VM 569: Day 5 - Small Animal Growing Cases
We know that the 5 month old Setter presenting with bilateral forelimb lameness has metaphyseal osteopathy. What are 2 other differentials that should be included on your rule out list?
- rickets -osteochondrodysplasia
What would a typical history be of a dog presenting with panosteitis (3)?
- SUDDEN onset of lameness - not affected by rest - last days-wks
What is the common clinical presentation for dogs presenting with metaphyseal osteopathy (3)?
- acute onset of swelling over distal forelimb - short history of lameness and pain on palpation - elevated rectal temperature
One of our cases was a 5 month old setter with a 7 day history of bilateral forelimb lameness and the following physical exam findings: - 104 temperature - reluctant to rise, supported to stand - stilted bilateral forelimb gait - narrow based stance **- warm and painful swelling of distal radii** What is your problem list for the patient?
- bilateral forelimb lameness - pain - reluctant to move - swelling of DISTAL radi - increased rectal temp - narrow based stance
What is a common signalment for dogs that develop panosteitis (3)?
- largbreed juvenile dogs - 5-18 months of age - males
What is the common signalment of a dog with metaphyseal osteopathy (3)?
- large breed dogs - 3-5 months age - males
In the radiographs of the 5 month old Setter presenting with bilateral forelimb lameness, swelling of the distal forelimb, and increased temperature- what do his radiographs reveal besides irregular radiolucent lines visible in the metaphysis (2)?
- mild metaphyseal sclerosis - NORMAL epiphysis
In the case of the 5 month old Setter with bilateral front limb lameness, increased temperature, and swelling of distal front limbs, what disease do you think is responsible for the clinical signs: A. Rickets B. osteochondrodysplasia C. metaphyseal osteopathy D. other
C. metaphyseal osteopathy
What are the three general steps in the pathology of panosteitis?
1. adipose tissue death 2. fibroclastic and osteoblastic activity 3. osteoclastic activity
What four steps should be taken to treat panosteitis?
1. analgesics (NSAIDs, multimodal) 2. cold packing 3. exercise restriction 4. nursing care (soft beds)
What are four question you may want to ask to further define the problem of the 5 month old Setter presenting with bilateral forelimb lameness, narrow based stance, and increased temperature?
1. have the hind limb been effected 2. any history of systemic illness? 3. history of trauma? 4. appetite?
Although we determine the severe LH lameness in the GSD to be due to panosteitis, what are four other differentials that may be on our rule out list?
1. hematogenous bacterial osteomyelitis 2. fungal osteomyelitis 3. hip OA (dysplasia, trauma) 4. slipped capital femoral epiphysis
What are four radiographically abnormalities associated with the hip radiographs of the 11 month old WHWT with left hind limb lameness?
1. increased and decreased opacity of femoral head 2. collapse of femoral head 3. poor coverage of femoral head 4. Morgan's line
If you were to perform synoviocentesis on an animal with metaphyseal osteopathy, what two findings may you expect?
1. increased volume 2. increased neutrophils
One of our cases involved a 9 month old GSD, she had severe LH lameness of 8 days duration and was not responding to NSAIDS or rest. There was also moderate pain on palpation of the femoral diaphysis. What are other questions that you may want to ask the owner (4)?
1. lameness in other limbs? 2. shifting lameness? 3. change in stride length? 4. weakness?
What are five problems that should be included on your problem list for the 11 month old WHWT with left hind leg pain (pain upon hip manipulation, crepitus, proximal muscle atrophy)?
1. left hind limb lameness 2. reduced weigh bearing a stance 3. left hip pain 4. left hip crepitus 5. left hind limb atrophy
What are the five pieces of information that should be included on our client advice sheet summary to patients with avascular necrosis of the femoral head?
1. may become bilateral 2. genetic component with WHWT 3. surgical treatment likely required 4. physical rehab important to maximize prognosis 5. prognosis favorable
What are the three small animal growing cases discussed in class?
1. panosteitis 2. metaphyseal osteopathy 3. avascular necrosis of femoral head
What are the five points that should be included on your client advice sheet summary for metaphyseal osteopathy?
1. prognosis generally good 2. relapse can occur (resolve by 8 months) 3. in severe cases --> potential permanent malformation (severely remodeled metaphysis) 4. acute death is RARE 4. ***dietary supplementation is NOT required***
What are the five important points about panosteitis that should be included on a client advice sheet?
