I have a 11 year old Boxer NM scheduled to come in that has a history or intermittent left foreleg lameness. Extremely lame for a day then will be good for a few days. Radiographically was diagnosed with RUIN syndrome- radio-ulnar ischemic necrosis bilaterally with the left being worse by a boarded radiologist.
I have not see the dog yet. My understanding is that some dogs are asymptomatic with the syndrome others are very painful. Also typically if they are going to have problems with this syndrome it shows up before this age.
This syndrome is new to me I have to say I have never heard of it.
If it is painful in areas of the radiographic lesion would - laser, acpuncture and or ESWT benefical? Any other thoughts would be great.
Thanks as always
Nancy Peterson, DVM, CCRT, CVA. CVSMT
Pawsitive Strides Veterinary REhabilitation and Therapy
Des Moines, IA
RUIN syndrome - Radio-ulnar ischemic necrosis syndrome
Re: RUIN syndrome - Radio-ulnar ischemic necrosis syndrome
Hey Nancy!
Well, this is a new one for me as well. I'm going to start off by looking to the research to see what I can find, and post THAT here... then think about your questions.
Schmid L, Klang A, Katic N, Ansón A, Gumpenberger M, Kneissl S. IMAGING DIAGNOSIS-RADIOGRAPHY AND COMPUTED TOMOGRAPHY OF RADIOULNAR ISCHEMIC NECROSIS IN A JACK RUSSELL TERRIER. Vet Radiol Ultrasound. 2018 Jan;59(1):E7-E11. doi: 10.1111/vru.12448. Epub 2016 Nov 2. PMID: 27804173.Abstract
A 7-year-old Jack Russell Terrier with a history of minor trauma was presented for lameness of the left forelimb. Radiography and computed tomography demonstrated a localized radioulnar osteolytic lesion with cortical bone loss and enthesiophytes. Based on results of diagnostic imaging and histopathological examination, the final diagnosis was radioulnar ischemic necrosis (RUIN), complicated by pathologic fracture. A rare disorder of unknown etiology, RUIN may be secondary to tearing of the interosseous ligament and potential ischemia. It should be differentiated from neoplastic or fungal disease. To the authors´ knowledge, this is the first canine case report describing RUIN.
Sukumaran K, Cashmore RG, Howlett CR. Repair of a pathological radial fracture secondary to radioulnar ischemic necrosis in a dog. J Am Vet Med Assoc. 2020 Aug 15;257(4):406-409. doi: 10.2460/javma.257.4.406. PMID: 32715885.
Case description: A 3-year-old 2.5-kg (5.5-lb) sexually intact male Pomeranian was presented with a 1-day history of non-weight-bearing lameness of the right forelimb.
Clinical findings: Signs of pain were localized to the proximal portion of the right antebrachium. Radiography revealed a minimally displaced fracture of the proximal portion of the radius that had propagated from a well-demarcated, ovoid, osteolytic lesion within the cortex of the caudolateral aspect of the radius. Computed tomographic findings supported the radiographic findings and did not reveal lesions in other evaluated body sites.
Treatment and outcome: At surgery, the lateral aspect of the radial cortex appeared expanded, and tenacious fibrous tissue filled the gap between the fracture fragments. Fibrous tissue was resected and submitted for histologic examination, and the fracture was reduced and stabilized with a bone plate and a positional screw. Histologic examination revealed the presence of viable bone, fibrous tissue, and areas of coagulative necrosis. Imaging and histologic findings were consistent with radioulnar ischemic necrosis (RUIN). The patient ambulated normally at reexamination 12 days after surgery. At reexamination 15 weeks after surgery, the patient continued to ambulate normally, and radiography and CT indicated healing of the fracture and resolution of the RUIN lesion.
Clinical relevance: RUIN should be considered as a differential diagnosis for a dog with forelimb lameness and radiographic focal osteolysis between the proximal and middle thirds of the diaphysis of the radius or ulna. Prognosis for dogs with RUIN may be good with surgical intervention.
Radioulnar Ischaemic Necrosis in a Dog with Concurrent Osteomyelitis and Bone Sequestration
Theresa L. Aller, Kathryn L. Phillips, Amy S. Kapatkin, Katherine D. WatsonVCOT Open 2020; 03(01): e19-e22 DOI: 10.1055/s-0040-1702152
An 11-month-old intact female Golden Retriever presented for a 3- to 4-week history of right thoracic limb lameness. Computed tomography of the limb showed a sequestrum with a periosteal and endosteal reaction at the level of the nutrient foramen of the radius. Septic osteomyelitis was suspected based on cytology. Repeat examination and imaging revealed improvement in the lesion and resolution of the lameness. This lesion is similar to reports of radioulnar ischaemic necrosis, but is the first report with concurrent osteomyelitis and sequestration.
Okay... now to think about it. I'll do that as a separate answer!
Laurie
Well, this is a new one for me as well. I'm going to start off by looking to the research to see what I can find, and post THAT here... then think about your questions.
