this would be a rate-limiting step. Possible that the plate is restricting normal caudal patella glide during flexion – any way to test his knowing that range of motion in flexion is indeed restricted? Am I too fixated on the implant?
Thank you!
Looking for guidance concerning delayed use of a right hindlimb following post-op repair of a femoral fracture…
The dog in question is a 13-month old, male neutered Australian Shepherd who suffered a femoral fracture after falling out the back of a truck at the end of January. No neuro deficits noted. Nothing special noted in the surgery report, except that an arthrotomy in the stifle was done (not sure why).
Owner noted that “recovery” was uneventful and that they did their best in keeping him exercise restricted. Xrays were done at the 8-week mark (see attached) and surgeon said it was okay to return to normal activity (running on property, hard play with other dogs in households).
Looking at the 8-week rads, I assumed that callous formation was due to the dog’s age, as well as the potential for a third separate bony fragment to have been replaced, but not secured. Additionally, there appears a bit of radiolucent lines in the bone indicating the need for more healing. Other variables are the abnormal position of the patella (but the views looked a bit rotated) and the length of the plate.
I began seeing him about 15- weeks post-op for delayed continued delayed use of the limb. On initial exam, he was 2/5 lame at walk with weight-bearing lameness at stand. He was the definition of maldaptive pain and even light palpation elicited attempts to bite. We re-started on pharmaceuticals (Carprofen, Amantadine) which facilitated better handling and more ability to perform manual therapy, acupuncture, and photobiomodulation.
After working on all the regions with compensatory strain (hips, SIJ, lumbar), Karl’s the degree of Karl’s weight-bearing improved, as did functionality (much better ease with stairs, ability to jump, etc). However, at a stand, Karl always off-loaded weight from the surgical limb.
Recently, we tried to wean analgesics and Karl developed a worsening in gait (with more pain at the level of the stifle). Serial exam features have demonstrated reduced stifle flexion by about 15 degrees, moderately thickened/proliferative stifle, as well as crepitus-like sensation on the localized to the lateral aspect of the affected stifle. Not painful during passive ROM of the stifle and no instability appreciated. Some mild patella tendon thickening, with no pain on palpation.
Based on regression, I had the owners get repeat xrays to look at healing and while the implants do not demonstrate movement/changes, I am still concerned about the length of the plate and the position of the patella.
My concern is that we could do all the strengthening and postural re-training in the world, but if there is pain at the level of the implant that requires constant analgesia, that this would be a rate-limiting step. Possible that the plate is restricting normal caudal patella glide during flexion – any way to test his knowing that range of motion in flexion is indeed restricted? Am I too fixated on the implant?
Thank you!