1. recurrence is the rule rather than the exception 2. each clinical episode may require treatment 3. self limiting disease with excellent prognosis 4. no long term effect recognized 5. clinical signs pre-empt radiographic evidence
***Unlike the other two small animal growing disorders, what type of dog does avascular necrosis of the femoral head tend to affect?***
SMALL breed dogs (panosteitis and metaphyseal osteopathy both affect larger breed dogs)
A pseudophysis is pathopneumonic for which condition discussed in class?
metaphyseal osteopathy
In which of the cases discussed in class are you most likely to see the following: - disrupted and necrotic trabeculae - ***hemorrhage and hemosiderin deposits*** - inflammatory cells
metaphyseal osteopathy
In which of the cases discussed in class would you most likely see a psedophysis?
metaphyseal osteopathy
One of our cases was a 5 month old Setter with a 7 day history of bilateral forelimb lameness. He is reluctant to move and vocalizing in pain. 5 days ago, the owner noticed swelling above carpi. What was the final diagnosis of this patient?
metaphyseal osteopathy
In which of the cases discussed in class would you potentially see a leukocytosis with a left shift on the blood work?
metphyseal osteopathy
Radiography of avascular necrosis of the femoral head can be classified as early, middle, or late- which stage is best described by the following? - heterogeneity of proximal epiphysis - increased and decreased density
middle
There are various radiographic stages of panosteitis: early, middle, and late. Which stage is best described by the following: - opacities become more delineated and coalesce - trabecular coarse - +/- periosteal reaction
middle
Would the following treatments be consistent for cases of mild or severe cases of metaphyseal osteopathy? - analgesia - NSAIDs - exercise restriction - nursing - correct dietary deficiency - supplements NOT recommended
mild
In the case of the 5 month old Setter with bilateral forelimb lameness, narrow based stance, and incased temperature as well as swelling and heat of the distal radius- what is the location of your problem?
distal radial metaphysis
Do we know the complete pathogenesis of metaphyseal osteopathy?
no
In the case of the 11 month old WHWT with a 3 week history of left hind limb lameness, was there a known traumatic even in his history?
no
Is the exact pathogenesis of panosteitis known?
no
Are the following radiographic findings consistent with early or late metaphyseal osteopathy? - pseudophysis - surrounding soft tissue swelling
early
Radiography of avascular necrosis of the femoral head can be classified as early, middle, or late- which stage is best described by the following? - widened joint space - thickened cartilage
early
There are various radiographic stages of panosteitis: early, middle, and late. Which stage is best described by the following: - increased opacity in medially canal near nutrient foramen - blurring of trabecular pattern - increased opacity of endosteal surfaces
early
In the case of the GSD with severe LH lameness, where are the increased opacities of the medulla cavity concentrated near?
nutrient foremen
What secondary problem will we most likely see associated with avascular necrosis of femoral head?
osteoarthritis (OA)
In the case of the GSD with panosteitis, once done performing additional radiographs, what other diagnostics should be performed?
further diagnostics are likely NOT required! CBC/biochem biopsy NOT necessary
What is the general prognosis for dog with metaphyseal osteopathy?
good
Although the 11 month old WHWT that presented with left hind lameness that was found to be due to avascular necrosis of the femoral head, presented as acute- what physical exam finding might suggest otherwise (aka that the condition is chronic)?
atrophy of the hind limb
Radiography of avascular necrosis of the femoral head can be classified as early, middle, or late- which stage is best described by the following? - femoral head collapse - secondary osteoarthritis
avascular necrosis of femoral head
Radiographic findings of the femoral head in avascular necrosis of the femoral head include a widened joint space and femoral head collapse. What will the femoral head itself look like on the radiograph (think consistency)?
heterogeneity of femoral head
The following problem list is most consistent with which case we discussed in class: - left hind limb lameness with decreased weight bearing - NON responsive to NSAIDs and rest - pain on palpation of femoral DIAPHYSIS - bilateral hindlimb atrophy - inappetence - increased rectal temp
panosteitis
Which disease discussed in class results in "thumb print" lesions in the medullary cavity of long bones?
panosteitis
In metaphyseal osteopathy, how do abnormalities in the metaphysis occur- i.e. what causes the pseudophysis?
in the area of the metaphysis, the vasculature feeding the bone makes a 180 turn the other way. This creates a narrowing of vessels and ultimately an OBSTRUCTION OF BLOOD SUPPLY
Are the following radiographic findings consistent with early or late metaphyseal osteopathy? - metaphyseal paracortical CUFFING - increased metaphyseal opacity
late
There are various radiographic stages of panosteitis: early, middle, and late. Which stage is best described by the following: - opacities resolve - medullary canal appears translucent with little trabecularation
late
In the case of the 8 month old GSD with severe LH lameness that is non-responsible to neither NSAIDs or rest, where is the location of our problem?