Schmid L, Klang A, Katic N, Ansón A, Gumpenberger M, Kneissl S. IMAGING DIAGNOSIS-RADIOGRAPHY AND COMPUTED TOMOGRAPHY OF RADIOULNAR ISCHEMIC NECROSIS IN A JACK RUSSELL TERRIER. Vet Radiol Ultrasound. 2018 Jan;59(1):E7-E11. doi: 10.1111/vru.12448. Epub 2016 Nov 2. PMID: 27804173.Abstract
A 7-year-old Jack Russell Terrier with a history of minor trauma was presented for lameness of the left forelimb. Radiography and computed tomography demonstrated a localized radioulnar osteolytic lesion with cortical bone loss and enthesiophytes. Based on results of diagnostic imaging and histopathological examination, the final diagnosis was radioulnar ischemic necrosis (RUIN), complicated by pathologic fracture. A rare disorder of unknown etiology, RUIN may be secondary to tearing of the interosseous ligament and potential ischemia. It should be differentiated from neoplastic or fungal disease. To the authors´ knowledge, this is the first canine case report describing RUIN.
Sukumaran K, Cashmore RG, Howlett CR. Repair of a pathological radial fracture secondary to radioulnar ischemic necrosis in a dog. J Am Vet Med Assoc. 2020 Aug 15;257(4):406-409. doi: 10.2460/javma.257.4.406. PMID: 32715885.
Case description: A 3-year-old 2.5-kg (5.5-lb) sexually intact male Pomeranian was presented with a 1-day history of non-weight-bearing lameness of the right forelimb.
Clinical findings: Signs of pain were localized to the proximal portion of the right antebrachium. Radiography revealed a minimally displaced fracture of the proximal portion of the radius that had propagated from a well-demarcated, ovoid, osteolytic lesion within the cortex of the caudolateral aspect of the radius. Computed tomographic findings supported the radiographic findings and did not reveal lesions in other evaluated body sites.
Treatment and outcome: At surgery, the lateral aspect of the radial cortex appeared expanded, and tenacious fibrous tissue filled the gap between the fracture fragments. Fibrous tissue was resected and submitted for histologic examination, and the fracture was reduced and stabilized with a bone plate and a positional screw. Histologic examination revealed the presence of viable bone, fibrous tissue, and areas of coagulative necrosis. Imaging and histologic findings were consistent with radioulnar ischemic necrosis (RUIN). The patient ambulated normally at reexamination 12 days after surgery. At reexamination 15 weeks after surgery, the patient continued to ambulate normally, and radiography and CT indicated healing of the fracture and resolution of the RUIN lesion.
Clinical relevance: RUIN should be considered as a differential diagnosis for a dog with forelimb lameness and radiographic focal osteolysis between the proximal and middle thirds of the diaphysis of the radius or ulna. Prognosis for dogs with RUIN may be good with surgical intervention.
Radioulnar Ischaemic Necrosis in a Dog with Concurrent Osteomyelitis and Bone Sequestration
Theresa L. Aller, Kathryn L. Phillips, Amy S. Kapatkin, Katherine D. WatsonVCOT Open 2020; 03(01): e19-e22 DOI: 10.1055/s-0040-1702152
An 11-month-old intact female Golden Retriever presented for a 3- to 4-week history of right thoracic limb lameness. Computed tomography of the limb showed a sequestrum with a periosteal and endosteal reaction at the level of the nutrient foramen of the radius. Septic osteomyelitis was suspected based on cytology. Repeat examination and imaging revealed improvement in the lesion and resolution of the lameness. This lesion is similar to reports of radioulnar ischaemic necrosis, but is the first report with concurrent osteomyelitis and sequestration.
Okay... now to think about it. I'll do that as a separate answer!
Laurie
LAURIE EDGE-HUGHES
Re: RUIN syndrome - Radio-ulnar ischemic necrosis syndrome
So...
I am thinking like you. It's strange to have this issue show up at 11 yo!
Maybe have an all around poke and feel to see if you can find some other reasons for the lameness that wouldn't show up radiographically: rib issues, pinched nerve in neck, medial shoulder, sesamoids and so on.)
If the RUIN is indeed causing lameness, then it should also be painful on palpation. So palpate the length of the radius and ulna bilaterally and the interosseus space between. And maybe try shear testing in various places along each forelimb, and mobilizing the proximal and distal radioulnar joint. And also assess end range supination / pronation - all as way to see if YOU can localize pain to the radiographically evident RUIN.
So, let's say it's the RUIN. Then, yes, I would target my treatments locally - laser & acupuncture. If it's painful, shockwave might not be tolerated... but you could play it by ear.
And then of course, controlled exercises to work on static balancing.
That's how I'd approach it anyways!
Let us know what you find when you examine the dog!
Best of luck!
Laurie
I am thinking like you. It's strange to have this issue show up at 11 yo!
Maybe have an all around poke and feel to see if you can find some other reasons for the lameness that wouldn't show up radiographically: rib issues, pinched nerve in neck, medial shoulder, sesamoids and so on.)
If the RUIN is indeed causing lameness, then it should also be painful on palpation. So palpate the length of the radius and ulna bilaterally and the interosseus space between. And maybe try shear testing in various places along each forelimb, and mobilizing the proximal and distal radioulnar joint. And also assess end range supination / pronation - all as way to see if YOU can localize pain to the radiographically evident RUIN.
So, let's say it's the RUIN. Then, yes, I would target my treatments locally - laser & acupuncture. If it's painful, shockwave might not be tolerated... but you could play it by ear.
And then of course, controlled exercises to work on static balancing.
That's how I'd approach it anyways!
Let us know what you find when you examine the dog!
Best of luck!
Laurie
LAURIE EDGE-HUGHES