6 mo puppy with flexural deformities in all 4 limbs

[lmp37dvm]

Hello Forum,
Sorry, this is going to be lengthy...

“M” is a 6 month old female Husky with flexural deformities in all 4 limbs (significant contracture of superficial digital tendon all 4 limbs) as well as right carpal valgus, bilateral elbow dysplasia due to radius and ulnar abnormalities, missing fibulas bilaterally, and “blunted” accessory carpal bones and calcanei (presumably due to prolonged tension of the SDF over these bones). Mia was purchased from a breeder at around 10 weeks old. She was the runt of the litter and noticeably calmer than her littermates. At that time, a veterinarian performed a wellness exam and declared her healthy. Per the current owners, she seemed like a normal happy puppy. She had some diarrhea when they first brought her home which resolved with metronidazole. Within the first 4 weeks of owning her, one family member noticed she was sitting oddly and another family member noticed she was starting to walk on her toes (there is disagreement as to which was noticed first). Initially, they were concerned that one of their other dogs had stepped on M and injured her because they were also starting to notice the right carpal varus. As M grew, the toe walking became more severe as well as other abnormalities which lead to more of a work up by the rDVM. This eventually led to M being evaluated at a university vet school. There is also disagreement within the family as to whether M is getting worse or is static.

She was seen by the Orthopedic Surgery service in early June where a CT was done. No diagnosis was determined as to why these changes have occurred and they recommended aggressive rehab and/or surgery to cut the SDF attachments at her digits. I just got a copy of the CT which I have not looked at yet. The owners would like to try rehab before moving forward with surgery. So here we are…

Other than the things already listed above, here are other findings from our initial visit:
• cow hocked to the point of almost interfering
o more significantly externally rotated in her right pelvic limb
• lame on her right pelvic grade 3/5
o inconsistent sensitivity to manipulation of her stifle; click on manipulation of her tarsus
• decreased ROM to both carpi (R>L) in both flexion and extension. Able to flex to about 60 degrees, unable to hyperextend past 180, barely able to get to 180
• Decreased ROM to both tarsi in flexion, only able to get to about 90 degrees.
• Decreased dorsi-flexion to all digits, specifically digits 3 and 4, all 4 limbs.

Prior to becoming certified in rehab, I did ambulatory equine work. M first made me think about the foals with flexural deformities I used to see. Granted we were seeing these foals in the first 24 hours after birth, so the timing is off, but we would treat them with oxytet and wrap the affected limb/limbs. In talking with other equine vets about these foals, many of them thought that the foals got better just with the wrapping alone...that the wrap contributed to making the tendon more lax more than the oxytet. Do you think it would be worth having some wraps made for Mia? I guess we could start with some disposable materials, but was thinking of using a company like TheraPaw to make something that could be reused. Granted, she would grow out of them, but it would be a start. Could I eventually incorporate some sort of toe-up device? Any opinion on this?

The owners would also like to get M spayed. Do you have an opinion on whether we should wait until she is older? I know there is a big push now, especially in the sport dog world, to either not spay or neuter, or wait until their growth plates are closed, etc. Seeing as though we are already dealing with contracted tendons, do we try to stop her from becoming more long and lanky by holding off on spaying her? In the end, I know the owner would prefer to spay her before she starts going into heat, but we discussed that there might be a benefit for how she will grow by waiting...but I also told her I wanted to consult with others to get their opinion.

When I saw M, I spent a lot of time discussing exercises and stretching, etc., with the owners. The owner admitted that she did the hot packing and stretching recommended at the university for a week and then stopped because she wasn't seeing any change! So, ultimately, I'm not sure how successful rehab is going to be since I get the feeling they are not going to be as aggressive as they need to be. She is a super sweet puppy, but she is a puppy and a Husky at that, so she is quite vocal about what she doesn't like...I get the impression it makes them uncomfortable. Along those lines...and I realize this is probably an unfair question...how long would you give rehab a chance before going forward with the surgery?

The only other thing I was considering is testing M for Neospora and Toxo. I took photos and videos of M to show the surgeon and neurologist I work with, and our neurologist suggested it and thought it would be reasonable to do. Sorry for the lengthy email, just want to do right by this puppy.

