Quads Contracture

[lehughes]

Hello Laurie,

I need your help with a case, please. I posted to the VetRehab group, but for some reason my post is not showing up.

I have read several posts regarding quadriceps contracture, but would like some more clarification and for someone to help me put this pup on the right track.

Zeus is a 15wo M Doberman puppy. Fell off bed 7/30/17, developed a minimally displaced spiral fracture of the left tibia extending from the tibial tuberosity physis distally to the diaphysis. Limb was casted according to owner at emergency hospital. Cast was replaced with larger splint by rDVM 8/9/2017. Splint removed 8/24/2017, rDVM notes say WB and normal ambulation. Next day, NWB and limb mildly stiff. I evaluated him 5 days later and requested radiographs before proceeding with therapy which are attached.
On my evaluation, Zeus is NWB-PWB with stifle hyperextension of left hind. Circumducts on swing phase and knuckles/drags left hind paw with slapping of paw onto the ground at a slower pace. There is a firm boney swelling around the stifle and tarsal joint LH. Hip ROM normal, stifle flexion/extension 140/182, did not measure tarsus. Painful hard end feel on stifle flexion. Atrophy and firmness of left quadriceps, but hamstrings and gluteal muscles normal.
I have been unable after multiple attempts to speak with the rDVM. Owners are very worried about returning leg to normal function.

Do I have the correct diagnosis of a quadriceps contracture? My thoughts are the fracture was located at the point of insertion of the quadriceps leading to a "tie down" and also that there may be contracture of the joint capsule.
Read that surgery is not a practical option for quadriceps contracture.
Rehabilitation would include laser, NMES, therapeutic exercises (I don't have an ultrasound unit). What setting do I use, how often and how do I avoid growth plates with my Cutting Edge laser?
Is this still a guarded long term prognosis for full return to function given flexion is >90 degrees?

I appreciate your time and efforts.
KH

[lehughes]

Hi Kerri!

Great question, unfortunate answer…
So, at this point in time you have likely lost your window of opportunity. A cast should not have been put on in extension, nor the splint. If (as in this scenario) a quads contracture is starting or is a potential (young dog with femoral fracture), a flexion splint should be created. Now, there is very little you can likely do.

BUT, to give it a go for the owners, try bandaging the leg into flexion as best you can (sort of like an ehmer sling, but you’ll never get that much flexion.) See photo attached.
You can do whatever modalities you want, but bottom line, the body has turned part of the quads into bone. You can’t fight that.
This is a classic mismanagement case unfortunately.

Check out: https://www.fourleg.com/media/CANINE%20Q ... TURES2.pdf

At this point, the growth plates aren’t a huge concern with laser. The contracture means that the stifle won’t properly move, which means the joint won’t get nutrition, which causes DJD. The same is likely to occur at the tarsus. (If the stifle won’t flex, neither can the tarsus…)

You will be very lucky to get this stifle to bend anywhere near 90 at this point, and the owners need to be aware that the leg will never be normal from here on in.

Sad… but still functional. Now they have a special needs dog… which is not the worst thing in the world. But they will need to be counselled to enjoy the dog they have and not the dog that 'could have been'.

Best of luck!

Laurie

[lehughes]

Hello Laurie,

I truly appreciate your time and thoughts about this case. It is always great to hear ideas even when the prognosis is so poor.

The owner took my advice and pursued a consult with Dr. D.M., DACVS and his associate at XXXX Veterinary Specialty Center. I did not receive an official medical record from the appointment, but Dr. M. called me to discuss his findings. He was convinced this pup indeed has a quadriceps contracture, very unusual given the fracture did not involve the femur. He was unable to flex the stifle at all himself and felt if we were to try and force it while under sedation that we would potentially fracture the femur. His associate did not give the owner any hope, recommended letting the little guy mature and grow some more as he does not appear in immediate pain, then amputate. We agree with you, it is an unfortunate case of mismanagement of the bandaging.

Although I give myself credit for having the correct diagnosis when the rDVM kept telling the owners that the hamstrings were stiff, it is disheartening. I was told the owner left the appointment very frustrated and has been quiet about his plan for the pup in our recent correspondence.

Thank you again for your expertise, I look forward to future discussions.

KH

[lehughes]

Awww….
But thank you for the update.
If the dog can use it as a peg leg, then it might be worth leaving on.

All the best,

Laurie