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The elbow

image of The elbow
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Abstract

Elbow disease is the most common cause of thoracic limb lameness in medium to large-breed dogs. This chapter covers clinical anatomy, clinical examination, diagnostic imaging, arthroscopy, surgical approaches to the elbow, elbow luxation, elbow dysplasia, incomplete ossification/intracondylar fissure-fracture of the humeral condyle, flexor enthesiopathy and salvage procedures for the elbow joint. Includes . : Arthroscopy of the elbow; Caudolateral approach to the elbow; Medial approach to the elbow; Subtotal coronoidectomy; OCD flap removal by medial arthrotomy; Closed reduction of traumatic lateral luxation; Collateral ligament repair; Dynamic proximal ulnar osteotomy/ostectomy; Ununited anconeal process internal fixation or removal; Lengthening of the radius.

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Figures

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19.1 Bony anatomy of the elbow joint. (a) Cranial view of the elbow. (b) Cranial view of the radius and ulna disarticulated. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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19.2 Ligaments of the elbow. (a) Lateral view. (b) Medial view. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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19.3 Neurovascular structures of the elbow. (a) Lateral view. (b) Medial view. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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19.4 Clinical examination should begin with assessment of conformation of the dog when standing. (a) A 3-year-old neutered male Springer Spaniel presented with bilateral thoracic limb lameness and was subsequently diagnosed with both bilateral medial coronoid process disease and incomplete ossification/intracondylar fissure-fracture of the humeral condyle (IOHC/ICFF). (b) Overlay illustrating the cranial long axes of the brachii, antibrachii and manus. Even allowing for breed conformation, the dog is standing with marked abduction of both elbows and external rotation of the manus, an adaptive posture suggestive of bilateral elbow medial compartment pain.
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19.5 Examination for evidence of elbow pain. (a) Full extension of the elbow; a hand is placed behind the olecranon and the antebrachium is pushed caudally and firmly held in this position for a few seconds. (b) Flexion of the elbow with concurrent supination (external rotation) of the antebrachium compresses the medial joint compartment.
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19.6 Arthroscopic appearance of the normal canine elbow joint via a medial portal. (a) The light post is positioned to view the caudomedial joint. (b) View of the caudomedial joint showing the anconeal process (A) and medial portion of the humeral condyle (MPHC). (c) The light post is positioned to view the centromedial joint. (d) The centromedial joint showing the MPHC and ulnar trochlear notch (UTN). (e) The light post is positioned to view the craniomedial joint. (f) The craniomedial joint showing the MPHC, medial coronoid process (MCP), radial head (R) and annular ligament (AL). Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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19.7 (a–b) Volume rendered CT images of a rare, traumatic caudal elbow luxation in a 5-year-old neutered male Labrador Retriever. (c–d) The joint was reduced closed and a transarticular external skeletal fixator applied to the humerus and radius for 3 weeks. (© Dr Kevin Parsons)
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19.8 Testing for collateral ligament integrity following closed reduction of the joint. The carpus and elbow are both flexed to 90 degrees and the elbow supported. (a) Lateral collateral integrity testing: supination is limited to about 70 degrees by the lateral collateral ligament (white lines) but rupture may allow this to increase to more than 140 degrees (yellow line). (b) Medial collateral integrity testing: pronation is limited to about 45 degrees by the medial collateral ligament (white lines) but rupture may allow this to increase to more than 90 degrees (yellow line).
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19.9 Lateral view of the elbow with placement of a Farrell suture for traumatic elbow luxation. Transverse bone tunnels are drilled in the humeral condyle at the level of the lateral and medial collateral ligament origins craniodistal to the epicondyles, through the radial head at the level of the insertion of the collateral ligament and through the ulna at the mid-portion of the ulnar trochlear notch equidistant between the articular surface and caudal ulnar cortex. Suture material is pre-placed through the humeral and ulnar and the humeral and radial holes prior to tying with the elbow at a mid-stance angle of 135 degrees. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission. (Redrawn after © John Wiley and Sons)
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19.10 (a) A 12-week-old entire female Staffordshire Bull Terrier with congenital right humeroradial elbow luxation. Note the prominent radial head laterally. (b) Craniocaudal radiograph showing lateral luxation of the radial head (arrowed). (c) Mediolateral radiograph revealing that the radial head (arrowed) is caudolaterally displaced relative to the humeral condyle, a hypoplastic medial coronoid process and trochlear notch (*), and a hypoplastic anconeal process (arrowhead).