I would love to hear if someone has any experience with a puppy like this or any ideas or thoughts or opinions on the things I’m considering. I have some photos and videos, hopefully they attach. Thanks for your time…

Laura

[lehughes]

Hi Laura,

Wow, this looks like a crazy case! I would look into different connective tissue disorders. I did a quick check, but didn't see anything that dealt with LACK of tissue extensibility. But I think one could spend more time looking for some odd genetic condition that could explain this. I would also agree that testing for neospora or toxa. would be wise as well. (I've rehabbed two dogs with a spinal neospora, but they didn't look like this...)

So, this is one of those cases where a dose of reality could be a hard pill to swallow. 1) There's no diagnosis, so would surgical release of the tendons help, hinder, or be futile? 2) You could add 'contraptions' of all sorts, but where do you stop? 3) Is this progressing or not?

Okay, so my thought would be to come up with exercises that the owners could do with M in order to work on tendon extensibility, while still having a 'fun' interaction with the dog. Passive stretching and making their puppy cry isn't going to happen! So throw out that thought.

So, I'd suggest digging as an exercise and walking in pea gravel as exercises for the toes. I'd add hill walking up and down, with periodic stops to sit - facing up or facing down to work on tarsal and carpal mobility / flexibility.

If you did go about adding a contraption or two, then 'MAKE THEM'. Since this is a 'crap shoot' at best, you don't want them spending all of their money on a guess (which is sort of the category I put surgery into on this case as well). So make your own toe ups use tubing or hair elastics and/or vet wrap. Look at a picture and recreate it. You are doing this for the 'short term' to see if it works. If you're happy, then go ahead and order a product.

I don't know what to think about the medication you mentioned (oxytet)... But I would say that this could be one of those weird cases that does well with chinese medicine. I think it's fair to offer that sort of a direction if things aren't adding up.

And on that note, isn't there a lab in California that deals with weird myopathies and such? I'm not 100% familiar, but could this be a case where sending a muscle biopsy could help to provide direction for a diagnosis? Just thinking out-loud on that point.

It makes me uncomfortable in this case to just chase the symptoms without knowing a diagnosis or at least having some kind of a 'guess' in mind.

Laurie

[backontrackvetrehab]

Any followup on this puppy?
I had a similar case about a year ago with contractions of the flexor tendons, very straight elbows and stifles and looong legs. My patient came to me after two failed surgeries for lateral patellar luxations. She was negative for toxo and neospora and the owners declined testing beyond that and radiographs. She was not too uncomfortable but didn't have much range of motion in the stifles, elbows, or front toes, and was very muscle wasted in the rear.

We did lots of weekly manual therapy and stretching (sometimes involving heat and always involving a lot of peanut butter!) and after the first 4 weeks or so we started her in the treadmill weekly as well. At first, we tried using wraps on the front toes, but she wouldn't tolerate it and after the first month or so she didn't need them. Now she comes in for maintenance manuals every 3 months and treadmill for conditioning. Her gait is not completely normal in the rear (still very straight in the stifles), but she has put on a lot of muscle mass and dramatically improved her ROM and flexibility in the front limbs. Still not sure what caused it, but she is maintaining nicely now, and the dog and the owners seem happy with the outcome!

Along similar lines, I have a Great Pyr puppy that I am planning to see soon with multiple congenital abnormalities including severe cow-hocks, severe underbite and dental abnormalities (according to the RDVM record). I'll post pictures and more info as soon as I see it, but I was wondering if anyone has tried bracing, wrapping, or assistive devices on these types of cases? Besides exercises to target areas of concern, any other tips for severe congenital conformational issues in large breed puppies? I've only ever approached them from a manual therapy and targeted exercise perspective.

Thanks,

Joni

[lehughes]

Thanks for your responses Joni!

As far as bracing, splinting, wrapping... I would suggest trying something cheap and easy as a first attempt before delving into more expensive measures.
On Bernese Mountain Dog from my past comes to mind. Hips, Knees, & Tarsal troubles. I tried some soft tarsal braces because the hyperextension was sickening to watch. We ended up using them as a way to get the dog to exercise the hips and extend from there a bit more. But he could only tolerate 10 - 15 minutes walking with them. So sometimes, out best plans are not always what helps FUNCTION. And 'functional' trumps 'normal' in cases where multiple oddities exist... when normal is non-achievable.

My findings anyways!

Laurie