Suspect palmolateral desmopathy with avulsion of the palmar accessory metacarpal ligament.

[WendyRobinson]

Hi Laurie,

Millie is a 6 year old, female spayed, golden retriever who is
6 weeks post acute LTL lameness with left carpus lateral swelling. Patient has been on activity restriction, laser therapy, Assisi loop, Therapaw carpal sport wrap and tumeric.

RADIOGRAPHIC FINDINGS
Stationary soft tissue swelling is seen palmar and lateral of the left carpal joint.
No evidence of subluxation or luxation of the carpus is noted. However, next to the stationary
soft tissue swelling, progressive enthesophytosis of the distal bone surface of the accessory
carpal bone as well as osseous remodeling with new bone formation and multifocal reduced
opacity of the proximal, lateral, and palmar contour of the 5th metacarpal bone is seen.
The antebrachiocarpal and intercarpal joints present no significant evidence of osteoarthritis
changes.
RADIOGRAPHIC DIAGNOSIS
• Suspect palmolateral desmopathy with avulsion of the palmar accessory metacarpal ligament.
INTERPRETATION OF THE FINDINGS & FURTHER RECOMMENDATIONS
The radiographic findings are highly suggestive for injury of the palmar accessory metacarpal
ligament with avulsion from the proximal 5th metacarpus and/or accessory metacarpal bone. The
soft tissue swelling is stationary which suggests enduring injury or disturbed healing of the
ligament. Further verification by means of ultrasound could be considered. Temporary
immobilization of the carpus may be required in order to achieve healing progress

We are currently trying to get a musculoskeletal Ultrasound scheduled. My question is should we be immobilizing the carpus and digits in a spoon splint or similar to prevent weight bearing on the paw and create some tendon laxity for healing or would a surgical consultation be more appropriate at this point ? Can the client expect a full recovery or is it possible that she may have a persistent or long term lameness?

Thank you as always
Dr. Wendy Robins

[lehughes]

Hey Wendy,

You have interesting cases! Fun!

So, I think that a spoon splint would be overkill in this scenario... but I also think that the dog might require something more than a Sports Wrap. I'd use a Therapaw carpoflex X with padding.

Here's my thinking. Will full immobilization make it heal? No. Not now. Maybe in the beginning... but we can always speculate with a 'maybe'. The opposite could be true - no splint... allow movement, reduce compressive forces at the joint.

I'll also throw out, does an U/S change your plan? Will surgery provide a solution? What kind of surgery? - Removal of avulsed bit and/or ligament 'reconstruction'. I am doubtful of either of these scenarios yielding a positive long-term result.

You don't say how long you've been treating this dog with the therapies described. Maybe you need more time to see how it's going? If this has been the treatment plan for 6 weeks, then you might need to change the plan. My advice changes based on which scenario is at play here.

So, if this were my case. I'd first start with a wrap - but stronger - the Carpoflex X. I'd laser weekly or twice a week. Send the owner home with a PEMF loop to use daily or twice or more per day. And Activity restriction. This would be my treatment plan for the first 3 - 4 weeks. (I'd hope to see improvements within 2 weeks however). You could add in general carpal mobilizations as well.

Then I'd switch to active use - 3-leg stands, walking with brace on, swimming (if available). Progressing exercise to include digging and trotting - see how the dog responds... and increase or decrease activity from there.

I've only had one other dog with this (oh, actually maybe two)... but the one that stands out was about 20ish years ago, and he did fine once the joint settled. To the best of my recollection, the owner just reduced his free time with other dogs... but no other interventions were done.

All in all, this is a case that boils down to trial and error... with a willingness to change direction in your treatment plan as needed.

I'm not sure if this is helpful or not. I guess if you tell me know long the dog has been on the regimen described, we can go from there.

Cheers,

Laurie

[WendyRobinson]

Thank you so much Laurie
Your input has been very helpful.
I searched for information all over on this type of injury without much luck.

Millie has been receiving laser once weekly for the past 7 week and owner has been using Assisi loop 2-3 times daily since initial injury. Owner has a Therapaw sport wrap on her when walking and has built her up to 20 minutes per day.
I am so glad a spoon splint is not recommended as they can be so problematic.

Based on your recommendations:
I placed a carpo-flex wrap with some additional support on the caudal aspect of the leg to provide increased immobilization of the area and have decreased her walks to two 10 minute potty walks daily for the next 2 weeks. I advised the client to have the wrap on inside the house as well if she is at all active and that it is OK to take off at night when she is sleeping as long as she is not going to get up and run around. We have increased her laser therapy to twice weekly for the next 2 weeks as well and owner is going to continue with the Assisi loop 2-3 times per day.

We are currently lasering the area at 4J/cm2. Would it be beneficial to increase the power a bit more?
Would PRP be advantageous?

Wendy Robinson

[David Lane]

I will jump in on the PRP question:

Answer: Maybe.

It depends what your goal is, and what the nature of injury is (ie: what the ultrasound tells us about the underlying lesion). If the goal is to reduce active inflammation, then yes, PRP will probably help. If the goal is to repair macroscopic damage by regrowing torn ligament... then we need to be much more conservative about touting the benefits of PRP. If there is macroscopic damage, then my first choice is PRP combined with some sort of stem cell product (BMAC, SVF, ADSC etc.), with a second choice of combining shockwave with all the other things you are already doing.

[lehughes]

Yep, I love shockwave as well!
Thanks for jumping in David!

And I'd increase your laser to 10J/cm2 and do multiple spots / angles in and around the region.

Keep us posted!

Cheers,

Laurie