Carpal Hyperextension & Conservative Management

[lehughes]

Hi Laurie,

I would like to kindly ask for your advice in case of my own dog. He is 6 y.o. collie smooth (27 kg) and he has the acute hyperextension injury of his right front leg. Unfortunately he fell down from the dogwalk during the agility training on Wednesday this week. It happened in a training hall, no wet, no bad entry to the dogwalk, he just lost his balance in high speed...

My veterinarian did the stress X-rays and recommended the arthrodesis surgery. He said, if "it goes well" (enough space in the area), he prefers the partial arthrodesis. But I REALLY want to avoid that. So I want to ask you, if you have any experiences with conservative treatment of this injury?

Of course I understand that we can't compete any more. In my practice I have seen several failed arthrodesis surgeries and my friend also has a dog with postsurgical chronic complication... so I rather would try to treat him in a conservative way and let the surgery as the last option...

I work in an Animal Hospital as the Canine Rehabilitation Therapist, so I have extensive options of following rehabilitative care (modalities - LLLT, PEMF, UWTM etc.).

He has the rigid bandage (cast) on his leg (for each 10 days) and I would like to know the follow-up treatment regime. (I started giving him some supplements enzyme therapy Vet-enzymy) Made in Canada. Which kind of brace is the best option and when?
Thank you very much, I appreciate all your suggestions

I.R.

Vigo Rtg carpus.jpg (179.59 KiB) Viewed 6859 times

[lehughes]

Hi I.R.,

Sorry for my tardy reply! Perhaps you are far down one path or another by now, but I figured I’d answer your questions anyways.

Firstly, feel the carpal bones and see how lax they are and also mobilize any of them that are stuck ventrally. (I recommend that this is ideally done before the cast / bandage goes on - so that the bones are all in a correct position)… but any time is better than not at all.

To begin, I would start with something quite rigid and progress to allowing more freedom of movement after SEVERAL months.
I’d suggest a Hero Brace (you get a discount as a FourLeg member) or Orthopets, as your best support for an injury where a surgeon is contemplating a full or partial arthrodesis. I’d look into seeing who can make one with a hinge (ideally to limit how my hyperextension was allowed). He’ll need something to wear for several months and perhaps into the long term if needing it for off leash activities. Perhaps when things are healed, you could get away with just a carpal wrap (i.e. Therapaw). It will depend upon how rigid the joint gets with your stabilization efforts.

Now, as far as modalities go, it’s a ‘catch 22’. They help with healing of tissues and cartilage repair, and preventing cartilage damage… but in your case, you NEED scar tissue and fibrosis to help hold the joint. So I would look at them as pain management and cartilage management. I’d not use them more than 2 x week. If you were a client (i.e. someone that didn’t have access to these tools), then I’d say once a week or every second week even. UWT use will depend on whether the brace can go in the water. If not, then don’t use the UWT for at least a month or two… when your dog can bear a wee bit of weight on the leg with HIGH water for maximum buoyancy.

I hope this helps. I’ll post it on the forum as well, and hopefully others can jump in with their experiences as well. I’ve had success with a few of these, but one has to be extra vigilant about no-non-brace use in the early stage so that the scar tissue can hold the joint.

Oh, and I’d recommend a joint supplement. I’m not familiar with the enzyme therapy you described. I’d suggest adding a glucosamine, fatty acid, MSM -type of supplement.

Best of luck and I’m so sorry that it’s YOUR dog you’re having to rehab!

Laurie

[Ivana]

Hi Laurie,
thank you very much for your advice and sharing the case of my Vigo here on the forum! I still would like to avoid the surgery (arthrodesis), so I will try all available options of conservative therapy...
It is interesting thing with the modalities as you wrote... so I will laser his carpus just once to two times per week. When the cast is off I use ice packs for pain management and swelling.
I started giving him other extra supplements: the glycosaminoglycan complex (GAG) and fatty acids
I have already contacted Orthopets, so I am waiting for their idea with the right type of bracing his leg.

I.R.

[David Lane]

I understand your reluctance to have a partial arthrodesis done, and fortunately it is a salvage procedure, meaning that there is no rush to perform it; you always have it in your back pocket if everything else fails. Luckily, a partial arthrodesis has much better outcomes than a pancarpal. FWIW, my approach for these cases is to get a proper orthotic and see how the dog does in that, while initiating therapy as per LEH above. Unfortunately, with rads like those, I have not had much success using conservative treatment and likely either a chronic orthotic or surgery is in your dog’s future. With the signalment of a young active dog, I suspect that surgery will have a better return to previous lifestyle than an orthotic will… but again, no harm in trying

Arthrodesis of any joint does have a high complication rate, but many of those complications relate to the casting that happens post-op. By having an orthotic that locks out, even if you do go to surgery, you can avoid a post-op cast and therefore reduce the complication rate. You can also remove the orthotic BID and perform PROM on the radiocarpal joint to limit the negative effects of continuous immobilization. Make sure that the manufacturer of the orthotic knows that there may be a dorsally applied plate down the road in case it affects the orthotic design.

My only other thought is regenerative medicine. I don’t know anyone with large numbers treating carpal hyperextensions this way, but if you have access to someone with experience/equipment, and an ultrasound report that has identified specific structures that are damaged and can be targeted, you can try injecting those structures with stem cells and PRP for a primary repair, again using the orthotic for post-op immobilization

[Ivana]

Hi David,
thank you very much for your post! That is an interesting thing you wrote regarding post op complications relate to casting. I have found that there are existing the special cast-less plates for arthrodesis too. I definitely will ask my vet surgeon for that and for the possibility of reparative medicine in this case. But I am afraid that we have the limited opportunities here... Anyway I am still thinking about conservative treatment to start with.
Ivana