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19.11 (a) Craniocaudal and (b) mediolateral radiographs of an 8-week-old entire male Pug with bilateral congenital humeroulnar luxation. Note the humeroulnar joint space is markedly widened and the proximal ulna is rotated approximately 90 degrees relative to the humeral condyle.
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19.12 Incongruity can occur via axial mismatch in radial length relative to the ulna. (a) Relative radial shortening with an increase in humeroradial joint space (red arrow) increasing load on the medial coronoid process (blue arrows). (b) Relative radial overlength (red arrow) increasing load on the anconeal process (blue arrow) and causing humeroulnar and radioulnar incongruity. (c) An underdevelopment of the ulnar trochlear notch may result in a bicentric humeroulnar incongruity with focal overload of the medial coronoid process and anconeal processes concurrently (red arrows). Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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19.13 (a) Ununited anconeal process (UAP) in an 8-month-old entire male German Shepherd Dog. (b) Postoperative radiograph following proximal oblique ulnar osteotomy and internal fixation of the UAP with a lag screw and anti-rotational K-wire. (c) Radiograph taken 6 weeks postoperatively; the UAP has fused. Note the prolific new bone formation at the site of ulnar osteotomy.
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19.14 Medial coronoid process fragmentation can be subcategorized as affecting either (a–b) the tip or (c–d) the radial incisure of the medial coronoid process. H = humeral condyle; MCP = medial coronoid process; R = radial head; * = coronoid fragment. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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19.15 Transverse CT images of (a) a normal Labrador Retriever elbow and (b) a Labrador Retriever elbow with medial coronoid process disease. Note the sclerotic change in the radial head (arrowed). (c) Arthroscopic image of the dog in (b): there is evidence of cartilage damage on the radial head where it articulates with the medial coronoid process. HC = humeral condyle; MCP = medial coronoid process; R = radial head; U = ulna.
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19.16 (a) Transverse and (b) 3D reconstruction CT images of an elbow affected by medial coronoid process disease; a fragment is evident (arrowed). (c) Arthroscopic view of the fragment (*) and fissure line (arrowed) extending along the radial incisure. R = radial head; U = ulna.
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19.17 Sliding humeral osteotomy. (a) A stepped locking plate and screws are applied to the medial aspect of the humerus following transverse osteotomy of the diaphysis. (b) Postoperatively, load is redistributed eccentrically (arrowed) through the lateral joint compartment, hence off-loading the abnormal medial compartment.
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19.18 Proximal abducting ulnar osteotomy (PAUL) procedure. (a) Intraoperative image and (b–c) postoperative radiographs. The surgery involves application of a stepped locking plate to the lateral aspect of the proximal ulna, abducting the ulna and shifting load to the lateral joint compartment.
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19.19 (a) Radiographic, (b) CT and (c) 3D reconstruction CT images of the appearance of osteochondritis dissecans (arrowed) of the medial portion of the humeral condyle (H). U = ulna.
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19.20 (a) Humeroulnar and radioulnar subluxation in a 6-month-old Jack Russell Terrier as a result of reduced growth of the distal ulnar physis. Proximal ulnar ostectomy was performed. (b) Radiograph taken 6 weeks following surgery showing improved elbow congruency. Note the prolific new bone formation at the site of ulna ostectomy.
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19.21 (a) Preoperative radiograph showing a short radius due to premature closure of the distal radial growth plate, and secondary severe distal humeroulnar subluxation. (b) Postoperative appearance following proximal ulnar ostectomy and placement of an intramedullary pin in the ulna. Note the substantial improvement in humeroulnar and humeroradial congruence. (c) Radiograph taken 4 weeks postoperatively; new bone is present at the site of ulnar ostectomy. (Courtesy of Martin Owen)
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19.22 (a) Computed tomographic and (b–c) arthroscopic appearance of the right elbow of a 3-year-old neutered male Springer Spaniel presenting with elbow pain. (a) Dorsal CT image revealing hypoattenuation of the condylar bone in this region (black arrows). Pronounced regional sclerotic change is present in the proximal portion of the condyle (white arrows). (b) Craniomedial and (c) caudomedial arthroscopic images of the same humeral condyle. A faint line is present in the cartilage (arrowed) at the location that fissure formation would be predicted to occur. AP = anconeal process; HC = humeral condyle; MCP = medial coronoid process; R = radial head.