left femur (+ bilateral hindlimb atrophy)
In the case of the 11 month old WHWT with left hind limb lameness, left hip pain, left hip crepitus, and left hind atrophy- what is the location of the problem?
left hip
In the case of the 5 month old Setter, you take radiographs and note - irregular radiolucent lines visible in the metaphysis - mild metaphyseal sclerosis - normal epiphysis Are there any other diagnostics you want to perform?
likely NOT required (CBC/chem & synovial fluid analysis)
In the case of the 11 month old WHWT, other than a physical exam and hip radiographs, are there any other diagnostics you want to perform?
likely not required
Would a scintigraphy of a dog with panosteitis be positive or negative?
positive
In metaphyseal osteopathy, what does the reabsorption of metaphyseal trabeculae due to obstruction of blood supply result in?
pseudophysis
Is non-surgical repair appropriate in the case of avascular necrosis of the femoral head?
rarely
Would the following treatments be consistent for cases of mild or severe cases of metaphyseal osteopathy? - multimodal analgesia - corticosteroids - IV fluids - nursing care - feeding tube - soft bed & turning
severe
True or false: metaphyseal osteopathy tends to have a paracute onset
true
True or false: in cases of metaphyseal osteopathy, general inflammatory signs may be noted
true: i.e. blood work with potential leukocytosis and left shift
Is avascular necrosis of the femoral head usually bilateral or unilateral?
unilateral
In the case of the GSD with panosteitis, what other imaging should be performed?
various imaging of the hips
Is the lameness of a dog with avascular necrosis of the femoral head usually weight bearing lameness or non-weight bearing lameness?
weight bearing
What breed has a genetic predisposition to avascular femoral head necrosis?
west highland white terrier
Can full recovery of avascular necrosis of the femoral head take a long time?
yes
Can dogs with metaphyseal osteopathy die from it?
yes: hypovolemic shock --> acute death
What age dogs are most often effected by metaphyseal osteopathy?
3-5 months (large)
What age dogs are most often effected by avascular necrosis of the femoral head?
4-11 months (small)
By what age does metapheal osteopathy resolve- how does this related to panosteitis?
8 months: earlier than panosteitis (remember our dog presented at 8 mo of age)
Roughly how long does it take from the pathogenesis (adipose tissue death --> fibrobastic and osteoblastic activity --> osteoclastic activity) of panosteitis last?
90 days (3 months)
True or false: metaphyseal osteopathy is due to a vitamin deficiency
false!!!
True or false: in panosteitis, the increased opacities of the medullary canal is new bone
false: it is necrotic tissue
True or false: In patients with panosteitis, recurrence is the EXCEPTION rather than the RULE.
false: recurrence is the rule rather than the exception
True or false: panosteitis is almost always fatal
false: self limiting disease with excellent prognosis
In the case of the 11 month old WHWT with a 3 week history of left hindlimb lameness, shifting it's weight on to the RH at stance, and moderate pain upon left hip abduction- what are some additional questions you would want to ask the owner?
- Any previous episodes of LH lameness? - Any RH lameness noted> - dog ever normal?
What are 2 surgical correction for avascular necrosis of the femoral head?
- femoral head and neck ostectomy - total hip replacement
In the case of the GSD with panosteitis, what other radiograph abnormalities are noted besides the increase of medullary opacity (focused near nutrient foramen) (5)?
1. shallow acetabulum 2. subchondral sclerosis 3. femoral head osteophytosis 4. osteophytes 5. poor coverage of femoral head
What were four other physical exam findings noted on the 11 month old WHWT besides the moderate, weight-bearing LH lameness?
1. shifting weight to Rh at stance 2. moderate pain upon left hip extension & abduction 3. mild crepitus on left hip manipulation 4. mild LH proximal muscle atrophy
In the case of the 11 month old WHWT with left hind limb lameness, we have determined the problem to be avascular necrosis of the formal head. However, what are four other differentials that should be included on our rule out list?
1. slipped capital femoral epiphysis 2. chronic lunation and associated OA 3. soft tissue tumor 4. hip dysplasia and associated OA
What age dogs are most often effected by panosteitis?
5 - 18 months (large)
What disease do you think is responsible for the clinical signs of severe LH lameness non-responsive to NSAIDs or rest in the 8 month old GSD? A. panosteitis B. hematogenous osteomyelitis C. fungal osteomyelitis D. other
A. panosteitis
In the case of the 11 month old WHWT with left hind limb lameness and hip crepitus, what disease do you think is responsible for the clinical signs? A. slipped capital femoral head B. avascular necrosis of femoral head C. chronic lunation and associated OA D. other
B. avascular necrosis of femoral head