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19.23 (a) IOHC/ICFF (arrowed) is occasionally visible on a craniocaudal radiograph if the X-ray beam is within 5 degrees of the orientation of the fissure. Lack of evidence of a fissure on plain radiographs does not rule out the possibility of IOHC/ICFF. (b–d) Variable appearance of IOHC/ICFF on CT; partial fissuring, cavitation and complete fissures may be present each with varying degrees of sclerotic change. (e–f) Incongruency may be present which can comprise either a shortened ulna or shortened radius (double-headed arrows), but some dogs do not demonstrate any evidence of incongruency. H = humerus; R = radius; U = ulna.
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19.24 Placement of a medial 4.5 mm cortical positional screw in an elbow with IOHC/ICFF under fluoroscopic guidance. (a) A K-wire is introduced across the condyle, following which a 3.2 mm cannulated drill bit is used to enlarge the hole before (b) placing the screw. (c) Postoperative radiograph showing good screw position. Note that the intracondylar fissure is still visible.
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19.25 Different manifestations of flexor enthesopathy as seen on radiographs and 3D volume rendered CT images. (a–f) Different degrees of mineralization (arrowed) are evident in the vicinity of the medial epicondyle and origin of the flexor tendons. Changes tend to be more advanced when concomitant elbow joint disease is present, most commonly elbow dysplasia with secondary osteoarthritis. (g–h) Region of mineralization distal to the medial epicondyle (arrowed); this was previously termed ‘ununited medial epicondyle’ but histological studies do not support a failure of fusion of the epicondyle.
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19.26 (a) The BioMedtrix TATE Elbow 2nd generation prosthesis. The arthroplasty system is an unlinked, semi-constrained, cementless, stemless implant. (b) Postoperative mediolateral radiograph showing the implant in place. (a, Reproduced with permission of BioMedtrix)
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19.27 Patient positioning for a mediolateral view of the elbow. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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19.28 Patient positioning for a craniocaudal view of the elbow. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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19.29 Patient positioning for a flexed mediolateral view of the elbow. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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19.30 Patient positioning for a craniolateral–caudomedial oblique (Cr15L-CdMO) view of the elbow. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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19.31 Patient positioning for a craniomedial–caudiolateral oblique (Cr15Mo-CdLO) view of the elbow. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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19.32 (a–b) Patient positioning for simultaneous CT examination of the elbows. Note the head and neck are flexed out of the primary area of interest.
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19.33 (a) Dorsal, (b) sagittal and (c) transverse multiplanar reconstructed CT images of the elbow of a dog. The reformatting allows easier observation of the osteochondrosis lesion (arrowed) of the medial part of the humeral condyle and the surrounding sclerosis.
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19.34 Sagittal reconstructed CT image of the elbow of a dog. Moderately severe elbow incongruence can be easily appreciated affecting the radioulnar (step) and humeroulnar (uneven joint width) articulations.
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19.35 Portal positions for medial elbow arthroscopy. (a) An egress needle is placed first to insufflate the joint with Hartmann’s solution; this needle is oriented in a craniodistal orientation and enters the caudomedial joint pouch at a point equidistant between the medial epicondyle and the olecranon. (b) The arthroscope portal is established at the level of the mid-trochlear notch of the ulna and the instrument portal is placed cranial to the arthroscope at the level of the apex of the medial coronoid process. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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19.36 (a) The curvilinear skin incision is made just caudal to the lateral epicondylar ridge. (b) The anconeus muscle can be incised along its fibres or (c) elevated from its origin on the lateral epicondylar ridge. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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19.37 (a–c) A modified caudolateral approach to the elbow joint. This approach may be preferred for internal fixation of the anconeal process. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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19.38 (a) The skin incision is centred over the medial epicondyle and extends proximally and distally for 3–4 cm. (b) Incision through the underlying fascia and subsequent retraction exposes the origin of the flexor tendons. (c) Blunt dissection between the deep digital flexor tendon and the flexor carpi radialis tendon exposes the joint capsule. (An alternative approach is to separate between the flexor carpi radialis and pronator teres tendons.) (d) The joint capsule is incised. Internal rotation of the elbow joint can aid inspection of the medial coronoid process. If necessary, the caudal aspect of the medial collateral ligament can be incised to increase exposure. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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19.39 (a) Cranial and (b) medial views of the trochlear notch of the ulna. The green line shows the recommended orientation of the osteotomy. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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19.40 (a) A limited arthrotomy is made to the medial joint compartment. (b) The medial coronoid process is ostectomized and removed. (c) The ostectomized fragment. (Courtesy of Noel Fitzpatrick)
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19.41 (a) The skin incision is centred over the medial epicondyle and extends proximally and distally for 3–4 cm. (b) Incision through the underlying fascia and subsequent retraction exposes the origin of the flexor tendons. (c) Blunt dissection between the deep digital flexor tendon and the flexor carpi radialis tendon exposes the joint capsule. (An alternative approach is to separate between the flexor carpi radialis and pronator teres tendons.) (d) The joint capsule is incised. Internal rotation of the elbow joint can aid inspection of the medial coronoid process. If necessary, the caudal aspect of the medial collateral ligament can be incised to increase exposure. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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19.42 (a) The elbow is fully flexed and held for a period to fatigue the periarticular musculature. (b) The joint is then extended to an angle of just less than 90 degrees. (c) The antebrachium is rotated inwardly while the thumb of the other hand is used to manipulate the anconeal process towards the lateral epicondyle. (d) Medial pressure is applied to the lateral aspect of the olecranon to force the anconeal process into the axial recess of the lateral epicondylar ridge. (e) Medial pressure is maintained on the olecranon and the elbow is extended to lock the anconeal process in this position. (f) Thumb pressure on the radial head and internal rotation of the antebrachium are applied to reduce the radial head. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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19.43 Repair of a torn lateral collateral ligament with a locking loop suture pattern. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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19.44 Prosthetic lateral collateral ligament placement with three bone anchors and figure-of-eight FiberWire. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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19.45 To lengthen the ulna, a cut is made in a distocranial to proximocaudal direction. The triceps muscle should pull the bone proximally. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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19.46 To shorten the ulna, a segmental ulnar ostectomy is performed equivalent to or slightly greater in size than the humeroradial gap. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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19.47 (a) Preoperative mediolateral radiograph of the elbow of a German Shepherd Dog with a humeroradial subluxation (and panosteitis). (b) Postoperative mediolateral radiograph showing reduction of the joint subluxation after a proximal segmental ulnar ostectomy.
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19.48 Distal ulnar osteotomy is an alternative in young dogs and causes less postoperative morbidity. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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19.49 (a) Following proximal ulnar osteotomy, the C-guide is used to place an anti-rotational K-wire into the UAP. The C-guide is then positioned over the apex of the UAP and the glide hole for the lag screw drilled into the ulna. The depth of this hole is pre-measured from preoperative radiographs. (b) A drill insert sleeve is placed into the glide hole and the drill bit for the lag part of the hole advanced into the UAP. The depth of this hole is again measured from preoperative radiographs. (c) The depth of the hole is measured and the hole is tapped a pre-measured distance (1–2 mm less than the depth). The screw is then placed and carefully tightened, taking care not to strip the threads; 1–2 washers can be placed if the depth of the hole is between screw sizes. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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19.50 (a) Following placement of the anti-rotational K-wire, a second K-wire is advanced from the apex of the anconeal process to exit the ulna gradually. (b) A cannulated drill bit of appropriate size is then advanced over the K-wire to form the glide hole for the lag screw. The depth of the hole is pre-measured from preoperative radiographs. (c) The second K-wire is then removed, a drill insert sleeve placed into the glide hole and the drill bit for the lag part of the hole advanced into the UAP. The depth of this hole is again measured from preoperative radiographs. Fixation is then completed as per Figure 19.49 . Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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19.51 Removal of an ununited anconeal process. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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19.52 A bilateral ESF with threaded bars, knurled nuts and sliding clamps is applied in order to distract the bones and increase radial length. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.

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